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

Utvärdering av en ny mall för en systematisk genomgång av hundens normala rörelsemönster : hur användbar är mallen för undervisning av veterinärstudenter?

Arbetet syftade till att skapa och utvärdera ett undervisningsmaterial om normalt rörelsemönster hos hund för veterinärstudenter. Undervisningsmaterialet byggdes kring en mall som skulle möjligöra för studenterna att på ett systematiskt sätt gå igenom hundens normala rörelsemönster. Mallen utformades med befintliga mallar för hältdetektion som grund. Dessa mallar bearbetades och omformades till en ny mall utgående från normalt rörelsemönster. Undervisningsmaterialet hade ytterligare två delar, ett filmarkiv med friska hundar som rör sig i främst skritt och trav filmade från sidan, bakifrån och framifrån, samt en sammanställning av hundens gångarter och grundläggande begrepp inom rörelseanalys hos hund. När undervisningsmaterialet var färdigt skapades en övning där studenterna skulle använda mallen samtidigt som de tittade på filmer ur filmarkivet. Övningsinstruktioner och undervisningsmaterial lades upp på internet tillsammans med en utvärdering. Samtliga studenter i årskurs 4 på veterinärprogrammet vid Sveriges lantbruksuniversitet fick tillgång till undervisningsmaterialet, övningen och utvärderingen via sin studentinloggning. Av sjuttioåtta studenter i årskurs 4 besvarade tjugofem utvärderingen. Studenterna var överlag mycket positiva till övningen och mallen. Exempelvis poängsattes övningens totalintryck i medelpoäng till 4,4 på en skala mellan 1 och 5. Materialets användbarhet bedömdes som hög och materialet ansågs vara lättbegripligt. Både övningens instruktioner och dokumentet med grundbegrepp fick i medeltal 4,56 poäng med avseende på den textmässiga kvaliteten. Studenterna visade stor vilja att upprepa övningen och upplevde själva att de ökade sitt kunnande om normalt rörelsemönster hos hund genom att göra övningen. Den genomsnittsliga ökningen i eget värderat kunnande efter övningen jämfört med före var 1,12 poäng högre på en femgradig skala. Vidare forskning krävs dock för att undersöka om det rör sig om en reell kunskapsökning. Förhoppningsvis kan arbetet inspirera till fler utvärderingar av befintliga och nya checklistor/mallar och fler vetenskapliga utvärderingar av undervisningsmaterial för veterinärstudenter.The work aimed at creating and evaluating an educational material for veterinary students about the normal patterns of movement in dogs. The teaching material was created around a template that would enable students to systematically go through the normal movement pattern of the dog. The template was created with inspiration from existing templates for lameness detection. These templates were combined and remodeled into a new template focused on normal patterns of movement. The teaching material had two additional parts, an archive of videos showing healthy dogs moving in mostly walk and trot, filmed from the side, rear and front, and a summary of the dog's gaits and basic concepts of motion analysis in the dog. When the teaching material was ready an exercise in which the students would use the template while watching videos from the archive were created. The instructions for the exercise were posted on the internet along with the educational material and an evaluation. All students in year 4 of the study program in veterinary medicine at the Swedish University of Agricultural Sciences had access to the teaching material, the exercise and the evaluation through the student internet login. Twenty-five of the seventy-eight students in the fourth grade responded to the evaluation. The students were generally very positive to the exercise and the template. For example, the overall impression of the exercise was in mean scored 4.4 on a scale between 1 and 5. The usefulness of the teaching material was judged to be high and the material was considered to be readily understood. Both exercise instructions and the document with the basic concepts was given an average score of 4.56 in terms of their textual quality. The students were generally willing to repeat the exercise and felt that they increased their knowledge about the normal pattern of canine movement by doing the exercise. Based on self-evaluation, the mean increase in their knowledge after the exercise compared to before was 1.12 points higher on a five-point scale. Further research is needed, however, in order to find out if there is a real increase in knowledge. Hopefully, the work can inspire to more evaluations of existing and new checklists/templates and more scientific evaluations of educational material for veterinary students

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

Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

<p>Abstract</p> <p>Background</p> <p>The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably.</p> <p>In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count.</p> <p>This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase.</p> <p>Method</p> <p>A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases.</p> <p>Results</p> <p>In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).</p> <p>With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably.</p> <p>In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke.</p> <p>Conclusion</p> <p>Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.</p

Quantitative Assessment of 99mTc-Depreotide Uptake in Oesophageal Cancer and Precursor Conditions and Its Reflection in Immunohistochemically Detected Somatostatin Receptors

Background. Somatostatin receptors (SSTRs) are over-expressed in several tumors making it possible for imaging with labelled SSTR. A previous study showed feasibility to image oesophageal cancer with SSTR analogue 99mTc-depreotide. Purpose. (1) To investigate expression of the SSTRs in different types of esophageal carcinoma and (2) to correlate such an expression with 99mTc-depreotide uptake in these lesions. Material and Methods. Total 28 patients (17 with esophageal cancer and 11 with Barrett's esophagus) were examined with 99mTc-depreotide scintigraphy. The SSTR2A, SSTR2B, SSTR3, and SSTR5 were analyzed immunohistochemically in the lesion samples. Results. Among the patients with adenocarcinoma 10/11 expressed different amounts of SSTRs, while SSTRs were absent in 5/6 patients with Squamous cell carcinoma (Sqcc). There was no correlation neither between the 99mTc-depreotide uptake and the amount of SSTRs nor between the amount of SSTRs and differentiation grade of the tumor. Conclusions. (1) SSTRs are expressed in esophageal carcinoma and more abundantly so in adenocancer specimens; (2) in vivo 99mTc-depreotide uptake does not obviously correlate with the immunohistochemically detection of SSTRs of different subtypes in esophageal carcinoma

Epidemiology of cardiac arrest outside and inside hospital Experiences from registries in Sweden

Cardiac arrest is a dramatic condition leading to sudden death if someone cannot perform two interventions, basic life support and early defibrillation, that have been proved to improve long-term survival. The ‘Utstein style’, recently introduced, represents a standard of practice both inside and outside hospital with recommended guidelines for the uniform reporting of clinical data from the patient suffering cardiac arrest. In Sweden the vast majority of patients suffering from cardiac arrest regardless whether inside or outside hospital are included in webbased national registers (one for out-of-hospital cardiac arrest (OHCA) and one for in-hospital-cardiac arrest (IHCA)). In this article we will present our experiences from OHCA and IHCA separately

Exploring the nanoscale origin of performance enhancement in Li1.1_{1.1}Ni0.35_{0.35}Mn0.55_{0.55}O2_2 batteries due to chemical doping

Despite significant potential as energy storage materials for electric vehicles due to their combination of high energy density per unit cost and reduced environmental and ethical concerns, Co-free lithium ion batteries based off layered Mn oxides presently lack the longevity and stability of their Co-containing counterparts. Here, we demonstrate a reduction in this performance gap via chemical doping, with Li$_{1.1}$Ni$_{0.35}$Mn$_{0.55}$O$_2$ achieving an initial discharge capacity of 159 mAhg$^{-1}$ at C/3 rate and a corresponding capacity retention of 94.3% after 150 cycles. We subsequently explore the nanoscale origins of this improvement through a combination of advanced diffraction, spectroscopy, and electron microscopy techniques, finding that optimized doping profiles lead to an improved structural and chemical compatibility between the two constituent sub-phases that characterize the layered Mn oxide system, resulting in the formation of unobstructed lithium ion pathways between them. We also directly observe a structural stabilization effect of the host compound near the surface using aberration corrected scanning transmission electron microscopy and integrated differential phase contrast imaging.Comment: 20 pages, 8 figure

Dynamic padding by retrofit airbags and knee bars. A study of Swedish mail delivery cars

Ostrom, M., Eriksson, A., Thorson, J., Romeo, D.J and Svensson, L., 1992. Dynamic padding by retrofit airbags and knee bars. A study of Swedish mail delivery cars. Safety Science, 15: 147-154.The present study demonstrates the feasibility of a retrofit driver airbag system and knee bars in passenger cars for mail delivery. The system was tested in field experiments, in rough road test, and in low and high speed barrier test. No faults of the system occurred and the crash tests revealed that the energy reducing capacity in frontal collisions was satisfactory. As airbags prevent injuries to non-belt-users, such as certain occupational drivers, we advocate a wider implementation of retrofit airbag systems. We also stress the importance of using seat belts in conjunction with airbags.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29859/1/0000207.pd

Opposite transcriptional regulation in skeletal muscle of AMP-activated protein kinase gamma3 R225Q transgenic versus knock-out mice

AMP-activated protein kinase (AMPK) is an evolutionarily conserved heterotrimer important for metabolic sensing in all eukaryotes. The muscle-specific isoform of the regulatory gamma-subunit of the kinase, AMPK gamma3, has an important role in glucose uptake, glycogen synthesis, and fat oxidation in white skeletal muscle, as previously demonstrated by physiological characterization of AMPK gamma3 mutant (R225Q) transgenic (TgPrkag3(225Q)) and gamma3 knock-out (Prkag3(-/-)) mice. We determined AMPK gamma3-dependent regulation of gene expression by analyzing global transcription profiles in glycolytic skeletal muscle from gamma3 mutant transgenic and knock-out mice using oligonucleotide microarray technology. Evidence is provided for coordinated and reciprocal regulation of multiple key components in glucose and fat metabolism, as well as skeletal muscle ergogenics in TgPrkag3(225Q) and Prkag3(-/-) mice. The differential gene expression profile was consistent with the physiological differences between the models, providing a molecular mechanism for the observed phenotype. The striking pattern of opposing transcriptional changes between TgPrkag3(225Q) and Prkag3(-/-) mice identifies differentially expressed targets being truly regulated by AMPK and is consistent with the view that R225Q is an activating mutation, in terms of its downstream effects. Additionally, we identified a wide array of novel targets and regulatory pathways for AMPK in skeletal muscle