Management practices and risk of occupational blood exposure in U.S. paramedics: non-intact skin exposure

Standard Precautions Among Emergency Medical Services in Urban and Rural Areas

Backround: Emergency medical services (EMS) workers are at risk of exposure to bloodborne pathogens and frequently exposed to blood and bodily fluids through percutaneous injuries. This study aimed to assess the consistency with which standard precautions (SPs) among rural and urban EMS providers were used. Methods: This study consisted of a cross-sectional survey conducted with a sample of certified EMS providers in West Virginia in which we ascertained details about sociodemographic characteristics, and the frequency of consistent SP. An email invitation was sent to a comprehensive list of agencies obtained from the Office of West Virginia EMS. Findings: A total of 248 out of 522 (47%) EMS providers completed the survey. The majority of the EMS providers (76%) consistently complied with SPs; however, more than one third (38%) of urban EMS providers indicated inconsistent use compared with 19% of rural EMS providers (p = .002). Most EMS providers reported low prevention practices to exposure of blood and body fluids in both areas. Conclusion/Application to Practice: The results emphasize the need to enhanced safe work practices among EMS providers in both rural and urban areas through education and increasing self-awareness. Occupational health professional in municipalities that serve these workers are instrumental in ensuring these workers are trained and evaluated for their compliance with SPs while in the field.

Take-home naloxone treatment for opioid emergencies: a comparison of routes of administration and associated delivery systems

INTRODUCTION

Naloxone reversal of opioid-induced respiratory depression outside of medical facilities has become more prevalent because of the escalating opioid epidemic in the USA. Take-home naloxone for treatment of opioid emergencies is now being recommended by numerous federal, state, and professional organizations. Areas covered: The scope of the opioid overdose epidemic is reviewed along with practical, clinical, regulatory, and usability considerations for take-home naloxone routes of administration currently available and associated delivery systems. Specific opioid-related factors are discussed in detail with emphasis placed on life-threatening respiratory depression and naloxone antagonism. A clinical overview, including pharmacokinetic and FDA approval information for each take-home naloxone product is discussed in detail as well as the impact of take-home naloxone in the community. Finally, given these products are to be used in a panic-stricken, life-threatening opioid emergency, an analysis of available usability data is provided with proposed directions for further study. Expert opinion: Based on the available clinical evidence, auto-injectable naloxone should be the preferred administration route for take-home naloxone treatment until additional safety, efficacy, and comparative outcomes data are available for unconventional routes of administration that unequivocally provide equal or superior results.

Occupational exposure to infection risk and use of personal protective equipment by emergency medical personnel in the Republic of Korea

BACKGROUND

Few studies of occupational exposure (OE) to infectious risk among emergency medical personnel (EMP) or their use of personal protective equipment (PPE) have been conducted in the Republic of Korea.

OBJECTIVE

To determine the status of OE to infectious risks and use of PPE.

METHODS

A convenience sample of 907 questionnaires (response rate, 88.5%) was collected from September 1, 2014, to January 31, 2015, in 5 metropolitan Korean cities.

RESULTS

Respiratory diseases were significantly prevalent (44.5%) and influenza (29.5%) was the most frequently reported illness. An exposure report was only made in 19.5% of cases. The primary reason for OE report noncompletion was the complexity of the reporting process (23.9%). A total of 365 participants reported OE to body fluids and blood (40.2%) with needlestick injury being the most frequent OE type (17.6%). More than 5 years of job experience (47.8%) (P < .001) and region (city) (P = .003) significantly increased OE to body fluids and blood. Puncture-resistant containers (71.9%) and disposable gloves (68.9%) were used. Job training and education on infection risks and use of PPE were not uniformly conducted (77.5%). Anxiety about OE to risk of infection from patients was common among EMP (63.2%).

CONCLUSIONS

EMP experienced significant OE to infectious risk and use PPE inadequately. Surveillance and education programs regarding OE should be developed.

Combining directed acyclic graphs and the change-in-estimate procedure as a novel approach to adjustment-variable selection in epidemiology

Background

Directed acyclic graphs (DAGs) are an effective means of presenting expert-knowledge assumptions when selecting adjustment variables in epidemiology, whereas the change-in-estimate procedure is a common statistics-based approach. As DAGs imply specific empirical relationships which can be explored by the change-in-estimate procedure, it should be possible to combine the two approaches. This paper proposes such an approach which aims to produce well-adjusted estimates for a given research question, based on plausible DAGs consistent with the data at hand, combining prior knowledge and standard regression methods.

Methods

Based on the relationships laid out in a DAG, researchers can predict how a collapsible estimator (e.g. risk ratio or risk difference) for an effect of interest should change when adjusted on different variable sets. Implied and observed patterns can then be compared to detect inconsistencies and so guide adjustment-variable selection.

Results

The proposed approach involves i. drawing up a set of plausible background-knowledge DAGs; ii. starting with one of these DAGs as a working DAG, identifying a minimal variable set, S, sufficient to control for bias on the effect of interest; iii. estimating a collapsible estimator adjusted on S, then adjusted on S plus each variable not in S in turn (“add-one pattern”) and then adjusted on the variables in S minus each of these variables in turn (“minus-one pattern”); iv. checking the observed add-one and minus-one patterns against the pattern implied by the working DAG and the other prior DAGs; v. reviewing the DAGs, if needed; and vi. presenting the initial and all final DAGs with estimates.

Conclusion

This approach to adjustment-variable selection combines background-knowledge and statistics-based approaches using methods already common in epidemiology and communicates assumptions and uncertainties in a standardized graphical format. It is probably best suited to areas where there is considerable background knowledge about plausible variable relationships. Researchers may use this approach as an additional tool for selecting adjustment variables when analyzing epidemiological data.

[Anaesthesia for HIV-infected patients]

France is one of main countries affected by the HIV-outbreak in Europe with more than 120,000 cases, among which 34,600 patients having developed an AIDS. The antiretroviral combination therapies (combined antiretroviral therapy [cART]) reduced by half the mortality. A low compliance to cART alters the virologic control and increases the morbimortality. If required, the therapeutic break should be the shortest possible, including the whole treatment (to limit the risk of viral resistance). The perioperative care should take into account the underlying conditions. During the preoperative period, the clinical picture could combine various complications: 1: respiratory impairment; 2: impairment of neuronal functions (related to viral factors, host response and environmental factors such as alcohol, drug addiction, HCV co-infection) inducing a cognitive dysfunction or a peripheral neuropathy; 3: lipodystrophy, dyslipidemia and insulin resistance are the main metabolic cART-related side effects, responsible for atherosclerosis and coronaropathy; 4: major nutritional impairment. Anesthesia for HIV patients is almost the same than usual, without HIV-related contraindication to regional anesthesia. Anesthetic drugs can be associated to cART. The main restriction belongs to the protease inhibitors, which could affect the metabolic pathways of opioids, NSAIDs and benzodiazepines (over dosage risks). During the postoperative period, the follow-up should include the thromboembolism prevention (increased risk compared to main people), the cardiovascular side effects, the nutritional status and the continuation of the treatment. Moreover, the psychological status related and a close collaboration with the corresponding physician is critical.

Management practices and risk of occupational blood exposure in U.S. paramedics: Needlesticks

BACKGROUND

The purpose of this study was to present risk estimates for needlestick in U.S. paramedics and estimated risk ratios for selected management practices.

METHODS

A mail survey was conducted among a national sample of U.S. paramedics in 2002-2003.

RESULTS

The adjusted response rate was 55% (n = 2,664). The overall 12-month risk of needlestick was 6.7% (95% confidence interval, 5.4-7.9). Risk ratios for provision of safety-engineered medical devices and two supervisory behaviors that emphasized safe work practices ranged from 2.5 to 3.2. The protective effect of working in an environment that included both of the supervisory behaviors was greater than the protective effect of always being provided with safety devices. A sensitivity analysis indicated that the risk ratio estimates were unlikely to be inflated by nonresponse bias.

CONCLUSIONS

These results suggest that greater provision of safety devices and interventions aimed at management practices that promote worker safety could substantially reduce the risk of needlestick among U.S. paramedics.