Prone Dispatch-Directed CPR in Out-of-Hospital Cardiac Arrest: Two Successful Cases.

Historically, dispatch-directed cardiopulmonary resuscitation (CPR) protocols only allow chest compression instructions to be delivered for patients able to be placed in the traditional supine position. For patients who are unable to be positioned supine, the telecommunicator and caller have no option except to continue attempts to position supine, which may result in delayed or no chest compressions being delivered prior to emergency medical services arrival. Any delay or lack of bystander chest compressions may result in worsening clinical outcomes of out-of-hospital cardiac arrest (OHCA) victims. We present the first two cases, to the best of our knowledge, of successfully delivered, bystander-administered, prone CPR instructions by a trained telecommunicator for two OHCA victims unable to be positioned supine.

9-1-1 Caller-Described Heart Attack Symptoms.

INTRODUCTION: Heart attacks (HAs) present clinically with varying symptoms, which are not always described by patients as chest pain (CP) or chest discomfort (CD). Emergency Medical Dispatchers (EMDs) select the CP/CD dispatch protocol for non-chest pain HA symptoms or classic HA complaint of CP/CD. Nevertheless, it is still unknown how often callers report HA symptoms other than CP/CD. OBJECTIVES: The objective of this study was to characterize the caller's descriptions of the primary HA symptoms, descriptions of the other HA symptoms, and the use of a case entry (CE) question clarifier. METHODS: A retrospective descriptive study analyzed randomly selected EMD audios (where CD/CD protocol was used) from five accredited emergency communication centers in the United States. Several Quality Performance Review (QPR) experts reviewed the audios and recorded callers' initial problem descriptions, the use of and responses to the CE question clarifier, including the EMD-assigned final determinant code. RESULTS: A total of 1,261 audios were reviewed. The clarifier was used only 8.5% of the time. The CP/CD symptoms were mentioned alone or with other problems 87.0% of the time. Overall, CP symptom was mentioned alone 70.8%, HA alone 4.0%, and CD symptom alone 1.4% of the time. CONCLUSION: 9-1-1 callers report potential HA cases using a variety of terms and descriptions-most commonly CP. Other less-common symptoms associated with a HA may be mentioned. Therefore, EMDs must be well-trained to be prepared to probe the caller with a clarifying query to elicit more specific information when "having a heart attack" is the only complaint initially mentioned.

Small-molecule screen reveals synergy of cell cycle checkpoint kinase inhibitors with DNA-damaging chemotherapies in medulloblastoma.

Medulloblastoma (MB) consists of four core molecular subgroups with distinct clinical features and prognoses. Treatment consists of surgery, followed by radiotherapy and cytotoxic chemotherapy. Despite this intensive approach, outcome remains dismal for patients with certain subtypes of MB, namely, MYC-amplified Group 3 and TP53-mutated SHH. Using high-throughput assays, six human MB cell lines were screened against a library of 3208 unique compounds. We identified 45 effective compounds from the screen and found that cell cycle checkpoint kinase (CHK1/2) inhibition synergistically enhanced the cytotoxic activity of clinically used chemotherapeutics cyclophosphamide, cisplatin, and gemcitabine. To identify the best-in-class inhibitor, multiple CHK1/2 inhibitors were assessed in mice bearing intracranial MB. When combined with DNA-damaging chemotherapeutics, CHK1/2 inhibition reduced tumor burden and increased survival of animals with high-risk MB, across multiple different models. In total, we tested 14 different models, representing distinct MB subgroups, and data were validated in three independent laboratories. Pharmacodynamics studies confirmed central nervous system penetration. In mice, combination treatment significantly increased DNA damage and apoptosis compared to chemotherapy alone, and studies with cultured cells showed that CHK inhibition disrupted chemotherapy-induced cell cycle arrest. Our findings indicated CHK1/2 inhibition, specifically with LY2606368 (prexasertib), has strong chemosensitizing activity in MB that warrants further clinical investigation. Moreover, these data demonstrated that we developed a robust and collaborative preclinical assessment platform that can be used to identify potentially effective new therapies for clinical evaluation for pediatric MB.

Antibacterial Activities of Wasabi against Escherichia coli O157:H7 and Staphylococcus aureus.

Escherichia coli O157:H7 and Staphylococcus aureus are two of the major pathogens frequently involved in foodborne outbreaks. Control of these pathogens in foods is essential to food safety. It is of great interest in the use of natural antimicrobial compounds present in edible plants to control foodborne pathogens as consumers prefer more natural "green" foods. Allyl isothiocyanate (AITC) is an antimicrobial compound naturally present in wasabi (Japanese horseradish) and several other edible plants. Although the antibacterial effects of pure AITC and wasabi extract (essential oil) against several bacteria have been reported, the antibacterial property of natural wasabi has not been well studied. This study investigated the antibacterial activities of wasabi as well as AITC against E. coli O157:H7 and S. aureus. Chemical analysis showed that AITC is the major isothiocyanate in wasabi. The AITC concentration in the wasabi powder used in this study was 5.91 ± 0.59 mg/g. The minimum inhibitory concentration (MIC) of wasabi against E. coli O157:H7 or S. aureus was 1% (or 10 mg/ml). Wasabi at 4% displayed higher bactericidal activity against S. aureus than against E. coli O157:H7. The MIC of AITC against either pathogen was between 10 and 100 µg/ml. AITC at 500 µg/ml was bactericidal against both pathogens while AITC at 1000 µg/ml eliminated E. coli O157:H7 much faster than S. aureus. The results from this study showed that wasabi has strong antibacterial property and has high potential to effectively control E. coli O157:H7 and S. aureus in foods. The antibacterial property along with its natural green color, unique flavor, and advantage to safeguard foods at the point of ingestion makes wasabi a promising natural edible antibacterial plant. The results from this study may be of significant interest to the food industry as they develop new and safe foods. These results may also stimulate more research to evaluate the antibacterial effect of wasabi against other foodborne pathogens and to explore other edible plants for their antimicrobial properties. To our knowledge, this is the first report on the antibacterial activity of wasabi in its natural form of consumption against E. coli O157:H7 and S. aureus.

Outcome accuracy of the Emergency Medical Dispatcher's initial selection of a diabetic problems protocol.

INTRODUCTION: Diabetes mellitus, although a chronic disease, also can cause acute, sudden symptoms requiring emergency intervention. In these cases, Emergency Medical Dispatchers (EMDs) must identify true diabetic complaints in order to determine the correct care. In 911 systems utilizing the Medical Priority Dispatch System (MPDS), International Academies of Emergency Dispatch-certified EMDs determine a patient's chief complaint by matching the caller's response to an initial pre-scripted question to one of 37 possible chief complaints protocols. The ability of EMDs to identify true diabetic-triggered events reported through 911 has not been studied. OBJECTIVE: The primary objective of this study was to determine the percentage of EMD-recorded patient cases (using the Diabetic Problems protocol in the MPDS) that were confirmed by either attending paramedics or the hospital as experiencing a diabetic-triggered event. METHODS: This was a retrospective study involving six hospitals, one fire department, and one ambulance service in Salt Lake City, Utah USA. Dispatch data for one year recorded under the Diabetic Problems protocol, along with the associated paramedic and hospital outcome data, were reviewed/analyzed. The outcome measures were: the percentage of cases that had diabetic history, percentage of EMD-identified diabetic problems cases that were confirmed by Emergency Medical Services (EMS) and/or hospital records as true diabetic-triggered events, and percentage of EMD-identified diabetic patients who also had other medical conditions. A diabetic-triggered event was defined as one in which the patient's emergency was directly caused by diabetes or its medical management. Descriptive statistics were used for categorical measures and parametric statistical methods assessed the differences between study groups, for continuous measures. RESULTS: Three-hundred ninety-three patient cases were assigned to the Diabetic Problems Chief Complaint protocol. Of the 367 (93.4%) patients who had a documented history of diabetes, 279 (76%) were determined to have had a diabetic-triggered event. However, only 12 (3.6%) initially assigned to this protocol did not have a confirmed history of diabetes. CONCLUSIONS: Using the MPDS to select the Diabetic Problems Chief Complaint protocol, the EMDs correctly identified a true diabetic-triggered event the majority of the time. However, many patients had other medical conditions, which complicated the initial classification of true diabetic-triggered events. Future studies should examine the associations between the five specific Diabetic Problems Chief Complaint protocol determinant codes (triage priority levels) and severity measures, eg, blood sugar level and Glasgow Coma Score.

Aspirin administration by emergency medical dispatchers using a protocol-driven aspirin diagnostic and instruction tool.

BACKGROUND: The American College of Cardiology and the American Heart Association recommend early aspirin administration to patients with symptoms of acute coronary syndrome (ACS)/acute myocardial infarction (AMI). The primary objective of this study was to determine if Emergency Medical Dispatchers (EMD) can provide chest pain/heart attack patients with standardised instructions effectively, using an aspirin diagnostic and instruction tool (ADxT) within the Medical Priority Dispatch System (MPDS) before arrival of an emergency response crew. METHODS: This retrospective study involved three dispatch centres in the UK and USA. We analysed 6 months of data involving chest pain/heart attack symptoms taken using the MPDS chest pain and heart problems/automated internal cardiac defibrillator protocols. RESULTS: The EMDs successfully completed the ADxT on 69.8% of the 44141 cases analysed. The patient's mean age was higher when the ADxT was completed, than when it was not (mean ± SD: 53.9 ± 19.9 and 49.9 ± 20.2; p<0.001, respectively). The ADxT completion rate was higher for second-party than first-party calls (70.3% and 69.0%; p=0.024, respectively). A higher percentage of male than female patients took aspirin (91.3% and 88.9%; p=0.001, respectively). Patients who took aspirin were significantly younger than those who did not (mean ± SD: 61.8 ± 17.5 and 64.7 ± 17.9, respectively). Unavailability of aspirin was the major reason (44.4%) why eligible patients did not take aspirin when advised. CONCLUSIONS: EMDs, using a standardised protocol, can enable early aspirin therapy to treat potential ACS/AMI prior to responders' arrival. Further research is required to assess reasons for not using the protocol, and the significance of the various associations discovered.

The accuracy of emergency medical dispatcher-assisted layperson-caller pulse check using the medical priority dispatch system protocol.

INTRODUCTION: Knowing the pulse rate of a patient in a medical emergency can help to determine patient acuity and the level of medical care required. Little evidence exists regarding the ability of a 911 layperson-caller to accurately determine a conscious patient's pulse rate. Hypothesis The hypothesis of this study was that, when instructed by a trained emergency medical dispatcher (EMD) using the scripted Medical Priority Dispatch System (MPDS) protocol Pulse Check Diagnostic Tool (PCDxT), a layperson-caller can detect a carotid pulse and accurately determine the pulse rate in a conscious person. METHODS: This non-randomized and non-controlled prospective study was conducted at three different public locations in the state of Utah (USA). A healthy, mock patient's pulse rate was obtained using an electrocardiogram (ECG) monitor. Layperson-callers, in turn, initiated a simulated 911 phone call to an EMD call-taker who provided instructions for determining the pulse rate of the patient. Layperson accuracy was assessed using correlations between the layperson-caller's finding and the ECG reading. RESULTS: Two hundred sixty-eight layperson-callers participated; 248 (92.5%) found the pulse of the mock patient. There was a high correlation between pulse rates obtained using the ECG monitor and those found by the layperson-callers, overall (94.6%, P < .001), and by site, gender, and age. CONCLUSIONS: Layperson-callers, when provided with expert, scripted instructions by a trained 911 dispatcher over the phone, can accurately determine the pulse rate of a conscious and healthy person. Improvements to the 911 instructions may further increase layperson accuracy.

Medical Priority Dispatch System breathing problems protocol key question combinations are associated with patient acuity.

INTRODUCTION: The Breathing Problems Chief Complaint (CC) protocol in the Medical Priority Dispatch System (MPDS) was the system's most frequently used protocol. While "severe breathing problems" is a significant predictor of cardiac arrest (CA), previous data have demonstrated that the DELTA-level determinant codes in this CC contain patients across a wide spectrum of acuity. HYPOTHESIS: The hypothesis in this study was that certain combinations of caller answers to the breathing problems protocol key questions (KQs) are correlated with different but specific patient acuities. METHODS: This was a retrospective study conducted at one International Academies of Emergency Dispatch (IAED) Accredited Center of Excellence. Key Question combinations were generated and analyzed from 11 months of dispatch data, and extracted from MPDS software and the computer assisted dispatch system. Descriptive statistics were used to evaluate measures between study groups. RESULTS: Forty-two thousand cases were recorded; 52% of patients were female and the median age was 61 years. Overall, based on the original MPDS Protocol (before generating KQ combinations), patients with abnormal breathing and clammy conditions were the youngest. The MPDS DELTA-level constituted the highest percentage of cases (74.0%) and the difficulty speaking between breaths (DSBB) condition was the most prevalent (50.3%). Ineffective breathing and not alert conditions had the highest cardiac arrest quotient (CAQ). Based on the KQ combinations, the CA patients who also had the not alert condition were significantly older than other patients. The percentage of CA outcomes in asthmatic patients was significantly higher in DSBB plus not alert; DSBB plus not alert plus changing color; and DSBB plus not alert plus clammy conditions cases, compared to asthmatic abnormal breathing cases. CONCLUSIONS: The study findings demonstrated that MPDS KQ answer combinations relate to patient acuity. Cardiac arrest patients are significantly less likely to be asthmatic than those without CA, and vice versa. Using a prioritization scheme that accounts for the presence of either single or multiple signs and/or symptom combinations for the Breathing Problems CC protocol would be a more accurate method of assigning DELTA-level cases in the MPDS.

Association between patient unconscious or not alert conditions and cardiac arrest or high-acuity outcomes within the Medical Priority Dispatch System "Falls" protocol.

INTRODUCTION: Falls are one of the most common types of complaints received by 9-1-1 emergency medical dispatch centers. They can be accidental or may be caused by underlying medical problems. Though "not alert" falls patients with severe outcomes mostly are "hot" transported to the hospital, some of these cases may be due to other acute medical events (cardiac, respiratory, circulatory, or neurological), which may not always be apparent to the emergency medical dispatcher (EMD) during call processing. OBJECTIVES: The objective of this study was to characterize the risk of cardiac arrest and "hot-transport" outcomes in patients with "not alert" condition, within the Medical Priority Dispatch System (MPDS®) Falls protocol descriptors. METHODS: This retrospective study used 129 months of de-identified, aggregate, dispatch datasets from three US emergency communication centers. The communication centers used the Medical Priority Dispatch System version 11.3-OMEGA type (released in 2006) to interrogate Emergency Medical System callers, select dispatch codes assigned to various response configurations, and provide pre-arrival instructions. The distribution of cases and percentages of cardiac arrest and hot-transport outcomes, categorized by MPDS® code, was profiled. Assessment of the association between MPDS® Delta-level 3 (D-3) "not alert" condition and cardiac arrest and hot-transport outcomes then followed. RESULTS: Overall, patients within the D-3 and D-2 "long fall" conditions had the highest proportions (compared to the other determinants in the "falls" protocol) of cardiac arrest and hot-transport outcomes, respectively. "Not alert" condition was associated significantly with cardiac arrest and hot-transport outcomes (p<0.001). CONCLUSIONS: The "not alert" determinant within the MPDS® "fall" protocol was associated significantly with severe outcomes for short falls (<6 feet; 2 meters) and ground-level falls. As reported to 9-1-1, the complaint of a "fall" may include the presence of underlying conditions that go beyond the obvious traumatic injuries caused by the fall itself.

Effect of a Medical Priority Dispatch System key question addition in the seizure/convulsion/fitting protocol to improve recognition of ineffective (agonal) breathing.

OBJECTIVE: To investigate the impact of a new assessment question in the Medical Priority Dispatch System (MPDS) seizure protocol on the ability of the Emergency Medical Dispatchers (EMDs) to identify the presence of agonal or ineffective breathing. METHODS: A retrospective comparative study was conducted using two datasets-each representing two versions of the MPDS protocols (version 10.4 and version 11.2) at the London Ambulance Service (LAS). The "before" dataset (April 2004 to March 2005, version 10.4) did not have a specific assessment Key Question to identify the presence of irregular/agonal breathing. The question was added in the "after" dataset (April 2005 to March 2006, version 11.2). The datasets comprised the number of patients, calls, responses, incidents, and outcome (i.e., cardiac arrest [CA] and blue-in [BI]) parameters categorized using MPDS determinant codes. A distribution of these parameters was stratified by protocol version. Two-by-two contingency tables to determine association between ("before" and "after") protocols and CA outcome were generated. The likelihood of classifying CA outcome under the "Not fitting now and breathing regularly (verified)"-protocol 12 ALPHA-level 1 (12-A-1) and combined DELTA descriptor codes, was established. Odds ratios (OR) and p-values at significance level of 0.05 cut-off were used to determine any significant associations. RESULTS: For both datasets, the percentage of the emergency parameters increased with increasing determinant level from ALPHA to DELTA. The percentage of CA outcome in the 12-A-1 descriptor code in protocol version 11.2 was lower than that in version 10.4 (0.18% vs. 0.24%). Within protocol version 11.2, CA outcome was twice more likely in the combined DELTA descriptor codes when compared to other protocol 12 descriptor codes (OR(95%CI): 2.10(1.30, 1.40), p=0.002). CONCLUSIONS: The addition of the new assessment question for "breathing regularly" to the dispatch question sequence in the MPDS seizure protocol provides a valuable tool for identifying true cardiac arrest patients. Most of these cases appeared to be specifically captured by the new code 12 DELTA-level 3 (12-D-3): "Irregular Breathing".

Ability of the medical priority dispatch system protocol to predict the acuity of "unknown problem" dispatch response levels.

OBJECTIVE: To determine if Medical Priority Dispatch System's (MPDS's) Protocol 32-Unknown Problem interrogation-based differential dispatch coding distinguishes the acuity of patients as found at the scene by responders, when little (if any) clinical information is known. METHODS: "Unknown problem" situations (i.e., all cases not fitting into any other chief complaint group) constitute 5-8% of all calls to dispatch centers. From the total patient encounters (n=599,107) in the aggregate data of one year (September 2005 to August 2006), we examined 3,947 (0.7%) encounters initially coded as "unknown problem" by the London Ambulance Service Communications Center for the scene presence of cardiac arrest (CA) and paramedic-determined high-acuity (blue-in [BI]/"lights and siren") findings. Odds ratios (ORs) with 95% confidence intervals (95% CIs) and p-values were used to assess the degree of associations between determinant codes and case outcomes (i.e., CA/BI). RESULTS: Statistically significant association between clinical dispatch determinant codes and case outcomes was observed in the "life status questionable" (LSQ; DELTA-1 [D-1]) and the "standing, sitting, moving, or talking" (BRAVO-1 [B-1]) code pair for the CA outcome (OR [95% CI]: 0.11 [0, 0.63], p=0.005) and for the BI outcome (OR [95% CI]: 0.47 [0.28, 0.77], p=0.003). The LSQ and all three code pairs (i.e., B-1; "community alarm notifications" [B-2]; and "unknown status" [B-3]) also demonstrated significant associations both with the CA outcome (OR [95% CI]: 0.43 [0.23, 0.81], p=0.010) and with the BI outcome (OR [95% CI]: 0.74 [0.56, 0.97], p=0.033). All the determinant code levels yielded significant association between BI and CA cases. CONCLUSION: This dispatch protocol for unknown problems successfully differentiates dispatch coding of low-acuity and non-CA patients only when specific situational information such as the patient's standing, sitting, moving, or talking can be determined during the interrogation process. Also, emergency medical dispatcher (EMD) reliance on caller-volunteered information to identify predefined critical situations does not appear to add to the protocol's ability to differentiate high-acuity and CA patients. LSQ proved to be a better predictor of both CA and BI outcomes, when compared with the BRAVO-level determinant codes within the "unknown problem" chief complaint. The B-3 (completely unknown) determinant code is a better predictor of severe outcomes than nearly all of the clinically similar BRAVO determinant codes in the entire MPDS protocol. Hence, the B-3 coding should be considered-in terms of its predictability for severe outcome-as falling somewhere between a typical DELTA and a typical BRAVO determinant code.

The Medical Priority Dispatch System's ability to predict cardiac arrest outcomes and high acuity pre-hospital alerts in chest pain patients presenting to 9-9-9.

OBJECTIVE: To establish emergency medical dispatcher (EMD) predictability of cardiac arrest (CA) and high acuity (blue in - BI) outcomes in chest pain patients by using the Medical Priority Dispatch System's (MPDS) priority levels, and its more specific clinical determinant codes. METHODS: A retrospective descriptive study was done on a one year's worth of aggregate 999 call data comprising number of patients, calls, incidences, and outcomes (as determined by paramedics) obtained from the London Ambulance Service (LAS). We used Fisher's exact test to establish and quantify associations (through odds ratios, 95% CI and p-values) between MPDS priority levels and patient outcomes, stratifying by various pairing of MPDS priority level determinant codes. RESULTS: 11.4% of the total calls were classified under the chest pain protocol (MPDS protocol 10). Of all the CA cases (n=3377), 3.1% (n=106) were classified under the chest pain protocol. MPDS priority levels were significantly associated with CA patient outcome (p=0.030) and BI patient outcome (p<0.001). Only the advanced life support response-levels CHARLIE/DELTA pairing was significantly associated with CA outcome (p=0.010) with CA outcome nearly twice more likely in the combined DELTA-priority level codes. ALPHA/CHARLIE and ALPHA/DELTA-level pairings were significantly associated with BI outcome (p<0.001 each), with increased odds of BI outcome in the CHARLIE and DELTA-priority levels. Clinically, the DELTA-level 4 code demonstrated reduced odds of CA and BI outcome when paired with CHARLIE-level patients, than the other DELTA-level patients. CONCLUSIONS: Significant associations existed between patient outcomes, as measured in this study, and the MPDS (UKE version) Protocol 10 (Chest Pain) priority levels and specific determinant codes. The (UKE version) DELTA-level 4 determinant code does not belong in the DELTA-priority level, and should be moved to the CHARLE-level, or eliminated altogether--to bring this protocol version in line with other international versions of the MPDS.

Profile of emergency medical dispatch calls for breathing problems within the medical priority dispatch system protocol.

INTRODUCTION: A common chief complaint to emergency dispatch communication centers worldwide is "breathing problems". The chief complaint of breathing problems represents a wide spectrum of underlying diseases, patient conditions, and onset types. The current debate is on the potential ability of a dispatch protocol to safely and with high specificity, differentiate patients with minor or non-critical conditions from those conditions that pose risk to the patient and require advanced life support evaluation and care. This issue also has extended into the paramedic prehospital evaluation realm. OBJECTIVE: The objective of this study was to describe the distribution of Medical Priority Dispatch System (MPDS) codes representing the spectrum of clinical descriptions within the breathing problems chief complaint and their associated outcomes, at the scene and during transport, as determined by [UK] paramedics. METHODS: A retrospective, one-year study (September 2005 to August 2006) of a de-identified aggregate dataset from the London Ambulance Service (LAS) Trust was evaluated. A profile of the distribution of calls, incidents, patients, and outcomes (cardiac arrest [CA] and blue-in [BI] high acuity i.e., patients transported with lights and siren based on paramedic protocol) for the breathing problems chief complaint was evaluated. Odds ratios and 95% confidence intervals (CI) were used to quantify associations between the MPDS priority level's concurrent asthmatic conditions and outcomes. Two-sided Fisher's exact p-values were obtained to determine statistically significant associations, at a level of0.05. RESULTS: Sixteen percent (95,848/599,093) of all the patients were classified under the breathing problems chief complaint. Of these 95,848 patients, 367 (0.38%) were CA outcomes, and 7.82% (n = 7,493) were BI outcomes.The Cardiac Arrest Quotient (i.e., the number of CA cases as a percentage of the number of patients) for the ECHO priority level was 46 times higher than was that of non-ECHO priority levels: DELTA and CHARLIE (17.05% vs. 0.37%). Asthmatics were associated with CA outcome (OR(95%CI): 0.60(0.47,0.77), p <0.001), but not with BI outcome. CONCLUSIONS: The MPDS coding yielded a richer mix of severe outcomes in the higher priority levels.The Severe Respiratory Distress coding had the greatest number of patients and severe outcomes. Future studies that help refine the Severe Respiratory Distress code in the MPDS by more specific subgroups of patients would be beneficial.

Cardiac arrest predictability in seizure patients based on emergency medical dispatcher identification of previous seizure or epilepsy history.

OBJECTIVE: To determine predictability of at-scene cardiac arrest from a dispatch determined patient history of seizure or epilepsy ("E" history). DESIGN AND METHODS: A retrospective study of a 1 year dataset from the London Ambulance Service (LAS) National Health Service (NHS) Trust was undertaken. Each of the nine determinant codes on the Medical Priority Dispatch System (MPDS) seizure protocol [Heward A, Damiani M, Hartley-Sharpe C. Does the use of the Advanced Medical Priority Dispatch System affect cardiac arrest detection? Emerg Med J 2004;21:115-8.] was examined for the addition of the "E" suffix finding. The cardiac arrest predictability of cases with reported "E" history was compared to those without using a protocol process to detect the infrequent but predictable presence of seizures caused by anoxic cardiac arrest. RESULTS: Only protocol codes 12-A-1, 12-D-2, 12-D-3, and 12-D-4 demonstrated significant associations between outcomes and determinant codes (p=0.016, 0.007, <0.001, and 0.048, respectively). These codes showed reduced risk of predicting CA with the "E" suffix protocol determinant codes (RD (95% CI): -0.0025 (-0.0044, -0.0005), chi-square p=0.009; RD (95% CI): -0.0024 (-0.0042, -0.0005), p=0.005; RD (95% CI): -0.020 (-0.029, -0.011), p<0.001; RD (95% CI): -0.01 (-0.017, -0.005), and p=0.034, respectively). CONCLUSIONS: Knowing whether a seizure patient is an epileptic or has had previous seizures is of clinical value and relevant to dispatch. By improving the discernment of the seizure protocol regarding seizure associated with anoxic cardiac arrest predictability, this information may now be applied at the response level as well as to emergency medical dispatcher's (EMD) decisions to stay on the telephone to enhance the monitoring of these patients.

Accuracy of emergency medical dispatchers' subjective ability to identify when higher dispatch levels are warranted over a Medical Priority Dispatch System automated protocol's recommended coding based on paramedic outcome data.

OBJECTIVES: To establish the accuracy of the emergency medical dispatcher's (EMD's) decisions to override the automated Medical Priority Dispatch System (MPDS) logic-based response code recommendations based on at-scene paramedic-applied transport acuity determinations (blue-in) and cardiac arrest (CA) findings. METHODS: A retrospective study of a 1 year dataset from the London Ambulance Service (LAS) National Health Service (NHS) Trust was undertaken. We compared all LAS "bluing in" frequency (BIQ) and cardiac arrest quotient (CAQ) outcomes of the incidents automatically recommended and accepted as CHARLIE-level codes, to those receiving EMD DELTA-overrides from the auto-recommended CHARLIE-level. We also compared the recommended DELTA-level outcomes to those in the higher ECHO-override cases. RESULTS: There was no significant association between outcome (CA/Blue-in) and the determinant codes (DELTA-override and CHARLIE-level) for both CA (odds ratio (OR) 0, 95% confidence interval (CI) 0 to 41.14; p = 1.000) and Blue-in categories (OR 0.89, 95% CI 0.34 to 2.33; p = 1.000). Similar patterns were observed between outcome and all DELTA-level and ECHO-override codes for both CA (OR 0, 95% CI 0 to 70.05; p = 1.000) and Blue-in categories (OR 1.17, 95% CI 0 to 7.12; p = 0.597). CONCLUSION: This study contradicts the belief that EMDs can accurately perceive when a patient or situation requires more resources than the MPDS's structured interrogation process logically indicates. This further strengthens the concept that automated, protocol-based call taking is more accurate and consistent than the subjective, anecdotal or experience-based determinations made by individual EMDs.

Dynamic closed-loop system for focus tracking using a spatial light modulator and a deformable membrane mirror.

A dynamic closed-loop method for focus tracking using a spatial light modulator and a deformable membrane mirror within a confocal microscope is described. We report that it is possible to track defocus over a distance of up to 80 microm with an RMS precision of 57 nm. For demonstration purposes we concentrate on defocus, although in principle the method applies to any wavefront shape or aberration that can be successfully reproduced by the deformable membrane mirror and spatial light modulator, for example, spherical aberration.

Exploration of the optimisation algorithms used in the implementation of adaptive optics in confocal and multiphoton microscopy.

We report on the introduction of active optical elements into confocal and multiphoton microscopes in order to reduce the sample-induced aberration. Using a flexible membrane mirror as the active element, the beam entering the rear of the microscope objective is altered to produce the smallest point spread function once it is brought to a focus inside the sample. The conventional approach to adaptive optics, commonly used in astronomy, is to utilise a wavefront sensor to determine the required mirror shape. We have developed a technique that uses optimisation algorithms to improve the returned signal without the use of a wavefront sensor. We have investigated a number of possible optimisation methods, covering hill climbing, genetic algorithms, and more random search methods. The system has demonstrated a significant enhancement in the axial resolution of a confocal microscope when imaging at depth within a sample. We discuss the trade-offs of the various approaches adopted, comparing speed with resolution enhancement.

Modified cardiopulmonary resuscitation (CPR) instruction protocols for emergency medical dispatchers: rationale and recommendations.

BACKGROUND: International consensus guidelines now support the use of "chest compressions-only" cardiopulmonary resuscitation (CPR) instructions (CCOIs) by emergency medical dispatch (EMD) personnel providing telephone assistance to untrained bystanders at a cardiac arrest scene. These guidelines are based largely on evolving experimental data and a clinical trial conducted in one venue with distinct emergency medical services (EMS) system features. Accordingly, the Council of Standards for the National Academies of Emergency Dispatch was asked to adapt a modified telephone CPR protocol, and specifically one that could be applied more broadly to the spectrum of EMS systems. METHODS: A group of international EMD specialists, researchers and professional association representatives analyzed available scientific data and considered variations in EMS systems, particularly those in Europe and North America. RESULTS AND CONCLUSIONS: Several recommendations were established: (1) to avoid confusion, bystanders already providing CPR should continue those previously learned methods; (2) following a sudden collapse unlikely to be of respiratory etiology, CCOIs should be provided when the bystander is not CPR-trained, declining to perform mouth-to-mouth ventilation or unsure of actions to take; (3) following 4 min of CCOIs, ventilations can be provided, but, for now, only at a compression-ventilation ratio of 100:2 until EMS arrives; (4) until more data become available, dispatchers should follow existing compression-ventilation protocols for children and adult cases involving probable respiratory/trauma etiologies; (5) EMD CPR protocols should account for EMS system features and receive quality oversight and expert medical direction.