The Greenland spatial fingerprint of Dansgaard-Oeschger events in observations and models.

Pleistocene Ice Ages display abrupt Dansgaard-Oeschger (DO) climate oscillations that provide prime examples of Earth System tipping points-abrupt transition that may result in irreversible change. Greenland ice cores provide key records of DO climate variability, but gas-calibrated estimates of the temperature change magnitudes have been limited to central and northwest Greenland. Here, we present ice-core δ15N-N2 records from south (Dye 3) and coastal east Greenland (Renland) to calibrate the local water isotope thermometer and provide a Greenland-wide spatial characterization of DO event magnitude. We combine these data with existing records of δ18O, deuterium excess, and accumulation rates to create a multiproxy "fingerprint" of the DO impact on Greenland. Isotope-enabled climate models have skill in simulating the observational multiproxy DO event impact, and we use a series of idealized simulations with such models to identify regions of the North Atlantic that are critical in explaining DO variability. Our experiments imply that wintertime sea ice variation in the subpolar gyre, rather than the commonly invoked Nordic Seas, is both a sufficient and a necessary condition to explain the observed DO impacts in Greenland, whatever the distal cause. Moisture-tagging experiments support the idea that Greenland DO isotope signals may be explained almost entirely via changes in the vapor source distribution and that site temperature is not a main control on δ18O during DO transitions, contrary to the traditional interpretation. Our results provide a comprehensive, multiproxy, data-model synthesis of abrupt DO climate variability in Greenland.

Voluntary first responders' experiences of being dispatched to suspected out-of-hospital cardiac arrest in rural areas: an interview study.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a leading cause of death, and survival outcomes vary across countries and regions. To improve survival, the European Resuscitation Council Guidelines encourage the implementation of technologies like smartphone applications to alert voluntary first responders (VFRs) who are near a suspected OHCA. VFRs are of great importance in the ´chain of survival´, but there is still a lack of knowledge about their experiences; especially of those operating in rural areas. Understanding those experiences is crucial in developing appropriate interventions to train, encourage, and safeguard VFRs in their mission. Therefore, the aim of this study was to describe VFRs´ experiences of being dispatched to suspected OHCA in rural areas. METHODS: The study used an inductive design. The data were collected using individual interviews with 16 VFRs and analysed using qualitative content analysis. RESULTS: The results are presented in terms of six generic categories ''Being motivated and prepared'', ''Having strategies to undertake the mission'', ''Collaborating with others'', ''Being ethically aware'', ''Supporting the family members'', and ''Coping with the mission'', which formed the basis of the main category 'Desire to save lives and help others'. The findings showed that VFRs had a genuine desire to contribute to save lives in this rural area. Regardless of the circumstances, they were prepared to leave everything and act to the best for the victim and their family members. In theirs' missions they collaborated with others at the scene and were guided by ethics while they acted in complex circumstances. CONCLUSIONS: VFRs dispatched in rural areas express a desire to save lives. In their missions, they acted in complex situations and experienced both emotional and ethical challenges. The design, implementation, and evaluation of support interventions directed at VFRs should be prioritised, especially in rural areas, as it can contribute to more people becoming and remaining VFRs, which in turn could contribute to sustainable development.

Ethics rounds in the ambulance service: a qualitative evaluation.

BACKGROUND: It is a common ethical challenge for ambulance clinicians to care for patients with impaired decision-making capacities while assessing and determining the degree of decision-making ability and considering ethical values. Ambulance clinicians' ethical competence seems to be increasingly important in coping with such varied ethical dilemmas. Ethics rounds is a model designed to promote the development of ethical competence among clinicians. While standard in other contexts, to the best of our knowledge, it has not been applied within the ambulance service context. Thus, the aim of this study was to describe ambulance clinicians' experiences of participating in ethics rounds. METHODS: This was a qualitative descriptive study, evaluating an intervention. Data were collected through sixteen interviews with ambulance clinicians who had participated in an intervention involving ethics rounds. The analysis was performed by use of content analysis. RESULTS: Two themes describe the participants' experiences: (1) Reflecting freely within a given framework, and (2) Being surprised by new insights. The following categories form the basis of the themes; 1a) Gentle guidance by the facilitator, 1b) A comprehensible structure, 2a) New awareness in the face of ethical problems, and 2b) Shared learning through dialogue. CONCLUSION: Incorporating structured ethics rounds seems to create a continuous development in ethical competence that may improve the quality of care in the ambulance service. Structured guidance and facilitated group reflections offer ambulance clinicians opportunities for both personal and professional development. An important prerequisite for the development of ethical competence is a well-educated facilitator. Consequently, this type of ethics rounds may be considered a useful pedagogical model for the development of ethical competence in the ambulance service.

Self-determination in older patients: Experiences from nurse-dominated ambulance services.

AIM: To describe ambulance clinicians' experiences of self-determination in older patients. DESIGN: The study had an inductive and explorative design, guided from a life-world perspective. METHODS: Thirty-two Swedish ambulance clinicians were interviewed in six focus groups in November 2019. The data were analysed with content analysis, developing manifest categories and latent themes. FINDINGS: The ambulance clinicians assessed the older patients' exercise of self-determination by engaging in conversation and by being visually alert, to eventually gain an overall picture of their decision-making capacity. This assessment was used as a platform when informing older patients of their rights, thus promoting their participation in care. Having limited time and narrow guidelines counteracted ambulance clinicians' ambitions to support older patients' general desire to avoid hospitalization, which resulted in an urge to displace their responsibility to external decision-makers. CONCLUSION: Expectations that older patients with impaired decision-making ability will give homogeneous responses mean an increased risk of ageist attitudes with a simplified view of patient autonomy. Such attitudes risk the withholding of information about options that healthcare professionals do not wish older patients to choose. When decision-making is difficult, requests for expanded guidelines may paradoxically risk alienation from the professional nursing role. IMPLICATIONS AND IMPACT: The findings show ambulance clinicians' unwillingness to shoulder their professional responsibility when encountering older patients with impaired decision-making ability. In assuming that all older patients reason in the same way, ambulance clinicians tend to adopt a simplistic and somewhat ageist approach when it comes to patient autonomy. This points to deficiencies in ethical competence, which is why increased ethics support is deemed suitable to promote and develop ethical competence. Such support can increase the ability to act as autonomous professionals in accordance with professional ethical codes. REPORTING METHOD: This study adhered to COREQ guidelines. PATIENT AND PUBLIC CONTRIBUTION: None.

Nurses' use of an advisory decision support system in ambulance services: A qualitative study.

AIM: To illuminate from the perspective of nurses in ambulance services the experiences of using a web-based advisory decision support system to assess care needs and refer patients. DESIGN: Inductive and descriptive approaches. METHOD: Thirteen semi-structured interviews were conducted in the spring of 2020. The data were analysed through the reflexive thematic analysis. RESULTS: The Swedish web-based advisory decision support system (ADSS) was found to strengthen nurses' feelings of security when they assess patients' care needs, promote their competence and professional pride, and help them manage stress. However, the system also generated difficulties for nurses to adjust to the dynamic ambulance team and revealed a discrepancy between their professional roles and responsibilities to refer patients and provide self-care advice. The nurses thought that the support system facilitated their increased participation and helped them understand patients and significant others by offering transparency in assessment and decision making. Thus, the support system provides nurses with an opportunity to strengthen patients' independence through information and education. However, in the care relationship, nurses worked to overcome patients' expectations. CONCLUSION: Nurses using the ADSS increased their security while performing assessments and referrals and found new opportunities to provide information and promote understanding of their decisions. However, nursing care values can be threatened when new support systems are introduced, especially as ambulance services become increasingly protocol-driven. IMPLICATIONS FOR PROFESSION AND/OR PATIENT CARE: These findings have implications for nurses' work environments and help them maintain consistency in making medical assessments and in providing equivalent self-care advice when referring patients to the different levels of care. The findings will also impact researchers and policymakers who formulate decision support systems. REPORTING METHOD: Consolidated criteria for reporting qualitative research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: None.

Support in acute situations when a community health nurse is called: experiences of older patients, their significant others, and involved healthcare professionals- a qualitative interview study.

BACKGROUND: Care decisions for older patients in acute situations are challenging to make, and there is limited knowledge of support in home healthcare settings, where older patients receive ongoing health care from, for example, community health nurses. Therefore, this study aimed to describe the support for all involved in acute situations when a community health nurse was called, as experienced by older patients, their significant others and healthcare professionals involved. METHODS: The study was conducted using a phenomenological reflective lifeworld research approach, in which meanings of the study phenomenon were analyzed. The included participants were those who had been involved in acute situations. Twelve participants from four acute situations were interviewed. The participant included three older patients, one significant other, four community health nurses, one registered nurse student, one specialist in general practice, and two ambulance personnel, with one being a registered nurse and the other a specialist ambulance nurse. RESULTS: Support in decision-making was received from the knowledge of temporality, which provided a comprehensive understanding based on past and present knowledge of the older patient. The knowledge of temporality allowed for the early detection of new symptoms and facilitated care decisions tailored to the older patient. There was a dependency on pre-existing mutual interpersonal support, and confidence developed through relational, caring, and medical competence. CONCLUSIONS: The advantages of temporality, confidence and mutual interpersonal support in acute situations highlight the importance of enhancing relational continuity in home healthcare settings and establishing a structural collaboration among community health nurses, specialists in general practice, and ambulance personnel. This collaboration aims to provide support for making decisions regarding tailored care.

Physicians' experiences and actions in making complex level-of-care decisions during acute situations within older patients' homes: a critical incident study.

BACKGROUND: Complex level-of-care decisions involve uncertainty in which decisions are beneficial for older patients. Knowledge of physicians' decision-making during acute situations in older patients' homes is limited. Therefore, this study aimed to describe physicians' experiences and actions in making complex level-of-care decisions during the assessment of older patients in acute situations within their own homes. METHODS: Individual interviews and analyses were performed according to the critical incident technique (CIT). In total, 14 physicians from Sweden were included. RESULTS: In making complex level-of-care decisions, physicians experienced collaborating with and including older patients, significant others and health care professionals to be essential for making individualized decisions regarding the patients' and their significant others' needs. During decision-making, physicians experienced difficulties when doubt or collaborative obstructions occurred. Physicians' actions involved searching for an understanding of older patients' and their significant others' wishes and needs, considering their unique conditions, guiding them, and adjusting care according to their wishes. Actions further involved promoting collaboration and reaching a consensus with all persons involved. CONCLUSION: Physicians strive to individualize complex level-of-care decisions based on older patients' and their significant others' wishes and needs. Furthermore, individualized decisions depend on successful collaboration and consensus among older patients, their significant others and other health care professionals. Therefore, to facilitate individualized level-of-care decisions, the health care organizations need to support physicians when they are making individualized decisions, provide sufficient resources and promote 24 - 7 collaboration between organizations and health care professionals.

Tension between local, regional and national levels in Norway's handling of COVID-19.

AIMS: This study aimed to explore the tension between local, regional, and national authorities evoked by some rural municipalities' decisions to impose local infection-control measures during the first weeks of the COVID-19 pandemic in Norway. METHODS: Eight municipal Chief Medical Officers of Health (CMOs) participated in semi-structured interviews, and six crisis management teams participated in focus-group interviews. Data were analysed with systematic text condensation. Boin and Bynander's interpretation of crisis management and coordination and Nesheim et al.'s framework for non-hierarchical coordination in the state sector inspired the analysis. RESULTS: Uncertainty in the face of a pandemic with unknown damage potential, lack of infection-control equipment, patient transport challenges, vulnerable staff situation and planning of local COVID-19 beds were some of the reasons for rural municipalities imposing local infection-control measures the first weeks of the pandemic. Local CMOs' engagement, visibility and knowledge contributed to trust and safety. Differences in perspectives between local, regional and national actors created tension. Existing roles and structures were adjusted, and new informal networks arose. CONCLUSIONS: Strong municipal responsibility in Norway and the quite unique arrangement with local CMOs in every municipality with the legal right to decide temporary local infection-control measures seemed to facilitate a balance between top-down and bottom-up decision making. Tension between rural, regional and national actors that arose due to local infection-control measures, and the following dialogue and mutual adjustment of perspectives, led to a fruitful balance between national and local measures in Norway's handling of the COVID-19 pandemic.

Hepatic enhancement at computed tomography: is there a dependence on body weight past institutional contrast dosing limits?

BACKGROUND: Although described in product monographs, the maximum contrast media (CM) dose at computed tomography (CT) varies among institutions. PURPOSE: To investigate whether an upper limit of 40 g of iodine in women and 50 g in men is sufficient or if there is a body weight (BW) dependence of mean hepatic enhancement (MHE) beyond those thresholds. MATERIAL AND METHODS: At our institution, CM injection duration is fixed to 30 s and dosed 600 mg iodine/kg up to 40 g in women and 50 g in men. Pre- and post-contrast hepatic attenuation values (HU) were retrospectively obtained in 200 women and 200 men with glomerular filtration rate >45 mL/min undergoing 18-flurodeoxyglucose PET-CT (18F-FDG PET-CT) of which half weighed below and half above those dose thresholds using iodixanol 320 mg iodine/mL or iomeprol 400 mg iodine/mL. The correlation between BW and MHE was assessed by simple linear regression. RESULTS: Weight range was 41-120 kg in women and 47-137 kg in men. There was no significant relationship between MHE and BW in women receiving <40 g (r = -0.05, P = 0.63) or in men receiving <50 g (r = 0.18, P = 0.07). Above those thresholds there was an inverse relationship (r = -0.64, P<0.001 in women and r = -0.30, P<0.002 in men). There was no apparent upper limit where the dependence of hepatic MHE on BW decreased. Hepatosteatosis limited MHE. CONCLUSION: Adjusting CM to BW diminishes the dependence of MHE on BW. There was no apparent upper limit for the relationship between BW and MHE in heavier patients at CM-enhanced CT.

Ambulance clinicians' understanding of older patients' self-determination: A vignette study.

BACKGROUND: Older patients are often vulnerable and highly dependent on healthcare professionals' assessment in the event of acute illness. In the context of ambulance services, this poses challenges as the assessment is normally conducted with a focus on identifying life-threatening conditions. Such assessment is not fully satisfactory in a patient relationship that also aims to promote and protect patient autonomy. AIM: To describe ambulance clinicians' understanding of older patients' self-determination when the patient's decision-making ability is impaired. RESEARCH DESIGN: A qualitative design with an inductive approach, guided by descriptive phenomenology. PARTICIPANTS: In total, 30 ambulance clinicians, comprised of 25 prehospital emergency nurses, 1 nurse and 4 emergency medical technicians participated in 15 dyadic interviews. ETHICAL CONSIDERATIONS: The research was conducted in accordance with the Declaration of Helsinki, and permission was granted by the Swedish Ethical Review Authority. FINDINGS: The findings are presented in two themes: (1) Movement between explicit and implicit will; and (2) Contradictions about the patient's best interests. The clinicians' interpretations are based on an understanding of the patient's situation using substitute decision-making in emergency situations and conversations that reveal the patient's explicit wishes. Sometimes the clinicians collaborate to validate the patient's implicit will, while they at other times subordinate themselves to others' opinions. The clinicians find themselves in conflict between personal values and organisational values as they try to protect the patient's self-determination. CONCLUSION: The results indicate that older patients with an impaired decision-making ability risk losing the right to self-determination in the context of ambulance services. The clinicians face challenges that significantly affect their ability to handle the older patient's unique needs based on a holistic perspective and their ability to be autonomous.

Tension between local, regional and national level in Norwegian handling of COVID-19.

INTRODUCTION: The initial phase of the COVID-19 pandemic can be described as a crisis - a threat that must be urgently addressed under conditions of deep uncertainty. We wanted to explore the tension between local, regional and national authorities evoked by some rural municipalities' decisions to impose local infection control measures during the first weeks of the COVID-19 pandemic in Norway. METHODS: Eight municipal chief medical officers of health (CMO) and six crisis management teams participated in semi-structured and focus group interviews. Data were analyzed with systematic text condensation. Boin and Bynander's interpretation of crisis management and coordination and Nesheim et al.'s framework for non-hierarchical coordination in the state sector inspired the analysis. RESULTS: Uncertainty in the face of a pandemic with unknown damage potential, lack of infection control equipment, patient transport challenges, vulnerable staff situation and planning of local COVID-19 beds were some of the reasons for rural municipalities imposing local infection control measures. Local CMOs' engagement, visibility and knowledge contributed to trust and safety. Differences in perspectives between local, regional and national actors created tension. Existing roles and structures were adjusted, and new informal networks arose. DISCUSSION: Strong municipal responsibility in Norway and the quite unique arrangement with local CMOs in every municipality with legal right to decide temporary local infection control measures seemed to facilitate a fruitful balance between top-down and bottom-up decision-making. The following dialogue and mutual adjustment of perspectives led to appropriate balance between national and local measures in Norway's handling of the COVID-19 pandemic.

Ethics education to support ethical competence learning in healthcare: an integrative systematic review.

BACKGROUND: Ethical problems in everyday healthcare work emerge for many reasons and constitute threats to ethical values. If these threats are not managed appropriately, there is a risk that the patient may be inflicted with moral harm or injury, while healthcare professionals are at risk of feeling moral distress. Therefore, it is essential to support the learning and development of ethical competencies among healthcare professionals and students. The aim of this study was to explore the available literature regarding ethics education that promotes ethical competence learning for healthcare professionals and students undergoing training in healthcare professions. METHODS: In this integrative systematic review, literature was searched within the PubMed, CINAHL, and PsycInfo databases using the search terms 'health personnel', 'students', 'ethics', 'moral', 'simulation', and 'teaching'. In total, 40 articles were selected for review. These articles included professionals from various healthcare professions and students who trained in these professions as subjects. The articles described participation in various forms of ethics education. Data were extracted and synthesised using thematic analysis. RESULTS: The review identified the need for support to make ethical competence learning possible, which in the long run was considered to promote the ability to manage ethical problems. Ethical competence learning was found to be helpful to healthcare professionals and students in drawing attention to ethical problems that they were not previously aware of. Dealing with ethical problems is primarily about reasoning about what is right and in the patient's best interests, along with making decisions about what needs to be done in a specific situation. CONCLUSIONS: The review identified different designs and course content for ethics education to support ethical competence learning. The findings could be used to develop healthcare professionals' and students' readiness and capabilities to recognise as well as to respond appropriately to ethically problematic work situations.

Variation in textural parameters of hepatic lesions during contrast medium injection.

BACKGROUND: Textural parameters extracted using quantitative imaging techniques have been shown to have prognostic value for hepatocellular carcinoma (HCC). PURPOSE: To evaluate whether the contrast medium timing of the image acquisition affects the reproducibility of textural parameters in HCC and hepatic tissue. MATERIAL AND METHODS: This retrospective study included 17 patients with 37 HCC lesions. Perfusion computed tomography (CT) was obtained after 50 mL contrast medium injection. HCC lesions were segmented for analysis. The gray-level co-occurrence (GLCM) textural analysis parameters, homogeneity, energy, entropy, inertia, and correlation were calculated. Variation was quantified by calculating the SD of each parameter during respective perfusion series and the inter lesion variation as the SD among the lesions. RESULTS: The average change in texture parameters in both HCC and hepatic tissue per second after injection was 0.01% to 0.3% of the respective texture parameter. In HCC, the average variation in homogeneity, energy, and entropy within each lesion after contrast medium injection was significantly less than the variation observed among the lesions (23% to 74%, P < 0.001). Significant differences in energy, entropy, inertia, and correlation between hepatic tissue and HCC were observed. However, when considering the intra-individual variation of hepatic tissue over time, only the HCC parameter energy was significantly outside that 95% confidence interval (P < 0.02). CONCLUSION: The contrast medium timing does not affect the reproducibility of textural parameters in HCC and hepatic tissue. Thus, contrast medium timing should not be an issue at CT texture analysis of HCC.

Exposure and response analysis of aleglitazar on cardiovascular risk markers and safety outcomes: An analysis of the AleCardio trial.

AIMS: The AleCardio trial aimed to characterize the efficacy and safety of peroxisome proliferator-activated receptor-αγ agonist aleglitazar in patients with type 2 diabetes mellitus and acute coronary syndrome. The trial terminated early because of futility and safety signals. We evaluated whether the safety signals could be attributed to increased exposure to aleglitazar. MATERIALS AND METHODS: The AleCardio trial enrolled 7226 patients to receive aleglitazar 150 µg or matching placebo on top of standard care. A population pharmacokinetic analysis was conducted in a pharmacokinetic substudy to identify covariates that explained interindividual variability in exposure. Subsequently, the effect of these covariates on surrogate and clinical outcomes was assessed in the full patient population. RESULTS: Concomitant administration of clopidogrel was identified as a covariate that influenced the apparent clearance of aleglitazar. Patients using clopidogrel had a mean predicted area under the plasma-concentration-time curve (AUC0-24 ) of 174.7 ng h/mL (SD: ±112.9 ng h/mL) versus 142.2 ng h/mL (SD: ±92.6 ng h/mL) in patients without clopidogrel. The effect of aleglitazar compared with placebo on HbA1c, haemoglobin, serum creatinine and adiponectin was modified by concomitant clopidogrel use (P for interaction 0.007, 0.002, <0.001 and < 0.001, respectively). CONCLUSIONS: Concomitant use of clopidogrel was identified as a covariate that explained interindividual variability in exposure to aleglitazar. Patients using clopidogrel showed an additional lowering of HbA1c, at the expense of an additional decrease in haemoglobin, and an increase in serum creatinine and adiponectin. Clopidogrel is a moderate inhibitor of CYP2C8. Because aleglitazar is metabolized by CYP2C8, a pharmacokinetic interaction could explain differences in exposure and response to aleglitazar.

Leaflet thickening and stent geometry in sutureless bioprosthetic aortic valves.

Underexpansion of transcatheter heart valves and the surgically implanted Perceval sutureless aortic valve bioprosthesis has been suggested as an underlying mechanism for hypo-attenuated leaflet thickening (HALT). This was a single-center prospective observational study that included 47 patients who underwent surgical aortic valve replacement with the Perceval sutureless bioprosthesis (LivaNova, London, United Kingdom) from 2012 to 2016 and were studied by four-dimensional cardiac computed tomography (CT). The association between overall and regional expansion and the prevalence of HALT was analyzed. In total 46 patients were included in the analysis. HALT was found in 39.1% of patients and the mean overall prosthesis expansion was 75.5 ± 5.2% (range 64.6-84.8%). Overall expansion did not differ between patients with HALT compared with patients without HALT (mean overall expansion 74.0 ± 5.2% vs. 76.5 ± 5.0%, P = 0.11). The prevalence of HALT was lower in patients with overall expansion > 80% compared to patients with expansion < 80% expansion though not significantly (20% vs. 44.4%, P = 0.16). None or trivial regional underexpansion was found in 94.7% of coronary cusps. There was no significant association between regional underexpansion and the prevalence of HALT (mean coronary cusp angle 120 ± 8° vs. 119 ± 10°, P = 0.53). The prevalence of HALT and overall underexpansion was high in the Perceval sutureless bioprosthetic valve. Overall underexpansion was not associated with HALT. Whether severe overall underexpansion increases the risk for HALT requires further study. Regional underexpansion was uncommon in the Perceval sutureless bioprosthetic valve and not associated with HALT.Clinical trial registration Unique identifier: NCT03753126 (http://www.clinicaltrials.gov).

Dyadic teams and nursing care: A critical incident study of nurses in the emergency medical service.

AIM AND OBJECTIVES: The aim of the study was to describe Emergency Medical Services (EMS) nurses' experiences of and coping with critical incidents, when providing nursing care as a member of a dyadic team. BACKGROUND: Nursing care in EMS is a complex task, taking into account the physical, psychological as well as existential dimensions of the patient's suffering. In this, EMS nurses are dependent on the dyadic team. Teams in EMS are described as essential for providing safe medical care. However, nursing care also comprises relationships with patients as a means of reducing patient suffering. DESIGN: The study has an inductive descriptive qualitative design, in adherence to the COREQ-checklist. METHODS: A critical incident technique was used. Thirty-five EMS nurses were interviewed individually, with a focus on dyadic teams providing nursing care. The interviews were analysed with the aim of defining main areas, categories and sub-categories. RESULTS: The experiences of critical incidents emerged to form two main areas: "Functional co-operation" and "Dysfunctional co-operation," comprising seven categories and sixteen sub-categories. Their coping with critical incidents encompassed two main areas: "Adapting oneself" and "Adapting nursing care and the colleague," comprising four categories and eight sub-categories. CONCLUSIONS: Reflection as part of the daily practice emerges as important for the development of nursing care both in relation to individual team members and also the dyadic team as a unit. In addition, the results highlight consensus within dyadic teams regarding the objectives of nursing care, as well as the importance of defined roles. RELEVANCE TO CLINICAL PRACTICE: This study underlines the importance of strengthening the dyadic EMS team's ability to co-operate using common goals and knowledge within clinical nursing care. The individual team members' different roles have to be explicit. In addition, clinical care has to be organised to generate preconditions for mutual performance monitoring through collegial feedback and reflection.

Using firefighters as medical first responders to shorten response time in rural areas in Sweden.

OBJECTIVE: To map out and describe an earlier response by using firefighters as medical first responders on while waiting for the ambulance and first incident person assignments focusing on frequency, event time and survival >30 days after performed cardiopulmonary resuscitation. DESIGN: Retrospective descriptive design. SETTING: Ambulance service in a county of southern Sweden with a population of 200 000 inhabitants (23/km2 ). PARTICIPANTS: Data were collected from four data systems within different organizations; emergency medical communication centre, fire deparment, ambulance services and conty hospital analysis unit. MAIN OUTCOME MEASURE(S): Data from 600 while waiting for the ambulance assignments, whereof 120 with first incident person present, collected between 1 January 2012 and 31 December 2016. Between 1 June 2014 and 1 October 2015, the two fire departments were dually dispatched on out-of-hospital cardiac arrests. RESULTS: Three main findings were made: there was a prolonged process time for dispatching fire fighters on while waiting for the ambulance assignments. Dual dispatches did not shorten the process time for dispatching full-time firefighters, and, in a majority of while waiting for the ambulance assignments where cardiopulmonary resuscitation was performed, firefighters or first incident persons arrived first on the scene. CONCLUSION: Minimising every minute that delays the performance of life-saving actions is crucial. By dispatching firefighters on while waiting for the ambulance assignments in rural areas, the response time in a majority of assignments was shortened. However, there was substantial delay in dispatching firefighters due to prolonged process time at the emergency medical communication centre. The emergency medical communication centre operator's ability to quickly assess the need for while waiting for the ambulance assignments plays a crucial role in the chain of survival.

Dual source abdominal computed tomography: the effect of reduced X-ray tube voltage and intravenous contrast media dosage in patients with reduced renal function.

BACKGROUND: X-ray tube voltage (kVp) reduction increases intravenous contrast medium (CM) attenuation at computed tomography (CT), but tube output limits its use in large patients. PURPOSE: To evaluate the feasibility and image quality of reducing CM dose by low kVp and using dual X-ray source at liver CT. MATERIAL AND METHODS: Patients with estimated glomerular filtration rate (eGFR) < 45 mL/min (n = 43) aged 60-91 years (75 ± 7.7), weighing 42-114 kg (75 ± 15) were prospectively scanned using a reduced CM dose of 0.25 or 0.3 g iodine (I)/kg with 70 or 80 kVp respectively, using either single-source or dual-source CT depending on patient size. Liver contrast-to-noise ratio (CNR), liver noise, and muscle noise were quantitatively compared with those of 43 consecutive patients aged > 65 years with eGFR > 45 mL/min scanned using a standard abdominal protocol at 120 kVp after receiving 0.5 gI/kg. RESULTS: There was no statistically significant difference in CNR, liver noise, or muscle noise at reduced CM protocols compared to the standard protocol: CNR was 4.6 (95% CI = 4.2-5.0) vs. 5.0 (95% CI = 4.5-5.5), liver noise was 11.1 (95% CI = 10.7-11.6) vs. 11.0 (95% CI = 10.5-11.6), muscle noise was 11.7 (95% CI = 11.2-12.1) vs. 10.8 (95% CI = 10.1-11.4). The mean SSDE was 70% higher with the reduced CM protocol. CONCLUSION: CM dosage can be reduced by 40-50% with maintained measured noise and CNR in patients with BMIs of 15-36 kg/m2 by lowering the tube voltage and dual-source CT scanning of the liver.

Triple Arterial Phase CT of the Liver with Radiation Dose Equivalent to That of Single Arterial Phase CT: Initial Experience.

Purpose To develop and evaluate a triple arterial phase CT liver protocol with a similar radiation dose to that of standard single arterial phase CT in study subjects suspected of having hepatocellular carcinoma (HCC). Materials and Methods The study consisted of a retrospective part A for protocol development (n = 15) and a prospective part B to evaluate diagnostic accuracy (n = 38). All 53 participants underwent perfusion CT with 50 mL contrast material between August 2013 and September 2014. Group B underwent an additional standard multiphasic liver CT examination with 120 mL of contrast material (range, 70-143 mL). Image sets from triple arterial phase imaging were reconstructed from perfusion CT by fusing images from three dedicated arterial time points. Triple arterial phase CT and standard single arterial phase CT were compared by two readers, who assessed subjective image quality and HCC detection rate. A third reader served as reference reader and assessed objective image quality. The paired Student t test, Wilcoxon signed rank test, jackknife alternative free-response receiver operating characteristic (JAFROC), and JAFROC curve were applied. Results The mean volume CT dose index was 11.6 mGy for triple arterial phase CT and 11.9 mGy for standard single arterial phase CT (P = .73). Triple arterial phase CT showed lower image noise and better contrast-to-noise ratio compared with standard single arterial phase CT (P < .001 and P = .032, respectively); however, there was no significant difference in lesion-to-liver-contrast ratio (P = .31). Subjective image quality was good for both protocols. The detection rate of the 65 HCC lesions was 82% for reader 1 and 83% for reader 2 at triple arterial phase CT and 80% for reader 1 and 77% for reader 2 at standard single arterial phase CT (P = .4). Conclusion Triple arterial phase imaging is feasible at the same radiation dose as that used for standard single arterial phase CT. Triple arterial phase imaging provides equivalent to superior image quality and equal HCC detection rate despite the use of less than half the contrast material dose used at standard single arterial phase CT. © RSNA, 2018.

Improving clinical trials for cardiovascular diseases: a position paper from the Cardiovascular Round Table of the European Society of Cardiology.

AIMS: Cardiovascular disease is the most common cause of mortality and morbidity in the world, but the pharmaceutical industry's willingness to invest in this field has declined because of the many challenges involved with bringing new cardiovascular drugs to market, including late-stage failures, escalating regulatory requirements, bureaucracy of the clinical trial business enterprise, and limited patient access after approval. This contrasts with the remaining burden of cardiovascular disease in Europe and in the world. Thus, clinical cardiovascular research needs to adapt to address the impact of these challenges in order to ensure development of new cardiovascular medicines. METHODS AND RESULTS: The present paper is the outcome of a two-day workshop held by the Cardiovascular Round Table of the European Society of Cardiology. We propose strategies to improve development of effective new cardiovascular therapies. These can include (i) the use of biomarkers to describe patients who will benefit from new therapies more precisely, achieving better human target validation; (ii) targeted, mechanism-based approaches to drug development for defined populations; (iii) the use of information technology to simplify data collection and follow-up in clinical trials; (iv) streamlining adverse event collection and reducing monitoring; (v) extended patent protection or limited rapid approval of new agents to motivate investment in early phase development; and (vi) collecting data needed for health technology assessment continuously throughout the drug development process (before and after approval) to minimize delays in patient access. Collaboration across industry, academia, regulators, and payers will be necessary to enact change and to unlock the existing potential for cardiovascular clinical drug development. CONCLUSIONS: A coordinated effort involving academia, regulators, industry, and payors will help to foster better and more effective conduct of clinical cardiovascular trials, supporting earlier availability of innovative therapies and better management of cardiovascular diseases.