Out-of-hospital cardiac arrest in children in Norway: A national cohort study, 2016-2021.

Aim: Children constitute an important and distinct subgroup of out-of-hospital cardiac arrest (OHCA) patients. This population-based cohort study aims to establish current age-specific population incidence, precipitating causes, circumstances, and outcome of paediatric OHCA, to guide a focused approach to prevention and intervention to improve outcomes. Methods: Data from the national Norwegian Cardiac Arrest Registry was extracted for the six-year period 2016-21 for persons aged <18 years. We present descriptive statistics for the population, resuscitation events, presumed causes, treatment, and outcomes, alongside age-specific incidence and total paediatric mortality rates. Results: Three hundred and eight children were included. The incidence of OHCA was 4.6 per 100 000 child-years and markedly higher in children <1 year at 20.9 child-years. Leading causes were choking, cardiac and respiratory disease, and sudden infant death syndrome. Overall, 21% survived to 30 days and 18% to one year. Conclusion: A registry-based approach enabled this study to delineate the characteristics and trajectories of OHCA events in a national cohort of children. Precipitating causes of paediatric OHCA are diverse compared to adults. Infants aged <1 year are at particularly high risk. Mortality is high, albeit lower than for adults in Norway. A rational community approach to prevention and treatment may focus on general infant care, immediate first aid by caretakers, and identification of vulnerable children by primary health providers. Cardiac arrest registries are a key source of knowledge essential for quality improvement and research into cardiac arrest in childhood.

Identifying excessive chronic alcohol use with phosphatidylethanol in patients with suspected severe injury-results from the IDART study.

INTRODUCTION: Acute and chronic alcohol use are well-known risk factors for accidents and injuries, and concurrent psychoactive drug use can increase injury risk further. Phosphatidylethanol (PEth) 16:0/18:1 is a biomarker used to determine alcohol consumption the previous 3-4 weeks. The aim was to investigate the prevalence of chronic alcohol use in trauma patients, as determined by PEth 16:0/18:1 concentrations, and how excessive chronic alcohol use relate to demographic variables, injury mechanisms and drug use. SETTING: Patients received at Norwegian trauma hospitals from March 2019 to February 2020. The study is part of the Impairing Drugs and Alcohol as Risk factors for Traumatic Injuries study. METHODS: All patients aged ≥ 16 years received with trauma team were included in the study. Data on injury date and mechanism, gender and age was registered. Blood samples were analyzed for 22 psychoactive medicinal and illicit drugs, ethanol and phosphatidylethanol 16:0/18:1. Regression analyses were conducted to assess associations between alcohol use and gender, age, injury mechanism and drug use. RESULTS AND CONCLUSION: Of the 4845 patients included in the study, 10% had PEth 16:0/18:1 concentration ≥ 600 nM (~430 ng/mL), indicative of excessive chronic alcohol use. Being male, between 44-61 years old, involved in violence, and testing positive for medicinal drugs was associated with excessive chronic alcohol use.Excessive chronic alcohol use was common among males, middle-aged, patients with violence as injury mechanism and those with medicinal drug use. These findings emphasize the need to detect and treat excessive chronic alcohol use among trauma patients.

Prevalence of use and impairment from drugs and alcohol among trauma patients: A national prospective observational study.

BACKGROUND: Being under the influence of psychoactive substances increases the risk of involvement in and dying from a traumatic event. The study is a prospective population-based observational study that aims to determine the prevalence of use and likely impairment from psychoactive substances among patients with suspected severe traumatic injury. METHOD: This study was conducted at 35 of 38 Norwegian trauma hospitals from 1 March 2019 to 29 February 2020. All trauma admissions for patients aged ≥ 16 years admitted via trauma team activation during the study period were eligible for inclusion. Blood samples collected on admission were analysed for alcohol, benzodiazepines, benzodiazepine-like hypnotics (Z-drugs), opioids, stimulants, and cannabis (tetrahydrocannabinol). RESULTS: Of the 4878 trauma admissions included, psychoactive substances were detected in 1714 (35 %) and in 771 (45 %) of these, a combination of two or more psychoactive substances was detected. Regarding the level of impairment, 1373 (28 %) admissions revealed a concentration of one or more psychoactive substances indicating likely impairment, and 1052 (22 %) highly impairment. Alcohol was found in 1009 (21 %) admissions, benzodiazepines and Z-drugs in 613 (13 %), opioids in 467 (10 %), cannabis in 352 (7 %), and stimulants in 371 (8 %). Men aged 27-43 years and patients with violence-related trauma had the highest prevalence of psychoactive substance use with respectively 424 (50 %) and 275 (80 %) testing positive for one or more compounds. CONCLUSION: The results revealed psychoactive substances in 35 % of trauma admissions, 80 % of which were likely impaired at the time of traumatic injury. A combination of several psychoactive substances was common, and younger males and patients with violence-related injuries were most often impaired. Injury prevention strategies should focus on high-risk groups and involve the prescription of controlled substances. We should consider toxicological screening in trauma admissions and incorporation of toxicological data into trauma registries.

Implementation and use of a supraglottic airway device in the management of out-of-hospital cardiac arrest by firefighter first responders - A prospective feasibility study.

Aim: We wanted to assess the implementation and use of a supraglottic airway (SGA) for on-call firefighter first responders in out-of-hospital cardiac arrest. Methods: We trained 502 firefighter first responders, located at 35 fire stations in the South-East of Norway, in the use of SGA during cardiopulmonary resuscitation in adult out-of-hospital cardiac arrest. Training consisted of 45 minutes of theoretical and practical training in small groups.Primary outcome was successful ventilation with SGA assessed by both firefighter first responders and first paramedic arriving on-scene. Secondary outcomes included time expenditure and complications related to the procedure, evaluation of the training, and descriptive characteristics of the out-of-hospital cardiac arrest cases. Results: An SGA was used by firefighter first responders in 23 out-of-hospital cardiac arrests, and successful ventilation was achieved in 20 (87%) cases. Air-leak was described in the three unsuccessful cases. The median procedural time was 30 seconds (IQR = 15-40), with no observed procedural complications. Firefighter first responders arrived in median time 9 minutes (IQR = 6-10 min) before the ambulance. They performed chest compressions on all patients and 6 (26%) of the patients received shock with semi-automatic external defibrillator. After training, all participants were able to successfully ventilate a manikin with the SGA. The cost of the SGA equipment for all fire stations was 3955 GBP. Conclusion: Implementation of an SGA for firefighter first responders in out-of-hospital cardiac arrest management seems feasible, safe and can be introduced with limited amount of training and limited use of resources.

Erroneous data: The Achilles' heel of AI and personalized medicine.

This paper reviews dilemmas and implications of erroneous data for clinical implementation of AI. It is well-known that if erroneous and biased data are used to train AI, there is a risk of systematic error. However, even perfectly trained AI applications can produce faulty outputs if fed with erroneous inputs. To counter such problems, we suggest 3 steps: (1) AI should focus on data of the highest quality, in essence paraclinical data and digital images, (2) patients should be granted simple access to the input data that feed the AI, and granted a right to request changes to erroneous data, and (3) automated high-throughput methods for error-correction should be implemented in domains with faulty data when possible. Also, we conclude that erroneous data is a reality even for highly reputable Danish data sources, and thus, legal framework for the correction of errors is universally needed.

Injuries after violence and accidents - the forgotten pandemic? / Skader etter vold og ulykker ­ den glemte pandemi?

All information on injuries should be collected in a national injury registry devised for research. This will pave the way for a new strategy for injury prevention.

Emergency cricothyroidotomy in difficult airway simulation - a national observational study of Air Ambulance crew performance.

BACKGROUND: Advanced prehospital airway management includes complex procedures carried out in challenging environments, necessitating a high level of technical and non-technical skills. We aimed to describe Norwegian Air Ambulance-crews' performance in a difficult airway scenario simulation, ending with a "cannot intubate, cannot oxygenate"-situation. METHODS: The study describes Air Ambulance crews' management of a simulated difficult airway scenario. We used video-observation to assess time expenditure according to pre-defined time intervals and technical and non-technical performance was evaluated according to a structured evaluation-form. RESULTS: Thirty-six crews successfully completed the emergency cricothyroidotomy with mean procedural time 118 (SD: ±70) seconds. There was variation among the crews in terms of completed procedural steps, including preparation of equipment, patient- monitoring and management. The participants demonstrated uniform and appropriate situational awareness, and effective communication and resource utilization within the crews was evident. CONCLUSIONS: We found that Norwegian Air Ambulance crews managed a prehospital "cannot intubate, cannot oxygenate"-situation with an emergency cricothyroidotomy under stressful conditions with effective communication and resource utilization, and within a reasonable timeframe. Some discrepancies between standard operating procedures and performance are observed. Further studies to assess the impact of check lists on procedural aspects of airway management in the prehospital environment are warranted.

Injury Prevention and long-term Outcomes following Trauma-the IPOT project: a protocol for prospective nationwide registry-based studies in Norway.

INTRODUCTION: Traumatic injuries constitute a major cause of mortality and morbidity. Still, the public health burden of trauma in Norway has not been characterised using nationwide registry data. More knowledge is warranted on trauma risk factors and the long-term outcomes following trauma. The Injury Prevention and long-term Outcomes following Trauma project will establish a comprehensive research database. The Norwegian National Trauma Registry (NTR) will be merged with several data sources to pursue the following three main research topics: (1) the public health burden of trauma to society (eg, excess mortality and disability-adjusted life-years (DALYs)), (2) trauma aetiology (eg, socioeconomic factors, comorbidity and drug use) and (3) trauma survivorship (eg, survival, drug use, use of welfare benefits, work ability, education and income). METHODS AND ANALYSIS: The NTR (n≈27 000 trauma patients, 2015-2018) will be coupled with the data from Statistics Norway, the Norwegian Patient Registry, the Cause of Death Registry, the Registry of Primary Health Care and the Norwegian Prescription Database. To quantify the public health burden, DALYs will be calculated from the NTR. To address trauma aetiology, we will conduct nested case-control studies with 10 trauma-free controls (drawn from the National Population Register) matched to each trauma case on birth year, sex and index date. Conditional logistic regression models will be used to estimate trauma risk according to relevant exposures. To address trauma survivorship, we will use cohort and matched cohort designs and time-to-event analyses to examine various post-trauma outcomes. ETHICS AND DISSEMINATION: The project is approved by the Regional Committee for Medical Research Ethics. The project's data protection impact assessment is approved by the data protection officer. Results will be disseminated to patients, in peer-reviewed journals, at conferences and in the media.

Assessment of the National Test Strategy on the Development of the COVID-19 Pandemic in Denmark.

During the COVID-19 pandemic, Denmark has pursued a mass testing strategy culminating in the testing of 12.167 individuals per 100,000 inhabitants per day during the spring of 2021. The strategy included free access to COVID-19 testing, and since 2021, compulsory documentation for negative tests or vaccination has been required for access to workplace, educational institutions, restaurants, and many other places. Testing and subsequent isolation if testing was positive were voluntary. The present study provides an analysis of whether testing frequency in Denmark showed any correlation to hospitalizations throughout the relevant stages of the pandemic. Mass testing was found not to correlate significantly with the number of hospitalizations during the pandemic. Interestingly, during the highest level of testing in spring 2021 the fraction of positive tests increased slightly; thus, the Danish mass testing strategy, at its best, failed to reduce the prevalence of COVID-19. Furthermore, the relationship between positives in antigen testing and in rt-PCR testing indicated that many patients were not tested early in their infection when the risk of transmission was at the highest. In conclusion, the Danish mass testing strategy for COVID-19 does not appear to have a detectable correlation to the number of hospitalizations due to COVID-19.

Control, trust and the sharing of health information: the limits of trust.

Clinical information about patients is increasingly being stored in electronic form and has therefore become more easily shareable. Data are collected as part of clinical care but have multiple other potential uses in relation to health system planning, audit and research. The use of clinical information for these secondary uses is controversial, and the ability to safeguard personal and sensitive data under current practices is contested.In this study, we investigate the attitudes of a representative sample of the Danish population towards transfer of clinical data from their general practice for secondary use. We specifically study: (1) patients' trust in different types of healthcare professionals, (2) their interest in being asked about secondary use of data and (3) their willingness to dispense from a requirement of informed consent based on their trust in healthcare professionals.We find that adult Danes are positive towards research that use patient data, and they generally trust general practitioners, hospitals and researchers to treat their data confidentially.Nevertheless, they feel that they have a right to control the use of their data, only 7.3% disagreeing, and that the data belong to them, only 14.0% disagreeing. Answers to further questions about the relation between trust, information and consent show that although trust modifies the wish for information and consent, there is still a strong view that the patient should control the use of data. We find no differences between those who have frequent contact with the healthcare system and those who do not.

Percutaneous vs surgical emergency cricothyroidotomy: An experimental randomized crossover study on an animal-larynx model.

BACKGROUND: Airway management is a paramount clinical skill for the anaesthesiologist. The Emergency Cricothyroidotomy (EC) constitutes the final step in difficult airway algorithms securing a patent airway via a front-of-neck access. The main distinction among available techniques is whether the procedure is surgical and scalpel-based or percutaneous and needle-based. METHODS: In an experimental randomized crossover trial, using an animal larynx model, we compared two EC techniques; the Rapid Four Step Technique and the Melker Emergency Cricothyrotomy Kit®. We assessed time expenditure and success rates among 20 anaesthesiologists and related this to previous training, seniority and clinical experience with EC. RESULTS: All participants achieved successful airway access with both methods. Average time to successful airway access for scalpel-based EC was 54 (±31) seconds and for percutaneous EC 89 (±38) seconds, with 35 (95% CI: 14-57) seconds time difference, P = .003. Doctors with recent (<12 months) EC training performed better compared to the non-training group (37 vs 61 seconds, P = .03 for scalpel-based EC, and 65 vs 99 seconds, P = .02 for percutaneous EC). We found no differences according to clinical seniority or previous real-life EC experience. CONCLUSIONS: Our study demonstrated that anaesthesiologists achieved successful airway access on an animal experimental model with both EC methods within a reasonable time frame, but the scalpel-based EC is performed more promptly. Recent EC training affected the time expenditure positively, while seniority and clinical EC experience did not. EC procedures should be regularly trained for.

Nonoperative Geriatric Hip Fracture Treatment Is Associated With Increased Mortality: A Matched Cohort Study.

OBJECTIVE: To report the mortality data and life expectancy of geriatric hip fracture patients who underwent nonoperative management and compare that with a matched operative cohort. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS: Geriatric (65 years of age and older) femoral neck or intertrochanteric fracture (OTA/AO 31A and 31B) patients. INTERVENTION: Operative treatment with either arthroplasty, cannulated screws, sliding hip screw device, or cephalomedullary nail compared with nonoperative cohort. MAIN OUTCOME MEASUREMENTS: In-hospital, 30-day, and 1-year mortality. RESULTS: Two hundred thirty-one patients, comprising 154 operative and 77 nonoperative patients, were compared. There were no significant differences among age, sex, fracture location, Charlson Comorbidity Index, preinjury living location, dementia, and history of cardiac arrhythmia between the 2 cohorts. Nonoperatively managed patients were found to have a significantly higher percent in-hospital (28.6 vs. 3.9; P < 0.0001), 30-day (63.6 vs. 11.0; <0.0001), and 1-year (84.4 vs. 36.4; P < 0.0001) mortality. The mean life expectancy after a hip fracture for the nonoperative cohort was significantly shorter than the operative group (221 vs. 1024 days; P < 0.0001). CONCLUSIONS: Nonoperatively treated hip fracture patients had an 84.4% 1-year mortality that was significantly higher than a matched operative cohort. Our results demonstrate the bleak overall prognosis for nonoperatively treated geriatric hip fractures as well as the associated reduction in mortality with surgical treatment. Our findings offer helpful information by providing updated mortality data when discussing nonoperative hip fracture management with patients and their family. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Functionalizing Arrays of Transferred Monolayer Graphene on Insulating Surfaces by Bipolar Electrochemistry.

Development of versatile methods for graphene functionalization is necessary before use in applications such as composites or as catalyst support. In this study, bipolar electrochemistry is used as a wireless functionalization method to graft 4-bromobenzenediazonium on large (10 × 10 mm(2)) monolayer graphene sheets supported on SiO2. Using this technique, transferred graphene can be electrochemically functionalized without the need of a metal support or the deposition of physical contacts. X-ray photoelectron spectroscopy and Raman spectroscopy are used to map the chemical changes and modifications of graphene across the individual sheets. Interestingly, the defect density is similar between samples, independent of driving potential, whereas the grafting density is increased upon increasing the driving potential. It is observed that the 2D nature of the electrode influences the electrochemistry and stability of the electrode compared to conventional electrografting using a three-electrode setup. On one side, the graphene will be blocked by the attached organic film, but the conductivity is also altered upon functionalization, which makes the graphene electrode different from a normal metal electrode. Furthermore, it is shown that it is possible to simultaneously modify an array of many small graphene electrodes (1 × 1 mm(2)) on SiO2.

Does transport time help explain the high trauma mortality rates in rural areas? New and traditional predictors assessed by new and traditional statistical methods.

BACKGROUND: Trauma is a leading global cause of death. Trauma mortality rates are higher in rural areas, constituting a challenge for quality and equality in trauma care. The aim of the study was to explore population density and transport time to hospital care as possible predictors of geographical differences in mortality rates, and to what extent choice of statistical method might affect the analytical results and accompanying clinical conclusions. METHODS: Using data from the Norwegian Cause of Death registry, deaths from external causes 1998-2007 were analysed. Norway consists of 434 municipalities, and municipality population density and travel time to hospital care were entered as predictors of municipality mortality rates in univariate and multiple regression models of increasing model complexity. We fitted linear regression models with continuous and categorised predictors, as well as piecewise linear and generalised additive models (GAMs). Models were compared using Akaike's information criterion (AIC). RESULTS: Population density was an independent predictor of trauma mortality rates, while the contribution of transport time to hospital care was highly dependent on choice of statistical model. A multiple GAM or piecewise linear model was superior, and similar, in terms of AIC. However, while transport time was statistically significant in multiple models with piecewise linear or categorised predictors, it was not in GAM or standard linear regression. CONCLUSIONS: Population density is an independent predictor of trauma mortality rates. The added explanatory value of transport time to hospital care is marginal and model-dependent, highlighting the importance of exploring several statistical models when studying complex associations in observational data.

Norwegian trauma care: a national cross-sectional survey of all hospitals involved in the management of major trauma patients.

BACKGROUND: Approximately 10% of the Norwegian population is injured every year, with injuries ranging from minor injuries treated by general practitioners to major and complex injuries requiring specialist in-hospital care. There is a lack of knowledge concerning the caseload of potentially severely injured patients in Norwegian hospitals. Aim of the study was to describe the current status of the Norwegian trauma system by identifying the number and the distribution of contributing hospitals and the caseload of potentially severely injured trauma patients within these hospitals. METHODS: A cross-sectional survey with a structured questionnaire was sent in the summer of 2012 to all Norwegian hospitals that receive trauma patients. These were defined by number of trauma team activations in the included hospitals. A literature review was performed to assess over time the development of hospitals receiving trauma patients. RESULTS: Forty-one hospitals responded and were included in the study. In 2011, four trauma centres and 37 acute care hospitals received a total of 6,570 trauma patients. Trauma centres received 2,175 (33%) patients and other hospitals received 4,395 (67%) patients. There were significant regional differences between health care regions in the distribution of trauma patients between trauma centres and acute care hospitals. More than half (52.5%) of the hospitals received fewer than 100 patients annually. The national rate of hospital admission via trauma teams was 13 per 10,000 inhabitants. There was a 37% (from 65 to 41) reduction in the number of hospitals receiving trauma patients between 1988 and 2011. CONCLUSIONS: In 2011, hospital acute trauma care in Norway was delivered by four trauma centres and 37 acute care hospitals. Many hospitals still receive a small number of potentially severely injured patients and only a few hospitals have an electronic trauma registry. Future development of the Norwegian trauma system needs to address the challenge posed by a scattered population and long geographical distances. The implementation of a trauma system, carefully balanced between centres with adequate caseloads against time from injury to hospital care, is needed and has been shown to have a beneficial effect in countries with comparable challenges.

Epidemiology of trauma: a population-based study of geographical risk factors for injury deaths in the working-age population of Norway.

INTRODUCTION: Trauma is a major global cause of morbidity and mortality. Population-based studies identifying high-risk populations and regions may facilitate primary prevention and the development of optimal trauma systems. This study describes the epidemiology of adult trauma deaths in Norway and identifies high-risk areas by assessing different geographical measures of rurality. METHODS: All trauma-related deaths in Norway from 1998 to 2007 among individuals aged 16-66 years were identified by accessing national registries. Mortality data were analysed by linkage to population and geographical data at municipal, county and national levels. Three measures of rurality (centrality, population density and settlement density) were compared based on their association with trauma mortality rates. RESULTS: The study included 8466 deaths, of which 78% were males. The national annual trauma mortality rate was 28.7 per 100,000. Population density was the best predictor of high-risk areas, and there was a consistent inverse relationship between mortality rates and population density. The most rural areas had 52% higher trauma mortality rates compared to the most urban areas. This difference was largely due to deaths following transport-related injury. Seventy-eight per cent of all deaths occurred in the prehospital phase. Rural areas and death following self-harm had higher proportion of prehospital deaths. CONCLUSION: Rural areas, as defined by population density, are at a higher risk of deaths following traumatic injuries and have higher proportions of prehospital deaths and deaths following transport-related injuries. The heterogeneous characteristics of trauma populations with respect to geography and mode of injury should be recognised in the planning of preventive strategies and in the organisation of trauma care.