[How effective is Blue®m?] / Hoe effectief is Blue®m?

Oral care products with active oxygen, such as Blue®m, can be used to support daily oral care. The question is, what evidence is currently available about the effectivity of Blue®m? In PubMed, 1 randomised controlled trial and 1 summary of a trial were found in which a Blue®m product was examined. Case studies were also found on the Blue®m website, none of which met the CARE criteria for describing case studies. After analyzing the scientific article and conducting a short-term pilot study, it can be concluded that there is currently no evidence that Blue®m oral care products are more effective than other oral care products.

Porous calcium phosphate cement for alveolar bone regeneration.

The present study aimed to provide information on material degradation and subsequent alveolar bone formation, using composites consisting of calcium phosphate cement (CPC) and poly(lactic-co-glycolic) acid (PLGA) with different microsphere morphology (hollow vs dense). In addition to the plain CPC-PLGA composites, loading the microspheres with the growth factors platelet-derived growth factor (PDGF) and insulin-like growth factor (IGF) was investigated. A total of four different CPC composites were applied into one-wall mandible bone defects in beagle dogs in order to evaluate them as candidates for alveolar bone regeneration. These composites consisted of CPC and hollow or dense PLGA microspheres, with or without the addition of PDGF-IGF growth factor combination (CPC-hPLGA, CPC-dPLGA, CPC-hPLGAGF , CPC-dPLGAGF ). Histological evaluation revealed significantly more bone formation in CPC-dPLGA than in CPC-hPLGA composites. The combination PDGF-IGF enhanced bone formation in CPC-hPLGA materials, but significantly more bone formation occurred when CPC-dPLGA was used, with or without the addition of growth factors. The findings demonstrated that CPC-dPLGA composite was the biologically superior material for use as an off-the-shelf material, due to its good biocompatibility, enhanced degradability and superior bone formation.

Maxillary sinus augmentation with microstructured tricalcium phosphate ceramic in sheep.

OBJECTIVE: The objective of this study was to evaluate the biological performance of osteoinductive microstructured tricalcium phosphate (MSTCP) particles in maxillary sinus floor augmentation surgery in sheep. MATERIAL AND METHODS: Sinus floor augmentation was performed in eight Swifter sheep. In each animal, the maxillary sinus floor was unilaterally augmented with MSTCP particles. Computed tomography (CT) imaging and histological analyses were performed after 12 weeks of implantation. RESULTS: Maxillofacial CT, histology, histomorphometrical analysis and sequential polychrome fluorescent labeling indicated that MSTCP particles provided a scaffold for cell ingrowth and bone formation. After a 12-week implantation period, the sinuses grafted with MSTCP showed an increased bone height of 6 mm and a mean total bone volume of 43%, with significant degradation of MSTCP particles. CONCLUSION: MSTCP particles represent a suitable bone substitute material for maxillary sinus floor augmentation surgery.

Blinded and uniform causes of death verification in cancer screening: a major influence on the outcome of a prostate cancer screening trial?

BACKGROUND: To assess the agreement between the causes of death assigned by a blinded and uniform review panel of the Rotterdam section of the European Randomised Study of Screening for Prostate Cancer and the official vital statistics and to explore the possible effect of the use of either of these two sources on the outcome of the screening trial. METHODS: A total of 670 deaths amongst men with prostate cancer, reviewed by the causes of death committee (CODC) up to 31st December 2006 were included in this study. The kappa statistics with confidence intervals (CI), sensitivity and specificity of the official statistics were determined, with the CODC considered the gold standard. The rate ratio (RR) and 95% confidence intervals (95% CI) for prostate cancer mortality, official statistics relative to CODC, were calculated following the Mantel-Haenszel procedure. RESULTS: The overall concordance and the kappa between official statistics and the CODC were 90.6% and 0.76 (0.71-0.82), remaining comparable when only the CODC category definitely prostate cancer was applied, with the sensitivity of official statistics increasing from 88.3% to 91.3% and specificity hardly changing (91.3% and 90.5%). High specificity and lower sensitivity is observed in the screening arm, whilst the opposite was seen in the control arm in men aged 55-69 and 70-74 years at entry. Considerable lower false positive rate was seen for both age groups in the screening arm (3.9% and 4.7%) compared to the control arm (8.4% and 14.3%). A statistically significant excess of prostate cancer death was observed for the official statistics in the age group 70-74 years, 1.53 (1.07-2.19), whilst it was not significant for men aged 55-69 at entry, 1.06 (0.83-1.36). CONCLUSION: In the Rotterdam ERSPC section, official statistics tended to overreport prostate cancer as an underlying cause of death, particularly in the age group 70-plus in the control arm, which would overestimate the true effect in favour of screening.

Initial risk stratification and presenting characteristics of patients with evolving myocardial infarctions.

OBJECTIVES: To describe the presenting characteristics and risk stratification of patients presenting to the emergency department with chest pain who have a normal initial troponin level followed by a raised troponin level within 12 h (evolving myocardial infarction (EMI)). METHODS: Data from the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a registry of patients presenting with undifferentiated chest pain, were used. This analysis included patients without ST segment elevation with at least two troponin assay results < or = 12 h apart. Patients were stratified into three groups: EMI (initial troponin assay negative, second troponin assay positive), non-ST elevation myocardial infarction (NSTEMI) (initial troponin assay positive) and no MI (all troponin assays negative). RESULTS: Of 4136 eligible patients, 5% had EMI, 8% had NSTEMI and 87% had no MI. Patients with EMI were more similar to those with NSTEMI than those with no MI with respect to demographic characteristics, presentation, admission patterns and revascularisation. The initial ECG in patients with EMI was most commonly non-diagnostic (51%), but physicians' initial impressions commonly reflected MI, unstable angina or high-risk chest pain (76%). This risk assessment was followed by a high rate of critical care admissions (32%) and revascularisation (percutaneous coronary intervention 17%) among patients with EMI. CONCLUSION: Patients with EMI appear similar at presentation to those with NSTEMI. Patients with EMI are perceived as being at high risk, evidenced by similar diagnostic impressions, admission practices and revascularisation rates to patients with NSTEMI.

[Revised guideline 'Vasectomy' from the Dutch Urological Association]. / Herziene richtlijn 'Vasectomie' van de Nederlandse Vereniging voor Urologie.

Vasectomy is a simple and reliable method of contraception. Problems associated with vasectomy include inadequate patient information, complications of the procedure e.g. infection and scrotal bleeding (4-22%), chronic scrotal pain after the procedure (2-5%) and spontaneous recanalisation with return of fertility (0.03-I12%). Later in life a substantial number of men come to regret having a vasectomy, notably those who underwent it at a young age and those without children of their own. After 10 years 2.4% of vasectomised Dutch men have a refertilisation procedure (usually a vasovasostomy) because of the wish for children in a new relationship. Since vasectomy is an elective procedure and not done on medical indication, it requires an extensive informed-consent procedure for the patient. Insufficient information may result in inadequate follow-up, omission of semen analysis, and consequent legal procedures should complications or pregnancy ensue. Clearance after the first semen analysis at 3 months can be given if azoospermia is seen or if less than 100,000 non-motile spermatozoa are present in the ejaculate.

Tissue polypeptide-specific antigen (TPS) determinations before and during intermittent maximal androgen blockade in patients with metastatic prostatic carcinoma.

OBJECTIVE: To evaluate the prognostic significance of serially measured tissue polypeptide-specific antigen (TPS) levels in patients with metastatic prostatic carcinoma treated with intermittent maximal androgen blockade (MAB). To determine its value with respect to predicting response to treatment and time to clinical progression. Finally to compare TPS with prostate-specific antigen (PSA) measurements in terms of prognostic impact in patients with metastatic prostatic carcinoma. METHODS AND PATIENTS: TPS and PSA measurements were performed before start of and monthly during intermittent MAB in 68 patients participating in EORTC protocol 30954. Both TPS and PSA were measured in serum. Fifty-six patients from eight centers were included in the final analysis because at least three TPS values were available. TPS and PSA values were correlated with clinical course of the disease. Median follow-up was 21.3 months. Three patient groups were defined on clinical grounds: (a) clinically progressive disease (n=18); (b) clinically stable disease (n=33); and (c) patients who did not reach a predefined nadir PSA value following 9 months of treatment (n=5). RESULTS: Pretreatment TPS was significantly higher in the clinically progressive patients than in the other patient groups (p=0.0041). When grouping patients according to their pretreatment TPS values (cut-off value of 100 U/l) the pretreatment TPS value (>100 U/l) proved to be a statistically significant prognostic factor with respect to time to progression: elevated TPS was associated with a 3.8 increased risk for progressive disease (p=0.0055). Pretreatment PSA (>100 ng/ml) was of no prognostic value for time to progression. In five patients increase of TPS coincided with or preceded clinical progression during treatment, whereas PSA remained normal. CONCLUSION: Additional value of pretreatment TPS measurements in metastatic prostate cancer patients is found in defining the patients with rapid clinical progression. Following MAB an increase in TPS signifies clinical progression even if PSA is found to remain normal.

Combination of Goldman risk and initial cardiac troponin I for emergency department chest pain patient risk stratification.

BACKGROUND: Accurate identification of low-risk emergency department (ED) chest pain patients who may be safe for discharge has not been well defined. Goldman criteria have reliably risk-stratified patients but have not identified any subset safe for ED release. Cardiac troponin I (cTnI) values have also been shown to risk-stratify patients but have not identified a subset safe for ED release. OBJECTIVE: To test the hypothesis that ED chest pain patients with a Goldman risk of < or =4% and a single negative cTnI (< or =0.3 ng/mL) at the time of ED presentation would be safe for discharge [<1% risk for death, acute myocardial infarction (AMI), revascularization]. METHODS: A prospective cohort study was performed in which consecutive ED chest pain patients were enrolled from July 1999 to November 2000. Data collected included patient demographics, medical and cardiac history, electrocardiogram, and creatine kinase-MB and cTnI. Goldman risk stratification score was calculated while patients were still in the ED. Hospital course was followed daily. Telephone follow-up occurred at 30 days. The main outcome was death, AMI, or revascularization (percutaneous transluminal coronary angioplasty/stents/coronary artery bypass grafting) within 30 days. RESULTS: Of 2,322 patients evaluated, 998 had both a Goldman risk < or =4% and a cTnI < or =0.3 ng/mL. During the initial hospitalization, 37 patients met the composite endpoint (3.7%): 6 deaths (0.7%), 17 AMIs (1.7%), 18 revascularizations (1.8%). Between the time of hospital discharge and 30-day follow-up, 15 patients met the composite endpoint: 4 deaths (0.4%), 6 AMIs (0.6%), and 5 revascularizations (0.5%). Overall, 49 patients met the composite endpoint (4.9%; 95% CI = 3.6% to 6.2%): 10 deaths (1.0%; 95% CI = 0.4% to 1.6%); 23 AMIs (2.3%; 95% CI = 1.4% to 3.2%), and 23 revascularizations (2.3%; 95% CI = 1.4% to 3.2%) within 30 days of presentation. CONCLUSIONS: The combination of two risk stratification modalities for ED chest pain patients (Goldman risk < or =4% and cTnI < or =0.3 ng/mL) did not identify a subgroup of chest pain patients at <1% risk for death, AMI, or revascularization within 30 days.

A randomized trial of the effects of early cardiac serum marker availability on reperfusion therapy in patients with acute myocardial infarction: the serial markers, acute myocardial infarction and rapid treatment trial (SMARTT).

OBJECTIVES: The purpose of this study was to assess whether the immediate availability of serum markers would increase the appropriate use of thrombolytic therapy. BACKGROUND: Serum markers such as myoglobin and creatine kinase, MB fraction (CK-MB) are effective in detecting acute myocardial infarction (AMI) in the emergency setting. Appropriate candidates for thrombolytic therapy are not always identified in the emergency department (ED), as 20% to 30% of eligible patients go untreated, representing 10% to 15% of all patients with AMI. Patients presenting with chest pain consistent with acute coronary syndrome were evaluated in the EDs of 12 hospitals throughout North America. METHODS: In this randomized, controlled clinical trial, physicians received either the immediate myoglobin/CK-MB results at 0 and 1 h after enrollment (stat) or conventional reporting of myoglobin/CK-MB 3 h or more after hospital admission (control). The primary end point was the comparison of the proportion of patients within the stat group versus control group who received appropriate thrombolytic therapy. Secondary end points included the emergent use of any reperfusion treatment in both groups, initial hospital disposition of patients (coronary care unit, monitor or nonmonitor beds) and the proportion of patients appropriately discharged from the ED. RESULTS: Of 6,352 patients enrolled, 814 (12.8%) were diagnosed as having AMI. For patients having AMI, there were no statistically significant differences in the proportion of patients treated with thrombolytic therapy between the stat and control groups (15.1% vs. 17.1%, p = 0.45). When only patients with ST segment elevation on their initial electrocardiogram were compared, there were still no significant differences between the groups. Also, there was no difference in the hospital placement of patients in critical care and non- critical care beds. The availability of early markers was associated with more hospital admissions as compared to the control group, as the number of patients discharged from the ED was decreased in the stat versus control groups (28.4% vs. 31.5%, p = 0.023). CONCLUSIONS: The availability of 0- and 1-h myoglobin and CK-MB results after ED evaluation had no effect on the use of thrombolytic therapy for patients presenting with AMI, and it slightly increased the number of patients admitted to the hospital who had no evidence of acute myocardial necrosis.

Paternity after bilateral vasectomy.

OBJECTIVES: To determine whether the occurrence of recanalization depends on the technique of vasectomy. MATERIALS AND METHODS: A survey was conducted among Dutch urologists using a questionnaire in which information was gathered about the surgical procedure, postoperative complications, results of semen analysis after vasectomy, time between vasectomy and occurrence of paternity, results of semen analysis after paternity, performance of revasectomy, results of histological examination of the revasectomy specimen and whether the event had changed the protocol of the urologists. RESULTS: In all, 32 cases of paternity after vasectomy were registered. Surgical techniques and the criteria for a successful vasectomy differed among the responding urologists. There was a difference in time to paternity between men who did and did not correspond with the criteria. In most cases, semen analysis after paternity showed numerous motile sperm. Six men initiated litigation after paternity and the vasectomy protocol was modified by five urologists. CONCLUSION: Paternity consequent on recanalization can occur at any time after bilateral vasectomy and does not depend on the surgical procedure or criteria for sterility. Because of the major consequences of paternity after vasectomy for both the man and urologist, accurate information about the possibility of recanalization should be given to the man beforehand.

Serial creatine kinase-MB results are a sensitive indicator of acute myocardial infarction in chest pain patients with nondiagnostic electrocardiograms: the second Emergency Medicine Cardiac Research Group Study.

OBJECTIVE: To determine the test performance characteristics of serial creatine kinase-MB (CK-MB) mass measurements for acute myocardial infarction (MI) in patients presenting to the ED with chest pain and nondiagnostic ECGs. METHODS: A prospective, observational test performance study was conducted. Hemodynamically stable patients aged > or = 25 years with chest discomfort, but without ECGs diagnostic for MI, were enrolled at 7 university teaching hospitals. Presenting ECGs showing > 1-mV ST-segment elevation in > or = 2 electrically contiguous leads were considered diagnostic for MI; patients with diagnostic ECGs on presentation were excluded. Real-time, serial CK-MB mass levels were obtained using a rapid serum immunochemical assay at the time of ED presentation (0-hour) and 3 hours later (3-hour). The following testing schemes were evaluated for their sensitivity and specificity for detection of MI during patient evaluation in the ED: 1) an elevated (> or = 8 ng/mL) presenting CK-MB level; 2) an elevated presenting and/or 3-hour CK-MB level; 3) a significant increase (i.e., > or = 3 ng/mL) within the range of normal limits for CK-MB concentrations during the 3-hour period (delta CK-MB); and/or 4) development of ST-segment elevation during the 3 hours (second ECG). RESULTS: Of the 1,042 patients enrolled, 777 (74.6%) were hospitalized, including all 67 MI patients (8.6% of admissions). As a function of duration of time in the ED, the test performance characteristics of serial CK-MBs for MI (and cumulative data for the additional ECG) were: [table: see text] The 0-hour to 3-hour CK-MB positive and negative predictive values were 52% to 55% and 96% to 99%, respectively. The sensitivities of serial CK-MB results as a function of the interval following chest discomfort onset were: [table: see text] CONCLUSION: Serial CK-MB monoclonal antibody mass measurements in the ED can identify MI patients with initially nondiagnostic ECGs. CK-MB sensitivity significantly increases over 3 hours of observation of stable chest discomfort patients in the ED; it also increases as a function of the total interval from onset until enzyme measurement.

Multicenter study of creatine kinase-MB use: effect on chest pain clinical decision making.

OBJECTIVE: To determine whether creatine kinase-MB isomer (CK-MB) levels affect initial physician decisions regarding patients with potential cardiac chest pain. METHODS: A prospective, multicenter, observational cohort study was performed at seven university teaching hospital EDs. Hemodynamically stable chest pain patients > or = 25 years old and without ST-segment elevation on their ECGs were observed with one to two sets of CK-MB level determinations obtained three hours apart prior to disposition. The physicians committed to a dichotomous (yes/no) absolute decision regarding the diagnosis of myocardial infarction (MI), need for hospital admission, and need for coronary care unit (CCU) admission both before and after enzyme results were obtained. The physicians ranked the perceived importance of initial history and physical, serial clinical observation, initial ECG, and CK-MB level to their decision making (rank score: 1 = most important, 4 = least important). RESULTS: Of the 1,042 patients enrolled, 777 (74.6%) were admitted to the hospital. For the 67 MI patients (8.6% of the admissions), changes in absolute decisions about the diagnosis of MI and planned CCU admission were associated with increased CK-MB importance (p = 0.04 and p = 0.02, respectively). Of the 146 patients who had new-onset angina or unstable angina, changes in absolute decisions were not associated with CK-MB importance. No patient who had MI or unstable angina was released from the ED. There were three of 67 (4%) MI patients and one of 146 (1%) unstable/new-onset angina patients initially slated for release home who were admitted to the hospital. CONCLUSIONS: For a minority of the patients who had subsequently proven MI, the CK-MB result helped guide disposition decisions. The CK-MB availability did not adversely impact the disposition of the patients who had unstable or new-onset angina.

Emergency-department diagnosis of acute myocardial infarction and ischemia: a cost analysis of two diagnostic protocols.

OBJECTIVE: To assess the potential cost savings of the emergency-department (ED) diagnosis of acute myocardial infarction (AMI) and other myocardial ischemia using a nine- hour ED evaluation protocol. METHODS: This one-year study of chest-pain evaluation unit (CPEU) patient charges was undertaken at two midwestern urban university hospital EDs. Included in the study were 447 patients presenting to the EDs with chest pain consistent with myocardial ischemia, nondiagnostic electrocardiograms (ECGs), and stable vital signs. Following initial ED evaluation, CPEU patients underwent nine hours of continuous ECG ST-segment monitoring with serum CK-MB levels determined at zero, three, six, and nine hours. Nonrandomized concurrent chest pain patients with routine ED evaluation and hospital admission without CPEU workup served as controls. At Center 1, patients with negative CPEU evaluations underwent immediate echocardiography (echo) and graded exercise testing (GXT) followed by ED release (CPEU;REL). At Center 2, CPEU patients were released from the ED for outpatient stress thallium testing (CPEU;REL). At Center 2, CPEU patients with positive workups as indicated by elevated CK-MB levels, ischemia by ST-segment monitoring, or positive echo/GXT/ stress thallium testing were admitted to the hospital for further testing. Control patients were admitted directly to the hospital to evaluate for AMI. Hospital charges for CPEU and control groups were compared. RESULTS: (Total charges in dollars, mean +/- SD, student's t-test): [table: see text] CONCLUSION: At both centers, hospital charges related to the acute evaluation of chest pain were significantly lower with this ED diagnostic protocol for AMI and myocardial ischemia.

Emergency department CK-MB: a predictor of ischemic complications. National cooperative CK-MB project group.

OBJECTIVE: To demonstrate that a positive CK-MB in the emergency department (ED) predicts an increased risk for complications of myocardial ischemia in patients admitted to the hospital for evaluation of chest pain. METHODS: 53 academic and community hospital EDs participated in this prospective observational cohort analysis of 5,120 patients with chest pain without ST-segment elevation on the initial ED 12-lead electrocardiogram. All patients were admitted for evaluation of chest pain in one of the participating hospitals as part of the National Cooperative CK-MB Project. Patients were stratified by whether or not they had an elevated CK-MB level in the ED. CK-MB measurements were made on ED presentation and two hours later. Patient medical records were reviewed for inpatient diagnoses--myocardial infarction (MI) or other diagnosis--and for ischemic complication--cardiac-related death, recurrent or delayed in-hospital MI, significant ventricular arrhythmias, new conduction defects, congestive heart failure, and cardiogenic shock. RESULTS: 369 (7.2%) of the 5,120 patients had MI. The proportion of patients with any complication in the MI group was 24%, while the complication rate in the non-MI group was 0.4%. In all patients, regardless of final diagnosis, the relative risk of any complication was 16.1 (95% CI 11.0-23.6) in those with a positive ED CK-MB versus negative ED CK-MB patients. Similarly, the relative risk of death was 25.4 (95% CI 10.8-60.2) in positive ED CK-MB versus negative ED CK-MB patients. CONCLUSIONS: Multicenter data support the hypothesis that CK-MB measurements can help risk-stratify ED chest pain patients whose initial ECGs are without diagnostic ST-segment elevation.

Effect of standard-dose versus high-dose epinephrine on myocardial high-energy phosphates during ventricular fibrillation and closed-chest CPR.

STUDY OBJECTIVE: To evaluate the effects of standard-dose versus high-dose epinephrine on myocardial high-energy phosphate metabolism during resuscitation from cardiac arrest. DESIGN: Prospective, nonrandomized, controlled study using a swine model of cardiac arrest and resuscitation. INTERVENTIONS: After anesthesia, intravascular pressure instrumentation, and ten minutes of ventricular fibrillation arrest, closed-chest CPR was begun. After three minutes of CPR, animals were allocated to receive either 0.02 mg/kg i.v. standard-dose epinephrine (eight) or 0.2 mg/kg i.v. high-dose epinephrine (nine). The animals underwent thoracotomy and rapid-freezing transmural myocardial core biopsy for high-energy phosphate analysis 3.5 minutes after epinephrine administration. High-energy phosphate values were blindly determined using high-pressure liquid chromatography. RESULTS: Intravascular pressure (mm Hg) and high-energy phosphate (nmol/mg protein) results for standard-dose epinephrine versus high-dose epinephrine are, respectively, coronary perfusion pressure, 15.3 +/- 7.8 versus 23.7 +/- 5.5 (P = .0009); phosphocreatine, 0.4 +/- 0.8 versus 6.2 +/- 4.4 (P = .0003); adenosine triphosphate, 9.8 +/- 4.8 versus 12.7 +/- 5.7 (P = .30); adenosine diphosphate, 5.4 +/- 2.1 versus 6.1 +/- 1.3 (P = .41); and adenylate charge, 0.68 +/- 0.12 versus 0.72 +/- 0.12 (P = .87). CONCLUSION: High-dose epinephrine does not deplete myocardial high-energy phosphate when given in this model of prolonged ventricular fibrillation. High-dose epinephrine increases coronary perfusion pressure compared with standard-dose epinephrine. High-dose epinephrine administration repletes phosphocreatine during closed-chest CPR, thereby increasing myocardial energy stores.

Effect of first-responder automated defibrillation on time to therapeutic interventions during out-of-hospital cardiac arrest. The Multicenter High Dose Epinephrine Study Group.

STUDY OBJECTIVES: The effect of automated defibrillation provided by basic emergency medical technician (EMT) first-responder units on the time intervals to other critical interventions in the management of out-of-hospital cardiac arrests is unknown. The purpose of this study was to define and compare elapsed time intervals to basic CPR, paramedic arrival, initial countershock, endotracheal intubation, IV access, and initial adrenergic drug therapy in first-responder automated defibrillation/paramedic versus basic EMT/paramedic emergency medical services systems. DESIGN: Prospectively collected data from a 15-month multicenter study of out-of-hospital, nontraumatic cardiac arrests were analyzed. The mean time intervals to critical therapeutic interventions between first-responder automated defibrillation/paramedic and basic EMT/paramedic groups were compared using the Student's t-test with Bonferroni correction. SETTING: Three first-responder automated defibrillation/paramedic and three basic EMT/paramedic urban emergency medical services systems. PARTICIPANTS: 1,578 patients with out-of-hospital cardiac arrest. INTERVENTIONS: The first-responder automated defibrillation/paramedic group received initial ECG analysis and/or automated countershock by first-responder/EMTs; the basic EMT/paramedic group received initial ECG analysis and/or manual countershock by paramedics. RESULTS: Elapsed time intervals in minutes +/- SD for first-responder automated defibrillation/paramedic versus basic EMT/paramedic groups, respectively, were as follows: Collapse to CPR, 4.3 +/- 3.9 versus 5.4 +/- 5.2 (P = .017); collapse to countershock, 10.7 +/- 5.9 versus 13.0 +/- 6.0 (P = .017); collapse to paramedic arrival, 13.0 +/- 5.4 versus 10.3 +/- 6.1 (P = .0001); paramedic arrival to IV access, 5.1 +/- 3.9 versus 7.0 +/- 5.0 (P = .0001); paramedic arrival to endotracheal intubation, 4.8 +/- 4.0 versus 6.8 +/- 5.8 (P = .0001); paramedic arrival to initial adrenergic drug therapy, 7.4 +/- 4.5 versus 8.2 +/- 4.7 (P = .015); collapse to IV access, 17.7 +/- 6.1 versus 16.6 +/- 7.4 (P = .10); collapse to endotracheal intubation, 17.3 +/- 6.4 versus 16.6 +/- 7.8 (P = .32); collapse to initial adrenergic drug therapy, 20.4 +/- 6.7 versus 18.1 +/- 7.2 (P = .010). The time intervals from paramedic arrival to IV access, endotracheal intubation, and initial adrenergic drug therapy remained shorter in the first-responder automated defibrillation/paramedic systems despite stratification by presenting cardiac rhythm. CONCLUSION: First-responder automated defibrillation/paramedic systems provide not only shorter times to initial countershock, as compared with basic EMT/paramedic systems, but by having delegated initial countershock to first-responders, they also allow for significantly shorter times from paramedic arrival to IV access, endotracheal intubation, and initial adrenergic drug therapy interventions.