Apples in Amsterdam and oranges in Leiden

In this journal, Bosch and colleagues report their experience with out-of-hospital cardiac arrest (OHCA) in the Leiden region and report a very high survival rate to discharge of 43 % [1]. They analyse the factors that contributed to this high survival rate. Also, they note that this survival rate in the Leiden region is approximately three times higher than the European average. The factors that seem to explain these very favourable results were the high proportion of witnessed arrests and of patients with a shockable rhythm, mostly ventricular fibrilla-tion, some ventricular tachycardia. A high proportion of patients were initially treated with an automated external defi-brillator (AED) and, last but not least, an 'optimised chain of survival' and the regional function of Leiden University Hospital are believed to be important for survival. Part of this optimisation is the in-hospital treatment where acute percutaneous coronary intervention (PCI) played a prominent role. There are indeed wide variations in outcome after OHCA, and there is no full understanding of the reasons for these differences. Large variation in general medical care, education , culture, and competing illnesses may play a role in a worldwide comparison but even within one country with, generally speaking, equal health care facilities, large differences are observed [2, 3]. Understanding these differences is currently a topic of great interest [4]. For a meaningful comparison, uniform and standardised data collection and reporting is of paramount importance. The Utstein reporting methodology has been accepted worldwide since its introduction in 1991. It was revised in 2004 and a second revision is just completed [5]. The most important and absolutely critical element in reporting is adoption of a uniform initial moment in time to start the body count after onset of the OHCA. Not all persons who have a sudden death will be subjected to a resuscitation attempt: persons not waking up in the morning, otherwise unwitnessed arrests, persons with do-not-resuscitate declarations are clear but not the only examples. It is now universally accepted that 'counting' starts when resuscitation action such as chest compressions and mouth-to-mouth ventilation is initiated. And even that moment is not always completely clear and uniformly defined. When resuscitation efforts are started, they may end unsuccessfully in the field, in the emergency room or even further on during hospital admission. Fortunately, efforts may also be successful, already before transport but sometimes only after prolonged resuscitation extending into the emergency room or …