Utilization of the Disaster Medical Assistance Team (DMAT) in an Inner-City Emergency Department During the COVID-19 Pandemic

OBJECTIVE

To evaluate the effect of the Disaster Medical Assistance Team (DMAT) in an inner-city emergency department during the coronavirus disease (COVID-19) pandemic.

METHODS

Data were abstracted from individual emergency department encounters over 6 weeks. The study compared left without being seen (LWBS) percentage, door-to-provider, and door-to-disposition times for 2 weeks before, during, and after the DMAT.

RESULTS

The LWBS percentages for the 2 weeks before and after the DMAT were 16.2% and 11.6%, respectively. The LWBS percentage during the DMAT was 8.1%. Door-to-disposition times for the 2 weeks before and after the DMAT were 7.36 hours and 8.53 hours, respectively. The door-to-disposition during the DMAT was 7.33 hours. Door-to-disposition was statistically significant during the 2 weeks of the DMAT compared to the 2 weeks after the DMAT (7.33 vs 8.53, P < 0.05) but not statistically significant when compared to the period before the DMAT (7.36 vs 7.33, P = 1.00). Door-to-provider time was the longest during the DMAT (122.5 minutes [2.04 hours]) when compared to the time frame before the DMAT (114.54 minutes [1.91 hours]) and after the DMAT (102.84 minutes [1.71 hours]).

CONCLUSION

The DMAT had the most positive impact on LWBS percentages. The DMAT showed no improvement in door-to-provider times in the study and only in door-to-disposition times when comparing the time the DMAT was present to after the DMAT departed.

Does Mixing Activated Charcoal With Cola Improve Tolerability Without Affecting Pharmacokinetics? A Randomized Controlled Crossover Trial

INTRODUCTION

Activated charcoal is the most common form of gastrointestinal decontamination used for the poisoned patient. One limitation to its use is patient tolerability due to palatability. Some recommend mixing activated charcoal with cola to improve palatability. An important question is whether mixing activated charcoal with cola affects the ability of the activated charcoal to adsorb xenobiotic.

METHODS

This was a prospective randomized controlled crossover trial. Five healthy adults aged 18 to 40 years were recruited. Participants received 45 mg/kg acetaminophen rounded down to the nearest whole tablet. One hour later, they were randomized to receive 50 g of an activated charcoal-water premixture alone or mixed with cola. Acetaminophen levels were collected. The area under the curve of acetaminophen concentrations over time was measured as a marker for degree of absorption. Participants also completed an appeal questionnaire in which they rated the activated charcoal preparations. Participants would then return after at least 7 days to repeat the study with the other activated charcoal preparation.

RESULTS

Four male participants and 1 female participant were recruited. There was no statistical difference in preference score for activated charcoal alone versus the cola-activated charcoal mixture. There was no statistical difference in the area under the curve of acetaminophen concentrations over time between activated charcoal alone and the cola-activated charcoal mixture. Of note, the study is limited by the small sample size, limiting its statistical power.

DISCUSSION

The absorption of acetaminophen in an overdose model is no different when participants received activated charcoal alone or a cola-activated charcoal mixture as suggested by area under the curve. In this small study, there was no difference in preference for activated charcoal alone or a cola-activated charcoal mixture across a range of palatability questions. On an individual level, some participants preferred the activated charcoal-cola mixture, and some preferred the activated charcoal alone.

Delay in hospital presentation is the main reason large vessel occlusion stroke patients do not receive intravenous thrombolysi

Objectives

Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the mainstays of treatment for large vessel occlusion stroke (LVOS). Prior studies have examined why patients have not received IVT, the most cited reasons being last-known-well (LKW) to hospital arrival of >4.5 hours and minor/resolving stroke symptoms. Given that LVOS patients typically present moderate-to-severe neurologic deficits, these patients should be easier to identify and treat than patients with minor strokes. This investigation explores why IVT was not administered to a cohort of LVOS patients who underwent EVT.

Methods

This is an analysis of the Optimizing the Use of Prehospital Stroke Systems of Care (OPUS-REACH) registry, which contains patients from 9 endovascular centers who underwent EVT between 2015 and 2020. The exposure of interest was the receipt of intravenous thrombolysis. Descriptive summary statistics are presented as means and SDs for continuous variables and as frequencies with percentages for categorical variables. Two-sample t tests were used to compare continuous variables and the chi-square test was used to compare categorical variables between those who received IVT and those who did not receive EVT.

Results

Two thousand forty-three patients were included and 60% did not receive IVT. The most common reason for withholding IVT was LKW to arrival of >4.5 (57.2%). The second most common contraindication was oral anticoagulation (15.5%). On multivariable analysis, 2 factors were associated with not receiving IVT: increasing age (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.78-0.93) and increasing time from LKW-to hospital arrival (OR 0.45 95% CI 0.46-0.49).

Conclusion

Like prior studies, the most frequent reason for exclusion from IVT was a LKW to hospital presentation of >4.5 hours; the second reason was anticoagulation. Efforts must be made to increase awareness of the time-sensitive nature of IVT and evaluate the safety of IVT in patients on oral anticoagulants.

Are Pediatric Manual Resuscitators Only Fit For Pediatric Use? A Comparison of Ventilation Volumes in a Moving Ambulance

BACKGROUND

The manual resuscitator device is the most common method of ventilating patients with respiratory failure, either with a facemask, or with an advanced airway such as an ETT. Barotrauma and gastric inflation from excessive ventilation volumes or pressure are concerning complications. Ventilating adult patients with pediatric manual resuscitator may provide more lung-protective tidal volumes based on stationary patient simulations. However, use of a pediatric manual resuscitator in mobile simulations contradictorily generates inadequate tidal volumes.

METHODS

Sixty-two EMS clinicians in a moving ambulance ventilated a manikin using pediatric and adult manual resuscitators in conjunction with oral-pharyngeal airway, i-gel, King LTS-D, or an endotracheal tube.

RESULTS

Oral-pharyngeal airway data were discarded due to EMS clinician inability to produce measurable tidal volumes. Mean ventilation volumes using the pediatric manual resuscitator were inadequate compared to those with the adult manual resuscitator on all other airway devices. In addition, i-gel, King LTS-D, and endotracheal tube volumes were statistically comparable. Paramedics ventilated larger volumes than emergency medical technicians.

CONCLUSIONS

Using a pediatric manual resuscitator on adult patients is not supported by our findings.

Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH): a pragmatic registry of large vessel occlusion stroke patients to create evidence-based stroke systems of care and eliminate disparities in access to stroke care

Background

Large vessel occlusion (LVO) strokes are best treated with rapid endovascular therapy (EVT). There are two routes that LVO stroke patients can take to EVT therapy when transported by EMS: primary transport (ambulance transports directly to an endovascular stroke center (ESC) or secondary transport (EMS transports to a non-ESC then transfers for EVT). There is no clear evidence which path to care results in better functional outcomes for LVO stroke patients. To find this answer, an analysis of a large, real-world population of LVO stroke patients must be performed.

Methods

A pragmatic registry of LVO stroke patients from nine health systems across the United States. The nine health systems span urban and rural populations as well as the spectrum of socioeconomic statuses. We will use univariate and multivariate analysis to explore the relationships between type of EMS transport, socioeconomic factors, and LVO stroke outcomes. We will use geographic information systems and spatial analysis to examine the complex movements of patients in time and space. To detect an 8% difference between groups, with a 3:1 patient ratio of primary to secondary transports, 95% confidence and 80% power, we will need approximately 1600 patients.

The primary outcome is the patients with modified Rankin Scale (mRS) ≤ 2 at 90 days. Subgroup analyses include patients who receive intravenous thrombolysis and duration of stroke systems. Secondary analyses include socioeconomic factors associated with poor outcomes after LVO stroke.

Discussion

Using the data obtained from the OPUS-REACH registry, we will develop evidence based algorithms for prehospital transport of LVO stroke patients. Unlike prior research, the OPUS-REACH registry contains patient-level data spanning from EMS dispatch to ninety day functional outcomes. We expect that we will find modifiable factors and socioeconomic disparities associated with poor outcomes in LVO stroke. OPUS-REACH with its breadth of locations, detailed patient records, and multidisciplinary researchers will design the optimal prehospital stroke system of care for LVO stroke patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02653-x.

Impact of COVID-19 on Emergency Medicine Residency Programs: A Cross-Sectional Study in New York State

Introduction

The 2019 novel coronavirus pandemic has caused significant disruptions in the clinical operations of hospitals as well as clinical education, training, and research at academic centers. New York State was among the first and largest epicenters of the pandemic, resulting in significant disruptions across its 29 emergency medicine (EM) residency programs. We conducted a cross-sectional observational study of EM residency programs in New York State to assess the impact of the pandemic on resident education and training programs.

Methods

We surveyed a cross-sectional sample of residency programs throughout New York State in June 2020, in the timeframe immediately after the state’s first “wave” of the pandemic. The survey was distributed to program leadership and elicited information on pandemic-prompted curricular modifications and other educational changes. The survey covered topics related to disruptions in medical education and sought details on solutions to educational issues encountered by programs.

Results

Of the 29 accredited EM residency programs in New York State, leadership from 22 (76%) responded. Of these participating programs, 11 (50%) experienced high pandemic impact on clinical services, 21 (95%) canceled their own trainees’ off-service rotations, 22 (100%) canceled or postponed visiting medical student rotations, 22 (100%) adopted virtual conference formats (most within the first week of the pandemic wave), and 11 (50%) stopped all prospective research (excluding COVID-19 research), while most programs continued retrospective research.

Conclusion

This study highlights the profound educational impact of the pandemic on residency programs in one of the hardest- and earliest-hit regions in the United States. Specifically, it highlights the ubiquity of virtual conferencing, the significant impact on research, and the concerns about canceled rotations and missed training opportunities for residents, as well as prehospital and non-physician practitioner trainees. This data should be used to prompt discussion regarding the necessity of alternate educational modalities for pandemic times and the sequelae of implementing these plans.

Identifying possible surrogate markers of COVID19 as a supplement to diagnostic testing in Upstate New York

Introduction

COVID19 has raised concerns for resource allocation across various sectors of healthcare. At the frontlines, emergency departments are required to triage a wide range of acuity and non-specific symptomology.

Methods

This retrospective study aimed to pave the way for more concrete detection and triage of patients by analyzing symptomology, physical findings, diagnostic testing and relevant hospital course of the 458 suspected cases that initially presented to an academic level one trauma center emergency department between March and August 2020. A total of 202 COVID positive cases were analyzed.

Results

The most common symptoms were cough (70.63%), fatigue (77%), and shortness of breath (59%). There was a significantly higher percentage of abnormal chest imaging in inpatient groups compared to the ED discharge group (42.86% vs 79%, p < 0.01). Laboratory studies, especially markers of inflammation (CRP, ESR), markers of tissue damage (lactic acid, troponin), and markers of infection were markedly higher and above normal reference ranges in complicated cases (p < 0.01). While there is limited data on the sensitivity and specificity of the current nasopharyngeal PCR test, there was no permutation of symptoms, physical findings, diagnostic testing that was more sensitive than that of the current PCR test calculated at 66.1% in our cohort.

Conclusion

Laboratory studies that otherwise are more commonly conducted inpatient, including markers of inflammation, tissue damage, and infection, may be useful in disposition planning of ED patients in conjunction with clinical correlation of presentation and chest imaging.

Living on the edge: the role of Atgolgin-84A at the plant ER-Golgi interface

The plant Golgi apparatus is responsible for the processing of proteins received from the endoplasmic reticulum (ER) and their distribution to multiple destinations within the cell. Golgi matrix components, such as golgins, have been identified and suggested to function as putative tethering factors to mediate the physical connections between Golgi bodies and the ER network. Golgins are proteins anchored to the Golgi membrane by the C-terminus either through transmembrane domains or interaction with small regulatory GTPases. The golgin N-terminus contains long coiled-coil domains, which consist of a number of α-helices wrapped around each other to form a structure similar to a rope being made from several strands, reaching into the cytoplasm. In animal cells, golgins are also implicated in specific recognition of cargo at the Golgi.Here, we investigate the plant golgin Atgolgin-84A for its subcellular localization and potential role as a tethering factor at the ER-Golgi interface. For this, fluorescent fusions of Atgolgin-84A and an Atgolgin-84A truncation lacking the coiled-coil domains (Atgolgin-84AΔ1-557) were transiently expressed in tobacco leaf epidermal cells and imaged using high-resolution confocal microscopy. We show that Atgolgin-84A localizes to a pre-cis-Golgi compartment that is also labelled by one of the COPII proteins as well as by the tether protein AtCASP. Upon overexpression of Atgolgin-84A or its deletion mutant, transport between the ER and Golgi bodies is impaired and cargo proteins are redirected to the vacuole. LAY DESCRIPTION: The Golgi apparatus is a specialised compartment found in mammalian and plant cells. It is the post office of the cell and packages proteins into small membrane boxes for transport to their destination in the cell. The plant Golgi apparatus consist of many separate Golgi bodies and is responsible for the processing of proteins received from the endoplasmic reticulum (ER) and their distribution to multiple destinations within the cell. Specialised proteins called golgins have been suggested to tether Golgi bodies and the ER. Here we investigate the plant golgin Atgolgin-84A for its exact within the Golgi body and its potential role as a tethering factor at the ER-Golgi interface. For this, we have fused Atgolgin-84A with a fluorescent protein from jellyfish and we are producing this combination in tobacco leaf cells. This allows us to see the protein using laser microscopy. We show that Atgolgin-84A localises to a compartment between the ER and Golgi that is also labelled by the tether protein AtCASP. When Atgolgin-84A is produced in high amounts in the cell, transport between the ER and Golgi bodies is inhibited and proteins are redirected to the vacuole.

Naloxone Administration by Untrained Community Members

STUDY OBJECTIVE

Access to naloxone is a priority for reducing opioid deaths. Although community members who complete naloxone training are able to administer nasal naloxone successfully and rapidly, little is known about the ability of community members to administer naloxone without training. The objective of this study was to assess the ability of untrained individuals to administer naloxone successfully in a simulated opioid overdose setting.

DESIGN

Prospective single-site open-label randomized usability assessment.

SETTING

Scenario station at a large state fair during August and September 2017.

PARTICIPANTS

A total of 207 healthy adults who were randomly assigned to administer naloxone using a nasal spray (NS) device (69 participants), an intramuscular (IM) kit (68 participants), or an improvised nasal atomizer (AT) kit (70 participants).

INTERVENTION

Participants were instructed to administer the device to a high-fidelity mannequin in a public environment with distractions to mimic those that might be present in an actual overdose. No device instructions or administration materials were provided.

MEASUREMENTS AND MAIN RESULTS

Participants were assessed by trained study team members who directly observed all naloxone administrations using the predetermined end-point criteria. Individual participant perceptions were evaluated immediately following the naloxone administration using a standardized questionnaire form. The primary outcome was successful administration, defined as administration within 7 minutes and without critical errors. Secondary outcomes were time to successful naloxone administration and ease of use of the device. The NS (66.7%, p<0.001) and IM (51.5%, p<0.001) devices had higher rates of successful administration than the improvised nasal AT device (2.9%). The NS device was administered more rapidly (median 16 sec) than the IM device (median 58 sec, p<0.001) or improvised nasal AT device (median 113 sec, p=0.012) devices, and it was the easiest to use.

CONCLUSION

In this study of naloxone administration, participants administered the NS and IM devices more successfully than the AT device. The NS device was administered most rapidly and was easiest to use.

Sonographic Detection of Cutaneous Myiasis

Cutaneous maggots are occasionally encountered in the emergency department. We present a case in which maggots were visually identified and ultrasound was used to detect additional maggots below the skin crevices in a patient with elephantiasis nostras verrucosa.

A randomized usability assessment of simulated naloxone administration by community members

BACKGROUND AND AIMS

Expanded access to naloxone has been identified as a key intervention for reducing opioid-related morbidity and mortality. It is not known which naloxone device will result in rapid, successful administration when administered by community members. The aims of this study were to estimate and compare (1) the rate of successful administration and (2) time to successful administration for single-step nasal spray, multi-step atomized nasal spray and intramuscular simulated naloxone by community members.

DESIGN

A prospective, single-site, open-label, randomized usability assessment of simulated naloxone administration in a convenience sample of community members. Participants were randomized to single-step nasal spray (SP), multi-step atomized nasal spray (AT) or intramuscular simulated (IM) naloxone and asked to administer the simulated medication to a mannequin after completing a 2-minute training video.

SETTING

New York, USA at a state fair that attracts between 60 000 and 120 000 individuals daily.

PARTICIPANTS

A total of 138 participants completed the study over a 2-day period in September 2016. All participants were at least 18 years of age and had no prior naloxone training.

MEASUREMENTS

The rate of successful administration and time to successful administration were recorded for each device.

FINDINGS

The SP device (100%; P < 0.001) had a higher rate of success compared with the IM device (69.6%). Although success differed between the AT (89.1%) device and IM device, as well as the AT device and SP device, these differences were not significant. The SP device also had a shorter median time to successful administration (34.3 sec) compared with the IM (99.9 sec; P < 0.001) and AT (110.3; P < 0.001) devices.

CONCLUSIONS

After video training, community members are able to (1) administer single-step nasal spray naloxone with a higher rate of success than intramuscular naloxone in a simulated overdose setting and (2) administer single-step nasal spray naloxone more rapidly than both intramuscular and multi-step atomized nasal spray naloxone.

Amyloid precursor protein, lipofuscin accumulation and expression of autophagy markers in aged bovine brain

Background

Autophagy is a highly regulated process involving the bulk degradation of cytoplasmic macromolecules and organelles in mammalian cells via the lysosomal system. Dysregulation of autophagy is implicated in the pathogenesis of many neurodegenerative diseases and integrity of the autophagosomal - lysosomal network appears to be critical in the progression of aging. Our aim was to survey the expression of autophagy markers and Amyloid precursor protein (APP) in aged bovine brains. For our study, we collected samples from the brain of old (aged 11–20 years) and young (aged 1–5 years) Podolic dairy cows. Formalin-fixed and paraffin embedded sections were stained with routine and special staining techniques. Primary antibodies for APP and autophagy markers such as Beclin-1 and LC3 were used to perform immunofluorescence and Western blot analysis.

Results

Histologically, the most consistent morphological finding was the age-related accumulation of intraneuronal lipofuscin. Furthermore, in aged bovine brains, immunofluorescence detected a strongly positive immunoreaction to APP and LC3. Beclin-1 immunoreaction was weak or absent. In young controls, the immunoreaction for Beclin-1 and LC3 was mild while the immunoreaction for APP was absent. Western blot analysis confirmed an increased APP expression and LC3-II/LC3-I ratio and a decreased expression of Beclin-1 in aged cows.

Conclusions

These data suggest that, in aged bovine, autophagy is significantly impaired if compared to young animals and they confirm that intraneuronal APP deposition increases with age.

Serum Calcium Concentration in Ethylene Glycol Poisoning

INTRODUCTION

The diagnosis of ethylene glycol intoxication can be challenging. Definitive testing for ethylene glycol is not readily available and clinical decisions are often based on clinical suspicion and the results of more readily available tests. One of these findings is hypocalcemia, presumable through complexation with the ethylene glycol metabolite oxalate.

METHODS

We performed a retrospective review of all patients admitted to a tertiary care hospital between 2005 and 2013 with laboratory confirmed ethylene glycol intoxication. Serum calcium on presentation was compared to blood gas pH on presentation as well as presentation serum bicarbonate.

RESULTS

We did not find any relationship between calcium and serum pH either by linear regression or when dichotomized by pH ≥ or <7.3. We did observe an inverse relationship between serum calcium and bicarbonate.

CONCLUSIONS

Hypocalcemia is not commonly observed following ethylene glycol poisoning, even in acidotic patients.

Can EMS Providers Provide Appropriate Tidal Volumes in a Simulated Adult-sized Patient with a Pediatric-sized Bag-Valve-Mask?

INTRODUCTION

In the prehospital setting, Emergency Medical Services (EMS) professionals rely on providing positive pressure ventilation with a bag-valve-mask (BVM). Multiple emergency medicine and critical care studies have shown that lung-protective ventilation protocols reduce morbidity and mortality. Our primary objective was to determine if a group of EMS professionals could provide ventilations with a smaller BVM that would be sufficient to ventilate patients. Secondary objectives included 1) if the pediatric bag provided volumes similar to lung-protective ventilation in the hospital setting and 2) compare volumes provided to the patient depending on the type of airway (mask, King tube, and intubation).

METHODS

Using a patient simulator of a head and thorax that was able to record respiratory rate, tidal volume, peak pressure, and minute volume via a laptop computer, participants were asked to ventilate the simulator during six 1-minute ventilation tests. The first scenario was BVM ventilation with an oropharyngeal airway in place ventilating with both an adult- and pediatric-sized BVM, the second scenario had a supraglottic airway and both bags, and the third scenario had an endotracheal tube and both bags. Participants were enrolled in convenience manner while they were on-duty and the research staff was able to travel to their stations. Prior to enrolling, participants were not given any additional training on ventilation skills.

RESULTS

We enrolled 50 providers from a large, busy, urban fire-based EMS agency with 14.96 (SD = 9.92) mean years of experience. Only 1.5% of all breaths delivered with the pediatric BVM during the ventilation scenarios were below the recommended tidal volume. A greater percentage of breaths delivered in the recommended range occurred when the pediatric BVM was used (17.5% vs 5.1%, p < 0.001). Median volumes for each scenario were 570.5mL, 664.0mL, 663.0mL for the pediatric BMV and 796.0mL, 994.5mL, 981.5mL for the adult BVM. In all three categories of airway devices, the pediatric BVM provided lower median tidal volumes (p < 0.001).

CONCLUSION

The study suggests that ventilating an adult patient is possible with a smaller, pediatric-sized BVM. The tidal volumes recorded with the pediatric BVM were more consistent with lung-protective ventilation volumes.

Age-Related Changes in Skeletal Muscle of Cattle

Sarcopenia, the age-related loss of muscle mass and strength, is a multifactorial condition that represents a major healthcare concern for the elderly population. Although its morphologic features have been extensively studied in humans, animal models, and domestic and wild animals, only a few reports about spontaneous sarcopenia exist in other long-lived animals. In this work, muscle samples from 60 healthy Podolica-breed old cows (aged 15-23 years) were examined and compared with muscle samples from 10 young cows (3-6 years old). Frozen sections were studied through standard histologic and histoenzymatic procedures, as well as by immunohistochemistry, immunofluorescence, and Western blot analysis. The most prominent age-related myopathic features seen in the studied material included angular fiber atrophy (90% of cases), mitochondrial alterations (ragged red fibers, 70%; COX-negative fibers, 60%), presence of vacuolated fibers (75%), lymphocytic (predominantly CD8+) inflammation (40%), and type II selective fiber atrophy (40%). Immunohistochemistry revealed increased expression of major histocompatibility complex I in 36 cases (60%) and sarcoplasmic accumulations of β-amyloid precursor protein-positive material in 18 cases (30%). In aged cows, muscle atrophy was associated with accumulation of myostatin. Western blot analysis indicated increased amount of both proteins-myostatin and β-amyloid precursor protein-in muscles of aged animals compared with controls. These findings confirm the presence of age-related morphologic changes in cows similar to human sarcopenia and underline the possible role of amyloid deposition and subsequent inflammation in muscle senescence.

Functional characterization of the ectopically expressed olfactory receptor 2AT4 in human myelogenous leukemia

The olfactory receptor (OR) family was found to be expressed mainly in the nasal epithelium. In the last two decades members of the OR family were detected to be functional expressed in different parts of the human body such as in liver, prostate or intestine cancer cells. Here, we detected the expression of several ORs in the human chronic myelogenous leukemia (CML) cell line K562 and in white blood cells of clinically diagnosed acute myeloid leukemia (AML) patients by RT-PCR and next-generation sequencing. With calcium-imaging, we characterized in greater detail the cell biological role of one OR (OR2AT4) in leukemia. In both cell systems, the OR2AT4 agonist Sandalore-evoked strong Ca²⁺ influx via the adenylate cyclase-cAMP-mediated pathway. The OR2AT4 antagonist Phenirat prevented the Sandalore-induced intracellular Ca²⁺ increase. Western blot and flow cytometric experiments revealed that stimulation of OR2AT4 reduced the proliferation by decreasing p38-MAPK phosphorylation and induced apoptosis via phosphorylation of p44/42-MAPK. Furthermore, Sandalore increased the number of hemoglobin-containing cells in culture. We described for the first time an OR-mediated pathway in CML and AML that can regulate proliferation, apoptosis and differentiation after activation. This mechanism offers novel therapeutic options for the treatment of AML.

A prospective evaluation of the contribution of ambient temperatures and transport times on infrared thermometry readings of intravenous fluids utilized in EMS patients

Background

During cold weather months in much of the country, the temperatures in which prehospital care is delivered creates the potential for inadvertently cool intravenous fluids to be administered to patients during their transport and care by emergency medical services (EMS). There is some potential for patient harm from unintentional infusion of cool intravenous fluids. Prehospital providers in these cold weather environments are likely using fluids that are well below room temperature when prehospital intravenous fluid (IVF) warming techniques are not being employed. It was hypothesized that cold ambient temperatures during winter months in the study location would lead to the inadvertent infusion of cold intravenous fluids during prehospital patient care.

Methods

Trained student research assistants obtained three sequential temperature measurements using an infrared thermometer in a convenience sample of intravenous fluid bags connected to patients arriving via EMS during two consecutive winter seasons (2011 to 2013) at our receiving hospital in Syracuse, New York. Intravenous fluids contained in anything other than a standard polyvinyl chloride bag were not measured and were not included in the study. Outdoor temperature was collected by referencing National Weather Service online data at the time of arrival. Official transport times from the scene to the emergency department (ED) and other demographic data was collected from the EMS provider or their patient care record at the time of EMS interaction.

Results

Twenty-three intravenous fluid bag temperatures were collected and analyzed. Outdoor temperature was significantly related to the temperature of the intravenous fluid being administered, b = 0.69, t(21) = 4.3, p < 0.001. Transport time did not predict the measured intravenous fluid temperatures, b = 0.12, t(20) = 0.55, p < 0.6.

Conclusions

Use of unwarmed intravenous fluid in the prehospital environment during times of cold ambient temperatures can lead to the infusion of cool intravenous fluid and may result in harm to patients. Short transport times do not limit this risk. Emergency departments should not rely on EMS agencies’ use of intravenous fluid warming techniques and should consider replacing EMS intravenous fluids upon ED arrival to ensure patient safety.

Endotracheal intubation with a video-assisted semi-rigid fiberoptic stylet by prehospital providers

BACKGROUND

Emergency medical technicians intubate patients in unfamiliar surroundings and with less than ideal positioning. This study was designed to evaluate advanced life support (ALS) emergency medical technicians' (EMTs) ability to successfully intubate a simulated airway using a video-assisted semi-rigid fiberoptic stylet, the Clarus Video System (CVS).

METHODS

ALS EMTs were first shown a brief slideshow and three example videos and then given 20 min to practice intubating a mannequin using both the CVS and standard direct laryngoscopy (DL). The mannequin was then placed on the floor to simulate field intubation at the scene. Each participant was given up to three timed attempts with each technique. Endotracheal tube position was confirmed with visualization by one of the study authors. Comparisons and statistical analysis were conducted using SPSS® Statistics 21 (IBM®). Demographics and survey results were also collected and analyzed.

RESULTS

The median total time for intubation was 15.00 s for DL and 15.50 s for CVS revealing no significant difference between the two techniques (p = 0.425), and there was no significant difference in the number of attempts required to successfully place the endotracheal tube (ETT) (p = 0.997). Demographic factors including handedness and eye dominance did not seem to affect outcomes. Participants reported a relatively high level of satisfaction with the CVS.

CONCLUSIONS

ALS EMTs were able to obtain intubation results similar to those of their usual direct laryngoscopy technique when utilizing a video-assisted semi-rigid fiberoptic stylet with very limited instruction and experience with the device. The CVS technique warrants further study for use as an alternative to DL and video laryngoscopy in the prehospital difficult airway scenario.

CD34+/CD45-dim stem cell mobilization by hyperbaric oxygen - changes with oxygen dosage

Because hyperbaric oxygen treatment mobilizes bone marrow derived-stem/progenitor cells by a free radical mediated mechanism, we hypothesized that there may be differences in mobilization efficiency based on exposure to different oxygen partial pressures. Blood from twenty consecutive patients was obtained before and after the 1st, 10th and 20th treatment at two clinical centers using protocols involving exposures to oxygen at either 2.0 or 2.5 atmospheres absolute (ATA). Post-treatment values of CD34+, CD45-dim leukocytes were always 2-fold greater than the pre-treatment values for both protocols. Values for those treated at 2.5 ATA were significantly greater than those treated at 2.0 ATA by factors of 1.9 to 3-fold after the 10th and before and after the 20th treatments. Intracellular content of hypoxia inducible factors -1, -2, and -3, thioredoxin-1 and poly-ADP-ribose polymerase assessed in permeabilized CD34+ cells with fluorophore-conjugated antibodies were twice as high in all post- versus pre-treatment samples with no significant differences between 2.0 and 2.5 ATA protocols. We conclude that putative progenitor cell mobilization is higher with 2.5 versus 2.0 ATA treatments, and all newly mobilized cells exhibit higher concentrations of an array of regulatory proteins.

Backboard time for patients receiving spinal immobilization by emergency medical services

Background

Use of backboards as part of routine trauma care has recently come into question because of the lack of data to support their effectiveness. Multiple authors have noted the potential harm associated with backboard use, including iatrogenic pain, skin ulceration, increased use of radiographic studies, aspiration and respiratory compromise. An observational study was performed at a level 1 academic trauma center to determine the total and interval backboard times for patients arriving via emergency medical services (EMS).

Findings

Patients were directly observed. Transport time was recorded as an estimate of initiation of backboard use; arrival time, nurse report time and time of removal from the backboard were all recorded. National Emergency Department Overcrowding Study (NEDOCS) score, Emergency Severity Index (ESI) and demographic information were recorded for each patient encounter. Forty-six patients were followed. The mean total backboard time was 54 min (SD ±65). The mean EMS interval was 33 min (SD ±64), and the mean ED interval was 21 min (SD ±15). The ED backboard interval trended inversely to ESI (1 = 5 min, 2 = 10 min, 3 = 25 min, 4 = 26 min, 5 = 32 min).

Conclusion

Patients had a mean total backboard time of around an hour. The mean EMS interval was greater than the mean ED interval. Further study with a larger sample directed to establishing associated factors and to target possible reduction strategies is warranted.

Evaluation of ambulance offload delay at a university hospital emergency department

Background

Ambulance offload delay (AOD) has been recognized by the National Association of EMS Physicians (NAEMSP) as an important quality marker. AOD is the time between arrival of a patient by EMS and the time that the EMS crew has given report and moved the patient off of the EMS stretcher, allowing the EMS crew to begin the process of returning to service. The AOD represents a potential delay in patient care and a delay in the availability of an EMS crew and their ambulance for response to emergencies. This pilot study was designed to assess the AOD at a university hospital utilizing direct observation by trained research assistants.

Findings

A convenience sample of 483 patients was observed during a 12-month period. Data were analyzed to determine the AOD overall and for four groups of National Emergency Department Overcrowding Scale (NEDOCS) score ranges. The AOD ranged from 0 min to 157 min with a median of 11 min. When data were grouped by NEDOCS score, there was a statistically significant difference in median AOD between the groups (p < 0.001), indicating the relationship between ED crowding and AOD.

Conclusion

The median AOD was considered significant and raised concerns related to patient care and EMS system resource availability. The NEDOCS score had a positive correlation with AOD and should be further investigated as a potential marker for determining diversion status or for destination decision-making by EMS personnel.

Blood culture results do not affect treatment in complicated cellulitis

BACKGROUND

Cellulitis, a frequently encountered complaint in the Emergency Department, is typically managed with antibiotics. There is some debate as to whether obtaining blood cultures and knowing their results would change the management of cellulitis, although most authors argue that information from blood cultures does not change the empirical management of uncomplicated cellulitis. However, for complicated cellulitis (as defined by the presence of significant comorbidity), there is considerable disagreement and lack of evidence as to the utility of blood cultures.

OBJECTIVE

Our aim was to determine the role of blood cultures in the management of complicated cellulitis.

METHODS

This retrospective chart review assessed the utility of obtaining blood cultures in complicated cellulitis (as defined by active chemotherapy, dialysis, human immunodeficiency virus/acquired immune deficiency syndrome, diabetes, or organ transplantation) vs. a cohort of individuals without medical comorbidity.

RESULTS

Six hundred and thirty-nine patients were identified, 314 of which were deemed cases and 325 controls. Within the cases, 29 of 314 returned as positive blood cultures vs. 17 of 325 positive blood culture controls within the cases (p = 0.05; odds ratio = 1.84; 95% confidence interval 0.99-3.43). A clinically significant change in management (a change in the class of antibiotic) was found in 6 of 314 cases vs. 4 of 325 controls (p = 0.578; odds ratio = 1.5525; 95% confidence interval 0.434-5.5541).

CONCLUSIONS

Within this cohort of patients with complicated cellulitis, blood cultures rarely changed management from empirical coverage.

Performance of emergency physicians utilizing a video-assisted semi-rigid fiberoptic stylet for intubation of a difficult airway in a high-fidelity simulated patient: a pilot study

Background

This study was designed to evaluate emergency physician success and satisfaction using a video-assisted semi-rigid fiberoptic stylet, the Clarus Video System (CVS), during a simulated difficult airway scenario.

Findings

Emergency physicians (EPs) of all levels were first shown a brief slide show and three example videos, and then given 20 min to practice intubating a mannequin using both the CVS and standard direct laryngoscopy (DL). The mannequin was then placed in a c-collar and set to simulate an apneic patient with an edematous tongue and trismus. Each EP was given up to three timed attempts with each technique. They rated their satisfaction with the CVS, usefulness for their practice, and the effectiveness of the tutorial. Direct laryngoscopy had a 65% success rate on the first attempt, 20% on the second, and 15% required three or more. The CVS had a 100% success rate with a single attempt. Average time for independent DL attempts was 43.41 s (SD = ±26.82) and 38.71 s (SD = ±34.14) with CVS. Cumulative attempt times were analyzed and compared (DL = 74.55 ± 68.40 s and CVS = 38.71 ± 34.14 s; p = 0.028). EPs rated their satisfaction with, and usefulness of, the CVS as ≥6 out of 10.

Conclusion

Emergency physicians were able to successfully intubate a simulated difficult airway model on the first attempt 100% of the time. Emergency physicians were satisfied with the CVS and felt that it would be useful in their practice.

Role of TL1A in the pathogenesis of rheumatoid arthritis

TNF-like ligand 1A (TL1A), a member of the TNF superfamily, is the ligand of DR3 and DcR3. Several types of cells, such as endothelial cells, monocytes/macrophages, dendritic cells, and CD4 and CD8 T cells, are capable of producing this cytokine. In present study, we demonstrated that TL1A aggravated collagen-induced arthritis in mice. It increased collagen-induced arthritis penetrance and clinical scores as well as the severity of the pathological findings. TL1A administration led to the occurrence of multiple enlarged germinal centers in the spleen, and it boosted serum anti-collagen Ab titers in vivo. In vitro, TL1A augmented TNF-alpha production by T cells upon TCR ligation, and it greatly enhanced Th17 differentiation and IL-17 production. We further showed that human rheumatoid arthritis (RA) synovial fluids had elevated TL1A titers, and human chrondrocytes and synovial fibroblasts were capable of secreting TL1A upon TNF-alpha or IL-1beta stimulation. Taken together, these data suggest that TL1A secretion in lymphoid organs might contribute to RA initiation by promoting autoantibody production, and TL1A secretion stimulated by inflammatory cytokines in RA joints might be a part of a vicious circle that aggravates RA pathogenesis.

Predicting pertussis in a pediatric emergency department population

Cases of pertussis, a potentially life-threatening illness in infants younger than 6 months of age, are at a 40-year high. Children frequently present to emergency departments for initial evaluation. Quick recognition of the illness allows rapid triage, isolation, and prevention of nosocomial transmission. A retrospective, case-control chart review was conducted of pediatric emergency department patients (0 to 18 years of age) presenting between January 1, 2003, and December 31, 2004. Analysis focused on the exploration of medical history and physical examination variables as predictors using laboratory verification of the presence of pertussis as a binary outcome variable. Infants younger than 2 months who have a cough or choking associated with cyanosis, as well as a cough and rhonchi on physical examination, have a high likelihood of pertussis and should be identified in triage, isolated immediately, and tested for pertussis. This may lead to appropriate therapy for this population and decrease the transmission of pertussis to other patients and staff in the pediatric emergency department.

Increased expression of Noga-A in ALS muscle biopsies is not unique for this disease

Nogo (RTN4) belongs to the reticulon (RTN) family of integral membrane proteins. RTN4A (Nogo-A), RTN4B (Nogo-B) and RTN4C (Nogo-C) are isoforms of RTN4. In the gastrocnemius muscle of transgenic mice bearing an SOD1 mutation ("ALS model"), increased Nogo-A mRNA and protein was reported, and similar changes were reported in muscle biopsies of patients with amyotrophic lateral sclerosis (ALS) but not with peripheral neuropathy or primary muscle diseases, leading to the proposal that Nogo-A in skeletal muscle is a new specific molecular marker of ALS. Here we report, based on studies of muscle biopsies from patients with ALS, peripheral neuropathies, polymyositis, dermatomyositis and morphologically nonspecific myopathies that, in addition of strong Nogo-A immunoreactivity within apparently-denervated small angular fibers in ALS and peripheral neuropathies, Nogo-A was strongly immunoreactive within desmin-positive regenerating muscle fibers in various myopathies, and its expression on immunoblots was increased in all those neuromuscular diseases. In conclusion, we have found that the presence of Nogo-A in diseased human muscle biopsies is not limited to ALS.

Utility of an immunization registry in a pediatric emergency department

OBJECTIVES

Determine prevalence of participation and underimmunization rate in a regional immunization registry (IR) among patients presenting to a university pediatric emergency department (PED). Rate of agreement between parental report and documented immunization status was also measured.

METHODS

A convenience sample of parents of patients younger than 11 years registered in the PED were approached with a short questionnaire. When informed consent was obtained, the Central New York (CNY) IR was accessed via computer to see if the child was in the registry and to ascertain if their immunizations were up-to-date (UTD). Rate of agreement between parental report and immunization status documented in the IR was calculated.

RESULTS

698 (97%) of 720 patients consented to participate. Of these, 235 (34%, 95% CI, 30-37) were enrolled in the IR. Eighty-five (36%, 95% CI, 30-42) enrolled patients were under age 2. Sixty-seven (29%, 95% CI, 23-34) were from private group practices, 146 (62%, 95% CI, 56-68) were from university/community health center clinics and the source of primary care for 22 patients (9%) was unknown. Only 67 (29%, 95% CI, 23-34) parents of children in the IR were aware that they were enrolled. Of IR patients, 225 (96%, 95% CI, 93-98) stated they were UTD, while only 143 (61%, 95% CI, 55-67) were documented to be so.

CONCLUSIONS

A significant number of patients seen in the PED were in the CNY IR. More than one-half of the parents of enrolled children did not recall that they had previously registered their child. Only 61% of patients were UTD, whereas parents reported that almost all were. In the PED, use of an IR would create an opportunity for intervention in a large number of patients who were not UTD.

Overcoming recruitment challenges in construction safety intervention research

BACKGROUND

Recruiting workers in small construction companies and securing their participation in voluntary safety programs or safety research poses unique challenges. Worker turnover and worksite changes contribute to difficulties in locating and enrolling participants. Economic pressures and time demands potentially threaten ongoing participation.

METHODS

Six simulation exercises designed to reduce back and fall injuries in small construction companies were developed based on data from focus groups of workers and company owners. Working with a workers' compensation insurer, we had access to owner-operators of general, heavy, and special trade construction companies reporting less than $10,000 in payroll expenses. Recruitment methods included a participation incentive, mailed invitations followed by phone contacts, and follow-up reminders.

RESULTS

Despite using recruitment methods recommended in the literature, participation rates were low over a 2-year intervention period. Because of these difficulties, factors affecting participation or nonparticipation became an additional research focus. Owners' perceptions of already having a good safety record and of the time demands of participation were the most commonly cited reasons for not participating.

CONCLUSIONS

Literature on recruitment emphasizes processes and procedures under investigator control rather than understanding potential participants' judgments about the adequacy of their existing practices and the potential benefits of intervention participation relative to potential time and productivity trade-offs. Greater attention to such judgments may enhance recruitment and participation in under-studied and difficult to access populations.