Publications

INTRODUCTION: Vitamin D deficiency can impact health and well-being and may affect workplace performance. Shift, indoor and night working, alongside variable awareness of vitamin D, likely puts ambulance staff at an increased risk of deficiency. Screening in one ambulance service detected that 46% of staff had insufficient or deficient vitamin D levels (i.e. 50.0 nmol/L or less, as defined by NICE). The aim of the EVOLVED study was to explore the behaviours and lifestyle factors of ambulance service staff with a range of vitamin D levels and understand the impacts on their work and personal lives.

METHODS: A purposive sample of 40 ambulance staff was recruited over four months and invited to a one-hour online semi-structured interview. Interviews explored behaviours and lifestyle factors of those above and below the recommended adequate vitamin D levels and included questions about the impacts of vitamin D level on personal and professional well-being, with the opportunity to suggest possible improvements. Interview transcription analysis was undertaken using an intuitive thematic analysis strategy.

RESULTS: Participants were aged between 21 and 69 years and worked in varying roles, including control room (n = 9), operational (n = 20) and support staff (n = 11) and included those from diverse ethnic backgrounds to represent Trust demographics. Five themes were identified: reaction to result; diet; deficiency symptoms and impacts; impact of work on maintaining adequate vitamin D levels; and activity levels.

CONCLUSION: A lack of awareness of vitamin D-related issues was identified, alongside a variety of improvement suggestions, including participants emphasising the importance of awareness, to allow staff to take responsibility to promote their own health and well-being. Strategies to promote awareness of vitamin D should be considered to improve staff well-being in this area. Participants positively perceived research exploring staff health and well-being, highlighting this as an area for future research.

INTRODUCTION: 'Deaths of despair' (DoD) - encompassing fatalities from suicide, drug overdoses and alcohol-related causes - represent a growing public health crisis. Socioeconomic vulnerability and healthcare disparities are well-documented drivers of DoD. While healthcare contacts preceding despair-related deaths have been studied extensively, the role of ambulance services is underexplored. This study aimed to address this gap by utilising ambulance service data to provide insights into 'calls of despair' received by a UK ambulance service over a 12-month period.

METHODS: This exploratory, retrospective study analysed data collected during 2023 by Yorkshire Ambulance Service (YAS), which serves urban and rural areas with varying levels of deprivation. Calls were included if they involved suicidal ideation and/or drug or alcohol misuse. Data were sourced from computer-aided dispatch and electronic patient records and were analysed to describe call characteristics, demographic profiles, geographical distribution, temporal trends and repeat caller patterns.

RESULTS: In 2023 YAS received 40,870 calls of despair. Nearly half of those calls originated from the most deprived quintile. Urban areas had more than double the rate of calls compared to rural areas. More than half (54%) of the calls involved drug and alcohol misuse, while 43% were related to suicidal ideation. Females were more likely to call for substance misuse (58%) than suicide (46%), and young females (<25 years) represented a disproportionate share of calls. Only 43% of calls resulted in hospital conveyance, suggesting ambulance services capture crises that are not reflected in hospital datasets. Repeat callers were common, with 119 individuals making more than 10 calls each.

CONCLUSION: The findings highlight the utility of ambulance service data in understanding despair-related crises, particularly among socioeconomically disadvantaged and young populations. Ambulance data offers a valuable lens for public health monitoring, capturing acute needs often absent in traditional healthcare datasets. These insights emphasise the need for targeted interventions and cross-sectoral approaches to address the underlying drivers of despair.

INTRODUCTION: In the United Kingdom, ambulance services attempt resuscitation on 30,000 people per year, with fewer than 9% surviving and leaving hospital. Correct ventilation during out-of-hospital cardiac arrest (OHCA) is essential, as both hypo- and hyperventilation are linked to increased mortality. Despite this, ventilations are frequently given outside of recommended guidelines. Devices providing real-time feedback on ventilations aim to improve performance. While systematic reviews show that real-time feedback devices improve chest compression performance, evidence regarding ventilation feedback devices (VFDs) has not yet been synthesised. This literature review aimed to synthesise evidence on the effects of VFDs in OHCAs.

METHODS: Databases searched in March 2025 included MEDLINE, CINAHL and Embase. Inclusion criteria were papers published after 1 January 2018, in English, involving adults, focused on clinical practice or simulated OHCA and employing primary research with interventional study designs. The intervention criteria required a VFD that measured and provided feedback on both tidal volume and ventilation rate. Study quality was assessed using the Critical Appraisal Skills Programme checklist. Methods for synthesis included a narrative summary of findings.

RESULTS: The searches yielded 793 results. Nine studies met the inclusion criteria: seven simulation studies and two real-world studies. Simulation studies confirmed that ambulance clinicians often did not meet advanced life support guidelines for ventilations. Introducing VFDs significantly improved compliance, accuracy and precision of delivered ventilations in simulated OHCA scenarios. Real-world studies found an increase in ventilation compliance; however, the study examining patient outcomes was of low quality and did not find a statistically significant effect.

CONCLUSION: The evidence suggests that VFDs are beneficial in simulated OHCA. Real-world studies suggest that the increase in ventilation performance may not be as significant as shown in simulation studies, and their effect on clinical outcomes has not yet been adequately explored.

INTRODUCTION: Previous investigations reveal that protracted resuscitative efforts are associated with poorer long-term patient outcomes. Aside from certain patient characteristics and interventions, such as shockable rhythms, bystander CPR and early defibrillation, little is known about factors influencing resuscitation duration and time to return of spontaneous circulation (ROSC). We hypothesised that early public safety answering point (PSAP) call-receipt-to-pressor (PSAP-to-pressor) administration would decrease the pressor-to-ROSC interval and shorten low-flow duration. Our objective was to quantify the relationship between the PSAP-to-pressor and pressor-to-ROSC intervals.

METHODS: We conducted a retrospective analysis using the 2020 ESO dataset containing calls from January to December 2020. Adults with non-traumatic, bystander-witnessed arrests were included. A Cox proportional hazard model was used to determine the association between PSAP-to-pressor interval and pressor-to-ROSC interval while controlling for potential confounders. The end of the event was defined as ROSC, field termination of resuscitation or hospital arrival without ROSC. Patients without ROSC upon hospital arrival were right censored.

RESULTS: Overall, 10,093 patients had data sufficient for analysis. The mean age of the participants was 65.3 (±15.5) years and 64.5% were male. Presumed cardiac aetiology was present in 83.7% of arrests, 29.4% presented with a shockable rhythm and 35.9% attained ROSC. The mean PSAP-to-pressor and pressor-to-ROSC intervals were 16.2 (±5.0) and 14.6 (±11.1) minutes, respectively. The mean time from the first adrenaline administration to the end of the event was 32.7 (±1.0), 41.5 (±1.2) and 51.6 (±3.8) minutes for the 0-10-, 11-20- and 21-30-minute PSAP-to-pressor intervals, respectively (p <0.001). After controlling for confounders, the PSAP-to-pressor time interval was associated with decreased likelihood of ROSC (HR = 0.97 per minute, p <0.001). When stratified by 10-minute increments with 0-10 minutes as reference, PSAP-to-pressor was negatively associated with ROSC for the 11-20- (HR = 0.86, p = 0.002) and 21-30- (HR = 0.66, p <0.001) minute categories.

CONCLUSION: This retrospective analysis from a national database revealed that increasing delays to first adrenaline administration were associated with prolonged resuscitation duration after drug administration and decreasing likelihood of ROSC.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) remains a major cause of mortality in the UK, with survival rates remaining low despite advancements in resuscitation techniques. The European Resuscitation Council and Resuscitation Council UK guidelines recommend controlled ventilation during cardiopulmonary resuscitation (CPR), yet studies show that ambulance clinicians often fail to meet these standards. In particular, hyperventilation has been linked to worse outcomes. This protocol describes a study that will explore the impact of different applications of real-time ventilation feedback on the quality of ventilations during CPR in a simulated environment.

METHODS: This exploratory simulation study will assess the effectiveness of real-time feedback on the quality of ventilations delivered by ambulance clinicians. Participants from North East NHS Foundation Trust will be randomly assigned to three arms, receiving a single episode of feedback, regular feedback or no feedback (used as a control group). Each arm will complete four simulated OHCA scenarios over six months, and their ventilation quality will be assessed at each session. The primary outcome will be the quality of ventilations, measured by rate and tidal volume, at the six-month mark. Secondary outcomes include trends in ventilation quality over time and participant characteristics.

DISCUSSION: This study aims to explore whether regular feedback improves the quality of ventilations during CPR and whether feedback sessions influence skill retention over a six-month period. Findings could inform training strategies, highlighting the role of real-time feedback in maintaining high-quality CPR skills. With a lack of prior research on ventilation skill maintenance in the UK, this study is expected to provide valuable insights into optimising clinical performance.

Individuals with homonymous hemianopia (HH) may benefit from adopting compensatory crossing and scanning strategies to successfully cross streets. In this study, we explored the effect of HH on street crossing outcomes, crossing behavior and scanning behavior in a virtual environment. Individuals with real HH (N = 18), unimpaired vision (N = 18), and simulated HH (N = 18) crossed a virtual street displayed through a head-mounted display. Virtual cars approached from both directions, traveling at a speed of either 30 or 50 km/h. Participants' crossing and scanning behaviors were recorded and analyzed across groups and the two car speeds. Although individuals with real and simulated HH took more time to cross compared to individuals with unimpaired vision depending on the car speed, the number of collisions and time-to-contact after crossings did not differ between groups. We observed no differences in the selection of car gaps, crossing initiation, and scanning behavior between groups. Our findings suggest that individuals with real and simulated HH align their crossing behavior to their visuomotor capabilities by using varying compensatory strategies. HH did not alter scanning behavior before crossing a virtual street. Despite its current shortcomings, virtual reality holds promise for street crossing research and rehabilitation.

PURPOSE: The purpose of this study was to investigate the development of contrast sensitivity function (CSF) in children with intermittent exotropia (IXT) over 1 year and to explore the impact of surgical realignment on CSF.

METHODS: A prospective study of 45 patients with IXT (aged 7-13 years) were matched with 30 healthy controls. Patients with IXT were categorized into the surgery group (n = 25) and the observation group (n = 20). Comprehensive ophthalmic examinations, including binocular and monocular CSF (measured by CSV-1000E), stereoacuity, and sensory fusion, were performed at baseline and the 1-year follow-up.

RESULTS: At baseline, the IXT surgery group exhibited significantly worse area under the log contrast sensitivity function (AULCSF) and contrast sensitivity (CS) at several spatial frequencies (SFs) compared with the controls (P < 0.05). After 1 year, the control group demonstrated significant improvement in binocular AULCSF and CS at 3, 12, and 18 cycles per degree (cpd; P < 0.05). The surgery group showed significant gains in binocular AULCSF, CS at 3 cpd, and 18 cpd (P < 0.05), whereas the observation group exhibited no significant changes in any metric (P > 0.05). Three-way analysis of covariance (ANCOVA), adjusting for baseline CS, revealed significant main effects of the group, SF, and eye condition on CS change (all P < 0.001), with no significant interactions. Post hoc comparisons showed that the control group had the greatest improvement, followed by the surgery group; whereas the observation group remained lowest across most metrics.

CONCLUSIONS: CSF is significantly impaired in children with IXT. The IXT may disrupt the normal development of contrast processing in children, whereas surgical realignment can partially reverse these effects. CSF assessment may provide valuable adjunctive information for the clinical management of pediatric IXT.

Augmented reality (AR) aims to combine elements of the surrounding environment with additional virtual content into a combined viewing scene. Displaying virtual human faces is a widespread practical application of AR technology, which can be challenging in optical see-through AR (OST-AR) because of limitations in its color reproduction. Specifically, OST-AR's additive optical blending introduces transparency and color-bleeding, which is exacerbated especially for faces having darker skin tones, and for brighter and more chromatic ambient environments. Given the increasing prevalence of social AR applications, it is essential to better understand how facial color reproduction is impacted by skin tone and ambient lighting in OST-AR. In this study, a psychophysical experiment was conducted to investigate how participants adjusted colorimetric dimensions of OST-AR-displayed faces to match the color of the same faces viewed on a conventional emissive display. These adjustments were made for faces having six different skin tones, while under different simulated ambient luminance ("low" vs. "high") and chromaticity (warm, neutral, cool). Additionally, participants rated their adjustments for overall appearance match and preference. The results indicate that the magnitude and specific dimensions of colorimetric adjustments needed to make matches varied across skin tones and ambient conditions. The current work is expected to facilitate virtual human face reproduction in AR applications and to foster more equitable and immersive extended reality environments.

BACKGROUND: Enabling women with breast cancer to actively participate in their care requires a better understanding of the interplay between contextual factors and mediators. This research explored the determinants of supportive care experiences for women living with breast cancer in rural communities of British Columbia.

METHODS: The study used a quantitative, descriptive, cross-sectional design. A survey regarding demographic, health, decision support, and breast cancer supportive care experiences was administered to 100 participants.

RESULTS: The combination of being less than 40 years old, having an undergraduate education, and being three to five years post-diagnosis is associated with higher (more positive) total survey scores. A linear combination of undergraduate school and health problems post-treatment showed higher medical treatment scores, with R2 = 23%.

CONCLUSION: The findings emphasize the growing need for psychosocial and emotional supportive care for cancer survivors. The results highlight the potential benefits of informed decision-support tools to fortify supportive care, emphasizing the need to facilitate better supportive care services for women battling breast cancer.

RECOMMENDATION: Supportive care plays a crucial role in guiding individuals' experiences with cancer through the healthcare system. Increasing supportive care centres, especially in rural areas, could improve patient-reported outcomes, and experiences, and ensure timely access to care.