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Fibrinolysis is an acceptable treatment for acute ST-segment elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) cannot be performed within 120 minutes. The American Heart Association has recommended Emergency Medical Services (EMS) interventions such as prehospital fibrinolysis (PHF), prehospital electrocardiogram (ECG), and hospital bypass direct to PCI center. Nova Scotia, Canada has incorporated these interventions into a unique province-wide approach to STEMI care. A retrospective cohort analysis comparing the primary outcome of 30-day mortality for patients receiving either prehospital or emergency department (ED) fibrinolysis (EDF) to patients transported directly by EMS from community or regional ED for primary PCI was conducted.
This retrospective, population-based cohort study included all STEMI patients in Nova Scotia who survived to hospital admission from July 2011 through July 2013. Three provincial databases were used to collect demographic, 30-day mortality, hospital readmission, and rescue PCI data. The results were grouped and compared according to reperfusion strategy received: PHF, EDF, patients brought by ambulance via EMS direct to PCI (EMS to PCI), and ED to PCI (ED to PCI).
There were 1,071 STEMI patients included with 145 PHF, 606 EDF, 98 EMS to PCI, and 222 ED to PCI. There were no significant differences in 30-day mortality across groups (n, %): PHF 5(3); EDF 36(6); EHS to PCI <5(2); and ED to PCI 10(4); P = .28. There was no significant difference in patients receiving fibrinolysis who underwent rescue PCI.
Prehospital fibrinolysis incorporated into a province-wide approach to STEMI treatment is feasible with no observed difference in patient 30-day mortality outcomes observed.
Night-time confinement, locking patients in their bedrooms overnight, is practiced within high-secure hospitals in the UK. This article provides context, sets out the history and reviews the ethical and pragmatic issues at stake. Thought is given to the future, where we appear to be moving toward a different approach.
Declaration of interest
E.S. is a consultant forensic psychiatrist at Ashworth Hospital. All his patients are confined at night. He represents the Royal College of Psychiatrists Forensic Faculty at the National Oversight Group, which is the strategic advisory body providing assurance to NHS England regarding the commissioning and provision of high-secure services.
Continuous positive airway pressure (CPAP) is commonly used in the treatment of acute cardiogenic pulmonary edema (ACPE) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In-hospital evidence is robust: CPAP has been shown to improve respiratory status and to reduce intubation rates. There is less evidence on prehospital CPAP, although the emergency medical services (EMS) adoption of this modality is increasing. The objectives of this study were to 1) measure the effectiveness of prehospital CPAP on morbidity, mortality, and transport times; and 2) audit the selection of patients by medics for appropriateness and safety.
We conducted a before-and-after study from August 1 to October 31 in 2010 and 2011, before and after the implementation of prehospital CPAP in a city of one million people with large rural areas. Medics were trained to apply CPAP to patients with respiratory distress and a presumed diagnosis of ACPE or AECOPD. Charts were selected using the search criteria of the chief complaint of shortness of breath, emergent transport to hospital, and any patients receiving CPAP in the field. Data extracted from ambulance call reports and hospital records were analysed with appropriate univariate statistics.
A total of 373 patients enrolled (186 pre-non-invasive ventilation [NIV] and 187 post-NIV), mean age 71.5 years, female 51.4%, and final diagnoses of ACPE 18.9%, AECOPD 21.9%. In the post group of 84 patients meeting NIV criteria, 41.6% received NIV; and of 102 patients not meeting the criteria, 5.2% received NIV. There were 12 minor adverse events in 36 applications (33.3%) as per protocol. Comparing post versus pre, there were higher rates of emergency department (ED) NIV (20.0% v. 13.4%, p<0.0001) and higher overall mortality (18.8% v. 14.9%, p<0.0001). There were no differences in ED intubation (2.1% v. 2.3%, p<0.001) and length of stay (6.8 v. 8.7 days, p=0.24).
Despite the robust in-hospital data supporting its use, we could not find benefit from CPAP in our prehospital setting with respect to morbidity, mortality, and length of stay. EMS must exercise caution in making the decision to invest in the equipment and training required to implement prehospital CPAP.
Domain analysis has a well-documented history in peer reviewed academic literature; however there are few instances of its application to facilitate the assessment of system specific navigation risk. This paper details one example of a practical approach to domain analysis for a busy section of the River Thames in Central London. The results correlate well to known high risk collision areas on the river and help to quantify and corroborate expert opinion and local knowledge. However a number of conditions must be accounted for in undertaking a robust study such as the geography of the study site, the purpose and audience of the research, and the availability of data and its limitations.
Long-term care (LTC) patients are often sent to emergency departments (EDs) by ambulance. In this novel extended care paramedic (ECP) program, specially trained paramedics manage LTC patients on site. The objective of this pilot study was to describe the dispatch and disposition of LTC patients treated by ECPs and emergency paramedics.
Data were collected from consecutive calls to 15 participating LTC facilities for 3 months. Dispatch determinants, transport rates, and relapse rates were described for LTC patients attended by ECPs or emergency paramedics. ECP involvement in end-of-life care was identified.
Of 238 eligible calls, 140 (59%) were attended by an ECP and 98 (41%) by emergency paramedics. Although the top three determinants were the same in each group, the overall distribution of dispatch determinants and acuity differed. In the ECP cohort, 98 of 140 (70%) were treated and released, 33 of 140 (24%) had “facilitated transfer” arranged by an ECP, and 9 of 140 (6%) were immediately transported to the ED by ambulance. In the emergency paramedic cohort, 77 of 98 (79%) were immediately transported to the ED and 21 of 98 (21%) were not transported. In the ECP group, 6 of 98 (6%) patients not transported triggered a 911 call within 48 hours for a related clinical reason, although none of the patients not transported by emergency paramedics relapsed.
ECP involvement in LTC calls was found to reduce transports to the ED with a low rate of relapse. These pilot data generated hypotheses for future study, including determination of appropriate populations for ECP care and analysis of appropriate and safe nontransport.
Insects (Superclass Hexapoda) are arguably the most diverse and successful of all groups of animals. It is estimated that 20 million species could be living today (Jarzembowski & Ross, 1993) but only about 1.4 million have been described. They occupy all main environments except for those that are fully marine, and they have evolved many different feeding and defence strategies (Gullan & Cranston, 1994). Insects are susceptible to climate change, particularly temperature changes, and many are dependant on the plants on which they feed.
The fossil record of insects is based predominantly on their occurrence in non-marine (lacustrine and fluvial) sediments. They are usually preserved as isolated wings or rarely as complete insects. The wings of different groups of insects have a distinct venation which provides characters to enable their identification and classification. The Cretaceous and Tertiary insect record is supplemented by their remarkable preservation in amber.
The richness of the fossil record of insects has only begun to be realized in the last few years with the publication of three main databases. Two of these are of insect families that occur in the fossil record (Ross & Jarzembowski, 1993: updated in Jarzembowski & Ross, 1996; Labandeira, 1995). The third is a database of genera (Carpenter, 1992), although unfortunately this only contains data up to the end of 1983 and it is now out of date. Since 1983, an additional 500 families and roughly 1 000 genera have been recorded as fossils.
On 24 September 1997 the Criminal Justice Commission (CJC) released a comprehensive report entitled Integrity in the Queensland Police Service: Implementation and Impact of the Fitzgerald Inquiry Reforms, in line with its statutory obligation to report to Parliament on the implementation of the recommendations of the Inquiry. Earlier reports have examined the implementation of the Inquiry's recommendations relating to recruitment and training and the restructuring of the police service (see CJC 1993, 1994). This most recent report addresses issues such as whether the Fitzgerald reforms have enhanced the effectiveness of the complaints investigation process, led to improved standards of behaviour within the Queensland Police Service (QPS), reduced the incidence of corruption and weakened the influence of the police ‘code of silence’. In addition to providing a retrospective assessment of the ‘Fitzgerald reforms’, the report identifies key areas where further action is required by the QPS and provides a reference point against which to measure future progress. This article summarises the key findings of the report and briefly discusses the implications for further reform of the QPS and the role of the CJC in that process.