Firefighters as first-responders in out-of-hospital cardiac arrest - A retrospective study of a time-gain selective dispatch system in the Skåne Region, Sweden.

AIM: To analyze the impact of a time-gain selective, first-responder dispatch system on the presence of a shockable initial rhythm (SIR), return of spontaneous circulation (ROSC) and 30-day survival after out-of-hospital cardiac arrest (OHCA). METHOD: A retrospective observational study comprising OHCA registry data and dispatch data in the Skåne Region, Sweden (2010-2018). Data were categorized according to dispatch procedures, two ambulances (AMB-only) versus two ambulances and firefighter first-responders (DUAL-dispatch), based on the dispatcher's estimation of a time-gain. Dual dispatch was sub-categorized by arrival of first vehicle (first-responder or ambulance). Logistic regressions were used, additionally with groups matched (1:1) for age, sex, location, witnessed event, bystander cardiopulmonary resuscitation and ambulance response time. Adjusted and conditional odds-ratios (aOR, cOR) with 95% confidence intervals (CI) are presented. RESULTS: Of 3,245 eligible cases, 43% were DUAL-dispatches with first-responders first on scene (FR-first) in 72%. Despite a five-minute median reduction in response time in the FR-first group, no association with SIR was found (aOR 0.83, 95%CI 0.64-1.07) nor improved 30-day survival (aOR 1.03, 95%CI 0.72-1.47). A positive association between ROSC and the FR-first group (aOR 1.25, 95%CI 1.02-1.54) disappeared in the matched analysis (cOR 1.12, 95%CI 0.87-1.43). Time to first monitored rhythm was 7:06 minutes in the FR-first group versus 3:01 in the combined AMB-only/AMB-first groups. CONCLUSION: In this time-gain selective first-responder dispatch system, a shorter response time was not associated with increased SIR, improved ROSC rate or survival. Process measures differed between the study groups which could account for the observed findings and requires further investigation.

Experience of using video support by prehospital emergency care physician in ambulance care - an interview study with prehospital emergency nurses in Sweden.

INTRODUCTION: When in need of emergency care and ambulance services, the ambulance nurse is often the first point of contact for the patient with healthcare. This role requires comprehensive knowledge of the ambulance nurse to be able to assign the right level of care and, if necessary, to provide self-care advice for patients with no further conveyance to hospital. Recently, an application was developed for transmitting real-time video to facilitate consultation between ambulance nurses and prehospital physicians in the role of regional medical support (RMS) for ambulance care. The use of video communication as a complement of medical support when referring to self-care is still an unexplored method in a prehospital setting. Our study aimed to elucidate ambulance nurses' experience of video consultation with RMS physician during the assessment of patients considered to be triaged to self-care. METHOD: We conducted a qualitative design study using semi-structured interviews with open questions. Twelve ambulance nurses were included in the study. To explore the ambulance nurses' experience of performing video consultation with RMS physician, in cases when a patient was assessed and triaged to self-care, a content analysis was performed. RESULTS: A main category emerged from the results: " Video consultation as decision support in the ambulance care promotes increased patient participation and for the ambulance nurses, it creates a feeling of increased patient safety ". The main category was based and formed on the following categories: " Simultaneous presence of ambulance nurse and a physician increases patient participation during the assessment resulting in a confident care decision ". "Interprofessional collaboration strengthens the medical assessment". "Video technology promotes accessibility for patients needs in the ambulance care regardless of emergency level". CONCLUSIONS: Ambulance nurses experienced that the use of video consultation increases patient involvement and confidence in healthcare when both the ambulance nurse and the physician were present when deciding on self-care advice. The live imaging allowed the ambulance nurse and prehospital physician to reach a consensus on the patient's current medical care needs, which in turn led to a feeling of increased patient safety for the ambulance nurses.

Perceptions of ambulance nurses on their knowledge and competence when assessing psychiatric mental illness.

AIMS AND OBJECTIVES: To obtain the current perception of the knowledge and competence of pre-hospital emergency specialist nurses (ambulance) in attending patients with psychiatric symptoms. BACKGROUND: Psychiatric illnesses have increased throughout the population. Consequently, pre-hospital emergency services frequently attend individuals with suspected or known mental illnesses. DESIGN: We employed a set of quantitative and qualitative methods to gain a deeper understanding of ambulance nurses' self-evaluated knowledge. METHODS: Seven ambulance nurses received and completed a survey questionnaire prior commencing employment in November 2019. Then, we conducted interviews to explore ambulance nurses' perceptions of their own knowledge and competence when attending individuals with mental disorders. The surveys were analysed with descriptive statistics, followed by content analysis. RESULTS: Three topics emerged: the encounter of patients with mental illness; the awareness of lacking knowledge about mental illnesses; and the expectations for future Prehospital Emergency Psychiatric Response Teams. Although ambulance nurses already possessed basic knowledge regarding psychiatric illnesses, it was insufficient, based on their perception of appropriate care. Ambulance nurses considered that combining pre-hospital and psychiatric expertise in the pre-hospital emergency unit would increase their in-depth knowledge about various psychiatric illnesses, the treatment options and the alternatives regarding where to deliver patients for continued care.

A Prehospital Emergency Psychiatric Unit in an Ambulance Care Service from the Perspective of Prehospital Emergency Nurses: A Qualitative Study.

The prevalence of mental illness is steadily increasing, and ambulance teams frequently attend cases with suspected mental illness. A pilot project, Psychiatric Emergency Response Team (PAP), was carried out in which a prehospital emergency nurse (PEN) was accompanied by a psychiatric specialist nurse in the assessment of individuals with mental illness. The aim of the present study was to evaluate a prehospital emergency psychiatric unit from the perspective of PENs. A qualitative method using content analysis was applied. Seven senior PENs who had worked for 1 year in a prehospital psychiatric ambulance unit were interviewed individually. The analysis resulted in one main theme, "Transition from limited care and insufficient competence to improved and adequate care for psychiatric patients in ambulance care". This emerged from six subcategories: inter-professional development, access to patient records, theambulance vehicle,non-conveyed patients, cooperation with the police and meetings with patients and next of kin. In conclusion, these results suggest that in ambulance care in general, there is a lack of knowledge and skills about mental illnesses and initial care options. The PAP concept opened new avenues for the care of patients with mental illness, which the PENs described very positively as being helpful and valuable.

The Experience of Using Video Support in Ambulance Care: An Interview Study with Physicians in the Role of Regional Medical Support.

Background: In order to facilitate more effective patient assessment and diagnostic support by improving the flow of information between ambulance nurses (AN) and physicians in the role of regional medical support (RMS), an application was developed for transmitting real-time video images. Objective: The objective of this study was to elucidate the physicians' experiences using a video application to support the assessment and triage procedure in ambulance care, when patients are deemed to not have an urgent need for emergency care. Design: The design for this research was a qualitative interview study. Ten physicians, working as RMS in ambulance care, were purposively selected to participate. The telemedicine concept studied consisted of a real-time video image application, in addition to the currently used mobile phone. When a patient was deemed eligible for inclusion in the study, the ambulance nurse (AN) contacted the RMS via telephone to initiate a video consultation. To elucidate the RMS experience of using the application, a conventional content analysis was performed. Results: The main theme "a feeling of being satisfied through a sense of increased patient safety" emerged from the following two categories: adds value in diagnosing situations (three subcategories, i.e., support in diagnosing, usability, and technical weakness) and increase communication opportunities (four subcategories, i.e., assessing the level of care, patient dialogue, professional communication, and team learning). Conclusions: Physicians in the role of RMS experienced a positive impact using video image transmission in addition to the currently used mobile phone. This evaluation was derived from a sense of increased patient safety in the assessment situation when patients were considered to be triaged to self-care.

Novel biomarkers for prediction of outcome in hip fracture patients-An exploratory study.

BACKGROUND: Little is known about the value of biomarkers for prognostication in hip fracture patients. The main objective of the present study was to assess if biomarkers add useful information to an existing risk score for prediction of 30-day mortality in patients suffering from out of hospital hip fractures. METHODS: In a prospective observational single centre study, association between plasma concentration of ninety-two biomarkers at admission and 30-day mortality was analysed using logistic regression adjusted for risk factors included in Nottingham Hip Fracture Score (NHFS). Biomarkers associated with the outcome in the adjusted analysis were further evaluated by calculating the net reclassification improvement (NRI) and the change in area under the receiver operating characteristics curve (AUC) relative to the NHFS. RESULTS: 997 patients were included. Sixty-two patients died within 30 days (6.2%). Eleven biomarkers were associated with 30-day mortality in adjusted analysis. Of these biomarkers Growth Differentiation Factor-15 (GDF-15) had NRI for the primary outcome (12.1%; 95% CI: 1.2-23.3) and Carbohydrate Antigen 125 (CA-125) improved the AUC relative to NHFS (improvement: 0.05; 95% CI: 0.01-0.10, P = .027). Both CA-125 and GDF-15 improved the AUC for a composite outcome of 30-day mortality and cardiovascular complications. CONCLUSIONS: Adding GDF-15 or CA-125 to the Nottingham Hip Fracture Score improves the discrimination with regard to predicting 30-day mortality and may help to identify a subgroup of hip fracture patients with a particularly poor prognosis. The value of these biomarkers should be explored in further studies to confirm clinical utility.

Effect of oxygen therapy on myocardial salvage in ST elevation myocardial infarction: the randomized SOCCER trial.

OBJECTIVE: Recent studies suggest that administration of O2 in patients with acute myocardial infarction may have negative effects. With the use of cardiac MRI (CMR), we evaluated the effects of supplemental O2 in patients with ST elevation myocardial infarction (STEMI) accepted for acute percutaneous coronary intervention (PCI). MATERIALS AND METHODS: This study was a randomized-controlled trial conducted at two university hospitals in Sweden. Normoxic STEMI patients were randomized in the ambulance to either supplemental O2 (10 l/min) or room air until the conclusion of the PCI. CMR was performed 2-6 days after the inclusion. The primary endpoint was the myocardial salvage index assessed by CMR. The secondary endpoints included infarct size and myocardium at risk. RESULTS: At inclusion, the O2 (n=46) and air (n=49) patient groups had similar patient characteristics. There were no significant differences in myocardial salvage index [53.9±25.1 vs. 49.3±24.0%; 95% confidence interval (CI): -5.4 to 14.6], myocardium at risk (31.9±10.0% of the left ventricle in the O2 group vs. 30.0±11.8% in the air group; 95% CI: -2.6 to 6.3), or infarct size (15.6±10.4% of the left ventricle vs. 16.0±11.0%; 95% CI: -4.7 to 4.1). CONCLUSION: In STEMI patients undergoing acute PCI, we found no effect of high-flow oxygen compared with room air on the size of ischemia before PCI, myocardial salvage, or the resulting infarct size. These results support the safety of withholding supplemental oxygen in normoxic STEMI patients.

Effects of oxygen therapy on wall-motion score index in patients with ST elevation myocardial infarction-the randomized SOCCER trial.

BACKGROUND: Although oxygen (O2 ) is routinely used in patients with acute myocardial infarction (AMI), it may have negative effects. In this substudy of the SOCCER trial, we aimed to evaluate the effects of O2 -treatment on myocardial function in patients with ST elevation myocardial infarction (STEMI). METHODS: Normoxic (≥94%) STEMI patients were randomized in the ambulance to either supplemental O2 or room air until the end of the percutaneous coronary intervention (PCI). The patients underwent echocardiography on day 2-3 after the PCI and once again after 6 months. The study endpoints were wall-motion score index (WMSI) and left ventricular ejection fraction (LVEF). RESULTS: Forty-six patients in the O2 group and 41 in the air group were included in the analysis. The index echocardiography showed no significant differences between the groups in WMSI (1.32±0.27 for O2 group vs 1.28±0.28 for air group) or LVEF (47.0±8.5% vs 49.2±8.1%). Nor were there differences at 6 months in WMSI (1.16±0.25 vs 1.14±0.24) or LVEF (53.5±5.8% vs 53.5±6.9%). CONCLUSION: The present findings indicate no harm or benefit of supplemental O2 on myocardial function in STEMI patients. Our results support that it is safe to withhold supplemental O2 in normoxic STEMI patients.

Recognition of out-of-hospital cardiac arrest by medical dispatchers in emergency medical dispatch centres in two countries.

INTRODUCTION: Survival after out-of-hospital cardiac arrest (OHCA) remains low. Early recognition by emergency medical dispatchers is essential for an effective chain of actions, leading to early cardiopulmonary resuscitation, use of an automated external defibrillator and rapid dispatching of the emergency medical services. AIM: To analyse and compare the accuracy of OHCA recognition by medical dispatchers in two countries. METHOD: An observational register-based study collecting data from national cardiac arrest registers in Denmark and Sweden during a six-month period in 2013. Data were analysed in two steps; registry data were merged with electronically registered emergency call data from the emergency medical dispatch centres in the two regions. Cases with missing or non-OHCA dispatch codes were analysed further by auditing emergency call recordings using a uniform data collection template. RESULTS: The sensitivity for recognition of OHCA was 40.9% (95% CI: 37.1-44.7%) in the Capital Region of Denmark and 78.4% (95% CI: 73.2-83.0%) in the Skåne Region in Sweden (p<0.001). With additional data from the emergency call recordings, the sensitivity was 80.7% (95% CI: 77.7-84.3%) and 86.0% (95% CI: 81.3-89.8%) for the two regions (p=0.06). The majority of the non-recognised OHCA were dispatched with the highest priority. CONCLUSION: The accuracy of OHCA recognition was high and comparable. We identified large differences in data registration practices despite the use of similar dispatch tools. This raises a discussion of definitions and transparency in general in scientific reporting of OHCA recognition, which is essential if used as quality indicator in emergency medical services.

The Effects of Oxygen Therapy on Myocardial Salvage in ST Elevation Myocardial Infarction Treated with Acute Percutaneous Coronary Intervention: The Supplemental Oxygen in Catheterized Coronary Emergency Reperfusion (SOCCER) Study.

OBJECTIVES: Despite a lack of scientific evidence, oxygen has long been a part of standard treatment for patients with acute myocardial infarction (AMI). However, several studies suggest that oxygen therapy may have negative cardiovascular effects. We here describe a randomized controlled trial, i.e. Supplemental Oxygen in Catheterized Coronary Emergency Reperfusion (SOCCER), aiming to evaluate the effect of oxygen therapy on myocardial salvage and infarct size in patients with ST elevation myocardial infarction (STEMI) treated with a primary percutaneous coronary intervention (PCI). METHODS: One hundred normoxic STEMI patients accepted for a primary PCI are randomized in the ambulance to either standard oxygen therapy or no supplemental oxygen. All patients undergo cardiovascular magnetic resonance imaging (CMR) 2-6 days after the primary PCI, and a subgroup of 50 patients undergo an extended echocardiography during admission and at 6 months. All patients are followed for 6 months for hospital admission for heart failure and subjective perception of health. The primary endpoint is the myocardial salvage index on CMR. DISCUSSION: Even though oxygen therapy is a part of standard care, oxygen may not be beneficial for patients with AMI and is possibly even harmful. The results of the present and concurrent oxygen trials may change international treatment guidelines for patients with AMI or ischemia.

TGFß-induced matrix production by bronchial fibroblasts in asthma: budesonide and formoterol effects.

To investigate the mechanisms of enhanced airway deposition of subepithelial collagen in asthma and its sensitivity to drug therapy with combination of an inhaled glucocorticosteroid (GC) and a long-acting ß(2)-agonist (LABA), a cell model system involving bronchial fibroblasts derived from biopsies from patients with stable mild-to-moderate asthma has been used. To mimic unstable conditions and severe asthma, fibroblasts were stimulated ex vivo with TGFß1. Primary fibroblasts established from central bronchial biopsies from 8 asthmatic patients were incubated for 24 h with 0.4% serum or TGFß1 (10 ng/ml) with/without the GC budesonide (BUD; 10 nM) and/or the LABA formoterol (FORM; 0.1 nM). Procollagen peptide I (PICP), metalloproteinase (MMP)-1 and tissue inhibitor of MMPs (TIMP-1) were determined in culture media using ELISA while the activity of MMP-2, -3, -9 by zymography. Metabolically labeled proteoglycans, biglycan and decorin, associated with collagen fibrillation/deposition, were separated using chromatography and SDS-PAGE. The levels of PICP and biglycan were increased 2-fold by TGFß1 (p < 0.05). The BUD and FORM combination reduced the PICP increase by 58% (p < 0.01) and the biglycan by 36% (p < 0.05) while each drug alone had no effect. Decorin levels were reduced by TGFß1 in fibroblasts of most patients; BUD alone and BUD and FORM completely counteracted this decrease. MMPs and TIMP-1 were not affected by TGFß1 or the drugs. These results suggest that BUD and FORM combination therapy, without affecting metalloproteolytic balance, has a potential to counteract enhanced collagen production by bronchial fibroblasts in asthma and to normalize the production of small proteoglycans which may affect collagen fibrillation and deposition.

Relationship between matrix production by bronchial fibroblasts and lung function and AHR in asthma.

The reasons for enhanced deposition of extracellular matrix in the airways of asthmatic patients and the subsequent consequences on lung function are uncertain. Here, we investigated the synthesis of procollagen I and proteoglycans, the activity of various metalloproteinases (MMPs) and the production of their inhibitor TIMP-1 in biopsy-derived bronchial fibroblasts from eight patients with stable mild-to-moderate asthma, and how they are related to patients' lung function and airway hyperreactivity (AHR). Following 24-h fibroblast incubation in 0.4% serum, procollagen I carboxyterminal propeptide (PICP), TIMP-1 and MMP-1 in cell media were analysed by ELISA, MMP-2, MMP-3, MMP-9 by zymography and total proteoglycan production by [(35)S]-sulphate-incorporation/ion chromatography. Patients' FEV(1)% predicted and methacholine log PD(20) negatively correlated with PICP synthesized by patients' bronchial fibroblasts (r = -0.74 and r = -0.71, respectively). PICP and proteoglycan amounts positively correlated (0.8 ≤ r ≤ 0.9) with MMP-2 and MMP-3 activity. A positive correlation (r = 0.75) was also found between proteoglycan production and TIMP-1. There was no correlation between MMP-9 activity and PICP or proteoglycan production. MMP-9 activity positively correlated with patients' FEV(1)% predicted (r = 0.97) and methacholine log PD(20) (r = 0.86), whereas negative associations (-0.6 ≤ r ≤ -0.7) were observed for MMP-2 and MMP-3. In stable mild-to-moderate asthma, increased procollagen I synthesis and activity of MMP-2 and MMP-3 in bronchial fibroblasts may negatively affect patients' lung function and AHR. In contrast, MMP-9 activity was not associated with procollagen or proteoglycan production, or worsening of patients' lung function and AHR. An enhanced production of procollagen I and proteoglycans might be a result of a negative feedback from their degradation by MMP-2 and MMP-3.

Budesonide/formoterol effects on metalloproteolytic balance in TGFbeta-activated human lung fibroblasts.

In the airways of asthmatic patients, activated fibroblasts account for an excessive matrix production including proteoglycans (PGs). Transforming growth factor-beta (TGFbeta), metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) play key roles in matrix turnover. It is unclear whether asthma therapy with combination of inhaled glucocorticoids and long-acting beta(2)-agonists affects metalloproteolytic equilibrium and by that counteracts airway fibrosis. The effects of the glucocorticoid, budesonide, and the long-acting beta(2)-agonist, formoterol, on the PG production and the activity of PGs' main regulators: MMP-3, MMP-9, MMP-2 and TIMP-1 were investigated in human lung fibroblasts (HFL-1) treated for 24h with TGFbeta1 (10 ng/ml) without/with budesonide (10(-9) to 10(-6)M) and/or formoterol (10(-11) to 10(-6)M). TGFbeta1 significantly increased production of PGs and TIMP-1, and the activity of MMP-3, MMP-9 and MMP-2. Concurrent budesonide/formoterol combination counteracted the enhanced: PG and TIMP-1 production, MMP-9 activity and MMP-9/TIMP-1 ratio, whereas MMP-2 and MMP-3 were not affected and so their ratios to TIMP-1 were significantly increased. Budesonide or formoterol alone achieved equal effects as budesonide/formoterol on MMP-9 and MMP-9/TIMP-1 ratio but had no effects on TIMP-1, MMP-2 or MMP-3. In the formoterol absence, higher budesonide concentrations were required to reduce the PG production, whereas formoterol alone had no effects. These results suggest that the budesonide/formoterol combination enhanced metalloproteolytic activity of human lung fibroblasts via a synergistic decrease of TIMP-1, and that this mechanism may be involved in the synergistic inhibition of the TGFbeta1-induced PG production. This implies that budesonide/formoterol combination therapy can counteract excessive matrix production and thus pathological airway fibrotic remodeling in asthma.

Lung fibroblast proteoglycan production induced by serum is inhibited by budesonide and formoterol.

Proteoglycans contribute to extracellular matrix remodeling in asthmatic airways. We investigated the effects of budesonide, a glucocorticoid, and formoterol, a long-acting beta2-adrenergic agonist, on serum-induced proteoglycan production by human lung fibroblasts. In 10% serum, total proteoglycan production was increased 1.5-fold (P < 0.01) compared with basal production in 0.4% serum. Budesonide (10(-8) M) reduced this increase by 44% (P < 0.01) and, whereas formoterol (10(-10)-10(-8) M) had no inhibitory effects, the drug combination abolished the increase (P < 0.01) without affecting fibroblast proliferation. This synergistic effect required functional glucocorticoid and beta-adrenergic receptors. The production of the proteoglycans decorin, biglycan, perlecan, and versican was increased 2.5- to 5-fold (P < 0.01) in 10% serum. Combination treatment with budesonide (10(-8) M) and formoterol (10(-10) M) abolished this increase to a significantly greater extent than either drug alone. In 10% serum, only versican mRNA was increased 1.4-fold (P < 0.05), whereas decorin mRNA was reduced to 39% (P < 0.01) of basal expression. These serum effects were counteracted by the drug combination, but there were no significant differences between the combination and either drug alone. Thus, the budesonide and formoterol combination seems to synergistically control serum-induced proteoglycan production, primarily at the post-transcriptional level. In conclusion, the proteoglycan upregulation characteristic of asthmatic airways may be limited by combination therapy with budesonide and formoterol.

Regulation of the chondroitin/dermatan fine structure by transforming growth factor-beta1 through effects on polymer-modifying enzymes.

The chondroitin/dermatan sulfate proteoglycans (CS/DSPGs), biglycan, decorin, and versican play several important roles in extracellular matrix influencing matrix organization, cell proliferation, and recruitment. Moreover, they bind and regulate growth factors in the extracellular matrix. We have previously shown that cultured human lung fibroblasts treated with transforming growth factor-beta (TGF-beta) alone or in combination with epidermal growth factor and platelet-derived growth factor, increase the production of these PGs. In this report, we describe that the structure of their galactosaminoglycan side chains is altered, albeit there is no alteration of polysaccharide length. The findings showed that iduronic acid content is reduced by 50% in decorin and biglycan, whereas 4-O-sulfation is increased 2-fold in versican. To unravel the mechanism behind these changes, the activities of chondroitin C-5 epimerase and of O-sulfotransferases in cellular fractions prepared from fibroblasts were quantitated, and transcript levels of the relevant sulfotransferases were measured by real time polymerase chain reaction (RT-PCR). The C-5 epimerase activity was reduced by 25% in TGF-beta1 treated cells and 50% in fibroblasts treated with the growth factor combination. No change in activity in dermatan 4-O sulfotransferase was observed, and only a minor decrease in dermatan 4-O-sulfotransferase-1 (D4ST-1) mRNA was observed. On the other hand, chondroitin 4-O sulfotransferase activity increased 2-fold upon TGF-beta1 treatment and 3-fold upon treatment with the growth factor combination. This is in agreement with a 2-fold up-regulation of chondroitin-4-O-sulfotransferase 1 (C4ST-1) mRNA, and no changes in chondroitin-4-O-sulfotransferase 2 (C4ST-2) mRNA. Thus, cellular activity and transcript level correlated well with the changes in the structure of the dermatan/chondroitin sulfate chains.