***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: > “ There are known knowns . These are things we know that we know . There are known unknowns . That is to say , there are things that we now know we do n't know . But there are also unknown unknowns . These are things we do not know we do n't know . ” > > —United States Secretary of Defense Donald Rumsfeld ( February 2002 ) > “ Thought is the wind , knowledge the sail , and mankind the vessel . ” > > August Hare ( 1792–1834 ) The international resuscitation community , under the auspices of the International Liaison Committee on Resuscitation ( ILCOR ) , has performed an exhaustive review of the published literature related to resuscitation and emergency cardiovascular care ( ECC ) . We had the opportunity to build on the detailed process developed over the past decade that facilitated the publication of the international consensus statement on therapeutic hypothermia1 and the Consensus on Cardiopulmonary Resuscitation ( CPR ) and ECC Science With Treatment Recommendations in 2005 (C2005).2 The overall process has been informed by the increasing evidence base behind good , systematic literature review s.3,4 There are , however , many questions that have never been addressed in a r and omized controlled trial , and much of the supporting scientific literature is at lower levels of evidence ( LOEs ) . In total , 356 worksheet authors from 29 countries throughout the world completed 411 worksheets on 277 topics . The information from these worksheets , with additional iterations from the writing groups and editorial board , makes up the evidence base from which the 2010 International Consensus on CPR and ECC Science with Treatment Recommendations ( CoSTR ) document is derived . As has been the process since the evidence evaluation for Guidelines 2000,5 volunteers from around the world were asked to perform systematic review s of the literature . These review s were conducted according to st and ardized instructions in completing the evidence worksheet template , and these worksheets were subsequently review ed in a detailed iterative process ( see www . ILCOR.org).6 A revised worksheet template ( based on that CONTEXT The survival benefit of well-performed cardiopulmonary resuscitation ( CPR ) is well-documented , but little objective data exist regarding actual CPR quality during cardiac arrest . Recent studies have challenged the notion that CPR is uniformly performed according to established international guidelines . OBJECTIVES To measure multiple parameters of in-hospital CPR quality and to determine compliance with published American Heart Association and international guidelines . DESIGN AND SETTING A prospect i ve observational study of 67 patients who experienced in-hospital cardiac arrest at the University of Chicago Hospitals , Chicago , Ill , between December 11 , 2002 , and April 5 , 2004 . Using a monitor/defibrillator with novel additional sensing capabilities , the parameters of CPR quality including chest compression rate , compression depth , ventilation rate , and the fraction of arrest time without chest compressions ( no-flow fraction ) were recorded . MAIN OUTCOME MEASURE Adherence to American Heart Association and international CPR guidelines . RESULTS Analysis of the first 5 minutes of each resuscitation by 30-second segments revealed that chest compression rates were less than 90/min in 28.1 % of segments . Compression depth was too shallow ( defined as < 38 mm ) for 37.4 % of compressions . Ventilation rates were high , with 60.9 % of segments containing a rate of more than 20/min . Additionally , the mean ( SD ) no-flow fraction was 0.24 ( 0.18 ) . A 10-second pause each minute of arrest would yield a no-flow fraction of 0.17 . A total of 27 patients ( 40.3 % ) achieved return of spontaneous circulation and 7 ( 10.4 % ) were discharged from the hospital . CONCLUSIONS In this study of in-hospital cardiac arrest , the quality of multiple parameters of CPR was inconsistent and often did not meet published guideline recommendations , even when performed by well-trained hospital staff . The importance of high- quality CPR suggests the need for rescuer feedback and monitoring of CPR quality during resuscitation efforts One hundred thirty-two physicians who successfully completed advanced cardiac life support ( ACLS ) training were r and omly placed in a control group or one of two groups receiving interventions design ed to provide reinforcement of previously mastered knowledge and skills . These interventions included mailed periodic reprints ( group 1 ) or quarterly patient management problems ( group 2 ) . All physicians were retested for knowledge and skills related to ACLS one year later . Fifty-two ( 39.4 % ) could successfully ventilate the mannequin , and 62 ( 47.0 % ) could perform cardiac compression adequately . No differences were noted among groups . Significant differences in knowledge were found . The control group initiated appropriate therapy in a mock-arrest situation 52 % of the time , while group 1 averaged 75 % and group 2 averaged 82 % . These results indicate that reinforcement after continuing medical education may enhance knowledge retention , but does not maintain motor skills . Yearly recertification in ACLS skills should be considered , and frequent practice sessions should be encouraged for those physicians who are not active participants in ACLS activities BACKGROUND Byst and er CPR improves outcomes after out of hospital cardiac arrest . The length of current 4-h classes in cardiopulmonary resuscitation ( CPR ) is a barrier to more widespread dissemination of CPR training and older adults in particular are underrepresented in traditional classes . Training with a brief video self-instruction ( VSI ) program has shown that this type of training can produce short-term skill performance at least as good as that seen with traditional American Heart Association ( AHA ) Heartsaver training , although it is unclear whether there is comparable skill retention . METHODS AND RESULTS Two hundred and eight-five adults between the ages of 40 and 70 who had no CPR training within the past 5 years were assigned at r and om to a no-training control group , Heartsaver ( HS ) training , or one of three versions of brief VSI ( i.e. , self-trained-ST subjects ) . Post-training performance of CPR skills was assessed in a scenario format by human examiners and by sensored manikin at Time 1 ( immediately post-training ) and again at Time 2 ( 2 months post-training ) . Performance by controls was assessed only once . Significant ( P<.001 ) decline was observed in the three measures recorded by examiners ; assess responsiveness ( from 72 % to 60 % for HS subjects and from 90 % to 77 % for ST subjects ) , call 911 ( from 82 % to 74 % for HS subjects and from 71 % to 53 % for ST subjects ) , and overall performance ( from 42 % to 30 % for HS subjects and from 60 % to 44 % for ST subjects ) . Significant ( P<.001 ) decline was observed in two of three skills measured by a sensored manikin : ventilation volume ( from 40 % to 36 % for HS subjects and from 61 % to 41 % for ST subjects , with a significant [ P=.028 ] interaction ) and correct h and placement ( from 68 % to 59 % for HS subjects and from 80 % to 64 % for ST subjects ) . Heartsaver and self-trained subjects generally showed similar rates of decline . At Time 2 , examiners rated trained subjects better than untrained controls in all skills except calling 911 , where self-trained subjects did not differ from controls ; manikin data revealed that trained subjects ' performance was better than that of controls for ventilation volume , but had declined to the level of controls for both h and placement and compression depth . CONCLUSIONS Adults between 40 and 70 years of age who participated in a CPR VSI program experienced performance decline in their CPR skills after a post-training interval of 2 months . However , this decline was no greater than that seen in subjects who took Heartsaver training . The VSI program produced retention performance at least as good as that seen with traditional training . Additional effort is needed to improve both initial performance and retention of CPR skills . CONDENSED ABSTRACT Retention of CPR skills was compared 2 months post-training for adults between 40 and 70 years old who had taken either a traditional Heartsaver CPR course or a 22-min video self-directed training course .  Although performance declines occurred in the 2-month interval , self-trained subjects generally demonstrated CPR skill retention equivalent to that of Heartsaver-trained subjects , although for both groups skill decline on some measures reached the level of untrained controls In a recent study we found that testing as a final activity in a skills course increases the learning outcome compared to spending an equal amount of time practicing . Whether this testing effect measured as skills performance can be demonstrated on long-term basis is not known . The research question was : does testing as a final activity in a cardio-pulmonary resuscitation ( CPR ) skills course increase learning outcome when assessed after half a year , compared to spending an equal amount of time practicing ? The study was an assessor-blinded r and omised controlled trial . A convenient sample of 7th semester medical students attending a m and atory CPR course was r and omised to intervention course or control course . Participants were taught in small groups . The intervention course included 3.5 h skills training plus 30 min of skills testing . The practice -only control course lasted 4 h. Both groups were invited to a retention assessment of CPR skills half a year later . Participants included 89/180 ( 50 % ) of those invited to participate in the study .  Mean performance score was 75.9 ( SD 11.0 ) in the intervention group ( N = 48 ) and 70.3 ( SD 17.1 ) in the control group , effect size 0.4 . The difference between groups was not statistically significant , P = 0.06 . This study suggests that testing as a final activity in a CPR skills course might have an effect on long-term learning outcome compared to spending an equal amount of time practicing the skills . Although this difference was not statistically significant , the identified effect size of 0.4 can have important clinical and educational implication OBJECTIVE To evaluate new instructional methods for teaching high school students cardiopulmonary resuscitation ( CPR ) and automated external defibrillator ( AED ) knowledge , actions and skills . METHODS We conducted a cluster-controlled trial of 3 instructional interventions among Seattle area high school students , with r and om allocation based on classrooms , during 2003 - 04 . We examined two new instructional methods : interactive-computer training and interactive-computer training plus instructor-led ( h and s-on ) practice , and compared them with traditional classroom instruction that included video , teacher demonstration and instructor-led ( h and s-on ) practice , and with a control group . We assessed CPR and AED knowledge , performance of key AED and CPR actions , and essential CPR ventilation and compressions skills 2 days and 2 months after training . All outcomes were transformed to a scale of 0 - 100 % . RESULTS For all outcome measures mean scores were higher in the instructional groups than in the control group . Two days after training all instructional groups had mean CPR and AED knowledge scores above 75 % , with use of the computer program scores were above 80 % . Mean scores for key AED actions were above 80 % for all groups with training , with h and s-on practice enhancing students ' positive outcomes for AED pad placement . Students who received h and s-on practice more successfully performed CPR actions than those in the computer program only group . In the 2 h and s-on practice groups the scores for 3 of the outcomes ranged from 57 to 74 % ; they were 32 to 54 % in the computer only group . For the outcome of continuing CPR until the AED was available scores were high , 89 to 100 % in all 3 training groups . Mean CPR skill scores were low in all groups . The highest mean score for successful ventilations was 15 % and for compressions , 29 % . The pattern of results was similar after 2 months . CONCLUSIONS We found evidence that interactive computer based self instruction alone was sufficient to teach CPR and AED knowledge and AED actions to high school students . All forms of instruction were highly effective in teaching AED use . In contrast to AED skills , CPR remains a set of difficult psychomotor skills that is challenging to teach to high school students as well as other members of the lay public CONTEXT The impact of clinical experience on learning outcome from a resuscitation course has not been systematic ally investigated . AIM To determine whether half a year of clinical experience before participation in an Advanced Life Support ( ALS ) course increases the immediate learning outcome and retention of learning . MATERIAL S AND METHODS This was a prospect i ve single blinded r and omised controlled study of the learning outcome from a st and ard ALS course on a volunteer sample of the entire cohort of newly graduated doctors from Copenhagen University . The outcome measurement was ALS-competence assessed using a vali date d composite test including assessment of skills and knowledge . INTERVENTION The intervention was half a year of clinical work before an ALS course . The intervention group received the course after a half-year of clinical experience . The control group participated in an ALS course immediately following graduation . RESULTS Invitation to participate was accepted by 154/240 ( 64 % ) graduates and 117/154 ( 76 % ) completed the study . There was no difference between the intervention and control groups with regard to the immediate learning outcome . The intervention group had significantly higher retention of learning compared to the control group , intervention group mean 82 % ( CI 80 - 83 ) , control group mean 78 % ( CI 76 - 80 ) , P=0.002 . The magnitude of this difference was medium ( effect size=0.57 ) . CONCLUSIONS Half a year of clinical experience , before participation in an ALS course had a small but statistically significant impact on the retention of learning , but not on the immediate learning outcome OBJECTIVES / PURPOSE To test registered nurses ' abilities to retain basic or advanced life support psychomotor skills  and theoretical knowledge . 
    Output:
    
Clinical experience , either prior to or after the courses , has a positive impact on retention of knowledge and skills .
The available evidence suggests that ALS knowledge and skills decay by 6 months to 1 year after training and that skills decay faster than knowledge .