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Objective:Research has shown that routine screening laboratory tests for patients with mental health symptoms admitted to psychiatry units find little unexpected clinical abnormalities. This study ...

Invasively monitoring blood pressure through the IO device has not been thoroughly demonstrated. This study attempted to establish baseline values of IO pressure in a healthy human population.This was a prospective, healthy volunteer, observational study. Participants had two IO devices placed (humerus and tibia), and participant IO pressures, vital signs, and pain scores were monitored for up to 60 minutes. Participants were contacted at 24-hours and 7 days post-testing to assess for adverse events. Summary statistics were calculated for systolic, diastolic, and mean humeral and tibial IO pressure. The ratio of IO to non-invasive blood pressure was calculated, and Bland Altman plots were created. The slope (linear) of the mean humeral and the tibial IO pressures were also calculated.Fifteen subjects were enrolled between April and July 2015. Fourteen of 15 humeral IOs were placed successfully (93.3%) and all 15 of the tibial IOs were placed successfully. Mean tibial systolic, diastolic, and mean IO pressure were 55.8 ± 27.9, 49.3 ± 27.1, and 48.4 ± 29.4 mm Hg, respectively. Humeral systolic, diastolic, and mean IO pressure were 32.9 ± 16.0, 27.4 ± 15.2, and 24.5 ± 14.3 mm Hg. The mean tibial IO pressure was 52.5% ± 32.0% of external cuff pressure ratio. The mean humeral IO pressure was 26.5% ± 15.2% of the external mean blood pressure. The Bland Altman plots showed an inconsistent relationship between the systolic and diastolic cuff pressure and the IO pressures. We observed a 1% per minute decrease in IO pressure from the initial placement until the final reading.Intraosseous pressure readings can be obtained in healthy human volunteers. However, absolute IOP values were not consistent between subjects. Future research may determine how IO pressure can be used to guide therapy in ill and injured patients.

Background In emergent situations, access to the vascular bed is frequently required for fluid and medication administration. Central venous catheter placement is associated with risk and may slow resuscitation in the unstable patient. The purpose of this study was to determine whether intraosseous pressure (IOP) could be consistently recorded and how similar this pressure was to central venous and arterial pressure in a porcine hemorrhagic shock model. Materials and methods After sedation, eight female swine had catheters placed in the femoral vein, aorta via femoral artery, and superior vena cava. IOP lines were placed in the proximal humerus, distal femur, and proximal tibia. Pressure readings were recorded continuously through the five stages of progressive hypovolemia. Pressure data were descriptively summarized, with the percent of change of IOP at each stage compared with arterial pressure using a multilevel mixed effects linear model with log transformation. Results The IOP baseline values were between 16 and 18 mm Hg, approximately 22% of baseline arterial pressure. The intraosseous (IO) waveform mostly closely resembled the arterial pressure waveform, including the presence of a dichroitic notch. Pressure variations caused by ventilation (respiratory variability) were also identified in all the tracings. The rate of pressure change in the humeral IO most closely matched the change in arterial pressure rate. IO blood gas analysis showed gas composition to most closely match venous blood. Conclusions IOP was reliably obtained in this porcine model and suggests potential for clinical application in humans.

Objective The objective of this study is to examine the annual utilization trends of emergency department (ED)–ordered magnetic resonance imaging (MRI) and computed tomography (CT) at an urban academic hospital from 2007 to 2011. We hypothesized that MRI and CT use would increase annually over the study period. Methods This was a retrospective observational study of ED encounters between January 1, 2007, and December 31, 2011. All patients seen by a provider were identified, and demographics were abstracted. Type of CT and/or MRI examination, clinical indication, and final disposition were collected. Records of patients with an ED-ordered MRI were also examined for presence of a CT within ±3 days of their encounter date. Unadjusted linear regression was used to assess for differences among years for both CT and MRI. Secondary outcomes were descriptively summarized. Results A total of 7089 MRI (20 per 1000) and 85673 CT (243 per 1000) examinations were ordered over a 60-month period. Computed tomography use decreased significantly ( P = .021). Magnetic resonance imaging use significantly increased (2.2 per 1000 ED visits each year, P = .005). Magnetic resonance imaging of the head was ordered most frequently (10.7 per 1000). The overwhelming majority of MRI images were completed for acute neurologic/behavioral problem. Of patients with an MRI completed, 89.4% had a CT completed within 3 calendar days with most of the CT examinations (81%) completed during the encounter. Conclusion There was a steady increase in MRI testing in our academic ED, with most MRIs ordered for acute neurologic or behavioral changes. There was a corresponding decreasing trend for CT scans.

The purpose of this study was to examine trends in oxygen administration following the 2010 American Heart Association guidelines recommendation to withhold oxygen therapy for patients with uncomplicated presentations of ACS whose SpO2 is 94% or higher.Following IRB review and approval, we performed a retrospective analysis of data obtained from Fisdap(TM), a national, clinical skills tracking system for paramedic students between June 2010 and December 2012. Inclusion criteria included: 1) student consent for research, 2) cardiac chest pain recorded as the chief complaint, and 3) SpO2 data available for review. O2 administration, route, and dose were abstracted, and the percent of patient encounters with oxygen administration was calculated for each year. Unadjusted logistic regression was used to determine if O2 administration rates changed significantly over the study period. Unadjusted logistic regression was also used to determine if there was a difference in the odds of receiving oxygen based on a patient's SpO2 value.10,552 patient encounters by 2,447 paramedic students from 195 paramedic programs representing 49 states were included for analysis. Prior to release of the new guidelines (2010), 71.9% (95% CI 69.8-74.0%) of patients with SpO2 ≥ 94% received supplemental O2. Rates of O2 administration were significantly lower in 2011 (64%; 95% CI 62.7-65.3%) and in 2012 (53.1%; 95% CI 51.5-54.7). The odds of a hemodynamically stable chest pain patient with SpO2 ≥ 94% receiving supplemental oxygen in 2011 were 1.4 times lower compared to patients in 2010 (95% CI 1.3-1.6). Similarly, the odds of patients in 2012 receiving supplemental oxygen were 2.3 times lower compared to patients in 2010 (95% CI 2.0-2.6). The odds of receiving supplemental oxygen decreased by 4% for each 1% increase in SpO2 beyond the 94% threshold (OR = 0.96; 95% CI 0.94-0.98).The prehospital administration of supplemental O2 decreased significantly following release of the 2010 updated guidelines; however, our data revealed that 50% of patients not meeting criteria for administration still received supplemental O2.

Background Patients with renal colic commonly present to the emergency department (ED) and are usually treated with analgesics, antiemetics and hydration. Computed tomographic (CT) scan is commonly utilized in evaluating patients with suspected renal colic. Objectives We compared diagnosis and treatment plans before and after CT in patients with suspected renal colic with the aim to evaluate how often changes in diagnosis, treatment and disposition are made. Methods In this prospective observational study, we enrolled a convenience sample of clinically Stable ED patients older than 17 with suspected renal colic for whom CT was planned. Exclusion criteria were: chronic kidney disease, urinary tract infection, recent CT and history of previous kidney stone. Pre-CT and Post-CT surveys were completed by the treating provider. Results The discharge diagnosis was renal colic in 62 of 93 enrolled patients (67%). Urinalysis showed blood in 52 of these patients (84%). CT confirmed obstructing kidney or bladder stone in 50 patients. There were five cases of alternative diagnoses noted on CT scan. After CT scan, 7 patients had changes in disposition. Sixteen providers felt that CT would not change management. In these cases, CT offered no alternative diagnosis and didn't change disposition. Conclusion CT scan didn't change management when providers did not expect it would. This indicates that providers who are confident with the diagnosis of renal colic should consider forgoing a CT scan. CT scan did occasionally find important alternative diagnoses and should be utilized when providers are considering other concerning pathology.

The primary aims of this study were to compare paramedic success rates and complications of two different video laryngoscopes in a prehospital clinical study.This study was a multi-agency, prospective, non-randomized, cross over clinical trial involving paramedics from four different EMS agencies. Following completion of training sessions, six Storz CMAC™ video laryngoscopes and six King Vision™ (KV) video laryngoscopes were divided between agencies and placed into service for 6 months. Paramedics were instructed to use the video laryngoscope for all patients estimated to be ≥ 18 years old who required advanced airway management per standard operating procedure. After 6 months, the devices were crossed over for the final 6 months of the study period. Data collection was completed using a telephone data collection system with a member of the research team (available 24/7). First attempt success, overall success, and success by attempt, were compared between treatment groups using exact logistic regression adjusted for call type and user experience.Over a 12-month period, 107 patients (66 CMAC, 41 KV) were treated with a study device. The CMAC had a significantly higher likelihood of first attempt success (OR = 1.85; 95% CI 0.74, 4.62; p = 0.188), overall success (OR = 7.37; 95% CI 1.73, 11.1; p = 0.002), and success by attempt (OR = 3.38; 95% CI 1.67, 6.8; p = 0.007) compared to KV. Providers reverted to direct laryngoscopy in 80% (27/34) of the video laryngoscope failure cases, with the remaining patients having their airways successfully managed with a supraglottic airway in 3 cases and bag-valve mask in 4 cases. The provider-reported complications were similar and none were statistically different between treatment groups. Complication rates were not statistically different between devices.The CMAC had a higher likelihood of successful intubation compared to the King Vision. Complication rates were not statistically different between groups. Video laryngoscope placement success rates were not higher than our historical direct laryngoscopy success rates.

Background A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD+ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD+ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology. Methods This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score≤3). Results Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR=1335; ACD+ITD=1403). Survival to HD with favorable neurologic function was greater with ACD+ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p =0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p =0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups. Conclusions Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD+ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD+ITD, regardless of the etiology of the cardiac arrest.

Objectives This study examines the effects of IV epinephrine administration on carotid blood flow (CBF) and end tidal CO 2 (ETCO 2 ) production in a swine model of active compression–decompression CPR with an impedance threshold device (ACD-CPR+ITD). Methods Six female swine (32±1kg) were anesthetized, intubated and ventilated. Intracranial, thoracic aorta and right atrial pressures were measured via indwelling catheters. CBF was recorded. ETCO 2 , SpO 2 and EKG were monitored. V-fib was induced and went untreated for 6min. Three minutes each of standard CPR (STD), STD-CPR+impedance threshold device (ITD) and active compression–decompression (ACD)-CPR+ITD were performed. At minute 9 of the resuscitation, 40μg/kg of IV Epinephrine was administered and ACD-CPR+ITD was continued for 1min. Statistical analysis was performed with a paired t -test. p values of Results Aortic pressure, cerebral and coronary perfusion pressures increased from STD p p =0.01), cerebral perfusion pressure (12±5 vs 22±10, p =0.01), and coronary perfusion pressure (8±7 vs 17±4, p =0.02); however, mean CBF and ETCO 2 decreased (respectively 29±15 vs 14±7.0ml/min, p =0.03; 20±7 vs 18±6, p =0.04). Conclusions In this model, administration of epinepherine during ACD-CPR+ITD signficantly increased markers of macrocirculation, while significantly decreasing carotid blood flow and ETCO 2 . This calls into question the ability of calculated perfusion pressures to accurately reflect oxygen delivery to end organs. The administration of epinepherine during ACD-CPR+ITD does not improve cerebral tissue perfusion.

Numerous studies have reported unsafe endotracheal tube (ETT) cuff pressures (CP) in the prehospital environment. The purpose of this study was to identify an optimal cuff inflation volume (CIV) to achieve a safe CP (20-30 cmH2O). This observational study utilized 30 recently harvested ovine tracheae, which were warmed from refrigeration in a water bath at 85°F prior to testing. Each trachea was intubated with five different ETT sizes (6.0-8.0 mm), and each size tube was tested with six cuff inflation volumes (5-10 cc). The order of ETT size for each trachea and CIV for each size ETT was randomly pre-assigned. Data were descriptively summarized and categorized before mixed-effects logistic regression was used to determine optimal CIV. Only 113 CP measurements (12.6%, N = 900) were within the optimal range (M = 54.75 cmH2O, SD = 38.52), all of which resulted from a CIV 6 or 7 cc (61% and 39%, respectively). CIVs of 5 cc (n = 150) resulted in underinflation (20 cmH2O) in all instances, while CIVs of 8, 9, or 10 cc (n = 150 each) resulted in overinflation (30 cmH2O) in all instances, regardless of ETT size. The odds of achieving a safe CP were greater with CIV of 6 cc for tube sizes 6.0 (OR = 15.9, 95% CI = 3.85-65.58, p0.01) and 6.5 mm (OR = 3.16, 95% CI = 1.06-9.39, p = 0.039); however, there was no significant difference in the odds of achieving a safe CP between CIV of 6 and 7 cc for tube sizes 7.0, 7.5, or 8.0 mm. Neither trachea circumference (M = 7.11 cm, SD = 0.40), nor tissue temperature (M = 81.32°F, SD = 0.93) were found to be significant predictors of CP (p = 0.20 and 0.81, respectively). Our study showed a high frequency of CP measurements outside of the desired norms. The CIV range of 6-7 cc resulted in the highest likelihood of achieving the desired cuff pressure range, while cuffs inflated with 8-10 cc resulted in dangerously high CPs in all instances. In the absence of a more ideal solution, the results of this study suggest that narrowing the recommended CIV from 5-10 cc to 6-7 cc might be a reasonable target for any tube size.

Introduction: The primary aim of this study was to determine which objectively-measured patient demographics, emergency department (ED) operational characteristics, and healthcare utilization frequencies (care factors) were associated with patient satisfaction ratings obtained from phone surveys conducted by a third-party vendor for patients discharged from our ED. Methods: This is a retrospective, observational analysis of data obtained between September 2011 and August 2012 from all English- and Spanish-speaking patients discharged from our ED who were contacted by a third-party patient satisfaction vendor to complete a standardized nine-item telephone survey by a trained phone surveyor. We linked data from completed surveys to the patient’s electronic medical record to abstract additional demographic, ED operational, and healthcare utilization data. We used univariate ordinal logistic regression, followed by two multivariate models, to identify significant predictors of patient satisfaction. Results: We included 20,940 patients for analysis. The overall patient satisfaction ratings were as follows: 1=471 (2%); 2=558 (3%); 3=2,014 (10%), 4=5,347 (26%); 5=12,550 (60%). Factors associated with higher satisfaction included race/ethnicity (Non-Hispanic Black; Hispanic patients), age (patients ≥65), insurance (Medicare), mode of arrival (arrived by bus or on foot), and having a medication ordered in the ED. Patients who felt their medical condition did not improve, those treated in our ED behavioral health area, and those experiencing longer wait times had reduced satisfaction. Conclusion: These findings provide a basis for development and evaluation of targeted interventions that could be used to improve patient satisfaction in our ED.

Objectives Emergency medical research performed under federal regulation 21 § CFR 50.24 provides a means to protect human subjects and investigate novel time-sensitive treatments. Although prospective individual consent is not required for studies conducted under this regulation, consent from a legally authorized representative (LAR) or the patient at the earliest feasible opportunity is required to obtain short- and long-term outcome data. The objective of this study was to determine which demographic, cardiac arrest, and patient outcome characteristics predicted the likelihood of obtaining informed consent following enrollment under exception from informed consent in a multicenter cardiac arrest study. Methods This investigation was an analysis of data collected during a multisite, randomized, controlled, out-of-hospital cardiac arrest clinical trial performed under 21 § CFR 50.24. Research personnel attempted to obtain informed consent from LARs and subjects for medical records review of primary outcome data, as well as consent for neurologic outcome assessments up to 1 year post–cardiac arrest. Hospital discharge and neurologic status were obtained from public records and/or medical records up until the time consent was formally denied, in accordance with federal regulations and guidance. Local institutional review boards also allowed medical records review for cases where consent was neither obtained nor declined despite multiple consent attempts. Patient demographic, cardiac arrest, and clinical outcome characteristics were analyzed in univariate multinomial regression models, with consent status (obtained, denied, neither obtained nor denied) as the dependent variable. A multivariate multinomial logistic regression was then performed. An exploratory secondary analysis following the same process was performed after assigning patients who neither consented nor declined to the declined consent group. Results Among a total study population of 1,655 cardiac arrest subjects, 457 were transported and had consent attempted (27.6%). The survival status and neurologic function at the time of hospital discharge were known in 440 of 457 (96%) subjects. In the multivariate analysis, initial rhythm of ventricular fibrillation/ventricular tachycardia (VF/VT) and survival with good neurologic outcome were strong predictors of obtaining consent (odds ratio [OR] = 3.15, 95% confidence interval [CI] = 1.73 to 5.75; OR = 7.64, 95% CI = 2.28 to 25.63, respectively). The exploratory secondary analysis also showed initial rhythm of VF/VT and survival with good neurologic outcome as strong predictors of obtaining consent (OR = 1.86, 95% CI = 1.17 to 2.95; OR = 4.52, 95% CI = 2.21 to 9.26, respectively). Conclusions Initial arrest rhythm and survival with good neurologic outcome were highly predictive of obtaining consent in this cardiac arrest trial. This phenomenon could result in underrepresentation of outcome data in the study arm with the worse outcome and represents a significant potential confounder in studies performed under 21 § CFR 50.24. Future revisions to the exception from informed consent regulations should allow access to critical survival data recorded as part of standard documentation, regardless of patient consent status.

Objective The aim of this study was to compare first-attempt and overall success rates and success rates in relation to placement time among 5 different airway management devices: Storz CMAC, Glidescope GVL, AirTraq, King LTS-D, and direct laryngoscopy (DL). Methods Emergency medical technician basic (EMT-B), EMT-paramedics (EMT-P), and emergency medicine residents and staff physicians placed each of the 5 devices in a random order into an AirSim (TruCorp, Belfast, UK) part-task training manikin. The difficult airway scenario was created by fixing the manikin head to a stationary object and introducing simulated emesis into the hypopharynx. First-attempt and overall success and success in relation to placement time were compared. Provider feedback about device performance was also evaluated. Results Ninety-four providers (16 EMT-basics, 54 EMT-paramedics, and 24 emergency department doctors of medicine) consented to participation. First-attempt and overall success rates for DL, King LTS-D, GVL, and CMAC were not statistically different. Compared with DL, the AirTraq was 96% less likely to be placed successfully (odds ratio, 0.04; 95% confidence interval [CI], 0.01-0.14). When time was factored into the model, the odds of successful placement of the King LTS-D were higher compared with DL (hazard ratio [HR], 1.80; 95% CI, 1.34-2.42) and lower for GVL (HR, 0.59; 95% CI, 0.44-0.80) and AirTraq (HR, 0.228; 95% CI, 0.16-0.325). Providers ranked the CMAC first in terms of performance and preference for use in their practice setting. Conclusion Overall success rates for DL, King-LTS-D, and both video laryngoscope systems were not different. When time was factored into the model, the King LTS-D was more likely to be placed successfully.

There are no published reports examining the effects that ketamine administered prior to hospital arrival has on patients after their transfer to the emergency department (ED).In order to better understand the risk-benefit ratio for the prehospital use of ketamine, we examined the ED courses of 13 patients to whom emergency medical services (EMS) had administered ketamine for chemical restraint.This project was undertaken as part of our EMS system's continuous quality improvement (CQI) process. Data were collected retrospectively. All patients who were given ketamine by EMS providers under our medical direction were identified by prehospital care report queries. The treating paramedic and emergency physician were provided a CQI form after disposition of the patient from their care. The data were tabulated and descriptive statistics were calculated.Thirteen patients were given ketamine by EMS providers, with 13 of 13 having EMS records and 12 of 13 having ED records available for review. Time from ketamine administration to peak sedation was5 minutes in 11 patients and 20 minutes for two patients. On emergency physician examination, five of 12 patients had Richmond Agitation Sedation Scale (RASS) scores of -5 (unarousable), one of 12 had a RASS score of -4 (deep sedation), four of 12 had RASS scores of -3 (moderate sedation), and two of 12 had RASS scores of -2 (light sedation). Three patients developed hypoxia, two in the ED and one prior to hospital arrival. Two of these patients required intubation and one was treated with jaw thrust. Indications for intubation were recurrent laryngospasm and intracranial bleeding. One additional patient experienced a single episode of hypersalivation, which was successfully treated with suctioning of the oropharynx. Of the nonintubated patients, three of 10 were diagnosed with an emergence reaction and five of 10 required additional sedation. The primary diagnosis on ED disposition was drug/ethanol intoxication (3), psychosis (4), intracranial bleeding (1), seizure (1), suicidal ideation (1), agitation (1), and altered mental status (1). Five patients were discharged from the ED, seven were admitted (two to the intensive care unit, four to medicine, and one to psychiatry), and one patient's disposition was unknown.In this series of 13 patients, ketamine administered by EMS produced moderate or deeper sedation. Respiratory complications included hypoxia, laryngospasm, and hypersalivation. Emergence reactions occurred in 30% of nonintubated patients, but they were successfully treated with small doses of benzodiazepines.

Introduction This study compared first-attempt placement success rates of the King LTS-D as a primary airway for patients requiring medication-assisted airway management (MAAM) against historical controls. Setting Rotor-wing division of a single critical care transportation company Methods 53 providers (RNs/EMT-P) consented to participation and were trained in the use of the King LTS-D. All patients in need of MAAM per agency treatment guidelines were screened for inclusion and exclusion criteria. After each placement attempt, providers completed data collection via telephone. The primary endpoint was comparison of first-attempt placement success rate between the King LTS-D and historical control endotracheal intubation (ETI) MAAM patients. Overall placement success, time to placement, pre- and post-placement SaO 2 , ETCO 2 at 2 minutes after placement, and complications were also analyzed. Results 38 patients received rapid sequence intubation with the King LTS-D by 23 of 58 consented providers. First-attempt success rate was 76% (29/38), with an overall success rate of 84% (32/38). The primary endpoint analysis showed no difference in first-attempt success rate between historical control ETI MAAM data and King LTS-D (71% vs 76%; OR=0.1.34 [95% CI Intubation time to insertion was 26 seconds (IQR = 12–46). Pre- and post-insertion SaO 1 2 values were 88.9 ± 12.6% and 92.1 ± 12.7%, respectively. Mean ETCO 2 at 2 minutes after placement was 34.8 ± 4.0. Vomit in the patient's airway was the most frequently reported complication (46%). Conclusion Success rates with the King LTS-D were not significantly different from historical control ETI data. Time to placement was comparable to previous reports.

Objective To compare paramedic insertion success rates and time to insertion between standard ETI and a supraglottc airway device (King LTS-D™) in patients needing advanced airway management. Methods Between June 2008 and June 2009, consented paramedics from 4 EMS systems performed ETI or placed a King LTS-D according to a predetermined randomization calendar. Data collection occurred following each placement via telephone. Placement success (ability to ventilate to chest rise, absence of gastric sounds, presence of bilateral lung sounds, and when applicable, quantitative end-tidal CO 2 reading) was compared between treatment groups. Time to ventilation (time from airway device in hand ready to place to time of first successful ventilation) was also compared. Results A total of 213 patients in need of advanced airway management were treated during the study period, with 9 patients excluded from the analysis. The remaining 204 placements by 110 of the 272 consented paramedics were analyzed (median placements per paramedic=1; range=1–7). The overall placement success rate was virtually equal across the two groups (ETI=80.2%, King LTS-D=80.5%; p =0.97). The median time to placement between ETI and the King LTS-D was also not significantly different (ETI=19.5s vs. King LTS-D=20.0s; z =−0.25; p =0.80). Conclusion In this study, no differences in placement success rate or time to insertion were detected between the King LTS-D and ETI.

Empirical studies of the behavioral or cognitive—behavioral treatment of social phobia have appeared with increasing frequency over the last decade, and there is reason for cautious optimism in the evaluation of treatment effectiveness. However, few studies have reported systematic followup data, and there is little information available about the durability of change in treated social phobics. We report on the followup evaluation of cognitive—behavioral group therapy (CBGT) for social phobia. Patients who received CBGT or a credible alternative treatment were recontacted after a period of 4.5 to 6.25 years and completed a battery of self-report questionnaires, an individualized behavioral test, and a structured interview with an independent assessor. Patients who received CBGT remained more improved than alternative treatment patients on measures from all assessment modalities. However, due to the long followup period, only a portion of the original study sample could be assessed, and these patients may have been less severely impaired than patients who did not participate in the long-term followup. Limitations of the current study and issues of sample attrition in the conduct of long-term followup studies are discussed.

This case series evaluated provider use of the King LTS-D as a primary airway in patients requiring rapid-sequence intubation (RSI).Twenty-seven paramedics completed a one-hour training session on the use of the device. All patients meeting the service's standard criteria for medication-assisted airway management were included in the study. Following each insertion, paramedics contacted a research hotline to complete data collection. The primary endpoint was successful insertion, with secondary endpoints including time from succinylcholine administration to successful ventilation, pre- and post-insertion vital signs (oxygen saturation [SaO(2)], pulse rate, and systolic and diastolic blood pressure), and end-tidal carbon dioxide [ETCO(2)] value 2 minutes after insertion. Analysis between pre- and postinsertion variables was completed using the Wilcoxon signed-rank test.A total of 11 patients met the enrollment criteria and were treated with the device by nine of the 27 paramedics enrolled in the study. All 11 insertions (100%) were successful, with 10 of the 11 (91%) successes achieved on the first insertion attempt. No significant difference existed between pre- and post-insertion pulse rate or blood pressure measures. A significant difference in SaO(2) values was present (p = 0.007). Median ETCO(2) for the study sample was 40 mmHg (interquartile range [IQR] = 33-46 mmHg). Seventy-three percent (8/11) of patients had a time interval of succinylcholine administration to first ventilation of 1 minute or less (range = 1-3 minutes). One case of aspiration was noted on hospital chart review.In this case series, paramedics were able to successfully place and use the King LTS-D in patients meeting our emergency medical services (EMS) system indications for RSI.

The aim of this study was to examine emergency medical services providers' use of a new intraosseous needle designed for pediatric patients.This prospective pilot study was conducted between May 2006 and October 2007. After completing an initial training session, the EZ-IO PD was deployed for use on patients. Emergency medical services (EMS) providers completed a telephone data collection process after each insertion attempt. Data regarding insertion failure or success (insertion of needle into the bone with subsequent fluid flow), time to fluid flow, provider comfort with the device, device performance assessment, and recommendation for future use were collected.Two hundred forty-six EMS providers (EMT-P and registered nurses) from 14 EMS agencies consented to participation. Nineteen insertions were completed by 19 different providers during the study period. Successful insertion was achieved in 18 (95%) of 19 patients (95% confidence interval [CI], 85%-100%). Successful insertion was achieved in less than 60 seconds by 13 (72%) of 15 providers (95% CI, 60%-94%; 4 providers, no response). Fourteen out of 17 providers (82%) reported feeling very comfortable (59%) or comfortable (23%) with the device (95% CI, 64%-100%; 2 non-responses). Fourteen (82%) of 17 providers (95% CI, 64%-100%) with a successful insertion felt that the device worked very well, and the remaining 3 (18%) felt that it worked well. Thirteen (78%) of 17 providers (95% CI, 56%-96%) recommended future use of the EZ-IO needle over the Illinois needle. Two providers (11%) recommended the use of both needles, and 2 providers (11%) were unsure if they would recommend one of the intraosseous needles over the other. A total of 5 complications were reported by the providers: infiltration during use (2); slow flow rate (2); and needle dislodgement (1) when moving the patient into the ambulance.This device has a high insertion success rate with our provider group. Most of our EMS providers also felt comfortable using the device and recommend the device for future use.

The National Standard Curriculum-Paramedic (NSC-P) is the accepted curriculum for paramedic programs across the country. The purpose of this study was to examine the completion of the NSC-P clinical internship recommendations by paramedic students.Paramedic student internship experience data from 2001 to 2005 was retrospectively reviewed from FISDAPtrade mark. Student records that met the following inclusion criteria were analyzed: 1) student provided consent for research, 2) data verified by a preceptor, and 3) student successfully graduated from their paramedic program. The data were descriptively evaluated to determine the number of students who completed 100% of the NSC-P recommendations, to determine what percentage of students were completing each category, and to determine the average number of tasks completed by students for each recommendation.Of the 1,817 student records that met the inclusion criteria, 140 (7.7%) completed 100% of the NSC-P recommended goals in each category. Students met or exceeded the recommended number of tasks most often for 15 medication administrations (92%), 25 successful IV accesses (88%), 30 geriatric assessments (63.7%), 5 live endotracheal intubations (63.5%), and 50 adult assessments (63.2%). A majority of PS are completing less than 50% of the NCS-P recommendations for 20 ventilations on an un-intubated patient, 20 psychiatric patient assessments, 8 pediatric respiratory distress assessments, and 10 obstetric patient assessments.A vast majority of paramedic students are not completing all of the NSC-P recommendations. The reasons for this shortcoming are likely multifaceted and require further research.

Establishing traditional intravenous (IV) access in adult trauma and medical patients can be difficult. We evaluated provider performance for obtaining intraosseous access with two FDA-approved intraosseous devices (F.A.S.T.1 and EZ-IO) in two sequential field trials.One hundred twenty-four providers consented to participate in the first field trial evaluating the use of the F.A.S.T.1 system. Three hundred eighty-nine providers consented to participate in the second field trial, evaluating the use of the EZ-IO. Following each insertion attempt, a telephone data collection process with a member of the research team was completed. Insertion success rate and measures of provider comfort and satisfaction with each device were collected and analyzed.One hundred seventy-eight insertions (89 F.A.S.T.1; 89 EZ-IO) were completed between February 2000 and December 2005. Sixty-four of the 89 insertions of the F.A.S.T.1 were successful, and 78 of the 89 insertions of the EZ-IO were successful (72% vs. 87%; chi2 = 6.8; p = 0.009). Providers using the F.A.S.T.1 attempted more IV insertions prior to using the IO device than the providers using the EZ-IO (2.6 vs. 2.0, p = 0.005). There were no differences in provider comfort or provider assessed device performance between the two devices (p = 0.52; p = 0.13, respectively).In our comparison of two field trials of prehospital provider use of the F.A.S.T.1 and EZ-IO systems, more successful insertions with the EZ-IO were achieved than with the F.A.S.T.1 device. Limitations of our comparison include nonrandomization, the sequential field trial design, the potential for a learning effect, and self-reporting of data points by providers. A prospective, randomized evaluation of these devices is warranted to draw definitive conclusions about provider insertion success rate with these devices.

Venous access is essential to providing emergency care for critically ill or injured patients. Obtaining peripheral or central access can be problematic and time consuming. Intraosseous (IO) fluid administration provides similar flow rates and central circulation times compared to central lines, but use of these devices to monitor blood pressure has not been explored. We report a case of successful IO pressure (IOP) monitoring through an IO during the resuscitation of a 31-year-old male. This is the first report of monitoring IOP in a clinical setting and comparing it to traditional measures of central pressure.

Conducting emergency research in the out-of-hospital and emergency department setting is a challenge because of the inability of patients to provide informed consent in many situations. Federal guidelines allowing research under an exception from informed consent for emergency research have been established (21 CRF 50.24). Community consultation and public disclosure, 2 required components of obtaining this exception, are seen by many as a barrier to resuscitation research. This article will provide a brief overview of the history of the exception from informed consent for emergency research and summarize our methods recently used to successfully complete community consultation and public disclosure for a trial evaluating 2 devices used during cardiopulmonary resuscitation in a large metropolitan area.

A brief but intense heat wave on 9 June 1979 caused catastrophic chick mortality in a population of Western Gulls on Santa Barbara Island, California, USA. Mortality ranged from 0 to 90%o in different areas of the colony. Mortality was not a function of the amount of vegetation cover available to chicks, nor did chick age or size affect the probability of mortality during the heat wave. In the absence of a heat wave, chick mortality due to heat stress is rare in this population. Microclimate analysis in 1980 showed that the area of high chick heat stress mortality in 1979 was characterized by higher ground and air temperatures and lower wind velocities than the area of low mortality. Taxidermic thin metal chick models had a higher integrated thermal load, or operative environmental temperature, in the area of previous high mortality. The persistent nesting by gulls in areas of high potential chick mortality cannot be explained by habitat shortage or by the competitive inferiority of those birds. Enhanced access to food resources may explain the persistence of one area, but not of several others. Analysis of long-term weather records for the southern Channel Islands region showed that heat waves during the breeding season are rare: of nine possible heat waves in 62 yr of data, five have occurred since 1973. The present nesting distribution of gulls on the island has probably not evolved in a regime of frequent heat waves, but rather in response to a long period of highly equable climatic conditions.

The μ-e-γ vertex is calculated in the intermediate charged vector boson theory, as a function of the square of the four momentum of the photon. Consistency arguments show that the boson anomalous magnetic moment should be taken equal to zero. The result is then specialized to a real photon. The experimental branching ratio $$\varrho = (\mu \to e + \gamma )/(\mu \to e + v + \bar v) = 1.2 \pm 1.5$$ fixes the cut-off value at less than one fifth the intermediate boson mass. It is concluded that this theory does not reasonably account for the experimental data, no matter how massive the boson is assumed to be.

The field theory of the electromagnetic interactions of massive charged vector bosons, based on the most general second-order Lagrangian, is considered. Besides the charge and mass of the spinone quantum, the theory is characterized by three additional parameters,x, λ andξ. The spin-one quantum has a magnetic dipole moment of (1 +x) magnetons and an electric dipole moment ofλ magnetons. Ifξ > 0, the theory also contains spin-zero quanta. The canonical formalism for theξ = 0 case is carried through, and it is shown, to order e2, that the theory can be expressed in manifestly covariant form, provided one uses a natural generalization of the definition and application of normal products in perturbation theory. If instead the calculation is performed as done by Lee and Yang, then one finds, in addition to the infinite, noncovariant, nonhermitian part of the interaction Hamiltonian proportional to x2 that they found, a similar term proportional toe2 alone, which however is also nongauge-invariant. The first (x2) of these terms contributes an infinite self-energy to the vector boson, and the second (e2) term contributes an infinite self-energy to the photon.

The introduction of an elementary electric-dipole moment interaction into the structure of weak interactions has previously been shown capable of accounting for the K20→2π decay and of leading to nucleon electric-dipole moments ∼10−20 cm·c, almost as large as the present experimental upper limit on the neutron electric dipole. It is shown here that the same interaction should contribute substantially to the Σ+ → p + γ decay amplitude, and is probably consistent with the restriction imposed on the amplitude by the experimental rate for this process. It is also shown that the unitarity contribution to this amplitude, which is due almost entirely to the decay mode Σ+ → π +N, and which simulates the effect of the elementaryT-noninvariant interaction, is substantial and will have to be included in any realistic analysis of the process.

Site Investigations of Pumped Storage Facilities is the topic of this paper. 3205 p 233-51.

The electric dipole moments of the nucleons and of the electron and muon are calculated in the intermediate vector boson theory. An intrinsic electric dipole is attributed to the charged vector boson, W±. Results are obtained with the regularization procedure proposed by Lee and Yang, both for their so-calledξ-limiting process, and for an alternative limiting procedure which is appropriate only if the W-boson does not exist. The theory predicts, for reasonable values of the several parameters, a neutron electric dipole as large as 1.3·10−6 nucleon magnetons, which is within a factor two of the present experimental upper bound, and which is readily measurable. The predicted electric dipoles of the other three fermions considered are too small to be measured by techniques currently in use.

A 10-year old girl (34.5 kg) being treated at our clinic for osteomyelitis erroneously received an overdose of lincomycin. On a single day she was given 2 infusions containing 6 g of lincomycin each, which corresponds to a dose of 343 mg/kg of body weight. There was an interval of 10 h between infusions. Apart from fatigue and unpleasant taste sensation, she demonstrated no signs of intoxication. None of the laboratory parameters (GOT, GPT, gamma-GT, LDH, G-LDH, LAP, alkaline phosphatase and CK; furthermore, the concentrations of glucose, BUN, creatinine, uric acid and bilirubin) offered any evidence of toxic organ damage. Osteomyelitis in children demands extremely high doses of antibiotics. In view of this fact, the therapeutic range of a substance is of utmost clinical interest.

The selection pressures experienced by clonal plants in heterogeneous environments may be significantly affected by physiological integration among ramets via rhizome connections. We experimentally examined how connections affected the response to saline soil conditions in Ambrosia psilostachya clones from natural saline basins in eastern Nebraska. Paired stems connected by uniform lengths of rhizome were grown in partitioned pots in 3 watering regimes: (1) both stems watered with tapwater, (2) both stems watered with salt water (1% NaCl), and (3) one stem watered with salt water and one with tapwater. All plants survived and grew in salt water, yet dry weight gain of salt-salt plants was only 34% of that for plants in uniform tapwater. Salt plants connected to tapwater plants had 2-fold higher dry weight gain than salt-salt plants. Their tapwater neighbors had significantly smaller biomass than pairs with both stems growing in tapwater. Measurements of leaf stomatal conductance, transpiration rate and water potential, together with root-shoot allocation patterns, suggest that rhizomes transported both water and photosynthate from tapwater plants to their neighbors in saline soil. These results indicate that ramets in a locally inferior environment can be helped by their neighbors, but at some cost to the contributing ramet. We discuss the consequences of this phenomenon for the evolution of local adaptation in populations of rhizomatous plants.