Favourable cost-benefit in an early defibrillation program using dual dispatch of ambulance and fire services in out-of-hospital cardiac arrest

Aims: Out-of-hospital cardiac arrest (OHCA) is fatal without treatment and time to defibrillation is an extremely important factor in relation to survival. We performed a cost-benefit analysis of dual dispatch defibrillation by ambulance and fire services in the County of Stockholm, Sweden. Methods and Results: A cost-benefit analysis was performed to evaluate the effects of dual dispatch defibrillation. The increased survival rates were estimated from a real world implemented intervention and the monetary value of a life (€ 2.2 million) was applied to this benefit by using results from a recent stated-preference study. The estimated costs include defibrillators (including expendables/maintenance), training, hospitalisation/health care, call-outs for the fire services, overhead resources and costs for the dispatch centre. The estimated number of additional saved lives was 16 per year, yielding a benefit-cost ratio of 36. The cost per quality-adjusted life years (QALY) was estimated to be € 13 000 and the cost per saved life was € 60 000. Conclusions: The intervention of dual dispatch defibrillation by ambulance and fire services in the County of Stockholm had positive economic effects. For the cost-benefit analysis the return on investment was high and the cost-effectiveness showed levels below the threshold value for economic efficiency used in Sweden. The cost-utility analysis categorises the cost per QALY as medium.Cost-benefit analysis; cost-utility analysis; cost-effectiveness analysis; cardiac arrest; defibrillation; ambulance; fire services

Behörighetsprövning vid dubbelrelevanta rättsfaktum - En granskning av domstols och skiljenämnds behörighetsprövning vid förekomsten av dubbelrelevanta rättsfaktum

Genom att införa en skiljeklausul som kontraktsvillkor kan avtalsparter undandra framtida tvister från allmän domstols behörighet och skapa behörighet för en skiljenämnd. Problem kan dock uppstå när en domstol eller skiljenämnd tvingas pröva och avgöra skiljeklausulens (nedan skiljeavtalets) verkningar och omfattning. För att avgöra om ett skiljeavtal omfattar en viss tvist kan en domstol eller skiljenämnd tvingas undersöka innebörden av kontraktet varom parterna tvistar. Denna situation uppstår när vissa sakomständigheter har avgörande betydelse för såväl behörighetsfrågan som för sakfrågan. Dessa omständigheter kallas dubbelrelevanta rättsfaktum. För att undvika att dubbelrelevanta rättsfaktum prövas vid behörighetsprövningen har HD infört påståendedoktrinen. Den rättsliga innebörden av påståendedoktrinen har diskuterats inom rättsvetenskapen och HD har i ett fåtal avgöranden prövat principen. Syftet med denna uppsats är att undersöka och diskutera HD:s doktrin från två perspektiv. Det första perspektivet utgår från rätten till rättvis rättegång och domstolsprövning av civila rättigheter och skyldigheter som stadgas i art. 6.1 i Europakonventionen om skydd för de mänskliga rättigheterna. Det andra perspektivet är processrättsligt och syftar till att granska de argument som framförts till stöd för doktrinen. Slutligen diskuteras alternativ till påståendedoktrinen för att hantera förekomsten av dubbelrelevanta rättsfaktum. Rättsliga lösningar i England, Norge och Danmark presenteras kortfattat för att visa på möjligheten att uppställa ett lågt ställt beviskrav för dessa omständigheter vid bedömningen av skiljeavtalets rättsverkningar. De huvudsakliga slutsatserna är att påståendedoktrinens innebörd varierar beroende på om det rör sig om ett konventionellt eller legalt skiljeförfarande. Innebörden av doktrinen är i huvudsak att en domstol, eller en skiljenämnd, ska utgå från parts påstående vid behörighetsprövningen utan att pröva riktigheten av påståendet. Inom rättsvetenskapen är de flesta författarna eniga om att ett påstående är tillräckligt för att tillerkänna en skiljenämnd behörighet. Det kan dock ifrågasättas om påståendedoktrinen uppfyller de krav som följer av art. 6.1 i Europakonventionen om skydd för de mänskliga rättigheterna rörande rätten till domstolsprövning. Vidare kan de argument som anförts till stöd för påståendedoktrinen ifrågasättas utifrån ett processrättsligt perspektiv. Slutligen fastslås att det är möjligt att införa ett beviskrav för dubbelrelevanta rättsfaktum vid behörighetsprövningen.By including an arbitration clause into a contract, two parties may exclude court jurisdiction as well as provide jurisdiction for an arbitration committee to resolve future disputes regarding the main contract. Problems may arise when an arbitration committee, or a court, have to decide the meaning and the scope of the arbitration clause (arbitration agreement below). Establishing jurisdiction by examining the applicability of an arbitration agreement may require a court or an arbitration committee to investigate the disputed contract itself. This situation arises when facts of a case are of relevance both for the jurisdictional question, as well as for the case itself. These facts are called doubly pertinent facts. In order to avoid an investigation of doubly pertinent facts on a jurisdictional level, the Swedish Supreme Court has introduced the doctrine of assertion. The legal status and meaning of the doctrine has been discussed in the jurisprudence and the Supreme Court has tried to establish the doctrine in a few landmark cases. The purpose of this thesis is to scrutinize and discuss the doctrine stipulated by the Supreme Court from two different angles. The first angle includes discussion based on the right to access courts in determining private law rights and obligations set forth in Art. 6.1 of the European Convention on Human Rights. The second angle includes a Swedish procedure law perspective and focuses on reviewing the arguments raised in support of the doctrine of assertion. Finally, this thesis discusses alternatives to the doctrine of assertion when dealing with doubly pertinent facts on a jurisdictional level. Legal solutions in the U.K., Norway and Denmark are briefly presented to establish the possibility of requiring a low standard of probability to be met in order for an arbitration committee to assume jurisdiction over a case. The main conclusions drawn are that the meaning of the doctrine of assertion differs depending on whether or not the dispute relates to a contractual arbitration clause or to a law that provides for dispute resolution by arbitration. In essence, the doctrine provides that a court, or an arbitration committee, should accept the assertions made by either party without demanding proof or evidence in support of it. A vast majority of authors argue that an assertion is sufficient to provide jurisdiction for an arbitration committee. However, arguments can be made that the doctrine of assertion is not in conformity with the right to access courts laid down in Art. 6.1 of the European Convention on Human Rights. Furthermore, the arguments made in support of the doctrine of assertion can be challenged and put into question by studying Swedish procedure law principles. Lastly, it is concluded that it is possible to apply a standard of proof for the asserted doubly pertinent facts on a jurisdictional level

A Study of the Magnetic Properties of Yb4LiGe4: Unusual Magnetism

Thesis advisor: Michael GrafThe R5T4 compounds (R = rare earth, T = Ge or Si) are interesting because the magnetic properties are very sensitively dependent on slight changes in the crystalline structure. Yb5Ge4 is one such compound, with (presumed) antiferromagnetic order occurring at TN = 1.7 K. We are interested in the effects of substituting Li in place of one Yb atom. Previous measurements of the magnetic properties of polycrystalline Yb4LiGe4 using NMR, specific heat, and resistance measurements at temperatures down to 0.5 K and in magnetic fields up to 4 Tesla were made to compare results with the parent compound. The resistance measurements showed a maximum at 1.1 K, which may indicate the onset of magnetic order. Thus we performed μSR measurements on Yb4LiGe4 and Yb5Ge4, and analysis of the data confirmed magnetic ordering (possibly antiferromagnetic) at 1.1 K. The μSR measurements also revealed a dependence on the magnetic history of the sample. Currently we are studying the pressure dependence of the (presumed) Néel Temperature in order to explore whether increased pressure can drive the TN to 0 K, and results will be discussed.Thesis (BS) — Boston College, 2010.Submitted to: Boston College. College of Arts and Sciences.Discipline: Physics Honors Program.Discipline: Physics

Out of hospital cardiac arrest outside home in Sweden, change in characteristics, outcome and availability for public access defibrillation

<p>Abstract</p> <p>Background</p> <p>A large proportion of patients who suffer from out of hospital cardiac arrest (OHCA) outside home are theoretically candidates for public access defibrillation (PAD). We describe the change in characteristics and outcome among these candidates in a 14 years perspective in Sweden.</p> <p>Methods</p> <p>All patients who suffered an OHCA in whom cardiopulmonary resuscitation (CPR) was attempted between 1992 and 2005 and who were included in the Swedish Cardiac Arrest Register (SCAR). We included patients in the survey if OHCA took place outside home excluding crew witnessed cases and those taken place in a nursing home.</p> <p>Results</p> <p>26% of all OHCAs (10133 patients out of 38710 patients) fulfilled the inclusion criteria. Within this group, the number of patients each year varied between 530 and 896 and the median age decreased from 68 years in 1992 to 64 years in 2005 (p for trend = 0.003). The proportion of patients who received bystander CPR increased from 47% in 1992 to 58% in 2005 (p for trend < 0.0001). The proportion of patients found in ventricular fibrillation (VF) declined from 56% to 50% among witnessed cases (p for trend < 0.0001) and a significant (p < 0.0001) decline was also seen among non witnessed cases.</p> <p>The median time from cardiac arrest to defibrillation among witnessed cases was 12 min in 1992 and 10 min in 2005 (p for trend = 0.029). Survival to one month among all patients increased from 8.1% to 14.0% (p for trend = 0.01). Among patients found in a shockable rhythm survival increased from 15.3% in 1992 to 27.0% in 2005 (p for trend < 0.0001).</p> <p>Conclusion</p> <p>In Sweden, there was a change in characteristics and outcome among patients who suffer OHCA outside home. Among these patients, bystander CPR increased, but the occurrence of VF decreased. One-month survival increased moderately overall and highly significantly among patients found in VF, even though the time to defibrillation changed only moderately.</p

Economic comparison of uprooting versus motor manual cleaning in Götaland and southern Norrland

En ökande brist på arbetskraft har lett till en kostnadsökning för motormanuell röjning. Mekaniserad röjning har prövats ända sedan 1970-talet, men aggregat som kapar eller klipper av röjstammarna är för kostsamma och bidrar inte till att förlänga röjningseffekten och är därför inte konkurrenskraftiga. En ny metod för tidig mekaniserad röjning som provats är rotryckning med kranspetsmonterat aggregat. Tidig röjning kan göra att stubbskott från lövträden växer ikapp huvudstammarna och att en ny röjning blir nödvändig. Skotten växer lättare ikapp huvudstammarna på höga boniteter. Vid rotryckning har lövträden som rycks bort ingen möjlighet att skjuta skott igen. Syftet med studien var att utföra en jämförande nuvärdesanalys av skötselprogram med rotryckning och motormanuell röjning. Detta gjordes på bestånd med ståndortsindex från T16 till T28, samt G16 till G32. Från kalmark och upp till en aritmetisk medelhöjd om cirka sex meter så räknades allt manuellt. Från sex meter och fram till slutavverkning gjordes simuleringar i Heureka StandWise som sedan räknade ut nuvärden. Prestationer för motormanuell röjning beräknades och jämfördes mot rotryckning. Rotryckning utfördes till en lägre kostnad än motormanuell röjning för bestånd med ståndortsindex G24, G28 och G32. För en hel omloppstid så gav rotryckning det högsta nuvärdet för granbestånd från G24 och högre. För tallbestånd gav skötselprogram med motormanuell röjning alltid det högsta nuvärdet. Det gjordes sedan en känslighetsanalys där produktiviteten för rotryckning och kostnaden för motormanuell röjning justerades. Känslighetsanalysen indikerade att en liten höjning av produktiviteten för rotryckning skulle göra röjningsmetoden konkurrenskraftig även i glesare bestånd såsom granbestånd med lägre ståndortsindex samt tallbestånd. Heureka StandWise saknar funktioner för inväxning av stubb- och rotskott, stubb- och rotskott har en betydande roll i inväxten på röjda bestånd och resultaten från Heureka StandWise kan där med vara något osäkra.An increasing shortage of labor has led to an increase in costs for motor manual cleaning. Mechanized cleaning has been studied since the 1970s, but devices that cut or trim the cleaning stems were too expensive and did not contribute to retain the cleaning effect. A new method for mechanized cleaning that has been tested is uprooting with a crane tip mounted device. Early cleaning can cause stump shoots from deciduous trees that catch up on the main stems and a second cleaning becomes necessary. The shoots are easier catching up on the main stems at higher site indexes. When uprooting has been done deciduous trees that have been removed have no opportunity to shoot new stems again. The objective of the study was to compare the net present-value of uprooting with motor- manual cleaning. This comparison was done on sites with sites indexes from T16 to T28, and G16 to G32. From bare land and up to an arithmetic average height of about six meters, everything was counted manually. From six meters up to final felling, simulations were made in Heureka StandWise which calculated the net present values automatically. Motor manual cleaning performance was calculated and compared to uprooting. Uprooting was performed at a lower cost than motor-manual cleaning on sites with site index G24, G28 and G32. For an entire rotation period, uprooting gave the highest net present value on spruce sites from G24 and higher. For pine sites, pre-commercial thinning programs with motor manual cleaning always gave the highest net present value. A sensitivity analysis was made by adjusting the productivity for uprooting and the cost of motor manual cleaning. The sensitivity analysis indicated that a slight increase in productivity for uprooting would make the cleaning method competitive even on less fertile spruce sites and on pine sites. Heureka StandWise has no functions for ingrowth of stump and root shoots, stump and root shoots have a significant role in the growth of cleaned sites and the results from Heureka StandWise can be uncertain

Acute infection with the intestinal parasite Trichuris muris has long-term consequences on mucosal mast cell homeostasis and epithelial integrity

A hallmark of parasite infection is the accumulation of innate immune cells, notably granulocytes and mast cells, at the site of infection. While this is typically viewed as a transient response, with the tissue returning to steady state once the infection is cleared, we found that mast cells accumulated in the large-intestinal epithelium following infection with the nematode Trichuris muris and persisted at this site for several months after worm expulsion. Mast cell accumulation in the epithelium was associated with the induction of type-2 immunity and appeared to be driven by increased maturation of local progenitors in the intestinal lamina propria. Furthermore, we also detected increased local and systemic levels of the mucosal mast cell protease MCPt-1, which correlated highly with the persistent epithelial mast cell population. Finally, the mast cells appeared to have striking consequences on epithelial barrier integrity, by regulation of gut permeability long after worm expulsion. These findings highlight the importance of mast cells not only in the early phases of infection but also at later stages, which has functional implications on the mucosal tissue

Uncertainty and Triple Access Planning in European Sustainable Urban Mobility Plans: a long way to go yet?

Triple Access Planning (TAP) is the idea that accessibility can be delivered through physical mobility, digital connectivity, and spatial proximity. There is great uncertainty as to how far one of these three elements will substitute for or complement the others in delivering the accessibility we need in future. Sustainable Urban Mobility (SUM) Planning is touted as a relatively new paradigm in local transport planning oriented to the achievement of a wide range of societal objectives. The paper presents a review of how well SUM Plans from eight European countries, and national guidelines from four currently account for TAP and uncertainty in their approach. Our findings suggest that while the concept of physical proximity is well-understood, other aspects of the TAP and uncertainty approach are not. Digital connectivity is largely ignored. The planning future is treated as largely certain, with no consideration of disruptive factors that might alter this future

Kinetics of electron-positron pair plasmas using an adaptive Monte Carlo method

A new algorithm for implementing the adaptive Monte Carlo method is given. It is used to solve the relativistic Boltzmann equations that describe the time evolution of a nonequilibrium electron-positron pair plasma containing high-energy photons and pairs. The collision kernels for the photons as well as pairs are constructed for Compton scattering, pair annihilation and creation, bremsstrahlung, and Bhabha & Moller scattering. For a homogeneous and isotropic plasma, analytical equilibrium solutions are obtained in terms of the initial conditions. For two non-equilibrium models, the time evolution of the photon and pair spectra is determined using the new method. The asymptotic numerical solutions are found to be in a good agreement with the analytical equilibrium states. Astrophysical applications of this scheme are discussed.Comment: 43 pages, 7 postscript figures, to appear in the Astrophysical Journa

Enhanced science-stakeholder communication to improve ecosystem model performances for climate change impact assessments

In recent years, climate impact assessments of relevance to the agricultural and forestry sectors have received considerable attention. Current ecosystem models commonly capture the effect of a warmer climate on biomass production, but they rarely sufficiently capture potential losses caused by pests, pathogens and extreme weather events. In addition, alternative management regimes may not be integrated in the models. A way to improve the quality of climate impact assessments is to increase the science-stakeholder collaboration, and in a two-way dialog link empirical experience and impact modelling with policy and strategies for sustainable management. In this paper we give a brief overview of different ecosystem modelling methods, discuss how to include ecological and management aspects, and highlight the importance of science-stakeholder communication. By this, we hope to stimulate a discussion among the science-stakeholder communities on how to quantify the potential for climate change adaptation by improving the realism in the models