Managing the risks associated with technological disruption in the road transport system: a control structure modelling approach

Road transport is experiencing disruptive change from new first-of-a-kind technologies. While such technologies offer safety and operational benefits, they also pose new risks. It is critical to proactively identify risks during the design, development and testing of new technologies. The Systems Theoretic Accident Model and Processes (STAMP) method analyses the dynamic structure in place to manage safety risks. This study applied STAMP to develop a control structure model for emerging technologies in the Australian road transport system and identified control gaps. The control structure shows the actors responsible for managing risks associated with first-of-a-kind technologies and the existing control and feedback mechanisms. Gaps identified related to controls (e.g. legislation) and feedback mechanisms (e.g. monitoring for behavioural adaptation). The study provides an example of how STAMP can be used to identify control structure gaps requiring attention to support the safe introduction of new technologies.

Forecasting emergent risks in advanced AI systems: an analysis of a future road transport management system

Artificial Intelligence (AI) is being increasingly implemented within road transport systems worldwide. Next generation of AI, Artificial General Intelligence (AGI) is imminent, and is anticipated to be more powerful than current AI. AGI systems will have a broad range of abilities and be able to perform multiple cognitive tasks akin to humans that will likely produce many expected benefits, but also potential risks. This study applied the EAST Broken Links approach to forecast the functioning of an AGI system tasked with managing a road transport system and identify potential risks. In total, 363 risks were identified that could have adverse impacts on the stated goals of safety, efficiency, environmental sustainability, and economic performance of the road system. Further, risks beyond the stated goals were identified; removal from human control, mismanaging public relations, and self-preservation. A diverse set of systemic controls will be required when designing, implementing, and operating future advanced technologies.Practitioner summary: This study demonstrated the utility of HFE methods for formally considering risks associated with the design, implementation, and operation of future technologies. This study has implications for AGI research, design, and development to ensure safe and ethical AGI implementation.

From Anti-doping-I to Anti-doping-II: Toward a paradigm shift for doping prevention in sport

Doping remains an intractable issue in sport and occurs in a complex and dynamic environment comprising interactions between individual, situational, and environmental factors. Anti-doping efforts have previously predominantly focused on athlete behaviours and sophisticated detection methods, however, doping issues remain. As such, there is merit in exploring an alternative approach. The aim of this study was to apply a systems thinking approach to model the current anti-doping system for four football codes in Australia, using the Systems Theoretic Accident Model and Processes (STAMP). The STAMP control structure was developed and validated by eighteen subject matter experts across a five-phase validation process. Within the developed model, education was identified as a prominent approach anti-doping authorities use to combat doping. Further, the model suggests that a majority of existing controls are reactive, and hence that there is potential to employ leading indicators to proactively prevent doping and that new incident reporting systems could be developed to capture such information. It is our contention that anti-doping research and practice should consider a shift away from the current reactive and reductionist approach of detection and enforcement to a proactive and systemic approach focused on leading indicators. This will provide anti-doping agencies a new lens to look at doping in sport.

Aquatain® causes anti-oviposition, egg retention and oocyte melanization and triggers female death in Aedes aegypti

Background

In arboviral disease systems where the virus can be transmitted from male to female vectors and from one generation to the next, targeting the female (especially when she is gravid) can help alter the persistence of the virus in nature and its transmission. A typical example is Aedes aegypti, which has become unmanageable due to the development of insecticide resistance. Despite evidence that monomolecular surface films prevent the selection of genetic resistance, their potential in Aedes vector control remains largely unexplored.

Methods

We examined the oviposition, egg retention, oocyte melanization, and female mortality of the Cayman Islands strain of Ae. aegypti, using choice (balanced and unbalanced) and no-choice bioassays involving Aquatain® Mosquito Formulation (AMF; Aquatain Products Pty Ltd.), a polydimethylsiloxane–based liquid used for mosquito control.

Results

When presented with similar opportunities to oviposit in two sites treated with AMF and two other sites with untreated water (control), egg deposition rates were significantly higher in the untreated water sites than in the AMF-treated sites (P < 0.05). We also observed a matching pattern of egg deposition preference in environments with more options in terms of AMF-treated sites. Females laid significantly more eggs when water was the only available medium than when all sites were treated with AMF (P < 0.05). Also, significantly more mature eggs were withheld in the AMF no-choice environment than in the no-choice test involving only water (P < 0.05). Internal oocyte melanization was not observed in females from the oviposition arenas with the lowest AMF presence (equal-choice and water-based no-choice); in contrast, this physiological response intensified as the number of AMF-treated sites increased. Female death occurred at high rates in AMF-treated environments, and this response increased with the increasing presence of such egg deposition sites.

Conclusions

This study demonstrated that AMF acted as a deterrent signal to ovipositing Ae. aegypti and as an indirect adulticide. These results suggest that AMF may be a promising control tool against the dengue vector, and this warrants further evaluation under field settings.

Graphical Abstract

Exploring utilisation of the allied health assistant workforce in the Victorian health, aged care and disability sectors

Background

Allied health assistants (AHAs) support allied health professionals (AHPs) to meet workforce demands in modern healthcare systems. Previous studies have indicated that AHAs may be underutilised in some contexts. This study aims to identify factors contributing to the effective utilisation of AHAs across health, aged care and disability sectors and possible pathway elements that may optimise AHA careers in Victoria.

Methods

Using an interpretive description approach data collection included a workforce survey and semi structured interviews (individual and group). Data analysis included descriptive statistics, independent t-tests and thematic analysis. Participants included allied health assistants, allied health professionals and allied health leaders in the health, aged care or disability sectors; educators, managers or student of allied health assistance training; and consumers of Victorian health, disability or aged care services.

Results

The literature scan identified numerous potential barriers to and enablers of AHA workforce utilisation. A total of 727 participants completed the survey consisting of AHAs (n = 284), AHPs & allied health leaders (n = 443). Thirteen group and 25 individual interviews were conducted with a total of 119 participants. Thematic analysis of the interview data identified four interrelated factors (system, training, individual and workplace) in pre-employment training and workplace environments. These factors were reported to contribute to effective utilisation of the AHA workforce across health, aged care and disability sectors. Study findings were also used to create a conceptual diagram of potential AHA career pathway elements.

Conclusion

This study identified pre-employment and workplace factors which may contribute to the optimal utilisation of the AHA workforce across Victorian health, aged care and disability sectors. Further study is needed to investigate the transferability of these findings to national and global contexts, and testing of the conceptual model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07171-z.

Social Network Organization, Structure, and Patterns of Influence Within a Community of Transgender Women in Lima, Peru: Implications for Biomedical HIV Prevention

Understanding social network structures can contribute to the introduction of new HIV prevention strategies with socially marginalized populations like transgender women (TW). We conducted 20 semi-structured interviews and four focus groups (n = 32) with TW from selected social networks in Lima, Peru between May and July, 2015. Participants described layers of social influence from diverse actors in their social networks. The majority identified a close relative as their primary social support, with whom they confided secrets but avoided issues of transgender identity, sexuality, and sex work. Participants described close circles of TW friends with whom they shared information about gender identity, body modification, and sexual partners, but avoided issues like HIV. Community leadership included political leaders (who advocated for transgender rights) as well as social leaders (who introduced TW to hormone therapy, body modification, and commercial sex). Detailed analysis of TW social networks can contribute to implementation and acceptability of new HIV prevention technologies.

F2-isoprostanes affect macrophage migration and CSF-1 signalling

F₂-isoprostanes (F₂-IsoP) are formed in vivo via free radical peroxidation of arachidonic acid. Enhanced oxidative stress is implicated in the development of atherosclerosis in humans and F₂-IsoP have been detected in atherosclerotic plaque. Colony stimulating factor-1 (CSF-1) is essential to macrophage survival, proliferation and differentiation and has been detected in human atherosclerotic plaques. Accumulation of macrophages within the vascular wall is an important component of atherosclerosis but little is known about the effect of F₂-IsoP on the migration of these cells. Our aim was to examine the effect of free and lipid-bound 15-F_2t-isoprostane (15-F_2t-IsoP) on macrophage migration and investigate the signalling pathways involved. Mouse macrophages (cell line BAC1.2F5) were pre-incubated with 15-F_2t-IsoP (free, bound to cholesterol or monoacylglycerol or within oxidized phospholipid) and cell migration was assessed using chemotaxis towards CSF-1 in Boyden chambers. Migration was also measured using the wound healing assay with primary mouse bone marrow derived macrophages. We showed that 15-F_2t-IsoP dose-dependently inhibited BAC1.2F5 macrophage spreading and adhesion but stimulated their migration towards CSF-1, with maximum effect at 10 µM. Analysis of CSF-1 stimulated signalling pathways in BAC1.2F5 macrophages showed that phosphorylation of Akt, a key mediator of cell migration, and one of its regulators, the mTORC2 component, Rictor, was significantly decreased. In contrast, phosphorylation of the adhesion kinases, FAK and Pyk2, and the adhesion scaffold protein, paxillin, was enhanced after treatment with 15-F_2t-IsoP. Mouse bone marrow macrophages were transfected with FAK or Pyk2 small interfering RNA (siRNA) to examine the role of FAK and Pyk2 in 15-F_2t-IsoP signalling. Pyk2 silencing inhibited 15-F_2t-IsoP-induced reduction in cell area and phospho-paxillin adhesion numbers. The size distribution of adhesions in the presence of 15-F_2t-IsoP was also affected by Pyk2 silencing and there was a trend for Pyk2 silencing to reduce 15-F_2t-IsoP-stimulated macrophage migration. These results demonstrate that 15-F_2t-IsoP affects macrophage adhesions and migration, which are integral components of macrophage involvement in atherosclerosis.

Clinical prediction models to support the diagnosis of asthma in primary care: a systematic review protocol

Substantial over-diagnosis and under-diagnosis of asthma in adults and children has recently been reported. As asthma is mostly diagnosed in non-specialist settings, a clinical prediction model (CPM) to aid the diagnosis of asthma in primary care may help improve diagnostic accuracy. We aim to systematically identify, describe, compare, and synthesise existing CPMs designed to support the diagnosis of asthma in children and adults presenting with symptoms suggestive of the disease, in primary care settings or equivalent populations. We will systematically search Medline, Embase and CINAHL from 1 January 1990 to present. Any CPM derived for use in a primary care population will be included. Equivalent populations in countries without a developed primary care service will also be included. The probability of asthma diagnosis will be the primary outcome. We will include CPMs designed for use in clinical practice to aid the diagnostic decision making of a healthcare professional during the assessment of an individual with symptoms suggestive of asthma. We will include derivation studies, and external model validation studies. Two reviewers will independently screen titles/abstracts and full texts for eligibility and extract data from included papers. The CHARMS checklist (or PROBAST if available) will be used to assess risk of bias within each study. Results will be summarised by narrative synthesis with meta-analyses completed if possible. This systematic review will provide comprehensive information about existing CPMs for the diagnosis of asthma in primary care and will inform the development of a future diagnostic model.

Metabolic fate of dietary terpenes fromEucalyptus radiata in common ringtail possum (Pseudocheirus peregrinus)

Arboreal marsupials consume terpenes in quantities that are toxic to other mammals, indicating that they possess special detoxification mechanisms. The metabolic fate of dietary terpenes was studied in the common ringtail possum (Pseudocheirus peregrinus). Three animals were fedEucalyptus radiata leaf for 10 days. Leaf consumption increased over three days to an average steady state of about 10-15 mmol total terpenes per day. GCMS analysis identified six urinary terpene metabolites, which were dicarboxylic acids, hydroxyacids, or lactones. Another nine metabolites could only be shown to be terpene-derived but of unknown structure. The amounts excreted were estimated by GC-FID, using response factors based on carbon content. Total 24-hr excretion of terpene-derived metabolites increased to 6.2-7.6 mmol on days 5-10, while glucuronic acid excretion remained constant at about 1.5 mmol. No other conjugates of terpene metabolites were found. The strategy used by the possum to detoxify dietary terpenes seems to be to polyoxygenate the molecules forming highly polar, acidic metabolites that can be readily excreted. Conjugation is minimal, perhaps to conserve carbohydrate and amino acids.

High uptake of HPV immunisation in Scotland--perspectives on maximising uptake

In September 2008, Scotland introduced a national human papillomavirus (HPV) immunisation programme with bivalent HPV vaccine, to prevent cervical cancer. This school-based programme routinely vaccinates girls aged between 12 and 13 years. A catch-up campaign, running over three years, also began at this time, offering vaccination to all girls aged 13 years to under 18 years old. The HPV immunisation campaign presented challenges due to this vaccine being targeted to girls in school and older girls who had left school. Following a long and comprehensive planning process, this campaign was successfully implemented across Scotland, delivering high vaccine uptake of 91.4% for three doses of vaccine in the first year (September 2008 to August 2009) for the routine cohort and 90.1% in the second year (September 2009 to August 2010) for the routine cohort. We describe the planning process, challenges and implementation strategies employed to achieve this high uptake.

Alcohol consumption and driving intentions amongst hotel patrons

To examine the extent to which hotel patrons drink in excess of current health recommendations, and to identify risk factors for excessive drinking, hotel patrons were invited to participate in a survey of social drinking, which included a free breath test. Patrons were approached at 15 min. intervals, and 1000 subjects were studied. Amongst this group of hotel patrons interviewed, 1 in 2 had consumed alcohol in excess of the daily limit recommended by the National Health & Medical Research Council. One in 10 intending drivers had a BAC over the legal limit. Excessive drinking and drink driving appear to be prevalent amongst hotel patrons, and hotels should be targets for interventions designed to reduce these problems. For example, the National Guidelines for the Responsible Serving of Alcohol should be more widely practised.

Pharmacological characterization of 2-methyl-N-((2'-(pyrrolidin-1-ylsulfonyl)biphenyl-4-yl)methyl)propan-1-amine (PF-04455242), a high-affinity antagonist selective for κ-opioid receptors

2-Methyl-N-((2'-(pyrrolidin-1-ylsulfonyl)biphenyl-4-yl)methyl)propan-1-amine (PF-04455242) is a novel κ-opioid receptor (KOR) antagonist with high affinity for human (3 nM), rat (21 nM), and mouse (22 nM) KOR, a ∼ 20-fold reduced affinity for human μ-opioid receptors (MORs; K(i) = 64 nM), and negligible affinity for δ-opioid receptors (K(i) > 4 μM). PF-04455242 also showed selectivity for KORs in vivo. In rats, PF-04455242 blocked KOR and MOR agonist-induced analgesia with ID(50) values of 1.5 and 9.8 mg/kg, respectively, and inhibited ex vivo [(3)H](2-(benzofuran-4-yl)-N-methyl-N-((5S,7R,8R)-7-(pyrrolidin-1-yl)-1-oxaspiro[4.5]decan-8-yl)acetamide ([(3)H]CI977) and [(3)H](2S)-2-[[2-[[(2R)-2-[[(2S)-2-amino-3-(4-hydroxyphenyl) propanoyl]amino]propanoyl]amino]acetyl]-methylamino]-N-(2-hydroxyethyl)-3-phenylpropanamide ([(3)H]DAMGO) binding to KOR and MOR receptors with ID(50) values of 2.0 and 8.6 mg/kg, respectively. An in vivo binding assay was developed using (-)-4-[(3)H]methoxycarbonyl-2-[(1-pyrrolidinylmethyl]-1-[(3,4-dichlorophenyl)acetyl]-piperidine ([(3)H]PF-04767135), a tritiated version of the KOR positron emission tomography ligand (-)-4-[(11)C]methoxycarbonyl-2-[(1-pyrrolidinylmethyl]-1-[(3,4-dichlorophenyl)acetyl]-piperidine ([(11)C]GR103545) in which PF-04455242 had an ID(50) of 5.2 mg/kg. PF-04455242 demonstrated antidepressant-like efficacy (mouse forced-swim test), attenuated the behavioral effects of stress (mouse social defeat stress assay), and showed therapeutic potential in treating reinstatement of extinguished cocaine-seeking behavior (mouse conditioned place preference). KOR agonist-induced plasma prolactin was investigated as a translatable mechanism biomarker. Spiradoline (0.32 mg/kg) significantly increased rat plasma prolactin levels from 1.9 ± 0.4 to 41.9 ± 4.9 ng/ml. PF-04455242 dose-dependently reduced the elevation of spiradoline-induced plasma prolactin with an ID(50) of 2.3 ± 0.1 mg/kg, which aligned well with the ED(50) values obtained from the rat in vivo binding and efficacy assays. These data provide further evidence that KOR antagonists have potential for the treatment of depression and addiction disorders.

Treating ST elevation myocardial infarction by primary percutaneous coronary intervention, in-hospital thrombolysis and prehospital thrombolysis. An observational study of timelines and outcomes in 625 patients

OBJECTIVE

To describe the effects of implementing of a percutaneous coronary intervention (PPCI) service and compare the distribution of reperfusion therapies 12 months pre and post introduction of PPCI.

DESIGN

Observational study with data collected 12 months pre and post-availability of Primary PCI as routine treatment.

SETTING

Lothian region in South-East Scotland. Patients 625 Patients who received reperfusion treatment between December 2005 and November 2007.

RESULTS

PHT was given to 96/328 patients (29%) prior to availability of PPCI as routine treatment. Following routine availability, PPCI was delivered to 248/297 patients who received reperfusion treatment (84%). Median diagnosis-to-PCI balloon inflation time and hospital door-to-balloon time were 84 and 54 min, respectively. Patients received PPCI balloon inflation within 90 min of diagnosis in 60% of cases. PPCI-related delay was 74 min compared with prehospital thrombolysis (PHT). PHT (152 min) and PPCI (166 min) had shorter symptom onset-to-assessment of reperfusion times than in-hospital thrombolysis (IHT) (226 min).

CONCLUSIONS

More than two-thirds of the total-ischaemic-time in (ST-segment elevation myocardial infarction) STEMI occurs before the patient reaches hospital, with less than one-third being accounted for by door-to-needle (IHT) or door-to-balloon (PPCI) time. The magnitude of difference in the time between symptom onset-and-assessment of reperfusion treatment efficacy is short and should be considered, particularly in patients treated with thrombolysis in hospitals without cath-lab facilities. Optimal reperfusion treatment including a combination of PHT, IHT and PPCI, as recommended in international guidelines, is feasible in the UK although the balance between the use of different treatments will differ between urban and rural areas.

Promotion of responsible drinking in hotels

This study reports on an intervention programme to promote responsible drinking in hotels. The licensees of eight hotels agreed to participate in a trial of measures designed to assist patrons to avoid drink-driving, and seven other hotels were used as controls. The interventions acceptable to licensees comprised commercial-quality promotional material with the theme "0.05 Know Your Limits", and a breath analysis machine and poster on its use. Patrons leaving the hotels on Thursday, Friday and Saturday nights were interviewed and breath-tested. Although the intervention material had been seen by one-third of patrons in the intervention hotels, there was no significant difference between them and control hotel patrons in either median BAC or the proportion who were going to drive with BAC over the legal limit. There was poor compliance by hotels with the intervention procedures, indicating that a major impediment to the implementation and evaluation of programmes to promote responsible drinking is a lack of motivation by many licensees, despite support by some licensees and the Australian Hotels Association.

One for the road: On the utility of citation data for identifying problem hotels

Drink drivers arrested in Tasmania are routinely asked by police where they had last been drinking, and these data were examined for 716 drivers arrested in Southern Tasmania during a 4-month period in 1992. Nearly half (43%) of arrested drink drivers cited individual hotels as the place where they had last been drinking. This enabled a citation score to be assigned to each of the 82 hotels in metropolitan Hobart. The distribution of citation scores was highly skewed, with eight hotels accounting for 45% of hotel citations, and two accounting for 20%. The hotels' citation scores were compared in relation to the rank order of their licence fees, since better measures of patronage proved unobtainable. Some hotels with small total alcohol sales did appear to have an unexpectedly large number of citations, suggesting less than responsible serving practices. Hoteliers' comments were sought on the interpretation of citation scores, and incorporated into a discussion of the limitations of the data in determining the extent of individual hotel responsibility for drink drivers. Important questions remaining include (1) what is the validity of citations made by drink drivers at the time of arrest; (2) what appropriate and quantifiable denominator can be used to adjust the number of citations to the level of patronage; and (3) what level of citations is too high and requires action?

Trends in hotel patronage and drink driving in Hobart, Tasmania

From 1990 to 1991 in the Hobart region there was a marked fall in both hotel patronage and the proportion of patrons subsequently driving with their blood alcohol concentration above the legal limit. This was associated with smaller falls in the number of drink drivers charged and alcohol-related road accidents, which continued in the following year. It appears that the pattern of drinking and driving is changing, presumably in response to random breath testing and tougher penalties for offences.

Rac1 signaling regulates CTGF/CCN2 gene expression via TGFbeta/Smad signaling in chondrocytes

OBJECTIVE

Connective tissue growth factor (CTGF) has been implicated in regulation of chondrocyte differentiation at multiple steps and has been implicated in the progression of diseases such as scleroderma and osteoarthritis. However, the pathways mediating the expression of CTGF/CCN2 and related factors in cartilage are not fully understood. We have previously shown that the Rho family of proteins and the actin cytoskeleton regulate both early and late chondrocyte differentiation.

RESULTS

Here we demonstrate that several CTGF/Cyr61/Nov (CCN) family members are differentially affected by either inhibition of actin polymerization (cytochalasin D treatment), promotion of actin polymerization (jasplakinolide treatment), inhibition of RhoA/rho kinase (ROCK) signaling (Y27632 treatment) and Rac1 signaling. We also show that the Smad site in the CTGF/CCN2 promoter is responsive to both Rac1 inhibition and cytochalasin D treatment, suggesting a role of TGFbeta/Smad signaling in mediating the effects of actin dynamics and Rac1.

CONCLUSION

Collectively, these data show that Rac1 and actin pathways control CTGF/CCN2 expression in chondrocytes which might be relevant to both skeletal development and associated diseases such as osteoarthritis.

Hematological abnormalities in adult patients with Down's syndrome

BACKGROUND

There is a paucity of data regarding hematological abnormalities in adults with Down's syndrome (DS).

AIMS

We aimed to characterize hematological abnormalities in adult patients with DS and determine their long-term significance.

METHODS

We retrospectively studied a cohort of nine DS patients referred to the adult hematology service in our institution between May 2001 and April 2008. Data collected were: full blood count (FBC), comorbidities, investigations performed, duration of follow-up and outcome to most recent follow-up.

RESULTS

Median follow-up was 26 months (9-71). Of the nine patients, two had myelodysplastic syndrome (MDS) at presentation. Of these, one progressed, with increasing marrow failure, and requiring support with transfusions and gCSF. The remaining eight patients, with a variety of hematological abnormalities including leukopenia, macrocytosis, and thrombocytopenia, had persistently abnormal FBCs. However there was no evidence of progression, and no patient has evolved to acute myeloid leukemia (AML).

CONCLUSIONS

MDS is a complication of DS and may require supportive therapy. However, minor hematological abnormalities are common in adult DS patients, and may not signify underlying marrow disease.

Pharmacokinetics of 1,8-cineole, a dietary toxin, in the brushtail possum (Trichosurus vulpecula): Significance for feeding

1,8-Cineole (cineole) is a Eucalyptus leaf toxin that defends against predation by herbivores such as the brushtail possum (Trichosurus vulpecula). The aim of the current study was to characterize the pharmacokinetics of cineole in the possum to improve understanding about how possums can avoid cineole toxicity when eating a Eucalyptus diet. Nine male possums were trapped in the wild and acclimated to captivity; a subcutaneous port was then implanted for venous blood sampling. Cineole was administered intravenously (10 and 15 mg kg(-1)) via a lateral tail vein and orally (30, 100 and 300 mg kg(-1)) by gavage, and blood concentrations of cineole and its metabolites were determined by gas chromatography. Cineole had a large terminal volume of distribution (V(z) = 27 l kg(-1)) and a high clearance (43 ml min(-1) kg(-1)), equal to hepatic blood flow. The terminal half-life was approximately 7 h. Oral bioavailability was low (F = 0.05) after low doses, but increased tenfold with dose, probably due to saturable first-pass metabolism. These findings indicate that when possums feed on a cineole diet, they eat until the cineole consumed is sufficient to saturate pre-systemic metabolism, leading to a rapid rise in bioavailability and cineole blood levels, and a cessation of the feeding bout. This is the first report on the pharmacokinetics of a dietary toxin in a wild herbivore, and provides insights into the interactions between the blood concentration of a plant secondary metabolite and the browsing behaviour of a herbivore.

Collaborative decision-making between paramedics and CCU nurses based on 12-lead ECG telemetry expedites the delivery of thrombolysis in ST elevation myocardial infarction

OBJECTIVES

To describe a prehospital thrombolysis (PHT) and expedited inhospital thrombolysis (IHT) programme in south-east Scotland using prehospital 12-lead ECG recordings transmitted by telemetry and autonomous paramedic-administered thrombolysis with decision support being provided by coronary care nurses.

DESIGN

Retrospective observational study.

SETTING

Three hospitals in south-east Scotland covering a population of 778,468 served by 54 ambulance vehicles.

PATIENTS

11,840 patients who telephoned the ambulance service with "chest pain" over 20 months, during which 812 patients were admitted with ST segment elevation myocardial infarction (STEMI).

MAIN OUTCOME MEASURES

All calls and cardiac/potential cardiac calls to the ambulance service, type/time of patient presentation, symptoms/call/door-to-thrombolysis times.

RESULTS

Of the 11,840 calls to the ambulance service for chest pain over 20 months of the initiative, 60% were cardiac/potentially cardiac-related by Scottish Ambulance Service triage. ST segment elevation was present in 8% of the 5150 12-lead ECGs transmitted by paramedics to the ECG receiving station in the CCU. Over the 20 months, 812 patients were admitted to the three hospitals with STEMI and 71% received thrombolysis. Median symptom-to-thrombolysis times were 91, 148 and 184 min, respectively, in the PHT, telemetry-facilitated IHT and self-presenting IHT groups. Median call-to-needle time for the PHT group was 40 min. In 2/146 cases the cardiologists judged that the patient should not have been administered PHT.

CONCLUSIONS

Based on prehospital 12-lead ECG telemetry, it is possible for paramedics and CCU nurses to conduct live reperfusion decision-making in patients with STEMI, with resultant benefits in symptoms-to-thrombolysis time.