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Survival for out-of-hospital cardiac arrest (OHCA) is, on average, approximately 10% but considerable variability exists among emergency medical services (EMS) systems across the United States. The medical director of an EMS system has considerable control and influence over outcomes in a system by developing evidence-based protocols and overseeing a robust system of quality assurance. A vision for system-level oversight of care that includes continuous data collection and assessment, personally delivered and constructive feedback to providers, and a constant drive for improvement can result in improvements in both processes and patient-centered outcomes.

Wessex Archaeology was commissioned by St Modwen Developments Ltd (hereafter 'the Client') to undertake an archaeological strip, map and sample on land off Centurion Way, west of Junction 10 of the M42, Tamworth, centred on National Grid Reference (NGR) 424006 300357 (hereafter 'the Site'). The proposals comprise industrial/warehouses/distribution development. A desk-based assessment (DBA) and geophysical survey (Wessex Archaeology 2013 and 2014) indicated the potential for below ground remains within the Site, including possible ditches/enclosures in the south-western part of Site. The strip, map and sample took place during general reduction across the Site, and during deeper excavation in advance of foundation, service trench and attenuation pond excavation. During excavation the presence of a field boundary ditch was confirmed and a stone land drain and stone quarry were uncovered. The upper fill of the quarry produced a small group of finds, comprising ceramic building material and pottery.

Wessex Archaeology was commissioned by St Modwen Properties PLC to undertake an archaeological watching brief on land off Centurion Way, west of Junction 10 of the M42, Tamworth, centred on National Grid Reference (NGR) 424006 300357. The watching brief comprised the monitoring of geotechnical test pits prior to a proposed industrial/warehouses/distribution development. A desk-based assessment (DBA) and geophysical survey indicated that there was potential for below ground remains within the Site, including possible ditches/enclosures in the southwestern part of Site. No significant archaeological features, deposits or artefacts were identified during the watching brief and a stone rubble land drain was most likely of a post-medieval date. The test pits were primarily located within the north-eastern part of the Site and the negative results support those of the geophysical survey in this area. Based on the results of the geophysical survey it is probable that the south-western part of Site was historically used for settlement and/or agricultural/pastoral use. However, it is difficult to draw any definitive conclusions regarding the archaeological potential of this part of the Site from the single test pit excavated here.

Purpose To quantify the coupled motion of the wrist during selected functional tasks and to determine the effects of constraining this coupled motion using a radial-ulnar deviation blocking splint on performance of these tasks. Methods Ten healthy, right-handed men performed 15 trials during selected functional tasks with and without a splint, blocking radial and ulnar deviation. The following tasks were performed: dart throwing, hammering, basketball free-throw, overhand baseball and football throwing, clubbing, and pouring. Kinematic coupling parameters (coupling, kinematic path length, flexion-extension range of motion, radial-ulnar deviation range of motion, flexion-extension offset, and radial-ulnar deviation offset) and performance were determined for each functional task. A generalized estimation equation model was used to determine whether each kinematic coupling parameter was significantly different across tasks. A repeated-measures generalized estimation equation model was used to test for differences in performance and kinematic coupling parameters between the free and splinted conditions. Results Wrist motion exhibited linear coupling between flexion-extension and radial-ulnar deviation, demonstrated by R 2 values from 0.70 to 0.99. Average wrist coupling and kinematic path lengths were significantly different among tasks. Coupling means and kinematic path lengths were different between free and splinted conditions across all tasks other than pouring. Performance was different between wrist conditions for dart throwing, hammering, basketball shooting, and pouring. Conclusions Wrist kinematic coupling parameters are task specific in healthy individuals. Functional performance is decreased when wrist coupling is constrained by an external splint. Clinical relevance Surgical procedures that restrict wrist coupling may have a detrimental effect on functional performance as defined in the study. Patients may benefit from surgical reconstructive procedures and wrist rehabilitation protocols designed to restore kinematic coupling.

Purpose To evaluate the outcomes (range of motion, function, and pain relief) of the volar approach to proximal interphalangeal (PIP) joint surface replacement arthroplasty (SRA) in active, high-demand patients. Methods A single surgeon performed PIP SRA in 6 joints using a volar approach. Patients with posttraumatic arthritis or osteoarthritis of the PIP joint were included. Range of motion, postoperative key pinch and grip strength, and Disabilities of the Arm, Shoulder, and Hand questionnaire data were collected. Complications, component integration, and use of cement were noted. Average follow-up was 35 months (range, 12–66 mo). Results Total arc of motion averaged 33° before surgery and improved significantly in all patients, for an average postoperative arc of motion of 60°. Grip strength averaged 30 kg in the affected hand and 35 kg in the contralateral hand after surgery. Postoperative key pinch strength averaged 6 and 7 kg in ipsilateral and contralateral hands, respectively. The average Disabilities of the Arm, Shoulder, and Hand score after surgery was 14. No coronal plane deformity or postural deformity was observed. Good component integration and stability were observed in all 5 cemented joints. The only noncemented joint demonstrated progressive subsidence of both components. Conclusions The volar approach to PIP SRA can result in excellent range of motion, function, and pain relief with minimal complications in active patients with osteoarthritis or posttraumatic arthritis. The volar approach offers the advantages of maintaining the integrity of the extensor mechanism and allowing early postoperative motion. This case series demonstrates compelling data for a prospective, randomized study comparing dorsal and volar approaches to PIP SRA in patients with osteoarthritis and posttraumatic arthritis. Type of study/level of evidence Therapeutic IV.

The utility of routine upper gastrointestinal (UGI) studies after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a matter of great debate. Because the morbidity and mortality rates associated with an unrecognized postoperative leak are high after LRYGB, diagnosis of a postoperative leak earlier would be of benefit. Clinical signs, however, may predict the diagnosis of a postoperative leak more often. This study explored the hypothesis that UGI studies are more predictive than clinical signs for the early diagnosis of a postoperative leak after LRYGB.All patients who underwent LRYGB at the authors' institution were included in this study. Charts were reviewed to examine immediate clinical signs (heart rate, temperature, and white blood cell count within the first 24 h), UGI studies, and clinical course. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of clinical signs and UGI studies were calculated.This study included 245 patients with a 3% rate of leak. The positive and negative predictive value of UGI studies were 67% and 99%, respectively. Only an elevated white blood count had a better predictive value (100% for negative predictive value). The efficiency of UGI studies (98%) was better than that of heart rate (83%), white blood count (8%), or temperature (95%).According to our data, UGI studies are the most predictive of an early leak diagnosis. Clinical signs alone may not be as useful in predicting leaks early after laparoscopic gastric bypasses. Routine early postoperative UGI studies are a reasonable approach to predicting leaks after LRYGB.

We appreciate the interest of Rodriguez-Cuellar et al. in our previous publication [1]. Their insightful comments underscore the controversy about routine radiological tests after laparoscopic Roux-en-Y gastric bypass (LRYGB). We agree that computed tomography (CT) scan has better sensitivity and specificity than upper gastrointestinal (UGI) studies, partly due to the modality and partly due to radiologist experience. Unfortunately, many of our patients cannot fit into our current CT scan machine, and we are fortunate to have an experienced radiologist to help with our UGI studies. Another excellent point brought up by the authors is that leak rates after LRYGB in experienced hands is low (under 1%). We have seen the learning curve effect ourselves when our first 300 LRYGB cases were examined [2]. In our personal experience, UGI studies may not have ‘‘helped’’ in the last year due to the lack of any leaks after LRYGB. However, even with a low incidence, a leak carries a 50% mortality. The cost in terms of human life and dollars due to a leak cannot be ignored. Early diagnosis can and will decrease mortality and morbidity. From our data, routine UGI series can help in this early diagnosis. Clinical signs and symptoms may not be enough to diagnose all leaks early, but neither are UGI studies; they are just another piece of data to help guide clinical care. Some ‘‘late’’ leaks probably start ‘‘slowly’’ when clinical signs and symptoms do not suggest any issues. In these patients, UGI may be helpful. How many of these patients exist? Fortunately, I do not have enough leaks to give you an exact incidence. We have had patients with no or few clinical signs that had a positive UGI which led to early operative treatment (\24 hours after surgery) with no resulting major morbidity after their reoperation. I do not know what would happen if there was a delay in the diagnosis. To be honest, as Rodriguez-Cuellar et al. suggested, leak rates are under 1%. Due to low rates, sensitivity rates may not be precise, thus the large variation reported in the literature. One should not feel that UGI study can take the place of good clinical judgment. Again, UGI study should be examined as an important but not the only piece of data. The reason we still perform routine UGI studies after LRYGB is that in some cases an UGI study may diagnose a leak before clinical signs and symptoms become obvious. The reason not to perform routine UGI studies is cost and patient discomfort. The cost of a delayed diagnosis of a leak needs to be considered when performing only selective UGI studies. Due to the current controversy, standard of care still involves either routine or selective UGI studies after LRYGB. Our personal recommendation is to utilize UGI studies routinely at least for surgeons in their learning curve. To suggest that UGI studies are not needed for this group of surgeons seems a bit nonchalant since a leak is a major cause of mortality after LRYGB. Even in experienced hands, an UGI study may help avoid the disastrous consequences of a delay in diagnosis of a leak after LRYGB. A. K. Madan (&) H. H. Stoecklein D. S. Tichansky Department of Surgery, University of Tennessee Health Science Center, 956 Court Ave., Room G210, Memphis, TN 38163, USA e-mail: amadan@utmem.edu

Wild turkey mortality rates, habitat use patterns, and recruitment were investigated on intensively managed pine forest of the Central Piedmont. Thirty-two adults and poults were captured with adult dosages of alpha-chloralose. Poults were easily sedated and usually recovered 1 day sooner than adults. The annual mortality rate for marked turkeys was 85%; September-February mortality was 65% (N=17), and March-August mortality was 57% (N=21). Turkeys that died during hunting seasons were recovered significantly (p < 0.05) closer to roads than those that died out of hunting seasons. High mortality during the hunting seasons and the association of hunting season mortality with roads suggests a crippling loss to legal harvest ratio as high as 4:1. Use of young pine plantations, hardwood leave strips, large stands of mixed hardwoods, mature pine stands, and fields was not significantly different (p > 0.1) from availability. Turkeys were associated with edges while on their winter and prenesting ranges. Nests were located in a variety of stand types, near edges, and in heavier cover than generally available. Nesting success was 48%. Post critical period brood survival was 90%. These data indicate that wild turkeys can adapt to the early stages of forest conversion for intensive pine management. Master of Science

Efficacy and safety are primary considerations in registration and use of toxicants for vertebrate pest control. Strychnine (0.5%) and zinc phosphide (2%) are currently registered by EPA for prairie dog control, but continued registration is uncertain. Two percent zinc phosphide bait has been suspected of producing lower and more erratic results than strychnine bait. In our study in western Nebraska in fall 1984, indices based on changes in burrow activity showed no difference in efficacy (P =0.66) or variability (P= 0.7) of control for strychnine and zinc phosphide, however neither toxicant consistently gave effective control or black-tailed prairie dogs. Costs for proper control (prebait and poison) were similar for strychnine and zinc phosphide. For clean-up or surviving prairie dogs, fumigation with aluminum phosphide was more effective than shooting and more cost effective than shooting combined with fumigation. Observed nontarget wildlife losses (4 horned larks and 2 lagomorphs) were small and of doubtful biological significance. Availability of both strychnine and zinc phosphide is part of the flexibility needed in an integrated approach to prairie dog control. Also, there is need for additional toxicants or methods that will give more consistently efficacious control.

Signed in print: Henry Holbrook; John Cooper; F. G. Claudet. The attempt to establish this bank (with head offices at New Westminster) was unsuccessful. -- Lowther, B. J., & Laing, M. (1968). A bibliography of British Columbia: Laying the foundations, 1849-1899. Victoria, BC: University of Victoria, p. 19.