Prehospital assessment of suspected stroke and TIA: An observational study.

BACKGROUND: Symptoms related to stroke diverge and may mimic many other conditions. AIMS: To evaluate clinical findings among patients with a clinical suspicion of stroke in a prehospital setting and find independent predictors of a final diagnosis of stroke or transient ischemic attack (TIA). METHODS: An observational multicenter study includes nine emergency hospitals in western Sweden. All patients transported to hospital by ambulance and in whom a suspicion of stroke was raised by the emergency medical service clinician before hospital admission during a four-month period were included. RESULTS: Of 1081 patients, a diagnosis of stroke was confirmed at hospital in 680 patients (63%), while 69 (6%) were diagnosed as TIA and 332 patients (31%) received other final diagnoses. In a multiple logistic regression analysis, factors independently associated with a final diagnosis of stroke or TIA were increasing age, odds ratio (OR) per year: 1.02, P = 0.007, a history of myocardial infarction (OR: 1.77, P = 0.01), facial droop (OR: 2.81, P < 0.0001), arm weakness (OR: 2.61, P < 0.0001), speech disturbance (OR: 1.92, P < 0.0001), and high systolic blood pressure (OR: 1.50, P = 0.02), while low oxygen saturation was significantly associated with other diagnoses (OR: 0.41, P = 0.007). More than half of all patients among patients with both stroke/TIA and other final diagnoses died during the five-year follow-up. CONCLUSIONS: Seven factors including the three symptoms included in the Face Arm Speech Test were significantly associated with a final diagnosis of stroke or TIA in a prehospital assessment of patients with a suspected stroke.

Caring science research in the ambulance services: an integrative systematic review.

BACKGROUND: The ambulance services are associated with emergency medicine, traumatology and disaster medicine, which is also reflected in previous research. Caring science research is limited and, since no systematic reviews have yet been produced, its focus is unclear. This makes it difficult for researchers to identify current knowledge gaps and clinicians to implement research findings. AIM: This integrative systematic review aims to describe caring science research content and scope in the ambulance services. DATA SOURCES: Databases included were MEDLINE (PubMed), CINAHL, Web of Science, ProQDiss, LibrisDiss and The Cochrane Library. The electronic search strategy was carried out between March and April 2015. The review was conducted in line with the standards of the PRISMA statement, registration number: PROSPERO 2016:CRD42016034156. REVIEW METHODS: The review process involved problem identification, literature search, data evaluation, data analysis and reporting. Thematic data analysis was undertaken using a five-stage method. Studies included were evaluated with methodological and/or theoretical rigour on a 3-level scale, and data relevance was evaluated on a 2-level scale. RESULTS: After the screening process, a total of 78 studies were included. The majority of these were conducted in Sweden (n = 42), fourteen in the United States and eleven in the United Kingdom. The number of study participants varied, from a case study with one participant to a survey with 2420 participants, and 28 (36%) of the studies were directly related to patients. The findings were identified under the themes: Caregiving in unpredictable situations; Independent and shared decision-making; Public environment and patient safety; Life-changing situations; and Ethics and values. CONCLUSION: Caring science research with an explicit patient perspective is limited. Areas of particular interest for future research are the impact of unpredictable encounters on openness and sensitivity in the professional-patient relation, with special focus on value conflicts in emergency situations.

Association between the reported intensity of an acute symptom at first prehospital assessment and the subsequent outcome: a study on patients with acute chest pain and presumed acute coronary syndrome.

BACKGROUND: To decrease the morbidity burden of cardiovascular disease and to avoid the development of potentially preventable complications, early assessment and treatment of acute coronary syndrome (ACS) are important. The aim of this study has therefore been to explore the possible association between patients' estimated intensity of chest pain when first seen by the ambulance crew in suspected ACS, and the subsequent outcome before and after arrival in hospital. METHODS: Data was collected both prospectively and retrospectively. The inclusion criteria were chest pain raising suspicion of ACS and a reported intensity of pain ≥4 on the visual analogue scale. RESULTS: All in all, 1603 patients were included in the study. Increased intensity of chest pain was related to: 1) more heart-related complications before hospital admission; 2) a higher proportion of heart failure, anxiety and chest pain after hospital admission; 3) a higher proportion of acute myocardial infarction and 4) a prolonged hospitalisation. However, there was no significant association with mortality neither in 30 days nor in three years. Adjustment for possible confounders including age, a history of smoking and heart failure showed similar results. CONCLUSION: The estimated intensity of chest pain reported by the patients on admission by the ambulance team was associated with the risk of complications prior to hospital admission, heart failure, anxiety and chest pain after hospital admission, the final diagnosis and the number of days in hospital. TRIAL REGISTRATION: ClinicalTrials.gov 151:2008/4564 Identifier: NCT00792181. Registred 17 November 2008 'retrospectively registered'.

Possible effects of a course in cardiovascular nursing on prehospital care of patients experiencing suspected acute coronary syndrome: a cluster randomised controlled trial.

BACKGROUND: Current research suggests that nurses can influence the outcome for patients with acute coronary syndrome (ACS). The aim of this study has been to evaluate whether a course in cardiovascular nursing (CVN) can improve ambulance nurses' (ANs') prehospital care of patients experiencing suspected ACS, related to pain intensity. METHODS: This is a cluster randomised controlled trial that was conducted in the ambulance services. Patients were allocated to one of two groups: in the first group, patients were treated by ANs who had attended the CVN course and in the second group patients were treated by ANs without this qualification. Inclusion criteria were: 1/pain raising suspicion of ACS, and 2/pain score ≥4 on a visual analogue scale (VAS). The primary outcome was the estimated intensity of pain or discomfort according to VAS 15 min after randomisation. Secondary outcomes were estimated intensity of pain or discomfort on admission to hospital and further requirement of pain treatment, as well as symptoms such as paleness and/or cold sweat; nausea and/or vomiting; anxiety, dyspnea, degree of alertness, respiratory depression and aggressiveness. A further secondary outcome measured was survival to 30 days. Lastly, a final diagnosis was made. A total of 38 ANs attended the CVN course. There were 1,747 patients who fulfilled the inclusion criteria. RESULTS: The pain score did not differ significantly between the two groups fifteen minutes after randomisation (median value of VAS was 4.0 in both groups). On admission to hospital the pain score was significantly lower for patients treated by an AN who had attended the CVN course (n = 332) compared with those treated by an AN who had not attended the course (n = 1,415) (median 2.5 and 3.0 respectively, p = 0.001). The ANs who had attended the course used higher doses of morphine. CONCLUSIONS: An educational intervention with a CVN course did not relate significantly to more efficient pain relief in suspected ACS during the first 15 min. However, this intervention was associated with more effective pain relief later on in the prehospital setting. Thus, a CVN course for ANs appears to be associated with reduced pain intensity among patients experiencing suspected ACS. This result needs however to be confirmed in further trials. TRIAL REGISTRATION: The ClinicalTrials.gov Protocol Registration System (registration number NCT00792181).

Swedish emergency medical services' identification of potential candidates for primary healthcare: Retrospective patient record study.

OBJECTIVE: To investigate patients who called the emergency medical services (EMS) for primary healthcare (PHC) problems. DESIGN: A retrospective and exploratory patient record study from an EMS perspective, comparing two groups: those who were potential candidates for PHC and those who were not. All data were gathered from EMS and hospital records. SETTINGS: The study was completed at the EMS and five hospital areas in the western region of Sweden. SUBJECTS: The patients (n = 3001) who called the EMS in 2011. Data were missing for 10%. MAIN OUTCOME MEASURES: The frequency and the clinical characteristics of the patients who called the EMS and were actually potential candidates for PHC. RESULTS: Of a total of 2703 patients, a group of 426 (16%) were assessed as potential candidates for PHC and could thus be treated at a level of care other than the emergency department. Patients who were classified as suitable for PHC were found at all priority levels and within all symptom groups, but were younger and healthier than the other group. CONCLUSION: Numerous patients seeking help from the EMS do not end up at the most appropriate level in the healthcare system. IMPLICATIONS: In the EMS, guidelines are needed to enable pre-hospital emergency nurses to assess and triage patients to the most appropriate level of healthcare. Key points Patients calling the emergency medical services do not always end up at an appropriate level of healthcare. In total, 16% of patients were identified by the Swedish emergency medical services as potential candidates for primary healthcare. These patients were younger and healthier than those needing care at the emergency department. They were found at all priority levels and within all symptom groups.

ECG signs of acute myocardial ischemia in the prehospital setting of a suspected acute coronary syndrome and its association with outcomes.

AIMS: The aims of this study were (a) to determine the prehospital prevalence of electrocardiographic (ECG) signs of acute myocardial ischemia in patients with suspected acute coronary syndrome and (b) to describe the relationships between the various ECG patterns and the diagnosis of acute myocardial infarction (AMI) and outcomes. METHODS: Prospective cohort study using data from an interventional trial in acute chest pain patients transported by the emergency medical services. These patients were classified into 3 groups: patients with ECG showing signs of acute myocardial ischemia, patients with ECG showing other abnormal changes (bundle-branch block, pacemaker rhythm, Q-wave or T-wave inversion) and patients without significant pathologic findings. All P values are age-adjusted. RESULTS: Among 1546 patients, 312 (20%) had ECG signs of acute myocardial ischemia. Of them, 57% had a final diagnosis of AMI versus 26% of those with other abnormal ECGs and 12% of those with ECG without significant pathologic findings (P<.0001). In all, 53% of all AMI cases involved patients without ECG signs of acute myocardial ischemia. Although ECG signs of acute myocardial ischemia predicted heart failure and ventricular tachyarrhythmias both prior to and after hospital admission, there was no significant difference in 30-day mortality between the 3 patient groups (4.3%, 3.7%, and 1.2%, respectively, P=.11). CONCLUSION: Among patients with a clinical suspicion of AMI in the prehospital setting, the prevalence of ECG signs suggesting AMI was low, as was the ability to identify AMI patients using ECG findings only. We therefore need better instruments in the prehospital triage of patients with acute chest pain.

Prehospital emergency care for patients with suspected hip fractures after falling - older patients' experiences.

AIMS AND OBJECTIVES: To describe and explain older patients' lived experiences of prehospital emergency care in cases of suspected hip fractures after falling. BACKGROUND: Falls among the elderly is an issue internationally and a public health problem that seems to be on the increase. In the emergency medical services, older people are frequent patients after having suffered a fall, but there is little information on how older patients experience prehospital emergency care in cases of suspected hip fractures after falling. DESIGN: Qualitative interview study. METHODS: Ten older patients were interviewed. These depth interviews were tape-recorded, transcribed verbatim and analysed for meanings. RESULTS: The comprehensive understanding of the phenomenon is: 'Glad to have been rescued, despite bad experiences as well as good'. The older patient is offered care in an open and friendly atmosphere concurrently with feeling anxiety about the treatment. Intervention with streamlined care and treatment can thus simultaneously be beneficial as well as doing harm. Patients experience confusion and the need to ask questions about what really happened in the ambulance. Bad experiences remain unexplained. These findings are based on three themes with relevant subthemes: efficiency, concerned encounters and suffering from care. CONCLUSIONS: Our study shows that prehospital emergency care when hip fracture is suspected - from patients' point of view - is insufficient and unsatisfying. Prehospital emergency care for these vulnerable patients could be improved through more compassion being shown towards older patients' existential needs and their increased participation. Furthermore, alternative methods of prehospital pain relief need to be developed. RELEVANCE TO CLINICAL PRACTICE: Responsibility for patients' safety regarding pain relief is emphasised. Pain relief in the emergency medical services should be individualised. This development should focus on care that is already good and gradually eradicate compassionless care.

Multi-Element Assessment of Potentially Toxic and Essential Elements in New and Traditional Food Varieties in Sweden.

With the global movement toward the consumption of a more sustainable diet that includes a higher proportion of plant-based foods, it is important to determine how such a change could alter the intake of cadmium and other elements, both essential and toxic. In this study, we report on the levels of a wide range of elements in foodstuffs that are both traditional and "new" to the Swedish market. The data were obtained using analytical methods providing very low detection limits and include market basket data for different food groups to provide the general levels in foods consumed in Sweden and to facilitate comparisons among traditional and "new" food items. This dataset could be used to estimate changes in nutritional intake as well as exposure associated with a change in diet. The concentrations of known toxic and essential elements are provided for all the food matrices studied. Moreover, the concentrations of less routinely analyzed elements are available in some matrices. Depending on the food variety, the dataset includes the concentrations of inorganic arsenic and up to 74 elements (Ag, Al, As, Au, B, Ba, Be, Bi, Ca, Cd, Co, Cr, Cs, Cu, Fe, Ga, Ge, Hf, Hg, K, Li, Mg, Mn, Mo, Na, Nb, Ni, P, Pb, Rb, S, Sb, Sc, Se, Si, Sn, Sr, Ta, Te, Th, Ti, Tl, U, W, V, Y, Zn, Zr, rare Earth elements (REEs) (Ce, Dy, Er, Eu, Gd, Ho, La, Lu, Nd, Pr, Sm, Tb, Tm, and Yb), platinum group elements (PGEs) (Ir, Os, Pd, Pr, Pt, Re, Rh, Ru, and Pr), and halogens (Br, Cl, and I)). The main focus (and thus the most detailed information on variation within a given food group) is on foods that are currently the largest contributors to dietary cadmium exposure in Sweden, such as pasta, rice, potato products, and different sorts of bread. Additionally, elemental concentrations in selected food varieties regarded as relatively new or "novel" to the Swedish market are provided, including teff flour, chia seeds, algae products, and gluten-free products.

[Documentation of prehospital emergency care]. / Över 100 doktorsavhandlingar inom den prehospitala akutsjukvården i Sverige.

The scientific documentation of prehospital emergency care in Sweden is slowly expanding. The first thesis on the value of a mobile coronary care unit was defended in 1982. Since then, at least 106 theses have been defended at 15 educational institutes in Sweden. The theses can be divided into nine different themes, of which acute disease and prognostic factors (n = 30) is the most common, followed in order of frequency by caring, assessment and decision (n = 18), patient and next of kin perspective (n = 14), trauma (n = 1 1), competence, learning, and education (n = 10), care needs, cooperation, and prioritization (n = 10), disaster (n = 7), workers' health and environment (n = 3), and ethics and values (n = 3). The University of Gothenburg had the highest number of theses defended (n = 28), followed by the Karolinska Institute (n = 24) and the University of Umeå (n = 10). The theses were written by 64 nurses, 36 physicians, two public health specialists, one physiotherapist, one priest, one social worker, and one statistician.

Being prepared for the unprepared: a phenomenology field study of Swedish prehospital care.

INTRODUCTION: This paper presents a study of prehospital care with particular focus on how ambulance personnel prepare themselves for their everyday assignments. METHODS: The caring science field study took a phenomenological approach, where data were analyzed for meaning. Two specialist ambulance nurses, three registered nurses, and six paramedics participated. RESULTS: The previously known discrepancy between in-hospital care and prehospital care was further interpreted in this study. The pre-information from an emergency medical dispatch (EMD) center provides ambulance personnel with basic expectations as to what they will have to take care of. At the same time that they maintain their certainty and control, our major findings indicate that prehospital care in emergency medical service requires the personnel to be prepared for an open and flexible encounter with the patient; to be prepared for the unprepared, i.e., to be open and to avoid being governed by predetermined statements. DISCUSSION: Our findings suggest that the outcomes of good prehospital care affect patient security. The seemingly time-consuming dialogue with the patient facilitates understanding and decision-making regarding the patient's medical needs, and it is comforting to the patient. The ambulance personnel need to be well prepared for this task and fully understand that the situation might differ considerably from the information provided by the EMD centers. All objective information is of great value in this care context, but ultimately it is the patient who provides reliable information about her/his own situation.

Optimization of production of the anti-keratin 8 single-chain Fv TS1-218 in Pichia pastoris using design of experiments.

BACKGROUND: Optimization of conditions during recombinant protein production for improved yield is a major goal for protein scientists. Typically this is achieved by changing single crucial factor settings one at a time while other factors are kept fixed through trial-and-error experimentation. This approach may introduce larger bias and fail to identify interactions between the factors resulting in failure of finding the true optimal conditions. RESULTS: In this study we have utilized design of experiments in order to identify optimal culture conditions with the aim to improve the final yield of the anti-keratin 8 scFv TS1-218, during expression in P. pastoris in shake flasks. The effect of: pH, temperature and methanol concentration on the yield of TS1-218 using buffered minimal medium was investigated and a predictive model established. The results demonstrated that higher starting pH and lower temperatures during induction significantly increased the yield of TS1-218. Furthermore, the result demonstrated increased biomass accumulation and cell viability at lower temperatures which suggested that the higher yield of TS1-218 could be attributed to lower protease activity in the culture medium. The optimal conditions (pH 7.1, temperature 11°C and methanol concentration 1.2%) suggested by the predictive model yielded 21.4 mg TS1-218 which is a 21-fold improvement compared to the yield prior to optimization. CONCLUSION: The results demonstrated that design of experiments can be utilized for a rapid optimization of initial culture conditions and that P. pastoris is highly capable of producing and secreting functional single-chain antibody fragments at temperatures as low as 11°C.

Patient trust and patient safety for low-priority patients: A randomized controlled trial pilot study in the prehospital chain of care.

BACKGROUND: Patients who call for an ambulance but only have primary care needs do not always get appropriate care. The starting point in this study is that such patients should be assigned to as basic of care as possible, while maintaining high levels of patient trust and patient safety. AIM: To evaluate patient trust and patient safety among low-priority ambulance patients referred to care at either the Community Health Centre (CHC) or the Emergency Department (ED). METHODS: This randomized controlled trial pilot study compared the level of patient trust and patient safety among low-priority ambulance patients who were randomized into two groups: CHC (n = 105) or ED (n = 83). RESULTS: There was a high level of trust in the care received, regardless of whether the patient received care at CHC or ED. Overall 31% fulfilled one or more of the given criteria for potentially jeopardizing patient safety. CONCLUSION: Patient selection for the trial indicated a potential limit in patient safety. There was a high level of trust in the care received regardless of whether the patient received care. The accuracy of patient selection for the new care model needs to be further improved with the intention to enhance patient safety even further.

Clinical reasoning in the emergency medical services: an integrative review.

Clinical reasoning is the process of gathering and understanding information conducted by clinicians in the emergency medical services (EMS) so as to make informed decisions. Research on clinical reasoning spans several disciplines, but a comprehensive view of the process is lacking. To our knowledge, no review of clinical reasoning in the EMS has been conducted. AIM: The aim was to investigate the nature, deployment, and factors influencing EMS clinicians' clinical reasoning by means of a review. METHOD: Data was collected through searches in electronic databases, networking among research teams, colleagues and friends, "grey literature," and through ancestry searches. A total of 38 articles were deemed eligible for inclusion and were analyzed using descriptive thematic analysis. The analysis resulted in an overarching finding - namely, the importance for EMS clinicians to adjust for perceived control in unpredictable situations. Within this finding, 3 themes emerged in terms of EMS clinicians' clinical reasoning: (1) maintaining a holistic view of the patient; (2) keeping an open mind; and (3) improving through criticism. Seven subthemes subsequently emerged from these three themes. RESULTS: This review showed that EMS clinicians' clinical reasoning begins with the information that they are given about a patient. Based on this information, clinicians calculate the best route to the patient and which equipment to use, and they also assess potential risks. They need to be constantly aware of what is happening on the scene and with the patient and strive to control the situation. This striving also enables EMS clinicians to work safely and effectively in relation to the patient, their relatives, other clinicians, associated organizations, and the wider community. A lack of contextually appropriate guidelines results in the need for creativity and forces EMS clinicians to use "workarounds" to solve issues beyond the scope of the guidelines available. In addition, they often lack organizational support and fear repercussions such as litigation, unemployment, or blame by their EMS or healthcare organization or by patients and relatives. CONCLUSION: Clinical reasoning is influenced by several factors. Further research is needed to determine which influencing factors can be addressed through interventions to minimize their impact on patient outcomes.

Functional mapping and single chain construction of the anti-cytokeratin 8 monoclonal antibody TS1.

The anti-cytokeratin (CK) 8 monoclonal antibody (mab) TS1 has been shown to efficiently bind to CK8 expressed in carcinomas in vivo. The anti-idiotypic antibody of TS1, alphaTS1, can be used to regulate the tumor:non-tumor ratio of TS1 by clearing non-tumor binding TS1 from the circulation. If the interaction of TS1 to CK8 and alphaTS1 is fully understood, mutations can be used to improve the tumor:non-tumor ratio. A scFv was made of the mab TS1 and residues earlier identified by Erlandsson et al. as important for the interaction with both its antigen CK8 and its anti-idiotype alphaTS1, were mutated to alanine or amides and expressed in E. coli. The effects of the mutations were studied by ELISA and residues important for the interactions to both CK8 and alphaTS1 were identified as mainly tyrosines, charged residues, a serine and a tryptophan. Altogether, nine amino acid residues in TS1 were found to be important in the interaction to alphaTS1 and six residues for the interaction to CK8. Important residues, clustered together in the modelled protein, were identified as residues from CDR 3 of the heavy chain and the unexpected participation of a residue in CDR 2 of the light chain. Some of the important residues are likely to be hotspots. Hotspots constitute a few residues in an interaction that contribute most to the binding, energetically. Amino acid residues in hotspots often cluster together in the center of the interaction interface, but can also be spread out to the periphery. The hotspots are often surrounded by hydrophobic patches, which are seen in the modelled TS1 protein used in this study. Amino acid residues that increased the affinity when mutated were also identified for both interactions. These residues are likely to be located outside the interacting interface. It can from this study be concluded that it is wise to precede the mutational procedure with experiments that can give guidelines for the selection of which amino acid residues to mutate. If the guidelines from the chemical modifications from Erlandsson et al. not had been used, this study would have left some residues unmutated and thereby missed important information.

Prehospital identification of factors associated with death during one-year follow-up after acute stroke.

OBJECTIVES: In acute stroke, the risk of death and neurological sequelae are obvious threats. The aim of the study was to evaluate the association between various clinical factors identified by the emergency medical service (EMS) system before arriving at hospital and the risk of death during the subsequent year among patients with a confirmed stroke. MATERIAL AND METHODS: All patients with a diagnosis of stroke as the primary diagnosis admitted to a hospital in western Sweden (1.6 million inhabitants) during a four-month period were included. There were no exclusion criteria. RESULTS: In all, 1,028 patients with a confirmed diagnosis of stroke who used the EMS were included in the analyses. Among these patients, 360 (35%) died during the following year. Factors that were independently associated with an increased risk of death were as follows: (1) high age, per year OR 1.07; 95% CI 1.05-1.09; (2) a history of heart failure, OR 2.08; 95% CI 1.26-3.42; (3) an oxygen saturation of <90%, OR 8.05; 95% CI 3.33-22.64; and (4) a decreased level of consciousness, OR 2.19; 95% CI 1.61-3.03. CONCLUSIONS: Among patients with a stroke, four factors identified before arrival at hospital were associated with a risk of death during the following year. They were reflected in the patients' age, previous clinical history, respiratory function, and the function of the central nervous system.

In vivo clearing of idiotypic antibodies with antiidiotypic antibodies and their derivatives.

At immunolocalization of experimental tumors, idiotypic monoclonal antibodies, such as TS1 against cytokeratin 8, can be used to carry and deposit in vivo terapeutics in the tumor. These carriers also remain in the circulation and may cause negative side-effects in other tissues. In this report, several derivatives of the antiidiotypic antibody alphaTS1 were produced and tested for their clearing capacity of the idiotypic carrier antibody TS1. Intact monoclonal alphaTS1, scFv of a alphaTS1 and alphaTS1 Fab'2 and fragments were produced by recombinant technology or by cleavage with Ficin. The scFv was tailored by use of the variable domain genes of the light and heavy chain from the hybridoma clone in combination with a (Gly4Ser)3-linker, followed by expression in E. coli. When tested for clearing capacity, the intact divalent antiidiotypic IgG was found to be the most efficient. The divalent and the monovalent Fab fragment also demonstrated significant clearing, but lower than the intact antiidiotypic IgG. The alphaTS1 scFv antibody when injected separately was not found to clear the idiotype, but could do so when preincubated with the idiotype. Rapid excretion and in vivo instability of this low molecular weight antibody fragment may be the major reasons. Similar results were obtained when the system was reversed and the 131I-labeled antiidiotype IgG was cleared with the idiotype fragment. It is concluded that both intact antiidiotypic IgG, and Fab'2 fragments are able to clear the idiotypic antibodies. The experimental data support the conclusion that the Fc parts from both the idiotype and the antiidiotype may contribute to this elimination.

Trust in the early chain of healthcare: lifeworld hermeneutics from the patient's perspective.

PURPOSE: Patients must be able to feel as much trust for caregivers and the healthcare system at the healthcare centre as at the emergency department. The aim of this study is to explain and understand the phenomenon of trust in the early chain of healthcare, when a patient has called an ambulance for a non-urgent condition and been referred to the healthcare centre. METHOD: A lifeworld hermeneutic approach from the perspective of caring science was used. Ten patients participated: seven female and three male. The setting is the early chain of healthcare in south-western Sweden. RESULTS: The findings show that the phenomenon of trust does not automatically involve medical care. However, attention to the patient's lifeworld in a professional caring relationship enables the patient to trust the caregiver and the healthcare environment. It is clear that the "voice of the lifeworld" enables the patient to feel trust. CONCLUSION: Trust in the early chain of healthcare entails caregivers' ability to pay attention to both medical and existential issues in compliance with the patient's information and questions. Thus, the patient must be invited to participate in assessments and decisions concerning his or her own healthcare, in a credible manner and using everyday language.

The early chain of care and risk of death in acute stroke in relation to the priority given at the dispatch centre: A multicentre observational study.

BACKGROUND: The early chain of care is critical for stroke patients. The most important part is the so-called 'system delay' i.e. the delay time from call to the emergency medical services until a diagnosis is established (computer tomography). AIM: The purpose of this study was to relate the initial priority level given by the dispatch centre to the early chain of care in acute stroke and to short-term and long-term mortality. METHODS: All patients hospitalised with the first and the final diagnosis of acute stroke, 15 December 2010-15 April 2011, were recruited across nine hospitals, each hospital with a stroke care unit. RESULTS: In all, 897 stroke patients were included. Priority at the dispatch centre: 54% received highest priority 1, 41% priority 2 and 5% priority 3. Median system delay from call to emergency medical services until diagnosis by computer tomography was 2 h and 52 min, 4 h and 49 min and 6 h and 33 min respectively in the three priority groups ( p<0.0001). There was a similarly strong association between priority level at the dispatch centre and system delay to arrival in a hospital ward, suspicion of stroke by the emergency medical services nurse as well as the physician on hospital admission and the proportion of patients given thrombolysis. Mortality during the subsequent 30 days was 22% among patients with priority 1 and 14% among patients with priority 2. CONCLUSION: Patients given a lower priority level at the dispatch centre had the longest system delay. Although many of these patients died, the risk of death was highest among those given the highest priority.

Acute coronary syndrome in relation to the occurrence of associated symptoms: A quantitative study in prehospital emergency care.

INTRODUCTION: Acute chest pain is a common symptom among prehospital emergency care patients. Therefore, it is crucial that ambulance nurses (ANs) have the ability to identify symptoms and assess patients suffering from acute coronary syndrome (ACS). The aim of this study is to explore the occurrence of dyspnoea and nausea and/or vomiting in the prehospital phase of a suspected ACS and the associations with patients' outcome. METHODS: This study has a quantitative design based on data from hospital records and from a previous interventional study (randomised controlled trial) including five Emergency Medical Service (EMS) systems in western Sweden in the years 2008-2010. RESULTS: In all, 1836 patients were included in the interventional study. Dyspnoea was reported in 38% and nausea and/or vomiting in 26% of patients. The risk of death within one year increased with the presence of dyspnoea. The presence of nausea and/or vomiting increased the likelihood of a final diagnosis of acute myocardial infarction (AMI). CONCLUSION: This study shows that dyspnoea, nausea and/or vomiting increase the risk of death and serious diagnosis among ACS patients. This means that dyspnoea, nausea and/or vomiting should influence the ANs' assessment and that special education in cardiovascular nursing is required.

Effects of Di-isononyl Phthalate on Neuropeptide Y Expression in Differentiating Human Neuronal Cells.

Neuropeptide Y (NPY) is an abundant neuropeptide in the mammalian brain important for behavioural consequences of stress and energy metabolism. We have addressed possible effects of the phthalate DiNP on NPY expression in human SH-SY5Y cells, a neuronal in vitro differentiation model. Pico- to nanomolar doses of DiNP and its metabolite MiNP resulted in decreased NPY mRNA and peptide expression in retinoid-differentiated cells. Thus, dys-regulated NPY may be an adverse outcome for exposure to low doses of DiNP in human beings.