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Gerald LB, Gerald JK, VanBuren JM, Lowe A, Guthrie CC, Klein EJ, Morrison A, Startup E, Denninghoff K. Randomized trial of the feasibility of ED-initiated school-based asthma medication supervision (ED-SAMS). Pilot Feasibility Stud 2021; 7:179. [PMID: 34579785 PMCID: PMC8474899 DOI: 10.1186/s40814-021-00913-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While using an inhaled corticosteroid (ICS) in the weeks after an ED visit reduces repeat visits, few children receive a needed prescription. Because a prescription may not be filled or used, dispensing ICS at discharge and supervising its use at school could overcome both barriers until follow-up care is established. To assess the feasibility of such an intervention, we conducted a pilot study among elementary-age school children with persistent asthma who were discharged from the ED following an asthma exacerbation. METHODS Eligible children were randomly assigned to ED-dispensing of ICS with home supervision or ED-dispensing of ICS with home and school supervision. The primary outcomes were ability to recruit and retain participants, ability to initiate school-supervised medication administration within 5 days of discharge, and participant satisfaction. RESULTS Despite identifying 437 potentially eligible children, only 13 (3%) were enrolled with 6 being randomized to the intervention group and 7 to the control group. Eleven (85%) randomized participants completed the 90-day interview (primary outcome) and 8 (62%) completed the 120-day interview (safety endpoint). Four (67%) intervention participants started their school regimen within 5 business days and 2 started within 6 business days. CONCLUSION While our pilot study did not meet its recruitment goal, it did achieve its primary purpose of assessing feasibility before undertaking a larger, more intensive study. Several major recruitment barriers need to be mitigated before EDs can successfully partner with schools to establish supervised ICS treatment. TRIAL REGISTRATION ClinicalTrials.gov , NCT03952286 . Registered 16 May 2019.
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Affiliation(s)
- Lynn B Gerald
- University of Arizona, Tucson, AZ, USA. .,Asthma and Airway Disease Research Center, 1501 N Campbell Avenue, Tucson, AZ, 85724, USA.
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Stoner MJ, Mahajan P, Bressan S, Lam SH, Chumpitazi CE, Kornblith AE, Linakis SW, Roland D, Freedman SB, Nigrovic LE, Denninghoff K, Ishimine P, Kuppermann N. Pediatric Emergency Care Research Networks: A Research Agenda. Acad Emerg Med 2018; 25:1336-1344. [PMID: 30393902 DOI: 10.1111/acem.13656] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 10/26/2018] [Accepted: 10/31/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pediatric emergency care research networks have evolved substantially over the past two decades. Some networks are specialized in specific areas (e.g., sedation, simulation) while others study a variety of medical and traumatic conditions. Given the increased collaboration between pediatric emergency research networks, the logical next step is the development of a research priorities agenda to guide global research in emergency medical services for children (EMSC). OBJECTIVES An international group of pediatric emergency network research leaders was assembled to develop a list of research priorities for future collaborative endeavors within and between pediatric emergency research networks. METHODS Before an in-person meeting, we used a modified Delphi approach to achieve consensus around pediatric emergency research network topic priorities. Further discussions took place on May 15, 2018, in Indianapolis, Indiana, at the Academic Emergency Medicine (AEM) consensus conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." Here, a group of 40 organizers and participants met in a 90-minute "breakout" session to review and further develop the initial priorities. RESULTS We reached consensus on five clinical research priorities that would benefit from collaboration among the existing and future emergency networks focused on EMSC: sepsis, trauma, respiratory conditions, pharmacology of emergency conditions, and mental health emergencies. Furthermore, we identified nonclinical research priorities categorized under the domains of technology, knowledge translation, and organization/administration of pediatric emergency care. CONCLUSION The identification of pediatric emergency care network research priorities within the domains of clinical care, technology, knowledge translation and organization/administration of EMSC will facilitate and help focus collaborative research within and among research networks globally. Engagement of essential stakeholders including EMSC researchers, policy makers, patients, and their caregivers will stimulate advances in the delivery of emergency care to children around the globe.
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Affiliation(s)
- Michael J. Stoner
- Division of Emergency Medicine Department of Pediatrics Nationwide Children's Hospital The Ohio State University College of Medicine Columbus OH
| | - Prashant Mahajan
- Department of Emergency Medicine C.S. Mott Children's Hospital of Michigan University of Michigan Medical School Ann Arbor MI
| | - Silvia Bressan
- Division of Pediatric Emergency Medicine Department of Women's and Children's Health University of Padova Padova Italy
| | - Samuel H. F. Lam
- Department of Emergency Medicine Sutter Medical Center Sacramento Sacramento CA
| | | | - Aaron E. Kornblith
- Department of Emergency Medicine and Pediatrics University of California at San Francisco San Francisco CA
| | - Seth W. Linakis
- Division of Emergency Medicine Department of Pediatrics Nationwide Children's Hospital The Ohio State University College of Medicine Columbus OH
| | - Damian Roland
- SAPPHIRE Group Health Sciences Leicester University Leicester UK & Paediatric Emergency Medicine Leicester Academic (PEMLA) group Children's Emergency Department Leicester Hospitals Leicester UK
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology Department of Pediatrics Alberta Children's Hospital and Alberta Children's Hospital Research Institute Cumming School of Medicine University of Calgary Calgary Alberta Canada
| | - Lise E. Nigrovic
- Division of Emergency Medicine Boston Children's Hospital Boston MA
| | - Kurt Denninghoff
- Department of Emergency Medicine University of Arizona College of Medicine Tucson AZ
| | - Paul Ishimine
- Departments of Emergency Medicine University of California at San Diego School of Medicine San Diego CA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics University of California at Davis School of Medicine, and UC Davis Health Sacramento CA
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Adelgais KM, Hansen M, Lerner EB, Donofrio JJ, Yadav K, Brown K, Liu YT, Denslow P, Denninghoff K, Ishimine P, Olson LM. Establishing the Key Outcomes for Pediatric Emergency Medical Services Research. Acad Emerg Med 2018; 25:1345-1354. [PMID: 30312993 DOI: 10.1111/acem.13637] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 11/28/2022]
Abstract
The evidence supporting best practices when treating children in the prehospital setting or even the effect emergency medical services (EMS) has on patient outcomes is limited. Standardizing the critical outcomes for EMS research will allow for focused and comparable effort among the small but growing group of pediatric EMS investigators on specific topics. Standardized outcomes will also provide the opportunity to collectively advance the science of EMS for children and demonstrate the effect of EMS on patient outcomes. This article describes a consensus process among stakeholders in the pediatric emergency medicine and EMS community that identified the critical outcomes for EMS care in five clinical areas (traumatic brain injury, general injury, respiratory disease/failure, sepsis, and seizures). These areas were selected based on both their known public health importance and their commonality in EMS encounters. Key research outcomes identified by participating stakeholders using a modified nominal group technique for consensus building, which included small group brainstorming and independent voting for ranking outcomes that were feasible and/or important for the field.
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Affiliation(s)
| | - Kathleen M. Adelgais
- Department of Pediatrics Section of Pediatric Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Matthew Hansen
- Department of Emergency Medicine Oregon Health Sciences University PortlandOR
| | - E. Brooke Lerner
- Departments of Emergency Medicine and Pediatrics Medical College of Wisconsin Milwaukee WI
| | - J. Joelle Donofrio
- Departments of Emergency Medicine and Pediatrics University of California San Diego Rady Children's Hospital San Diego CA
| | - Kabir Yadav
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | - Kathleen Brown
- Department of Emergency Medicine The George Washington University School of Medicine and Children's National Medical Center Washington DC
| | - Yiju T. Liu
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | | | - Kurt Denninghoff
- Department of Emergency Medicine University of Arizona School of Medicine Tucson AZ
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics University of California San Diego Rady Children's Hospital San Diego CA
| | - Lenora M. Olson
- Division of Pediatric Critical Care Department of Pediatrics University of Utah School of Medicine Salt Lake City UT
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Walter FG, Chan JTS, Winegard B, Shirazi FM, Chase PB, Chow YY, de Boer M, Denninghoff K. Hazmat Emergency Preparedness in Hong Kong: What are the Dangerous Goods in Kowloon? HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790801500307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Hazmat emergency preparedness is critical, especially as Hong Kong prepares for major international events, such as the 2008 Olympic Equestrian Games. No published medical study has described the identities and quantities of dangerous goods (DG) in the Kowloon area and listed what antidotes are needed for these DG. This study describes what hazardous materials are most common in Kowloon to prioritise emergency preparedness and training. Materials & methods Design A descriptive, cross-sectional study. Setting The Hong Kong Special Administrative Region, specifically Kowloon. Sample The Hong Kong Fire Services Department (HKFSD) Dangerous Goods Database (DGD). Interventions Descriptive statistical analyses with Stata 9.2. Chief outcome Identifying and quantifying dangerous goods in the HKFSD DGD. Results Most DG do not have antidotes. The most common DG with recognised antidotes are carbon monoxide, methylene chloride, fluorine, fluorides, fluoroboric acid, cyanides, nitriles, methanol, nitrobenzene, nitrites, and nitrates. The most common categories of DG are substances giving off inflammable vapours, compressed gases, and corrosive and poisonous substances. Conclusions Hazmat emergency preparedness and training should emphasize these most common categories of DG. Disaster planning should ensure adequate antidotes for DG with recognised antidotes, i.e., oxygen for carbon monoxide and methylene chloride; calcium gluconate or calcium chloride for fluorine, fluorides, and fluoroboric acid; hydroxocobalamin for cyanides and nitriles; ethanol for methanol; and methylene blue for methaemoglobinaemia produced by nitrobenzene, nitrites, and nitrates. Supportive care is essential for patients exposed to hazardous materials because most dangerous goods do not have antidotes.
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Affiliation(s)
| | - JTS Chan
- Alice Ho Miu Ling Nethersole Hospital, Accident and Emergency Department, 11 Chuen On Road, Tai Po, N.T., Hong Kong
| | | | | | | | - YY Chow
- Tuen Mun Hospital, Department of Orthopaedics and Traumatology, Tsing Chung Koon Road, Tuen Mun, N.T., Hong Kong
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5
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Gaither JB, Chikani V, Stolz U, Viscusi C, Denninghoff K, Barnhart B, Mullins T, Rice AD, Mhayamaguru M, Smith JJ, Keim SM, Bobrow BJ, Spaite DW. Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes. PREHOSP EMERG CARE 2017; 21:575-582. [PMID: 28481163 DOI: 10.1080/10903127.2017.1308609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Low body temperatures following prehospital transport are associated with poor outcomes in patients with traumatic brain injury (TBI). However, a minimal amount is known about potential associations across a range of temperatures obtained immediately after prehospital transport. Furthermore, a minimal amount is known about the influence of body temperature on non-mortality outcomes. The purpose of this study was to assess the correlation between temperatures obtained immediately following prehospital transport and TBI outcomes across the entire range of temperatures. METHODS This retrospective observational study included all moderate/severe TBI cases (CDC Barell Matrix Type 1) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049). Cases were compared across four cohorts of initial trauma center temperature (ITCT): <35.0°C [Very Low Temperature (VLT)]; 35.0-35.9°C [Low Temperature (LT)]; 36.0-37.9°C [Normal Temperature (NT)]; and ≥38.0°C [Elevated Temperature (ET)]. Multivariable analysis was performed adjusting for injury severity score, age, sex, race, ethnicity, blunt/penetrating trauma, and payment source. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) for mortality were calculated. To evaluate non-mortality outcomes, deaths were excluded and the adjusted median increase in hospital length of stay (LOS), ICU LOS and total hospital charges were calculated for each ITCT group and compared to the NT group. RESULTS 22,925 cases were identified and cases with interfacility transfer (7361, 32%), no EMS transport (1213, 5%), missing ITCT (2083, 9%), or missing demographic data (391, 2%) were excluded. Within this study cohort the aORs for death (compared to the NT group) were 2.41 (CI: 1.83-3.17) for VLT, 1.62 (CI: 1.37-1.93) for LT, and 1.86 (CI: 1.52-3.00) for ET. Similarly, trauma center (TC) LOS, ICU LOS, and total TC charges increased in all temperature groups when compared to NT. CONCLUSION In this large, statewide study of major TBI, both ETs and LTs immediately following prehospital transport were independently associated with higher mortality and with increased TC LOS, ICU LOS, and total TC charges. Further study is needed to identify the causes of abnormal body temperature during the prehospital interval and if in-field measures to prevent temperature variations might improve outcomes.
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Abstract
Realizing the vast medical benefits of validated protocols, recommendations and practice guidelines requires acceptance and implementation by frontline care providers. Knowledge translation is the science of accelerating the transfer of knowledge to practice by understanding and creatively addressing the barriers that prevent adoption of new professional standards. In an attempt to improve patient care and reduce mortality, the Surviving Sepsis Campaign and The Institute for Healthcare Improvement created the resuscitation and management bundles for patients with severe sepsis and septic shock. These bundles have been accepted as best practice by many clinicians since multiple clinical trials have produced similar positive results when they were implemented. However, transferring these research outcomes-based guidelines to the clinical practice arena has been associated with poor compliance due to important barriers to implementation. Delays in the adoption of sepsis bundles are not surprising since the time from validation to implementation of a new clinical practice is typically 17 years. Using sepsis bundles as a model, this article explores why guidelines are important, examines physician adherence to protocols, and reviews the literature on strategies to improve clinical compliance and enhance knowledge translation.
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Affiliation(s)
- Lisa Stoneking
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA,
| | - Kurt Denninghoff
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Lawrence DeLuca
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Samuel M. Keim
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Benson Munger
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
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Biros MH, Dickert NW, Wright DW, Scicluna VM, Harney D, Silbergleit R, Denninghoff K, Pentz RD. Balancing ethical goals in challenging individual participant scenarios occurring in a trial conducted with exception from informed consent. Acad Emerg Med 2015; 22:340-6. [PMID: 25716051 PMCID: PMC7272239 DOI: 10.1111/acem.12602] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 10/21/2014] [Accepted: 10/22/2014] [Indexed: 11/27/2022]
Abstract
In 1996, federal regulations were put into effect that allowed enrollment of critically ill or injured patients into Food and Drug Administration (FDA)-regulated clinical trials using an exception from informed consent (EFIC) under narrowly prescribed research circumstances. Despite the low likelihood that a legally authorized representative (LAR) would be present within the interventional time frame, the EFIC regulations require the availability of an informed consent process, to be applied if an LAR is present and able to provide prospective consent for patient enrollment into the trial. The purpose of this article is to describe a series of unanticipated consent-related questions arising when a potential surrogate decision-maker appeared to be available at the time of patient enrollment into a trial proceeding under EFIC.
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Affiliation(s)
- Michelle H Biros
- The Department of Emergency Medicine Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
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8
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McMullan JT, Jones E, Barnhart B, Denninghoff K, Spaite D, Zaleski E, Silbergleit R. Degradation of benzodiazepines after 120 days of EMS deployment. PREHOSP EMERG CARE 2014; 18:368-74. [PMID: 24548058 DOI: 10.3109/10903127.2013.869642] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION EMS treatment of status epilepticus improves outcomes, but the benzodiazepine best suited for EMS use is unclear, given potential high environmental temperature exposures. OBJECTIVE To describe the degradation of diazepam, lorazepam, and midazolam as a function of temperature exposure and time over 120 days of storage on active EMS units. METHODS Study boxes containing vials of diazepam, lorazepam, and midazolam were distributed to 4 active EMS units in each of 2 EMS systems in the southwestern United States during May-August 2011. The boxes logged temperature every minute and were stored in EMS units per local agency policy. Two vials of each drug were removed from each box at 30-day intervals and underwent high-performance liquid chromatography to determine drug concentration. Concentration was analyzed as mean (and 95%CI) percent of initial labeled concentration as a function of time and mean kinetic temperature (MKT). RESULTS 192 samples were collected (2 samples of each drug from each of 4 units per city at 4 time-points). After 120 days, the mean relative concentration (95%CI) of diazepam was 97.0% (95.7-98.2%) and of midazolam was 99.0% (97.7-100.2%). Lorazepam experienced modest degradation by 60 days (95.6% [91.6-99.5%]) and substantial degradation at 90 days (90.3% [85.2-95.4%]) and 120 days (86.5% [80.7-92.3%]). Mean MKT was 31.6°C (95%CI 27.1-36.1). Increasing MKT was associated with greater degradation of lorazepam, but not midazolam or diazepam. CONCLUSIONS Midazolam and diazepam experienced minimal degradation throughout 120 days of EMS deployment in high-heat environments. Lorazepam experienced significant degradation over 120 days and appeared especially sensitive to higher MKT exposure.
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Beskind DL, Rhodes SM, Stolz U, Birrer B, Mayfield TR, Bourn S, Denninghoff K. When should you test for and treat hypoglycemia in prehospital seizure patients? PREHOSP EMERG CARE 2014; 18:433-41. [PMID: 24459993 DOI: 10.3109/10903127.2013.864358] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Seizure is a frequent reason for activating the Emergency Medical System (EMS). Little is known about the frequency of seizure caused by hypoglycemia, yet many EMS protocols require glucose testing prior to treatment. We hypothesized that hypoglycemia is rare among EMS seizure patients and glucose testing results in delayed administration of benzodiazepines. METHODS This was a retrospective study of a national ambulance service database encompassing 140 ALS capable EMS systems spanning 40 states and Washington DC. All prehospital calls from August 1, 2010 through December 31, 2012 with a primary or secondary impression of seizure that resulted in patient treatment or transport were included. Median regression with robust and cluster (EMS agency) adjusted standard errors was used to determine if time to benzodiazepine administration was significantly related to blood glucose testing. RESULTS Of 2,052,534 total calls, 76,584 (3.7%) were for seizure with 53,505 (69.9%) of these having a glucose measurement recorded. Hypoglycemia (blood glucose <60 mg/dL) was present in 638 (1.2%; CI: 1.1, 1.3) patients and 478 (0.9%; CI: 0.8, 1.0) were treated with a glucose product. A benzodiazepine was administered to 73 (11.4%; CI: 9.0, 13.9) of the 638 hypoglycemic patients. Treatment of seizure patients with a benzodiazepine occurred in 6,389 (8.3%; CI: 8.1, 8.5) cases and treatment with a glucose product occurred in 975 (1.3%; CI: 1.2, 1.4) cases. Multivariable median regression showed that obtaining a blood glucose measurement prior to benzodiazepine administration compared to no glucose measurement or glucose measurement after benzodiazepine administration was independently associated with a 2.1 minute (CI: 1.5, 2.8) and 5.9 minute (CI: 5.3, 6.6) delay to benzodiazepine administration by EMS, respectively. CONCLUSIONS Rates of hypoglycemia were very low in patients treated by EMS for seizure. Glucose testing prior to benzodiazepine administration significantly increased the median time to benzodiazepine administration. Given the importance of rapid treatment of seizure in actively seizing patients, measurement of blood glucose prior to treating a seizure with a benzodiazepine is not supported by our study. EMS seizure protocols should be revisited.
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McMullan JT, Pinnawin A, Jones E, Denninghoff K, Siewart N, Spaite DW, Zaleski E, Silbergleit R. The 60-day temperature-dependent degradation of midazolam and Lorazepam in the prehospital environment. PREHOSP EMERG CARE 2012; 17:1-7. [PMID: 23148574 DOI: 10.3109/10903127.2012.722177] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The choice of the optimal benzodiazepine to treat prehospital status epilepticus is unclear. Lorazepam is preferred in the emergency department, but concerns about nonrefrigerated storage limits emergency medical services (EMS) use. Midazolam is increasingly popular, but its heat stability is undocumented. OBJECTIVE This study evaluated temperature-dependent degradation of lorazepam and midazolam after 60 days in the EMS environment. METHODS Lorazepam or midazolam samples were collected prior to (n = 139) or after (n = 229) 60 days of EMS deployment during spring-summer months in 14 metropolitan areas across the United States. Medications were stored in study boxes that logged temperature every minute and were stored in EMS units per local agency policy. Mean kinetic temperature (MKT) exposure was derived for each sample. Drug concentrations were determined in a central laboratory by high-performance liquid chromatography. Concentration as a function of MKT was analyzed by linear regression. RESULTS Prior to deployment, measured concentrations of both benzodiazepines were 1.0 relative to labeled concentration. After 60 days, midazolam showed no degradation (mean relative concentration 1.00, 95% confidence interval [CI] 1.00-1.00) and was stable across temperature exposures (adjusted R(2) -0.008). Lorazepam experienced little degradation (mean relative concentration 0.99, 95% CI 0.98-0.99), but degradation was correlated to increasing MKT (adjusted R(2) 0.278). The difference between the temperature dependence of degradation of midazolam and lorazepam was statistically significant (T = -5.172, p < 0.001). CONCLUSIONS Lorazepam experiences small but statistically significant temperature-dependent degradation after 60 days in the EMS environment. Additional study is needed to evaluate whether clinically significant deterioration occurs after 60 days. Midazolam shows no degradation over this duration, even in high-heat conditions.
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Affiliation(s)
- Jason T McMullan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH 45267-0769, USA.
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11
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Cudnik MT, Sasson C, Rea TD, Sayre MR, Zhang J, Bobrow BJ, Spaite DW, McNally B, Denninghoff K, Stolz U. Increasing hospital volume is not associated with improved survival in out of hospital cardiac arrest of cardiac etiology. Resuscitation 2012; 83:862-8. [PMID: 22353637 DOI: 10.1016/j.resuscitation.2012.02.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 02/04/2012] [Accepted: 02/06/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Resuscitation centers may improve patient outcomes by achieving sufficient experience in post-resuscitation care. We analyzed the relationship between survival and hospital volume among patients suffering out-of-hospital cardiac arrest (OHCA). METHODS This prospective cohort investigation collected data from the Cardiac Arrest Registry to Enhance Survival database from 10/1/05 to 12/31/09. Primary outcome was survival to discharge. Hospital characteristics were obtained via 2005 American Hospital Association Survey. A hospital's use of hypothermia was obtained via direct survey. To adjust for hospital- and patient-level variation, multilevel, hierarchical logistic regression was performed. Hospital volume was modeled as a categorical (OHCA/year≤10, 11-39, ≥40) variable. A stratified analysis evaluating those with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) was also performed. RESULTS The cohort included 4125 patients transported by EMS to 155 hospitals in 16 states. Overall survival to hospital discharge was 35% among those admitted to the hospital. Individual hospital rates of survival varied widely (0-100%). Unadjusted survival did not differ between the 3 hospital groups (36% for ≤10 OHCA/year, 35% for 11-39, and 36% for ≥40; p=0.75). After multilevel adjustment, differences in survival across the groups were not statistically significant. Compared to patients at hospitals with ≤10 OHCA/year, adjusted OR for survival was 1.04 (CI(95) 0.83-1.28) among 11-39 annual volume and 0.97 (CI(95) 0.73-1.30) among the ≥40 volume hospitals. Among patients presenting with VF/VT, no difference in survival was identified between the hospital groups. CONCLUSION Survival varied substantially across hospitals. However, hospital OHCA volume was not associated with likelihood of survival. Additional efforts are required to determine what hospital characteristics might account for the variability observed in OHCA hospital outcomes.
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Affiliation(s)
- Michael T Cudnik
- Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH, United States.
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Bobrow BJ, Vadeboncoeur TF, Spaite DW, Potts J, Denninghoff K, Chikani V, Brazil PR, Ramsey B, Abella BS. The Effectiveness of Ultrabrief and Brief Educational Videos for Training Lay Responders in Hands-Only Cardiopulmonary Resuscitation. Circ Cardiovasc Qual Outcomes 2011; 4:220-6. [DOI: 10.1161/circoutcomes.110.959353] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bentley J. Bobrow
- From the Department of Emergency Medicine (B.J.B., P.R.B.) and Resuscitation Science Center (B.J.B.), Maricopa Medical Center, Phoenix, AZ; Arizona Department of Health Services (B.J.B., V.C., P.R.B.), Bureau of EMS and Trauma System, Phoenix, AZ; Arizona Emergency Medicine Research Center (B.J.B., D.W.S., K.D.), Department of Emergency Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine (T.F.V.), Mayo Clinic, Jacksonville, FL; The American Heart Association (J.P.), Dallas,
| | - Tyler F. Vadeboncoeur
- From the Department of Emergency Medicine (B.J.B., P.R.B.) and Resuscitation Science Center (B.J.B.), Maricopa Medical Center, Phoenix, AZ; Arizona Department of Health Services (B.J.B., V.C., P.R.B.), Bureau of EMS and Trauma System, Phoenix, AZ; Arizona Emergency Medicine Research Center (B.J.B., D.W.S., K.D.), Department of Emergency Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine (T.F.V.), Mayo Clinic, Jacksonville, FL; The American Heart Association (J.P.), Dallas,
| | - Daniel W. Spaite
- From the Department of Emergency Medicine (B.J.B., P.R.B.) and Resuscitation Science Center (B.J.B.), Maricopa Medical Center, Phoenix, AZ; Arizona Department of Health Services (B.J.B., V.C., P.R.B.), Bureau of EMS and Trauma System, Phoenix, AZ; Arizona Emergency Medicine Research Center (B.J.B., D.W.S., K.D.), Department of Emergency Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine (T.F.V.), Mayo Clinic, Jacksonville, FL; The American Heart Association (J.P.), Dallas,
| | - Jerald Potts
- From the Department of Emergency Medicine (B.J.B., P.R.B.) and Resuscitation Science Center (B.J.B.), Maricopa Medical Center, Phoenix, AZ; Arizona Department of Health Services (B.J.B., V.C., P.R.B.), Bureau of EMS and Trauma System, Phoenix, AZ; Arizona Emergency Medicine Research Center (B.J.B., D.W.S., K.D.), Department of Emergency Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine (T.F.V.), Mayo Clinic, Jacksonville, FL; The American Heart Association (J.P.), Dallas,
| | - Kurt Denninghoff
- From the Department of Emergency Medicine (B.J.B., P.R.B.) and Resuscitation Science Center (B.J.B.), Maricopa Medical Center, Phoenix, AZ; Arizona Department of Health Services (B.J.B., V.C., P.R.B.), Bureau of EMS and Trauma System, Phoenix, AZ; Arizona Emergency Medicine Research Center (B.J.B., D.W.S., K.D.), Department of Emergency Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine (T.F.V.), Mayo Clinic, Jacksonville, FL; The American Heart Association (J.P.), Dallas,
| | - Vatsal Chikani
- From the Department of Emergency Medicine (B.J.B., P.R.B.) and Resuscitation Science Center (B.J.B.), Maricopa Medical Center, Phoenix, AZ; Arizona Department of Health Services (B.J.B., V.C., P.R.B.), Bureau of EMS and Trauma System, Phoenix, AZ; Arizona Emergency Medicine Research Center (B.J.B., D.W.S., K.D.), Department of Emergency Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine (T.F.V.), Mayo Clinic, Jacksonville, FL; The American Heart Association (J.P.), Dallas,
| | - Paula R. Brazil
- From the Department of Emergency Medicine (B.J.B., P.R.B.) and Resuscitation Science Center (B.J.B.), Maricopa Medical Center, Phoenix, AZ; Arizona Department of Health Services (B.J.B., V.C., P.R.B.), Bureau of EMS and Trauma System, Phoenix, AZ; Arizona Emergency Medicine Research Center (B.J.B., D.W.S., K.D.), Department of Emergency Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine (T.F.V.), Mayo Clinic, Jacksonville, FL; The American Heart Association (J.P.), Dallas,
| | - Bob Ramsey
- From the Department of Emergency Medicine (B.J.B., P.R.B.) and Resuscitation Science Center (B.J.B.), Maricopa Medical Center, Phoenix, AZ; Arizona Department of Health Services (B.J.B., V.C., P.R.B.), Bureau of EMS and Trauma System, Phoenix, AZ; Arizona Emergency Medicine Research Center (B.J.B., D.W.S., K.D.), Department of Emergency Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine (T.F.V.), Mayo Clinic, Jacksonville, FL; The American Heart Association (J.P.), Dallas,
| | - Benjamin S. Abella
- From the Department of Emergency Medicine (B.J.B., P.R.B.) and Resuscitation Science Center (B.J.B.), Maricopa Medical Center, Phoenix, AZ; Arizona Department of Health Services (B.J.B., V.C., P.R.B.), Bureau of EMS and Trauma System, Phoenix, AZ; Arizona Emergency Medicine Research Center (B.J.B., D.W.S., K.D.), Department of Emergency Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine (T.F.V.), Mayo Clinic, Jacksonville, FL; The American Heart Association (J.P.), Dallas,
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Bobrow B, Vadeboncoeur T, Spaite D, Potts J, Denninghoff K, Chikani V, Brazil P, Ramsey B, Abella B. Impact of brief or ultra-brief Hands-Only CPR video training on the confidence of lay citizens to perform CPR. Resuscitation 2010. [DOI: 10.1016/j.resuscitation.2010.09.392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tiongson JM, Gardner K, Urban M, Ferguson C, McNulty A, Denninghoff K. Induced Proteinuria And Hematuria Is Transient: Effects Of Long Distance Bicycling Between Diabetics And Non-diabetics. Med Sci Sports Exerc 2010. [DOI: 10.1249/01.mss.0000384586.40041.df] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Denninghoff K, Walter FG, Langa A, He Y, Chipman RA. Spectrophotometry of hydroxocobalamin and hemoglobin reveals production of an unanticipated methemoglobin variant. Clin Toxicol (Phila) 2009; 46:545-50. [DOI: 10.1080/15563650701846270] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lin TJ, Walter FG, Hung DZ, Tsai JL, Hu SC, Chang JS, Deng JF, Chase JS, Denninghoff K, Chan HM. Epidemiology of organophosphate pesticide poisoning in Taiwan. Clin Toxicol (Phila) 2008; 46:794-801. [PMID: 18608266 DOI: 10.1080/15563650801986695] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The nationwide epidemiology of organophosphate pesticide (OP) poisoning has never been reported in detail for Taiwan. METHODS This study retrospectively reviewed all human OP exposures reported to Taiwan's Poison Control Centers (PCCs) from July 1985 through December 2006. RESULTS There were 4799 OP exposures. Most OP exposures were acute (98.37%) ingestions (74.50%) of a single OP (80.37%) to attempt suicide (64.72%) in adults (93.25%). Males were the most common gender (64.95%). Most patients (61.97%) received atropine and/or pralidoxime. The mortality rate for all 4799 OP exposures was 12.71%. Exposures to single OPs without co-intoxicants caused 524 deaths; of these, 63.36% were due to dimethyl OPs. CONCLUSION Dimethyl OPs cause the majority of deaths in Taiwan.
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Affiliation(s)
- Tzeng Jih Lin
- Department of Emergency, Kaohsiung Medical University Hospital, Taipei, Taiwan
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Walter FG, Chan JTS, Winegard B, Chase PB, Shirazi F, Chow YY, de Boer M, Denninghoff K. Hazmat disaster preparedness in Hong Kong: what are the hazardous materials on Lantau, Lamma, and Hong Kong Islands? Am J Disaster Med 2008; 3:213-233. [PMID: 18822840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Hazmat disaster preparedness is critical, especially as Hong Kong prepares for major international events, such as the 2008 Olympic Equestrian Games. No published medical study describes the identities and quantities of hazardous materials (HMs) in Hong Kong and lists what antidotes are needed for these dangerous goods (DGs). This study describes what HMs are most common in Hong Kong to prioritize disaster preparedness and training. DESIGN A descriptive, cross-sectional study. SETTING The Hong Kong Special Administrative Region, specifically Lantau, Lamma, and Hong Kong Islands. SAMPLE The Hong Kong Fire Services Department (HKFSD) Dangerous Goods Database (DGD). INTERVENTIONS Descriptive statistical analyses with Stata 9.2. MAIN OUTCOME MEASURES Identifying and quantifying HMs in the HKFSD DGD. RESULTS Most HMs do not have antidotes. The most common HMs with recognized antidotes are carbon monoxide, methylene chloride, fluorides, cyanides, nitriles, hydrazine, methanol, and nitrates. The most common categories of DGs are substances giving off inflammable vapors, compressed gases, and corrosive and poisonous substances. CONCLUSIONS Hazmat disaster preparedness and training should emphasize these most common categories of DGs. Disaster planning should ensure adequate antidotes for HMs with recognized antidotes, ie, oxygen for carbon monoxide and methylene chloride; calcium gluconate and calcium chloride for fluorides; hydroxocobalamin or amyl nitrite, sodium nitrite, and sodium thiosulfate for cyanides and nitriles; pyridoxine for hydrazine; fomepizole or ethanol for methanol; and methylene blue for methemoglobinemia produced by nitrates. Supportive care is essential for patients exposed to HMs because most DGs do not have antidotes.
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Affiliation(s)
- Frank G Walter
- Bureau of Emergency Preparedness and Response, Arizona Department of Health Services, Tucson, USA
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Denninghoff K. Additions and Corrections to alpha(v) integrins mediate the rise in intracellular calcium in endothelial cells on fibronectin even though they play a minor role in adhesion. J Biol Chem 1995. [DOI: 10.1074/jbc.270.50.30235] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Schwartz MA, Denninghoff K. Alpha v integrins mediate the rise in intracellular calcium in endothelial cells on fibronectin even though they play a minor role in adhesion. J Biol Chem 1994; 269:11133-7. [PMID: 7512559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
We have investigated which integrins mediate the elevation of intracellular calcium ([Ca2+]i) triggered by spreading of endothelial cells on fibronectin (FN). Specific anti-integrin monoclonal antibodies immobilized on glass surfaces were used as agonists to trigger cell spreading. These experiments demonstrated that an antibody to alpha v could induce the rise in [Ca2+]i, whereas two antibodies to alpha 5 beta 1 were inactive, despite their ability to induce cell spreading and elevation of intracellular pH. Antibodies in solution were then used as agonists to block association of specific integrins with FN. These experiments also showed that alpha v integrin(s) but not alpha 5 beta 1 mediated the rise in [Ca2+]i in cells spreading on FN. Adhesion assays in the presence of function-blocking anti-integrin antibodies and affinity chromatography on FN columns of surface-labeled cell extracts were carried out to characterize the integrins that bind to FN. Both methods showed that alpha v integrin(s) and alpha 5 beta 1 participate in FN binding; however, the contribution from alpha v integrin(s) was much less than that of alpha 5 beta 1. These results demonstrate that two receptors for FN on the same cells can trigger distinct intracellular signaling pathways and, furthermore, that an integrin whose contribution to adhesion is barely detectable can have a major effect on cellular responses. The results also suggest that the specificity for activation of the calcium signaling pathway resides primarily in the integrin alpha subunit.
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Affiliation(s)
- M A Schwartz
- Scripps Research Institute, Committee on Vascular Biology, La Jolla, California 92037
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