Developing medical simulations for opioid overdose response training: A qualitative analysis of narratives from responders to overdoses

Medical simulation offers a controlled environment for studying challenging clinical care situations that are difficult to observe directly. Overdose education and naloxone distribution (OEND) programs aim to train potential rescuers in responding to opioid overdoses, but assessing rescuer performance in real-life situations before emergency medical services arrive is exceedingly complex. There is an opportunity to incorporate individuals with firsthand experience in treating out-of-hospital overdoses into the development of simulation scenarios. Realistic overdose simulations could provide OEND programs with valuable tools to effectively teach hands-on skills and support context-sensitive training regimens. In this research, semi-structured interviews were conducted with 17 individuals experienced in responding to opioid overdoses including emergency department physicians, first responders, OEND program instructors, and peer recovery specialists. Two coders conducted qualitative content analysis using open and axial thematic coding to identify nuances associated with illicit and prescription opioid overdoses. The results are presented as narrative findings complemented by summaries of the frequency of themes across the interviews. Over 20 hours of audio recording were transcribed verbatim and then coded. During the open and axial thematic coding process several primary themes, along with subthemes, were identified, highlighting the distinctions between illicit and prescription opioid overdoses. Distinct contextual details, such as locations, clinical presentations, the environment surrounding the patient, and bystanders' behavior, were used to create four example simulations of out-of-hospital overdoses. The narrative findings in this qualitative study offer context-sensitive information for developing out-of-hospital overdose scenarios applicable to simulation training. These insights can serve as a valuable resource, aiding instructors and researchers in systematically creating evidence-based scenarios for both training and research purposes.

A review of performance assessment tools for rescuer response in opioid overdose simulations and training programs

Since the 1990s, more than 600 overdose response training and education programs have been implemented to train participants to respond to an opioid overdose in the United States. Given this substantial investment in overdose response training, valid assessment of a potential rescuers' proficiency in responding to an opioid overdose is important. The aim of this article is to review the current state of the literature on outcome measures utilized in opioid overdose response training. Thirty-one articles published between 2014 and 2020 met inclusion criteria. The reviewed articles targeted laypersons, healthcare providers, and first responders. The assessment tools included five validated questionnaires, fifteen non-validated questionnaires, and nine non-validated simulation-based checklists (e.g., completion of critical tasks and time to completion). Validated multiple choice knowledge assessment tools were commonly used to assess the outcomes of training programs. It is unknown how scores on these assessment tools may correlate with actual rescuer performance responding to an overdose. Seven studies reported ceiling effects most likely attributed to participants' background medical knowledge or experience. The inclusion of simulation-based outcome measures of performance, including the commission of critical errors and the time to naloxone administration, provides better insight into rescuer skill proficiency.

Automated non-culture-based sequence typing of meningococci from body fluids

In recent years, the polymerase chain reaction has been used for the non-culture diagnosis of meningococcal disease, and sequence-based typing takes this further by providing the full characterisation normally only available by culture. In this study, porA gene sequencing was used to perform non-culture-based sequence typing of Neisseria meningitidis strains direct from body fluids. Non-culture porA gene sequencing provided the serosubtype of the infecting organism, and proved to be a useful method as N. meningitidis was not isolated from any of the patients in this study. In conclusion, porA gene sequencing is a very useful tool for the non-culture characterisation of meningococci and provides important information for public health management of cases and contacts.

Automation of fluorescence-based PCR for confirmation of meningococcal disease

A fluorescence-based PCR method was developed, fully automated, and used to confirm infection with Neisseria meningitidis by detection of the meningococcus-specific ctrA gene. The method provided a highly sensitive, high-throughput assay that was reproducible and less labor-intensive than manual methods.

Confirmation of meningococcal disease by urinary antigen testing

The meningococcus is an important cause of morbidity and mortality and a rapid laboratory diagnosis is required through accurate, non-culture-based methods. Body fluids that are easily obtainable are preferred for this route of diagnosis and urine is the specimen of choice as it can be obtained non-invasively. Urine samples were tested from patients with suspected meningococcal disease and tested by latex agglutination and PCR. It was shown that urinary PCR is not useful for the laboratory confirmation of MD but latex agglutination testing may be useful in certain settings prior to confirmatory testing by a reference laboratory.

Semiautomation of multilocus sequence typing for the characterization of clinical isolates of Neisseria meningitidis

The Scottish Meningococcus and Pneumococcus Reference Laboratory (SMPRL) provides a national service for the laboratory confirmation of meningococcal and pneumococcal disease in Scotland. Part of this service includes the serogrouping of meningococcal isolates followed by typing and subtyping. The procedures for this are labor-intensive but important for the identification of linked cases and the surveillance of disease so that effective public health measures can be taken. However, different strains of meningococci, such as those within the electrophoretic type 37 complex, occurring during case clusters of disease are now indistinguishable by current methods. The SMPRL has started using multilocus sequence typing (MLST) as a routine method for the characterization of isolates of Neisseria meningitidis. MLST produces nucleotide sequence data of seven housekeeping genes providing results that are useful for public health management. However, the method is laborious and time-consuming and therefore lends itself towards automation. The SMPRL therefore developed a semiautomated method for MLST using a 96-well format liquid handler and an automated DNA sequencer. Semiautomated MLST is now provided as a reference service for Scotland. This work describes the methodology required for the characterization of N. meningitidis and highlights its usefulness for public health intervention.

Introduction of an automated service for the laboratory confirmation of meningococcal disease in Scotland

The Scottish Meningococcus and Pneumococcus Reference Laboratory provides a national service for the laboratory confirmation of meningococcal and pneumococcal disease in Scotland. The main tests used for the laboratory confirmation of meningococcal disease are culture, the polymerase chain reaction (PCR), antibody testing, and more recently DNA sequencing. This paper describes the automation of PCR for the laboratory confirmation of meningococcal disease and the typing of meningococcal isolates using DNA sequencing. Both methods have been automated using a robotic liquid handler and automated DNA sequencer. These methods, along with standard culture phenotyping and antibody testing, provide Scotland with an excellent service for the confirmation of meningococcal disease.

Meningococcal disease due to serogroup Y in Scotland, 1992-1999

Meningococcal disease is an important cause of morbidity and mortality. A retrospective analysis was performed of all cases of invasive group-Y disease that were laboratory-confirmed in Scotland between 1992 and 1999. A total of 1881 meningococcal isolates were characterised, 78 of which were serogroup Y. The incidence of non-invasive group-Y disease remained level between 1992 and 1999. Only 12 isolates were from invasive disease, comprising five strain types. Invasive group-Y disease was associated mostly with the young or old. Serogroup-Y meningococcal disease was uncommon and a rare cause of invasive disease in Scotland between 1992 and 1999; however, it is essential that microbiologists are aware of its potential for increasing in incidence due to the recent introduction of the MenC vaccine, and its increased incidence in the USA.

Pneumococcal disease and asplenia: the importance of vaccination

Pneumococcal disease is an important cause of morbidity and mortality, particularly in certain patient groups including those who have been splenectomised or have no functioning spleen. Recent deaths in two asplenic patients from pneumococcal disease should remind doctors of the importance of vaccination in asplenic individuals. The current guidelines for vaccination in such patients are highlighted and discussed. The need for a national asplenic register is also suggested.

Serotypes/groups distribution and antimicrobial resistance of invasive pneumococcal isolates: implications for vaccine strategies

Based on the invasive pneumococcal isolates referred to reference laboratories in Scotland in 1988-99, we identified the distribution of serotypes/groups and their antimicrobial resistance patterns in order to evaluate the coverage of polysaccharide and the new pneumococcal conjugate vaccines. A total of 5659 invasive isolates were included. Of these, 5124 (90.5%) were blood isolates, 308 (5.5%) were CSF isolates, 143 (2.5%) were blood and CSF and 84 (1.5%) were other normally sterile isolates. The most prevalent 11 serotypes/groups were 14, 9, 19, 6, 23, 1, 3, 4, 7, 8 and 18, in numerical order. These accounted for 84% of total serotypes/groups. The serotypes/groups included in the 23 and 14-valent polysaccharide vaccines accounted for 96% and 88% of all isolates. Both vaccines accounted for 98% of penicillin non-susceptible and 100% of erythromycin non-susceptible isolates. The 7, 9, and 11-valent conjugate vaccines covered 61, 68 and 80% of invasive isolates respectively. The coverage of these vaccines was substantially higher in youngest age group with 84, 86 and 93% of invasive isolates in children < 2 years included in the 7, 9 and 11-valent conjugate vaccines compared with 58, 64 and 77% in adults > or = 65 years of age. The serotype/group distribution of invasive isolates in Scotland varied from year to year over the period 1993-9. The coverage of the 23-valent vaccine remained above 95% in each year but the coverage of the 7, 9 and 11-valent conjugate vaccines showed more marked fluctuation with coverage as low as 53, 60 and 75% in some years. Continued surveillance of invasive pneumococcal isolates is required to inform the development of appropriate vaccine strategies to prevent pneumococcal disease in Scotland.

Clonal structure of invasive Streptococcus pyogenes in Northern Scotland

We have used molecular techniques to characterize 51 group A streptococci from Scotland and 17 'serious disease' isolates from other countries, in order to establish the clonal structure of invasive Streptococcus pyogenes strains circulating between 1986 and 1993. Strains were grouped by restriction endonuclease analysis, pulsed field gel electrophoresis and ribotyping patterns, and were examined for the presence of alleles of the speA gene by polymerase chain reaction and DNA sequence analysis. Serious and fatal infections in Scotland were caused by several clones. One clone (9 of 51 strains) was M type 1 and possessed the speA gene allele 2. This was the clone previously identified as causing severe infection in the USA. Another clone (5 of 51 strains) was M type 3 and had speA gene allele 3. In view of the clear association of more than one clone with severe, invasive and fatal infections, horizontal gene exchange between genotypes merits further investigation.

A bacteriological assessment of ampicillin with sulbactam as antibiotic prophylaxis in patients undergoing biliary tract operations. The West of Scotland Surgical Infection Study Group

A prospective audit of 644 patients undergoing biliary tract operations has been conducted in ten district general hospitals. All patients received a single dose of ampicillin 2 g and sulbactam 1 g as antibiotic prophylaxis. Bacteria were cultured from the bile of 121 patients. In patients with sterile bile the incidence of postoperative infection was 2.5%, while in those with colonized bile it was 22% (P less than 0.0001). The 35 patients from whose bile bacteria of two or more species were isolated, had a higher incidence of wound infection (34%) than those whose bile yielded only one species of bacterium (17%; P less than 0.05). Seventeen of the 27 patients with colonized bile who developed postoperative infection were shown to be infected by the same organisms that had been isolated from their bile. The patients whose bile yielded organisms resistant to the prophylactic antibiotic combination did not have a significantly higher rate of infection than those from whose bile only sensitive organisms were obtained. A marked difference in sensitivity patterns between the participating hospitals was observed.

Production of a variant of beta-lactamase II with selectively decreased cephalosporinase activity by a mutant of Bacillus cereus 569/H/9

1. Mutants of Bacillus cereus 569/H/9 have been screened in a search for strains that synthesize variants of beta-lactamase II. 2. One of these mutants (strain 569/H/9/1) produces a beta-lactamase II-like enzyme that shows a selective decrease in cephalosporinase activity. 3. beta-Lactamase II from strain 569/H/9/1 has been purified to apparent homogeneity and its kinetic properties have been examined. This enzyme resembles the parent beta-lactamase II in its relative activity with benzylpenicillin as substrate when Zn(II) is replaced by other metal ions, but differs detectably from the parent enzyme in its isoelectric point.

S-carboxymethylcysteine in the fluidification of sputum and treatment of chronic airway obstruction

The clinical results and changes in sputum found in both a short-term inpatient trial and a subsequent long-term outpatient investigation (three-month double-blind controlled study) of 82 patients with chronic bronchitis treated with a new mucolytic agent, S-carboxymethylcysteine (Mucodyne), are reported. Fluidification of sputum with reduction in certain measurements of the viscosity of morning sputum aliquots, associated with improvement in the ability to cough up bronchial secretions, significant increase in sputum volume output, and improvement in ventilation (as estimated by the forced expiratory volume in one second), were observed in both trials as dose-related responses, with an increase in the ease of expectoration and a reduction in cough frequency and dyspnea. Therapy with S-carboxymethylcysteine was well tolerated, and there were no serious adverse effects, either immediate or delayed. We suggest that the effect of the drug in fluidifying sputum may be due to a mucoregulatory mechanism which reverses the sputum macromolecular disturbances seen in chronic bronchitis.