Ziad Nehme

Objectives: Adolescent alcohol consumption has declined across many high-income countries since the early 2000s, yet it remains unclear whether these reductions have led to less alcohol-related harm, particularly among higher-risk groups. Methods: Using the National Ambulance Surveillance System, we examined ambulance attendances for alcohol intoxication among adolescents (10–19 years) in Victoria, Australia, from January 2012 and December 2023. Multivariable regression, stratified by gender, assessed monthly changes in attendance rates per 10 000 by remoteness, adjusting for seasonality and COVID-19 lockdowns. Results: A total of 25 928 attendances were recorded. A small but significant monthly decline in alcohol intoxication ambulance attendance was observed among males in major cities (B = −0.01 [0.01], P < .001). No significant trends were identified for males in regional areas or for females in metropolitan or regional areas. Conclusion: Despite declining adolescent alcohol consumption, intoxication-related ambulance attendances have remained largely stable over the past decade. The modest decline among males in metropolitan areas was considerably smaller than survey-reported declines in consumption, suggesting that population surveys capture different drinking patterns than those leading to acute harms. These findings highlight the need for ongoing monitoring and targeted prevention strategies, particularly for high-risk subgroups and regional populations.

Postcardiac arrest syndrome is a complex multisystem disorder that evolves after return of spontaneous circulation and remains a major determinant of morbidity and mortality following out-of-hospital cardiac arrest. Beyond anoxic brain injury and transient myocardial dysfunction, many patients develop a systemic ischemia/reperfusion response with endothelial and microvascular dysfunction, vasoplegia, and immune dysregulation—features that contribute to shock and organ failure. Hemodynamic instability is often mixed with low systemic vascular resistance despite preserved or recovering cardiac output, but management is still largely supportive and centered on achieving a target mean arterial pressure. An increasing understanding of the central role of inflammation, including gastrointestinal barrier disruption, cytokine release, complement activation, nitric oxide–cGMP signaling, and immune phenotypic heterogeneity has prompted evaluation of targeted adjunctive therapies. However, randomized trials of immunomodulators and other vasoactive strategies have yielded mixed results, reflecting biological heterogeneity and limited phenotypic stratification. This review synthesizes contemporary understanding of the inflammatory and hemodynamic mechanisms underpinning postcardiac arrest syndrome, examines current and emerging pharmacologic strategies, and highlights priorities for future investigation, including mechanistic phenotyping, prospective biobanking, and prospective trial requirements to guide more precise management strategies in postcardiac arrest care.

Background: Timely recognition and response to acute coronary syndrome (ACS) by emergency medical services is critical to reducing delays and improving outcomes. This study examines whether emergency medical services identification, care, and times (the interval from emergency medical services call to hospital arrival) differ by culturally and linguistically diverse (CALD) background among patients with ACS. Methods: We conducted a retrospective cohort study using ambulance data linked with the Department of Health's hospital data sets (January 2015–June 2019). The CALD group comprised individuals born in non–English‐speaking countries or who preferred to speak a language other than English (LOTE). Based on preferred language, the CALD group was stratified as CALD‐LOTE versus CALD‐English. Results: Of the 28 557 ACS cases, 30.2% were CALD immigrants: 9.5% CALD‐LOTE and 20.7% CALD‐English. Chest pain was the most common chief complaint (69.1%) but was lowest among CALD‐LOTE patients (59.4%) (CALD‐English=68.6%, Australian born=70.8%). Time‐critical ambulance dispatch (lights and sirens) was not statistically different across groups, but paramedic ACS identification was lower in CALD‐LOTE than in Australian‐born patients (57.2% versus 69.0%; adjusted odds ratio=0.84 [95% CI, 0.76–0.92]). CALD‐LOTE and CALD‐English patients had higher rates of direct transfer to percutaneous coronary intervention–capable hospitals compared with Australian‐born patients with ACS. Emergency medical services times were not statistically different in metropolitan areas but were marginally longer in rural areas among CALD patients than among non‐CALD patients (67.5 versus 63.7 minutes; P =0.02). Conclusions: Despite lower ACS identification by paramedics, CALD‐LOTE patients were more often transported to percutaneous coronary intervention–capable hospitals. Given the implications of missed early identification of ACS for outcomes, further research is needed to understand this variation and to inform tailored strategies for improvement.

Background: Atrial fibrillation is a leading cause of emergency medical services (EMS) use, but sex differences across prehospital, hospital, and postdischarge care remain poorly characterized. Methods: We performed a population‐based linked cohort study of adults attended by EMS for atrial fibrillation in Victoria, Australia, from January 1, 2015, to June 30, 2019. EMS records were linked to emergency department, hospital admission, and death data sets. Multivariable models evaluated sex differences in care and outcomes. Results: Among 16 415 atrial fibrillation EMS attendances, 9329 (56.8%) were in women, median age 76 years. Age‐standardized attendance rates were higher in women (77 versus 57 per 100 000 person‐years; incidence rate ratio, 1.35 [95% CI, 1.33–1.38]), especially in metropolitan areas and adults aged ≥70 years. Women had lower odds of prehospital treatment (56% versus 62%; adjusted odds ratio [aOR], 0.85 [95% CI, 0.79–0.92]) and mobile intensive care paramedic attendance (aOR, 0.85 [95% CI, 0.78–0.93]). Presentation‐conditioned aspirin and appropriate analgesia did not differ by sex. Women had fewer cardioversions (aOR, 0.79 [95% CI, 0.70–0.89]) but similar ablation rates (aOR, 0.95 [95% CI, 0.83–1.10]), higher 30‐day and 6‐month EMS reattendance (adjusted hazard ratios [aHRs], 1.29 and 1.35), and lower 30‐day and long‐term mortality (aHRs, 0.83 and 0.71). Conclusions: Women attended by EMS for atrial fibrillation had lower global prehospital treatment, higher reattendance, and lower mortality than men, supporting standardized prehospital pathways and rapid‐access follow‐up.

Objective: To compare epidemiology, treatment pathways and outcomes for patients attended by emergency medical services (EMS) for atrial fibrillation (AF) and transported to public versus private hospitals within a universal healthcare system. Methods: Population-based cohort study using linked ambulance, emergency department, hospital admission and mortality data in Victoria, Australia (January 2015 to June 2019). We included adult EMS attendances for AF with successful linkage and compared invasive cardiac procedures (coronary angiography, cardioversion and catheter ablation) during the index admission and follow-up as well as subsequent EMS reattendance and all-cause mortality using multilevel-adjusted regression models. Results: Among 16 415 EMS attendances for AF, 14 526 (88%) were transported to public hospitals. Public hospital patients were older (median 78 vs 73 years) and more socioeconomically disadvantaged (24.5% vs 11.5% in the most disadvantaged quintile). The age-standardised incidence of EMS-transported AF was higher for public hospitals (121 vs 14 per 100 000 person-years). After adjustment, public hospital patients were less likely to undergo coronary angiography (adjusted OR (aOR) 0.29, 95% CI 0.23 to 0.36), catheter ablation (aOR 0.08, 95% CI 0.04 to 0.18) or cardioversion (aOR 0.47, 95% CI 0.36 to 0.63) during the index admission; disparities persisted during follow-up. Public hospital patients were more likely to have EMS reattendance within 30 days (adjusted HR (aHR) 1.56, 95% CI 1.09 to 2.24) but had lower adjusted long-term mortality over a median follow-up of 1.57 years (IQR 0.67 to 2.93; aHR 0.80, 95% CI 0.72 to 0.88). Conclusions: In a universal healthcare system, hospital sector after EMS transport for AF was associated with substantial differences in procedural care and recurrent ambulance utilisation. These findings highlight sector-based variation in access to rhythm-control interventions and postdischarge pathways.

Background Atrial fibrillation (AF) is a major contributor to the Australian healthcare burden, requiring frequent use of emergency medical services (EMS) and hospitalisations. The Safe Treatment of Atrial Fibrillation in the CommunitY (STAY) pilot study aimed to assess the feasibility and safety of an integrated, community-based model of care for low-risk patients presenting to EMS with acute AF. Methods Between December 2021 and June 2024, we enrolled low-risk patients aged ≥18 years with acute AF. After paramedic clinical assessment and a 12-lead ECG, AF and low-risk status (defined as the absence of cardiorespiratory compromise and recent bleeding) were confirmed by a cardiologist prior to enrolment. Patients were treated with metoprolol and/or rivaroxaban where appropriate and transitioned to virtual care and rapid-access AF (AFX) clinics, avoiding transport to ED. Primary outcomes were time to definitive specialist care and hospital admission or death within 30 days. Results Of 573 patients with AF, 445 (78%) were at low risk and suitable for the STAY model of care; 57 (12%) were recruited. Paramedics administered metoprolol to 54% and rivaroxaban to 40% without adverse effects. 41 patients received virtual care video-telehealth consultations and 55 patients attended an AFX clinic with a mean wait time of 3.1±2.6 days. The wait for either virtual care or an AFX clinic was 1.1±1.6 days. At 30 days, there were no deaths, and hospital admission had occurred in three patients (5%). Conclusions In our pilot study, integrated community-based care was feasible for managing low-risk patients with AF. There was no requirement for patient transport or ED evaluation; access to specialist care was rapid and subsequent hospitalisation was uncommon. Community-based care was implemented without impacting patient safety. The STAY model of care requires further assessment to assess its potential for application at scale to reduce the burden of AF and to provide streamlined community-based care.