A Strained 9-1-1 System and Threats to Public Health

The goal of this study was to understand safety climate in the United States (U.S.) fire service, which responded to more than 31 million calls to the 9-1-1 emergency response system in 2013. The majority of those calls (68 %) were for medical assistance, while only 4 % of calls were fire-related, highlighting that the 9-1-1 system serves as a critical public health safety net. We conducted focus groups and interviews with 123 firefighters from 12 fire departments across the United States. Using an iterative analytic approach supported by NVivo 10 software, we developed consensus regarding key themes. Firefighters concurred that the 9-1-1 system is strained and increasingly called upon to deliver Emergency Medical Services (EMS) in the community. Much like the hospital emergency department, EMS frequently assists low-income and elderly populations who have few alternative sources of support. Firefighters highlighted the high volume of low-acuity calls that occupy much of their workload, divert resources from true emergencies, and lead to unwarranted occupational hazards like speeding to respond to non-serious calls. As a result, firefighters reported high occupational stress, low morale, and desensitization to community needs. Firefighters' called for improvements to the 9-1-1 system-the backbone of emergency response in the U.S.-including better systems of triage, more targeted use of EMS resources, continuing education to align with job demands, and a strengthened social safety net to address the persistent needs of poor and elderly populations.

A behavioral economics intervention to encourage epinephrine-carrying among food-allergic adults: a randomized controlled trial

BACKGROUND

Adolescents and young adults with food allergies are at increased risk of adverse events, including death from anaphylaxis. Epinephrine is the cornerstone of emergency response, yet few individuals with serious food allergies consistently carry their emergency medication. Behavioral economics offers promising, previously untapped opportunities for behavior change in this arena.

OBJECTIVE

To test the effectiveness of modest financial incentives in promoting the carrying of epinephrine and to evaluate the acceptability of text messaging for delivering reminders and key health messages to young adults with food allergies.

METHODS

A mixed-methods randomized controlled trial in young adults with food allergies investigated the carrying of epinephrine auto-injectors using financial incentives plus text message reminders vs text message reminders alone. Epinephrine carriage was assessed 10 times during the 49-day intervention using rapid-reply cell phone photographs plus daily code words.

RESULTS

The intervention (financial incentive) group had their epinephrine auto-injectors at 54% of check-ins vs 27% of check-ins in the control (text-only) group (P = .023). Participants in the 2 groups consistently reported favorable impressions of text messaging as a desirable, unobtrusive way to receive information and support for food allergy management.

CONCLUSION

Although the intervention and control groups reported favorable impressions of text message-based reminder systems, the intervention group performed significantly better than the control group on a photograph-based measurement of epinephrine carriage. There remained ample room for improvement in the 2 groups given the goal of consistent, uninterrupted epinephrine carriage by people with potentially life-threatening food allergies.

TRIAL REGISTRATION

https://clinicaltrials.gov; NCT02354729.

Modelling and experimental validation of Textile Pockets based active inflatable device

This paper aims with the mathematical modelling of an active inflatable device. This device is composed of a compressor, an Electro-pneumatic Pressure Converter (EPC) and an Inflatable Textile fabric Pocket (ITP). The later has interesting mechanical properties and is fabricated using Jacquard knitting technique which allows automatic production of unlimited varieties of pattern weaving without any mould. Thanks to these features, these ITPs have provided a better alternative to the classical airbags made by stretchable polymer material. The proposed mathematical model is obtained by combining sub-models of two main parts of the whole system. In this way, a generalised and flexible model is obtained which can easily take into consideration the ITPs of different shapes. The pressure dynamics inside the ITP are considered by taking into account the air flow rate, variation of the volume of ITP and the length of pneumatic lines joining ITP with compressed air source. The parameters of the whole mathematical model are obtained via identification techniques. The effectiveness of the model is assessed through several experimental tests with the help of a servo hydraulic fatigue testing machine.

Parameter Estimation of a Hyperelastic Constitutive Model for the Description of Polyurethane Foam in Large Deformation

Polyurethane foam is widely used in such areas as the automotive industry and sport, and in the field of packaging because of its low stiffness, high compressibility and its ability to absorb strain energy. The quasi-static behaviours of polyurethane foam are highly nonlinear and elastic. This paper demonstrates that the nonlinear elastic mechanical behaviour of compressible polyurethane foam during the loading and unloading quasi-static compression tests can be described by applying Ogden's modified model. The experimental data from a uniaxial compression of three types of polyurethane foam in three different strain rates are used for parameter identification. A nonlinear optimization method helps to ensure that the parameters are satisfied with stability conditions. Thanks to the optimized parameter results, the numerical simulations agree with the experimental data. Finally, the errors between the model results and the experimental results are analyzed and the unloading phases are discussed in detail.

Quasi-static behavior identification of polyurethane foam using a memory integer model and the difference-forces method

Flexible polyurethane foam is widely used in numerous comfort applications such as automotive seat cushions and mattresses. It would be interesting to design a mechanical model which describes the behavior of this material in a series of test conditions. This study is devoted to the modeling of the quasi-static behavior of polyurethane foam using a memory integer model. Polyurethane foam undergoing large compressive deformation exhibits highly nonlinear elasticity and a viscoelastic behavior. The memory integer model describes the nonlinearity in a polynomial function and the viscoelasticity through a convolution function. Uniaxial compression tests help to identify the mechanical parameters of the model. The difference between the force responses of foam in load and unload phases constitute the base element of the method used in this article. Numerous precautions are taken into account to obtain accurate results which verify the thermodynamic conditions. Finally, the reliability as well as the limits of the memory integer model are discussed.

Evolution of the role of the transplant pharmacist on the multidisciplinary transplant team

Transplant pharmacists have been recognized as an essential part of the transplant team by their colleagues along with several governing and professional organizations. The specific education, training and responsibilities of the transplant pharmacist have not been clearly delineated in the literature. Various pharmacists across the country have been called upon to serve on the transplant team necessitating standardization of their fundamental and desirable activities. Therefore, the purpose of this manuscript is to describe the training and role of a transplant pharmacist on the patient care team and provide a roadmap to implementation of novel transplant pharmacy services.

Geometric and postural analysis of mild idiopathic scoliotic patients

Understanding the aggravation process of mild idiopathic scoliosis is still a challenge. The aim of this study is to investigate the spine and pelvis configuration with regard to gravity line using 3D reconstruction coupled with foot pressure measurements. The distance between each vertebral center and the gravity line is calculated in order to observe the global equilibrium of spine. A protocol has been set and used for 10 mild idiopathic scoliotic patients. 34 asymptomatic volunteers who were previously observed with the same protocol were used as reference for biomechanical comparisons. The first results showed differences between scoliotic and asymptomatic subjects and also among scoliotic patients. The proposed protocol should allow clinicians to follow up scoliotic patients with an innovative and efficient tool.

Risk stratification after myocardial infarction using signal-averaged electrocardiographic criteria adjusted for sex, age, and myocardial infarction location

BACKGROUND

The objectives were to investigate the factors influencing signal-averaged ECGs (SAECGs) recorded in patients after myocardial infarction (MI) and to develop criteria for predicting arrhythmic events (AEs) that account for these factors.

METHODS AND RESULTS

SAECGs were recorded 5 to 15 days after MI in 2461 patients without bundle-branch block. The duration (QRSd), terminal potential (VRMS), and terminal duration (LAS) of the filtered QRS were measured. During follow-up (17 +/- 8 months), AEs (arrhythmic death; ventricular tachycardia, VT; ventricular fibrillation, VF) occurred in 80 patients (3.3%). Receiver operating characteristic curves showed that QRSd discriminated patients with all types of AEs, but VRMS and LAS discriminated only VT patients; QRSd minus LAS also discriminated AE patients. Sex, age, and MI location significantly affected the SAECG; survivors without VT or VF were divided into subgroups (2 sex x 4 age x 2 MI), and QRSd values exceeding the 70th percentile in each subgroup predicted AEs with a sensitivity of 65.4%. An unadjusted QRSd criterion showed the same overall sensitivity and specificity but with less uniform values for each subgroup. A Cox model was constructed by use of multiple prognostic indicators, and in rank order, QRSd, previous MI, and Killip class were predictive of AEs.

CONCLUSIONS

SAECG adjustments for sex, age, and MI location did not improve sensitivity and specificity but produced a more uniform predictive performance. The proposed criteria are based only on QRSd, because late potentials (VRMS and LAS) did not discriminate patients with sudden death. Duration of high-level activity during QRS (QRSd-LAS) can predict AEs, suggesting that the arrhythmogenic substate involves a large mass of myocardium.

Platelet membrane receptor glycoprotein IIb/IIIa antagonism in unstable angina. The Canadian Lamifiban Study

BACKGROUND

Ligand binding to the platelet membrane receptor glycoprotein (GP) IIb/IIIa, the final and obligatory step to platelet aggregation, can now be inhibited by pharmacological agents. This study was designed to evaluate the potential of lamifiban, a novel nonpeptide antagonist of GP IIb/IIIa, for the management of unstable angina.

METHODS AND RESULTS

In a prospective, dose-ranging, double-blind study, 365 patients with unstable angina were randomized to an infusion of 1, 2, 4, or 5 micrograms/min of lamifiban or of placebo. Treatment was administered for 72 to 120 hours. Outcome events were measured during the infusion period and after 1 month. Concomitant aspirin was administered to all patients and heparin to 28% of patients. Lamifiban, all doses combined, reduced the risk of death, nonfatal myocardial infarction, or the need for an urgent revascularization during the infusion period from 8.1% to 3.3% (P = .04). The rates were 2.5%, 4.9%, 3.3%, and 2.4% with increasing doses. At 1 month, death or nonfatal infarction occurred in 8.1% of patients with placebo and in 2.5% of patients with the two high doses (P = .03). The highest dose of lamifiban additionally prevented the need for an urgent intervention. Lamifiban dose-dependently inhibited platelet aggregation. Bleeding times were significantly prolonged with platelet inhibition of > 80%. Major (but neither life-threatening nor intracranial) bleedings occurred in 0.8% of patients with placebo and 2.9% with lamifiban.

CONCLUSIONS

The nonpeptide GP IIb/IIIa antagonist lamifiban protected patients with unstable angina from severe ischemic events during a 3- to 5-day infusion and reduced the incidence of death and infarction at 1 month, suggesting considerable promise for this new therapeutic approach.

Myocardial infarction patients in the 1990s--their risk factors, stratification and survival in Canada: the Canadian Assessment of Myocardial Infarction (CAMI) Study

OBJECTIVES

This study sought to evaluate the in-hospital and postdischarge mortality of patients with an acute myocardial infarction in the 1990s.

BACKGROUND

The widespread implementation of therapeutic interventions that modify the natural history of coronary artery disease has led to changes in the profile and survival of patients with an acute myocardial infarction. Although data exist for selected subsets of patients with an acute myocardial infarction, at this time there is little recent prospective information on all patients presenting with an acute myocardial infarction, particularly for survival after hospital discharge.

METHODS

All patients < or = 75 years old presenting with an acute myocardial infarction between July 1, 1990 and June 30, 1992 at nine Canadian hospitals were prospectively evaluated and followed up for 1 year. From November 1991, patients of all ages were included. In two centers, recruitment continued until December 31, 1992. A total of 3,178 patients were recruited.

RESULTS

The in-hospital mortality rate of patients < or = 75 years old was 8.4%, and that at 1 year after hospital discharge was 5.3%. For patients of all ages recruited after November 1, 1991, the in-hospital mortality rate was 9.9% and 7.1% for 1 year after hospital discharge. For patients < or = 75 years old, age carried an independent in-hospital but no post discharge risk. Female patients had a twofold greater risk of dying in hospital. After hospital discharge, only 1.7% of patients < or = 75 years old and 1.9% of patients of all ages died of a presumed arrhythmic death. Premature ventricular contractions had no independent prognostic value. The relatively low in-hospital (5.3%) and postdischarge (6.1%) reinfarction rate may have contributed to improved survival. A greater reinfarction rate in patients >75 years old (17.4% vs. 9.6%, p < 0.001) may have contributed to their poorer outcome.

CONCLUSIONS

One-year mortality after acute myocardial infarction continues to decrease, and changes in the prognostic value of traditional methods of risk stratification have occurred.

Thigmotaxis as an index of anxiety in mice. Influence of dopaminergic transmissions

When mice are introduced into an open-field, they are inclined to explore mainly the peripheral zone of this open-field. This tendency to remain close the walls, called thigmotaxis, decreases gradually during the first minutes of exploration. We have considered the degree of thigmotaxis during this period of decrease as an index of anxiety in mice. This hypothesis has been validated with several reference anxiogenic drugs (dexamphetamine, pentylenetetrazole, yohimbine, idazoxan) which increased thigmotaxis; and with anxiolytic drugs (buspirone, phenobarbital), which reduced it. On this test the selective or non-selective indirect dopamine agonists GBR 12783, dexamphetamine and cocaine induced an increase of thigmotaxis. Finally, the simultaneous involvement of D1 and D2 dopamine receptors has been evidenced in the anxiogenic-like effect associated with an increase of dopaminergic transmissions.

Neutrophils recruited to the lungs of humans by segmental antigen challenge display a reduced chemotactic response to leukotriene B4

Allergic asthma is characterized by an infiltration of the lung with inflammatory cells including eosinophils and neutrophils. The mechanism by which inflammatory cells are recruited to the lung in IgE-mediated disorders is unknown. In order to explore the mechanism responsible for cell recruitment, ragweed-allergic volunteers underwent segmental (bronchoscopic) antigen challenge, followed 24 h later by bronchoalveolar lavage (BAL). Experimental conditions were chosen to favor neutrophil, rather than eosinophil, recruitment. Chemotactic responses of purified BAL neutrophils (under agarose) were then compared with blood neutrophils obtained from the same subjects. We hypothesized that neutrophils recruited to the lung would be desensitized to the chemotaxin(s) responsible for their recruitment. BAL neutrophils showed a profound inhibition of their chemotactic response to an optimal concentration of leukotriene B4 (LTB4) ex vivo (approximately 40% of the response of blood neutrophils) with a slightly reduced response to the anaphylatoxin C5a and to FMLP. In addition, they displayed a normal production of superoxide anion in response to phorbol myristate acetate. These results demonstrate that neutrophils recruited to the lung of humans by local antigen challenge display a marked inhibition of their chemotactic response to LTB4, and are consistent with the hypothesis that LTB4 is instrumental in recruiting neutrophils to the lung in IgE-mediated reactions.

Immunoglobulin E-mediated increase in vascular permeability correlates with eosinophilic inflammation

An increase in bronchovascular permeability is thought to play an important role in the pathogenesis of allergic asthma. We sought to determine whether the increase in permeability observed 24 h after segmental antigen challenge in ragweed-allergic human volunteers was associated with the infiltration and degranulation of a specific cell type. A 20,000-fold range of antigen concentrations was used to alter the number and type of inflammatory cells recruited to the lung by challenge. Although large numbers of inflammatory cells were recruited to lung air spaces over a large range of antigen concentrations, significant numbers of eosinophils (731.3 +/- 232.9 x 10(3)/ml) were recruited only when the concentration of antigen used for segmental challenge was > or = 100-fold higher than the concentration needed to produce an 8 to 10 mm wheal 20 min after intradermal skin testing. In addition, large increases in bronchoalveolar lavage (BAL) albumin concentration (636.3 +/- 170.5 micrograms/ml) were observed only in this same group of subjects. The correlation coefficient between the logarithms of the BAL eosinophil concentration and albumin concentration was +0.82 (p < 0.001), and between eosinophil-derived neurotoxin and albumin it was +0.88 (p < 0.001). In a stepwise, multiple regression analysis, eosinophils accounted for 67% of the variance in BAL albumin concentration, whereas no other cell type was a significant predictor of albumin flux into BAL fluid. We conclude that eosinophil recruitment and degranulation are associated with large increases in bronchovascular permeability after segmental antigen challenge in humans.

Effect of antigen dose on the recruitment of inflammatory cells to the lung by segmental antigen challenge

Bronchoscopic antigen challenge of atopic volunteers results in an immediate release of inflammatory mediators and, after a number of hours, the recruitment of inflammatory cells to the lung. The purpose of this work was to investigate the effect of antigen dose on the subsequent recruitment of inflammatory cells to the lung. Twenty-two volunteers without asthma, eight nonatopic control subjects, and 14 ragweed-allergic subjects underwent 25 local antigen-challenge procedures that consisted of a baseline lavage of a control segment, antigen challenge of another segment in the contralateral lung, and lavage of the challenged segment 24 hours later. A 25,000-fold range of antigen doses was used from 0.004 to 100 PNU/ml (0.02 to 500 ng/ml of ragweed antigen E [Amb a I]). Challenge of nonatopic control subjects resulted in the recruitment of only a small number of inflammatory cells, less than a twofold increase in comparison with the cells of control lavage; this increase was primarily due to an increase in neutrophils. Challenge of atopic subjects, in contrast, resulted in approximately a threefold to ninefold increase in inflammatory cells with more cells recruited at larger doses of antigen. Only subjects challenged with a "high" dose of antigen (greater than or equal to 1 PNU/ml) recruited significant quantities of eosinophils to the lung. In these subjects, a twofold increase in macrophages, a fourfold increase in lymphocytes, a 90-fold increase in neutrophils, and an 800-fold increase in eosinophils were observed; the number of neutrophils and eosinophils recruited averaged between 30 and 60 million.(ABSTRACT TRUNCATED AT 250 WORDS)

Teratogenic effect of the cholesterol synthesis inhibitor AY 9944 on rat embryos in vitro

AY 9944 [trans-1,4-bis(2-chlorobenzylaminomethyl) cyclohexane dihydrochloride] is an amphiphilic cationic molecule. This chemical is an established inhibitor of cholesterol synthesis and is teratogenic in rats. The mechanisms of this teratogenicity remain to be clarified. This study used cultured rat whole embryos to ascertain whether AY 9944 had a direct effect on embryos, or whether its action was indirect, via the maternal cholesterol metabolism. Four experimental conditions were investigated: (A) controls; (B) 10 day untreated embryos were cultured in serum of treated rats; (C) 10 day untreated embryos were cultured in serum containing added AY 9944 (0-1,000 micrograms/ml); and (D) 10 day embryos from females treated on day 4 of gestation were cultured in normal serum. In group B there was no growth retardation; some slight nonspecific abnormalities were not significant. In group C, direct addition of AY 9944 to culture medium retarded growth and differentiation in a dose-dependent manner. No malformation was observed, but histological examinations showed numerous areas of cell necrosis, especially in the CNS. In group D, not only was growth retardation observed, but also characteristic malformations of AY 9944 teratogenesis, including pituitary agenesis. These results show that AY 9944 teratogenicity is initiated prior to day 10.

The use of nuclear medicine in the diagnosis of Paget's disease of the mandible. Report of a case

Traditionally, incisional bone biopsy has been required in order to establish and confirm a diagnosis of Paget's disease (Osteitis deformans) of the mandible and/or maxilla. This article presents a case report of a patient who refused such biopsy. The patient was referred with a three year history of intermittent mandibular pain, accompanied by occasional swelling of the adjacent soft tissues. Although several health professionals had been consulted, no diagnosis had been established. Furthermore, an incisional biopsy had apparently been performed in the area of the left mandible, as reported by the patient, with no conclusive results. On examination, the patient refused all proposed repeat biopsy, but did agree to a full laboratory workup which included: routine blood studies; nuclear medicine bone studies of total body regions including the head and neck, followed by sialography of the submandibular salivary glands. A definitive diagnosis of Paget's disease was reported on 99-m-MDP-technetium bone scans of the mandible. The patient was subsequently treated with the appropriate medication which resulted in a remission of the disease over the three year follow-up period. The histopathological diagnosis was never confirmed because of the patient's repeated refusal to be biopsied.

Cholesterol prevents the teratogenic action of AY 9944: importance of the timing of cholesterol supplementation to rats

These studies were conducted to determine whether dietary cholesterol supplementation could prevent fetal malformations induced by the amphipathic drug AY 9944, which is well known as a cholesterol biosynthesis inhibitor, and to investigate whether the plasma maternal sterol level and the nature of the sterols found in treated Wistar rats could explain this prevention. Pituitary agenesis was the most constant element of holoprosencephaly when AY 9944 was administered on d 4 of gestation at two dosages, 50 or 75 mg/kg. The rate of malformed fetuses was dose related. A strong negative correlation was established between maternal plasma sterol levels on d 10 of gestation (day of pituitary gland formation) and the rate of fetal anomalies (r = -0.97, P less than 0.01). Supplementation of AY 9944-treated rats with cholesterol had an obvious preventive action on fetal malformations. When cholesterol was added to the diet the same day as AY 9944 treatment and maintained until d 15, the prevention of malformations was almost complete. When the supplementation was initiated later, the prevention of anomalies decreased. The nature of plasma maternal sterols shows that the cholesterol supplementation modifies significantly the ratio of cholesterol to 7-dehydrocholesterol in treated rats. Therefore, maternal plasma sterol perturbations may play a role in the teratogenic action of AY 9944.