Reporting and improving quality of cardiopulmonary resuscitation (CPR) during out of hospital cardiac arrest.

Cand.med Jo Kramer-Johansen (f.1969) has studied how quality of CPR can be measured and modified by automated feedback during out of hospital cardiac arrest. The results from 284 episodes of cardiac arrest treated in the ambulance services of Akershus, London, and Stockholm show variable and poor quality of CPR characterized by too shallow chest compressions and too many and too long pauses. In the thesis he discusses and recommends standards for measuring and reporting CPR quality for the purposes of avoiding confounded clinical trials and for quality assurance and improvement in all professional services. The Norwegian Air Ambulance Foundation supported this work with a full time scholarship. Supervisors have been Professor Petter Andreas Steen and Lars Wik (NAKOS)

Mixed convolutional and long short-term memory network for the detection of lethal ventricular arrhythmia

Early defibrillation by an automated external defibrillator (AED) is key for the survival of out-of-hospital cardiac arrest (OHCA) patients. ECG feature extraction and machine learning have been successfully used to detect ventricular fibrillation (VF) in AED shock decision algorithms. Recently, deep learning architectures based on 1D Convolutional Neural Networks (CNN) have been proposed for this task. This study introduces a deep learning architecture based on 1D-CNN layers and a Long Short-Term Memory (LSTM) network for the detection of VF. Two datasets were used, one from public repositories of Holter recordings captured at the onset of the arrhythmia, and a second from OHCA patients obtained minutes after the onset of the arrest. Data was partitioned patient-wise into training (80%) to design the classifiers, and test (20%) to report the results. The proposed architecture was compared to 1D-CNN only deep learners, and to a classical approach based on VF-detection features and a support vector machine (SVM) classifier. The algorithms were evaluated in terms of balanced accuracy (BAC), the unweighted mean of the sensitivity (Se) and specificity (Sp). The BAC, Se, and Sp of the architecture for 4-s ECG segments was 99.3%, 99.7%, and 98.9% for the public data, and 98.0%, 99.2%, and 96.7% for OHCA data. The proposed architecture outperformed all other classifiers by at least 0.3-points in BAC in the public data, and by 2.2-points in the OHCA data. The architecture met the 95% Sp and 90% Se requirements of the American Heart Association in both datasets for segment lengths as short as 3-s. This is, to the best of our knowledge, the most accurate VF detection algorithm to date, especially on OHCA data, and it would enable an accurate shock no shock diagnosis in a very short time.This study was supported by the Ministerio de Economía, Industria y Competitividad, Gobierno de España (ES) (TEC-2015-64678-R) to UI and EA and by Euskal Herriko Unibertsitatea (ES) (GIU17/031) to UI and EA. The funders, Tecnalia Research and Innovation and Banco Bilbao Vizcaya Argentaria (BBVA), provided support in the form of salaries for authors AP, AA, FAA, CF, EG, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the author contributions section

A probabilistic function to model the relationship between quality of chest compressions and the physiological response for patients in cardiac arrest

Cardiopulmonary resuscitation quality (CPRQ) parameters can be derived from electric signals obtained during resuscitation. We propose to model a probabilistic relationship between CPRQ parameters and the physiological response as judged by ECG-features, to guide therapy in a clinical context. A total of 821 compression sequences were extracted from 394 out-of-hospital resuscitation episodes. Sequences were categorized as effective if the post sequence cardiac rhythm had better prognosis than the pre-sequence rhythm by a positive difference, otherwise as non effective if the difference was negative. CPRQ parameters related to depth and rate were calculated. Three alternative approaches were designed for the binary classifier based on the CPRQ parameters: quadratic discriminant analysis (QDA), logistic regression (LR) and artificial neural networks (ANN). The positive class discriminant function defined the probability of effective compressions (Pec). The classification accuracies were around 0.6 for all three models. The highest probability estimates of effective chest compressions corresponded to the depth (5–6 cm) and rate (100–120 min −1 ) currently recommended in the CPR guidelines. We have proposed a novel method to relate the quality of chest compressions to the physiologic response to CPR.acceptedVersio

Engaging the older cancer patient:Patient Activation through Counseling, Exercise and Mobilization - Pancreatic, Biliary tract and Lung cancer (PACE-Mobil-PBL) - study protocol of a randomized controlled trial

Abstract Background Several intervention studies have demonstrated that exercise training has beneficial effects among cancer patients. However, older cancer patients are underrepresented in clinical trials, and only few exercise-based studies have focused specifically on older patients with cancer. In particular, research investigating the effects of exercise training among older patients with advanced cancer is lacking. The purpose of the current study is to investigate the effect of a 12-week multimodal and exercise-based intervention among older patients (≥65 years) with advanced pancreatic, biliary tract or lung cancer, who are treated with first-line palliative chemotherapy, immunotherapy or targeted therapy. Methods PACE-Mobil-PBL is a two-armed randomized controlled trial. Participants will be randomized 1:1 to an intervention group (N = 50) or a control group (N = 50). Participants in the intervention group will receive standard oncological treatment and a 12-week multimodal intervention, comprised of: (I) supervised exercise training, twice weekly in the hospital setting, (II) home-based walking with step counts and goal-setting, (III) supportive and motivational nurse-led counseling, and (IV) protein supplement after each supervised training session. Participants in the control group will receive standard oncological treatment. The primary outcome is physical function measured by the 30-s chair stand test. Secondary outcomes include measures of feasibility, activity level, physical capacity and strength, symptom burden, quality of life, toxicity to treatment, dose reductions, inflammatory biomarkers, body weight and composition, hospitalizations and survival. Assessments will be conducted at baseline, and after 6, 12 and 16 weeks. Discussion The current study is one of the first to investigate the effect of an exercise-based intervention specifically targeting older patients with advanced cancer. PACE-Mobil-PBL supports the development of health promoting guidelines for older patients with cancer, and the study results will provide new and valuable knowledge in this understudied field. Trial registration The study was prospectively registered at ClinicalTrials.gov on January 26, 2018 (ID: NCT03411200)

Description of call handling in emergency medical dispatch centres in Scandinavia: recognition of out-of-hospital cardiac arrests and dispatcher-assisted CPR

Background The European resuscitation council have highlighted emergency medical dispatch centres as an important key player for early recognition of Out-of-Hospital Cardiac Arrest (OHCA) and in providing dispatcher assisted cardiopulmonary resuscitation (CPR) before arrival of emergency medical services. Early recognition is associated with increased bystander CPR and improved survival rates. The aim of this study is to describe OHCA call handling in emergency medical dispatch centres in Copenhagen (Denmark), Stockholm (Sweden) and Oslo (Norway) with focus on sensitivity of recognition of OHCA, provision of dispatcher-assisted CPR and time intervals when CPR is initiated during the emergency call (NO-CPRprior), and to describe OHCA call handling when CPR is initiated prior to the emergency call (CPRprior). Methods Baseline data of consecutive OHCA eligible for inclusion starting January 1st 2016 were collected from respective cardiac arrest registries. A template based on the Cardiac Arrest Registry to Enhance Survival definition catalogue was used to extract data from respective cardiac arrest registries and from corresponding audio files from emergency medical dispatch centres. Cases were divided in two groups: NO-CPRprior and CPRprior and data collection continued until 200 cases were collected in the NO-CPRprior-group. Results NO-CPRprior OHCA was recognised in 71% of the calls in Copenhagen, 83% in Stockholm, and 96% in Oslo. Abnormal breathing was addressed in 34, 7 and 98% of cases and CPR instructions were started in 50, 60, and 80%, respectively. Median time (mm:ss) to first chest compression was 02:35 (Copenhagen), 03:50 (Stockholm) and 02:58 (Oslo). Assessment of CPR quality was performed in 80, 74, and 74% of the cases. CPRprior comprised 71 cases in Copenhagen, 9 in Stockholm, and 38 in Oslo. Dispatchers still started CPR instructions in 41, 22, and 40% of the calls, respectively and provided quality assessment in 71, 100, and 80% in these respective instances. Conclusions We observed variations in OHCA recognition in 71–96% and dispatcher assisted-CPR were provided in 50–80% in NO-CPRprior calls. In cases where CPR was initiated prior to emergency calls, dispatchers were less likely to start CPR instructions but provided quality assessments during instructions.publishedVersio

Evidence for the formation of comet 67P/Churyumov-Gerasimenko through gravitational collapse of a bound clump of pebbles

The processes that led to the formation of the planetary bodies in the Solar System are still not fully understood. Using the results obtained with the comprehensive suite of instruments on-board ESA’s Rosetta mission, we present evidence that comet 67P/Churyumov-Gerasimenko likely formed through the gentle gravitational collapse of a bound clump of mm-sized dust aggregates (“pebbles”), intermixed with microscopic ice particles. This formation scenario leads to a cometary make-up that is simultaneously compatible with the global porosity, homogeneity, tensile strength, thermal inertia, vertical temperature profiles, sizes and porosities of emitted dust, and the steep increase in water-vapour production rate with decreasing heliocentric distance, measured by the instruments on-board the Rosetta spacecraft and the Philae lander. Our findings suggest that the pebbles observed to be abundant in protoplanetary discs around young stars provide the building material for comets and other minor bodies

Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) study protocol: a stepped wedge randomised trial of stroke screening using the National Institutes of Health Stroke Scale in the ambulance

Background Less than 50% of stroke patients in Norway reach hospital within 4 h of symptom onset. Early prehospital identification of stroke and triage to the right level of care may result in more patients receiving acute treatment. Quality of communication between paramedics and the stroke centre directly affects prehospital on-scene time, emphasising this as a key factor to reduce prehospital delay. Prehospital stroke scales are developed for quick and easy identification of stroke, but have poor sensitivity and specificity compared to an in-hospital assessment with the National Institutes of Health Stroke Scale (NIHSS). The aim of the Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) is to assess whether a structured learning program, prehospital NIHSS and a mobile application facilitating communication with the stroke physician may improve triage of acute stroke patients. Methods A stepped wedge cluster randomised controlled intervention design will be used in this trial in Oslo, Norway. Paramedics at five ambulance stations will enrol adult patients with suspected stroke within 24 h of symptom onset. All paramedics will begin in a control phase with standard procedures. Through an e-learning program and practical training, a random and sequential switch to the intervention phase takes place. A mobile application for NIHSS scoring, including vital patient information for treatment decisions, transferring data from paramedics to the on-call stroke physician at the Stroke Unit at Oslo University Hospital, will be provided for the intervention. The primary outcome measure is positive predictive value (PPV) for prehospital identification of patients with acute stroke defined as the proportion of patients accepted for stroke evaluation and discharged with a final stroke diagnosis. One thousand three hundred patients provide a 50% surplus to the 808 patients needed for 80% power to detect a 10% increase in PPV. Discussion Structured and digital communication using a common scale like NIHSS may result in increased probability for better identification of stroke patients and less stroke mimics delivered to a stroke team for acute diagnostics and treatment in our population.publishedVersio