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Background: Cardiac arrest (CA) survivors experience continuous exposures to potential traumas though chronic cognitive, physical and emotional sequelae and enduring somatic threats (ESTs) (i.e., recurring somatic traumatic reminders of the event). Sources of ESTs can include the daily sensation of an implantable cardioverter defibrillator (ICD), ICD-delivered shocks, pain from rescue compressions, fatigue, weakness, and changes in physical function. Mindfulness, defined as non-judgmental present-moment awareness, is a teachable skill that might help CA survivors cope with ESTs. Here we describe the severity of ESTs in a sample of long-term CA survivors and explore the cross-sectional relationship between mindfulness and severity of ESTs., Methods: We analyzed survey data of long-term CA survivors who were members of the Sudden Cardiac Arrest Foundation (collected 10-11/2020). We assessed ESTs using 4 cardiac threat items from the Anxiety Sensitivity Index-revised (items range from 0 "very little" to 4 "very much") which we summed to create a score reflecting total EST burden (range 0-16). We assessed mindfulness using the Cognitive and Affective Mindfulness Scale-Revised. First, we summarized the distribution of EST scores. Second, we used linear regression to describe the relationship between mindfulness and EST severity adjusting for age, gender, time since arrest, COVID-19-related stress, and loss of income due to COVID., Results: We included 145 CA survivors (mean age: 51 years, 52% male, 93.8% white, mean time since arrest: 6 years, 24.1% scored in the upper quarter of EST severity). Greater mindfulness (β: -30, p = 0.002), older age (β: -0.30, p = 0.01) and longer time since CA (β: -0.23, p = 0.005) were associated with lower EST severity. Male sex was also associated with greater EST severity (β: 0.21, p = 0.009)., Conclusion: ESTs are common among CA survivors. Mindfulness may be a protective skill that CA survivors use to cope with ESTs. Future psychosocial interventions for the CA population should consider using mindfulness as a core skill to reduce ESTs., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Identifying correlates of psychological symptoms in cardiac arrest (CA) survivors is a major research priority. In this longitudinal survey study, we evaluated associations between mindfulness, baseline psychological symptoms, and 1-year psychological symptoms in long-term CA survivors. We collected demographic and CA characteristics at baseline. At both timepoints, we assessed posttraumatic stress symptoms (PTS) through the PTSD Checklist-5 (PCL-5) and depression and anxiety symptoms through the Patient Health Questionnaire-4 (PHQ-4). At follow-up, we assessed mindfulness through the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R). We used adjusted linear regression to predict 1-year PCL-5 and PHQ-4 scores, with particular consideration of the CAMS-R as a cross-sectional correlate of outcome. We included 129 CA survivors (mean age: 52 years, 52% male, 98% white). At 1-year follow-up, in adjusted models, CAMS-R (β: -0.35, p < 0.001) and baseline PCL-5 scores (β: 0.56, p < 0.001) were associated with 1-year PCL-5 scores. CAMS-R (β: -0.34, p < 0.001) and baseline PHQ-4 scores were associated with 1-year PHQ-4 scores (β: 0.37, p < 0.001). In conclusion, mindfulness was inversely associated with psychological symptoms in long-term CA survivors. Future studies should examine the longitudinal relationship of mindfulness and psychological symptoms after CA., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background Cardiac arrest survivorship refers to the lived experience of long-term survivors of cardiac arrest and the many postdischarge challenges they experience. We aimed to gather a nuanced understanding of these challenges and of survivors' perceptions of ways to improve the recovery process. Methods and Results We conducted 15 semistructured, one-on-one interviews with cardiac arrest survivor members of the Sudden Cardiac Arrest Foundation; the interviews were conducted by telephone and recorded and transcribed verbatim. We used thematic analysis, informed by the Framework Method, to identify underlying themes regarding cardiac arrest survivorship challenges and recommendations to improve cardiac arrest survivorship. Regarding challenges, the overarching theme was a feeling of unpreparedness to confront postarrest challenges because of lack of resources, education, and appropriate expectations for recovery. Regarding recommendations, we uncovered 3 overarching themes including systemic recommendations (eg, providing appropriate resources and expectations, educating providers about survivorship, following up with survivors, including caregivers in treatment planning), social recommendations (eg, attending peer support groups, spending time with loved ones, providing support resources for family members), and individual coping recommendations (eg, acceptance, resilience, regaining control, seeking treatment, focusing on meaning and purpose). Conclusions We described common challenges that survivors of cardiac arrest face, such as lacking resources, education, and appropriate expectations for recovery. Additionally, we identified promising pathways that may improve cardiac arrest survivorship at systemic, social, and individual coping levels. Future studies could use our findings as targets for interventions to support and improve survivorship.

We aimed to elucidate gaps in the provision of cognitive and psychological resources in cardiac arrest survivors. We conducted an online survey study between October 29, 2019, and November 15, 2019 with cardiac arrest survivors and caregiver members of the Sudden Cardiac Arrest Foundation. We queried survivors as to whether they experienced cognitive or psychological symptoms since their cardiac arrest. Next, we queried both survivors and caregivers on the provision of resources through three metrics: (1) discussions with providers about potential cognitive or psychological symptoms, (2) neurologist or psychologist appointments scheduled by providers, and (3) mental health referrals by providers. We then ran Chi-square goodness-of-fit tests to compare the proportion of survivors and caregivers who reported resource provision (observed values) to the proportion of survivors who reported experiencing cognitive and psychological symptoms, respectively (expected values). We included responses from 167 survivors and 52 caregivers. A total of 73.1% ( n  = 122) survivors reported experiencing cognitive symptoms and 67.1% ( n  = 112) psychological symptoms since their cardiac arrest. When compared to these two proportions, provision of resources was significantly lower in all three metrics: (1) fewer discussions with providers about potential for developing cognitive symptoms (31%) and psychological symptoms (26.3%), (2) fewer neurologist appointments scheduled (8.4%) and psychologist appointments scheduled (4.8%), and (3) fewer referrals to mental health (6%). Informal caregivers also reported significantly lower provision of resources in all three metrics, with the exception of discussions about developing cognitive symptoms. Our results suggest that there are discrepancies in the provision of cognitive and psychological resources in cardiac arrest survivors with good neurologic recovery. Systematic referral processes may be needed to standardize resource provision to consistently meet the pervasive cognitive and psychological needs of cardiac arrest survivors.

Aim: To estimate the proportion of significant posttraumatic stress (PTS) in both cardiac survivors with good neurologic recovery and informal caregivers, and to pilot test the hypothesis that greater PTS are associated with worse quality of life (QoL) in both cardiac arrest survivors and informal caregivers of cardiac arrest survivors., Methods: We distributed an online survey to survivor and caregiver members of the Sudden Cardiac Arrest Foundation. Participants provided demographic and cardiac arrest characteristics and completed the PTSD Checklist-5 (PCL-5), the Lawton Instrumental Activities of Daily Living scale, and the WHOQOL-BREF. We identified covariates through bivariate correlations or linear regressions as appropriate. Six multiple regression models (three each for survivors and caregivers) examined associations between PCL-5 scores with each QoL subscale, adjusted for covariates identified from the bivariate models., Results: We included 169 survivors (mean months since arrest: 62.8, positive PTS screen: 24.9%) and 52 caregivers (mean months since arrest: 43.2, positive PTS screen: 34.6%). For survivors, the following showed significant bivariate associations with QoL: Lawton scores, daily memory problems, sex, months since arrest, age, and income; for caregivers, months since arrest, age, and income. In adjusted models, greater PCL-5 scores were associated with worse QoL (β: -0.35 to -0.53, p < .05)., Conclusions: Our pilot results suggest that PTS are prevalent years after the initial cardiac arrest and are associated with worse QoL in survivors and informal caregivers. Further study is needed to validate these findings in a larger, representative sample., (© 2021 The Authors.)

Bats are known to be reservoirs for a variety of mammalian pathogens, including viruses, fungi, and bacteria. Many of the studies examining the microbial community inhabiting bats have investigated bacterial taxa found within specific bat tissues and isolated bat guano pellets, but relatively few studies have explored bacterial diversity within bat guano piles. In large bat caves, bat guano can accumulate over time, creating piles several meters deep and forming complex interactions with coprophagous organisms in a habitat with low light and oxygen. As the guano decays, the nutrient composition changes, but the bacterial communities deep within the pile have not been characterized. Here, we assess the bacterial communities across varying depths within the guano pile using both culture-independent and culture-dependent methods. We found that although similar taxa are found throughout the guano pile, the relative abundances of taxa within the pile shift, allowing certain taxa to dominate the bacterial community at varying depths. We also identified potential bacterial functions being performed within the bat guano as various depths within the pile and found little variation in terms of the dominant predicted functions, suggesting that although the relative abundances of bacterial taxa are changing, the functions being performed are similar. Additionally, we cultured 15 different bacterial species, including 2 not present in our culture-independent analysis, and discuss the pathogenicity potential of these taxa. This study represents the first characterization of the bacterial community from the extreme environment within a bat guano pile and demonstrates the potential for bat caves as resources for identifying new bacterial species.

A sudden cardiac arrest in school or at a school event is potentially devastating to families and communities. An appropriate response to such an event-as promoted by developing, implementing, and practicing a cardiac emergency response plan (CERP)-can increase survival rates. Understanding that a trained lay-responder team within the school can make a difference in the crucial minutes between the time when the victim collapses and when emergency medical services arrive empowers school staff and can save lives. In 2015, the American Heart Association convened a group of stakeholders to develop tools to assist schools in developing CERPs. This article reviews the critical components of a CERP and a CERP team, the factors that should be taken into account when implementing the CERP, and recommendations for policy makers to support CERPs in schools., (© 2016 The Author(s).)

Research describing survivors of sudden cardiac arrest (SCA) has centered on quantifying functional ability, perceived quality of life, and neurocognitive assessment. Many gaps remain, however, regarding survivors' psychosocial perceptions of life in the aftermath of cardiac arrest. An important influence upon those perceptions is the presence of support and its role in a survivor's life. An Internet-based pilot survey study was conducted to gather data from SCA survivors and friends and/or family members (FFMs) representing their support system. The survey was distributed to members of the Sudden Cardiac Arrest Foundation (SCAF) via the Internet by SCAF leadership. Questions included both discrete multiple-choice and open-ended formats. Inductive thematic analyses were completed by three independent researchers trained in qualitative research methodology to identify primary themes consistent among study participants until thematic saturation was achieved. No statistical inferences were made. A total of 205 surveys were returned over the 5-month study period (July to November 2013); nine were received blank, leaving 196 surveys available for review. Major themes identified for survivors (N = 157) include the significance of and desire to share experiences with others; subculture identification (unique experience from those suffering a heart attack); and the need to seek a new normal, both personally and inter-personally. Major themes identified for FFMs (N = 39) include recognition of loved one's memory loss; a lack of information at discharge, including expectations after discharge; and concern for the patient experiencing another cardiac arrest. This pilot, qualitative survey study suggests several common themes important to survivors, and FFMs, of cardiac arrest. These themes may serve as a basis for future patient-centered focus groups and the development of patient-centered guidelines for patients and support persons of those surviving cardiac arrest.

In commercial agriculture, populations and interactions of rhizosphere microflora are potentially affected by the use of specific agrichemicals, possibly by affecting gene expression in these organisms. To investigate this, we examined changes in bacterial gene expression within the rhizosphere of glyphosate-tolerant corn (Zea mays) and soybean (Glycine max) in response to long-term glyphosate (PowerMAX™, Monsanto Company, MO, USA) treatment. A long-term glyphosate application study was carried out using rhizoboxes under greenhouse conditions with soil previously having no history of glyphosate exposure. Rhizosphere soil was collected from the rhizoboxes after four growing periods. Soil microbial community composition was analyzed using microbial phospholipid fatty acid (PLFA) analysis. Total RNA was extracted from rhizosphere soil, and samples were analyzed using RNA-Seq analysis. A total of 20-28 million bacterial sequences were obtained for each sample. Transcript abundance was compared between control and glyphosate-treated samples using edgeR. Overall rhizosphere bacterial metatranscriptomes were dominated by transcripts related to RNA and carbohydrate metabolism. We identified 67 differentially expressed bacterial transcripts from the rhizosphere. Transcripts downregulated following glyphosate treatment involved carbohydrate and amino acid metabolism, and upregulated transcripts involved protein metabolism and respiration. Additionally, bacterial transcripts involving nutrients, including iron, nitrogen, phosphorus, and potassium, were also affected by long-term glyphosate application. Overall, most bacterial and all fungal PLFA biomarkers decreased after glyphosate treatment compared to the control. These results demonstrate that long-term glyphosate use can affect rhizosphere bacterial activities and potentially shift bacterial community composition favoring more glyphosate-tolerant bacteria., (Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.)

Glyphosate is one of the most widely used herbicides in agriculture with predictions that 1.35 million metric tons will be used annually by 2017. With the advent of glyphosate tolerant (GT) cropping more than 10 years ago, there is now concern for non-target effects on soil microbial communities that has potential to negatively affect soil functions, plant health, and crop productivity. Although extensive research has been done on short-term response to glyphosate, relatively little information is available on long-term effects. Therefore, the overall objective was to investigate shifts in the rhizosphere bacterial community following long-term glyphosate application on GT corn and soybean in the greenhouse. In this study, rhizosphere soil was sampled from rhizoboxes following 4 growth periods, and bacterial community composition was compared between glyphosate treated and untreated rhizospheres using next-generation barcoded sequencing. In the presence or absence of glyphosate, corn and soybean rhizospheres were dominated by members of the phyla Proteobacteria, Acidobacteria, and Actinobacteria. Proteobacteria (particularly gammaproteobacteria) increased in relative abundance for both crops following glyphosate exposure, and the relative abundance of Acidobacteria decreased in response to glyphosate exposure. Given that some members of the Acidobacteria are involved in biogeochemical processes, a decrease in their abundance could lead to significant changes in nutrient status of the rhizosphere. Our results also highlight the need for applying culture-independent approaches in studying the effects of pesticides on the soil and rhizosphere microbial community., (Copyright © 2015 The Authors. Published by Elsevier B.V. All rights reserved.)

The etiological agent of necrotic enteritis (NE) is Clostridium perfringens (CP), which is an economically significant problem for broiler chicken producers worldwide. Traditional use of in-feed antibiotic growth promoters to control NE disease have resulted in the emergence of antibiotic resistance in CP strains. Identification of probiotic bacteria strains as an alternative to antibiotics for the control of intestinal CP colonization is crucial. Two experiments were conducted to determine changes in intestinal bacterial assemblages in response to CP infection and in-feed bacitracin methylene disalicylate (BMD) in broiler chickens. In each experiment conducted in battery-cage or floor-pen housing, chicks were randomly assigned to the following treatment groups: 1) BMD-supplemented diet with no CP challenge (CM), 2) BMD-free control diet with no CP challenge (CX), 3) BMD-supplemented diet with CP challenge (PCM), or 4) BMD-free control diet with CP challenge (PCX). The establishment of CP infection was confirmed, with the treatment groups exposed to CP having a 1.5- to 2-fold higher CP levels (P < 0.05) compared to the non-exposed groups. Next-generation sequencing of PCR amplified 16S rRNA genes, was used to perform intestinal bacterial diversity analyses pre-challenge, and at 1, 7, and 21 d post-challenge. The results indicated that the intestinal bacterial assemblage was dominated by members of the phylum Firmicutes in all treatments before and after CP challenge, especially the Lactobacillaceae and Clostridiales families. In addition, we observed post-challenge emergence of members of the Enterobacteriaceae and Streptococcaceae in the non-medicated PCX treatment, and emergence of the Enterococcaceae in the medicated PCM treatment. This study highlights the bacterial interactions that could be important in suppressing or eliminating CP infection within the chicken intestine. Future studies should explore the potential to use commensal strains of unknown Clostridiales, Lactobacillaceae, Enterobacteriaceae, Streptococcaceae, and Enterococcaceae in effective probiotic formulations for the control of CP and NE disease., (© 2015 Poultry Science Association Inc.)

The International Classification of Diseases (ICD) standardizes diagnostic codes into meaningful criteria to enable the storage and retrieval of information regarding patient care. Whereas other countries have been using ICD, 10th Revision (ICD-10), for years, the United States will transition from ICD, Ninth Revision, Clinical Modification (ICD-9-CM), to ICD-10, on 1 October 2015. This transition is one of the largest and most technically challenging changes that the medical community has experienced in the past several decades. This article outlines the implications of moving to ICD-10 and recommends resources to facilitate the transition.

Microbial succession during leaf breakdown was investigated in a small forested stream in west-central Georgia, USA, using multiple culture-independent techniques. Red maple (Acer rubrum) and water oak (Quercus nigra) leaf litter were incubated in situ for 128 days, and litter breakdown was quantified by ash-free dry mass (AFDM) method and microbial assemblage composition using phospholipid fatty acid analysis (PLFA), ribosomal intergenic spacer analysis (RISA), denaturing gradient gel electrophoresis (DGGE), and bar-coded next-generation sequencing of 16S rRNA gene amplicons. Leaf breakdown was faster for red maple than water oak. PLFA revealed a significant time effect on microbial lipid profiles for both leaf species. Microbial assemblages on maple contained a higher relative abundance of bacterial lipids than oak, and oak microbial assemblages contained higher relative abundance of fungal lipids than maple. RISA showed that incubation time was more important in structuring bacterial assemblages than leaf physicochemistry. DGGE profiles revealed high variability in bacterial assemblages over time, and sequencing of DGGE-resolved amplicons indicated several taxa present on degrading litter. Next-generation sequencing revealed temporal shifts in dominant taxa within the phylum Proteobacteria, whereas γ-Proteobacteria dominated pre-immersion and α- and β-Proteobacteria dominated after 1 month of instream incubation; the latter groups contain taxa that are predicted to be capable of using organic material to fuel further breakdown. Our results suggest that incubation time is more important than leaf species physicochemistry in influencing leaf litter microbial assemblage composition, and indicate the need for investigation into seasonal and temporal dynamics of leaf litter microbial assemblage succession.

The use of fluorescence in situ hybridization (FISH) to identify and enumerate specific bacteria within a mixed culture or environmental sample has become a powerful tool in combining microscopy with molecular phylogenetic discrimination. However, processing a large number of samples in parallel can be difficult because the bacterial cells are typically fixed and hybridized on microscope slides rather than processed in solution. In addition, gram-positive cells and certain environmental samples present a unique challenge to achievement of adequate cell fixation and uniform hybridization for optimal FISH analysis. Here, we describe a protocol for FISH in solution that can be performed entirely in suspension, in a microcentrifuge tube format, prior to microscopy. This protocol can be applied to both gram-positive and -negative cells, as well as complex microbial assemblages. The method employs a rapid technique for performing multiple hybridizations simultaneously, which may be used to qualitatively assess the presence of specific phylogenetic groups in bacterial cultures or environmental samples, and/or directly quantify fluorescence by fluorometry or flow cytometry.

Objectives: The purpose of this study was to determine whether gender differences exist in the characteristics and outcomes for out-of-hospital cardiac arrest (OHCA) occurring in a rural setting., Background: In urban settings, women have a lower incidence of OHCA than men but otherwise a comparable survival for ventricular fibrillation (VF) OHCA. Whether OHCA gender differences exist in rural settings is not clear., Methods: The study consisted of a prospective collection and analysis of nontraumatic, adult OHCA prompting a 911 call in six rural Indiana counties., Results: Over an average period of 2.2 years, 138 women and 250 men experienced OHCA (annual incidence rate: 56.4 per 100,000 men and 29.3 per 100,000 women). Women were older, less likely to experience OHCA in a public setting, more likely to be in an extended care facility, and less likely to have a witnessed arrest than were men. Women were less likely to present with an initial rhythm of VF than men (33.3% vs 53.6%, P < .001). Women in VF had a longer time interval from 911 call to first shock compared with men. Women had poorer survival to hospital discharge for all OHCA (2.2% vs 7.2%, P = .04) and VF OHCA (2.2% vs 13.4%, P = .05) compared with men. After age adjustment, female gender remained associated with a poorer OHCA survival outcome. With adjustment for all significant arrest characteristics, female gender was no longer associated with survival., Conclusions: In a rural population, women suffering OHCA have a dismal survival rate likely because of multiple unfavorable arrest characteristics.

Background: It is commonly assumed that car passengers who suffer from motion sickness will benefit from being able to see the road ahead., Hypothesis: It was hypothesized that variations in the external view (including restrictions to forward view and the provision of an artificial real-time video view) would affect the development of sickness during a 30-min suburban car journey., Method: Motion sickness was investigated in 4 experiments using 15 different conditions, with 20 subjects in each condition. The conditions involved artificial restrictions to view, restrictions arising from different seating positions, and the provision of a video view of the road ahead. Subjects provided ratings of motion sickness at 1-min intervals during the 30-min journey. The motion sickness susceptibility of subjects was matched between groups of subjects and the car motions were measured in three axes to determine whether the motion conditions were similar across conditions within each experiment., Results: Absence of a visual field (blindfolded) resulted in similar sickness to that with no external forward view (with or without a side view). A wide or narrow forward view (with or without a side view) reduced sickness. For the conditions of these experiments, seating position did not significantly affect sickness. The provision of a real-time video view of the road ahead did not reduce motion sickness. There was circumstantial evidence that horizontal acceleration at frequencies below 0.1 Hz contributed to sickness., Conclusions: It is concluded that sickness in cars is dependent on the visual scene. The minimization of sickness by the provision of visual information requires improved understanding of those factors that combine to cause and suppress sickness.

Objective: To determine whether there were associations between the characteristics of first-responder automated external defibrillator (AED) training and AED application rates., Methods: This multicenter retrospective cohort study analyzed data from ten emergency medical services systems where first responders were trained and equipped with AEDs. Data were provided for all out-of-hospital cardiac arrests (OHCAs) occurring over two years, including whether the first-responder AED was applied (pads attached to patient). Systems were surveyed to determine the characteristics of their initial and continuing AED training. Data were analyzed using odds ratios (ORs) with 95% confidence intervals (95% CIs)., Results: Overall, the first-responder AED was applied to 53% of 2,181 OHCAs. First responders applied AEDs to 60% of OHCAs when a national AED training curriculum was used and to 49% of OHCAs when a locally created curriculum was used (OR=1.58; 95% CI=1.32-1.88). First responders applied AEDs to 61% of OHCAs when they were trained to the level of Certified First Responder or higher and to 28% of OHCAs when they were trained only in cardiopulmonary resuscitation (OR=3.97; 95% CI=3.20-4.93). First responders applied AEDs to 66% of OHCAs when they each had an opportunity to apply the AED during continuing training and to 17% of OHCAs when they did not have this opportunity (OR=9.04; 95% CI=7.15-11.42). First responders applied AEDs to 59% of OHCAs when they had not received continuing training within one year of their initial training and to 42% of OHCAs when they had received continuing training in the first year (OR=2.00; 95% CI=1.67-2.40)., Conclusion: Use of a national AED training curriculum, training to the level of Certified First Responder or higher, and the ability for each first responder to apply the AED during continuing training were associated with higher AED application rates. Continuing training within the first year did not appear to be as important as actually using the AED during the training.

Corn stover is emerging as a viable feedstock for producing bioethanol from renewable resources. Dilute-acid pretreatment of corn stover can solubilize a significant portion of the hemicellulosic component and enhance the enzymatic digestibility of the remaining cellulose for fermentation into ethanol. In this study, dilute H2SO4 pretreatment of corn stover was performed in a steam explosion reactor at 160 degrees C, 180 degrees C, and 190 degrees C, approx 1 wt % H2SO4, and 70-s to 840-s residence times. The combined severity (Log10 [Ro] - pH), an expression relating pH, temperature, and residence time of pretreatment, ranged from 1.8 to 2.4. Soluble xylose yields varied from 63 to 77% of theoretical from pretreatments of corn stover at 160 and 180 degrees C. However, yields >90% of theoretical were found with dilute-acid pretreatments at 190 degrees C. A narrower range of higher combined severities was required for pretreatment to obtain high soluble xylose yields when the moisture content of the acidimpregnated feedstock was increased from 55 to 63 wt%. Simultaneous saccharification and fermentation (SSF) of washed solids from corn stover pretreated at 190 degrees C, using an enzyme loading of 15 filter paper units (FPU)/ g of cellulose, gave ethanol yields in excess of 85%. Similar SSF ethanol yields were found using washed solid residues from 160 and 180 degrees C pretreatments at similar combined severities but required a higher enzyme loading of approx 25 FPU/g of cellulose.

Objectives: To determine the rate at which fire and police first responders (FRs) apply automated external defibrillators (AEDs) and to ascertain reasons for not applying them., Methods: Twenty-one emergency medical services (EMS) systems whose FRs had been supplied with AEDs by a philanthropic foundation provided data for all out-of-hospital cardiac arrest (OHCA) patients. Data including the incidence of AED application and explanations for not applying AEDs were analyzed using descriptive statistics., Results: A total of 2,456 OHCAs were reported. AED application information was available for 2,439 patients and revealed that FRs had not applied AEDs to 1,025 patients (42%). Fire FRs were more likely than police FRs to have applied AEDs (relative risk 1.87, 95% confidence interval 1.65-2.12). Reasons for not applying AEDs were listed for 664 (65%) of the OHCA patients to whom AEDs had not been applied. The predominant reason the FRs did not apply an AED was that the transporting ambulance defibrillator had already been applied (74%). However, when response times for FRs and the transporting ambulances were compared for these OHCA patients, it was found that the transporting ambulances arrived after the FRs 23% the time, simultaneously with the FRs 45% of the time, and before the FRs only 32% of the time., Conclusion: Fire and police FRs did not apply AEDs to a significant number of OHCA patients. Use of the transport ambulance defibrillator was the primary reason given for not applying the FR AED. Given low AED application rates by FRs, future studies are needed to determine the characteristics of communities in which equipping FRs with AEDs is the most beneficial deployment strategy, and how to increase AED application by FRs in communities with FR AED programs.

Why does LEA-D intervention seem to work in some systems but not others? Panelists agreed that some factors that delay rapid access to treatment, such as long travel distances in rural areas, may represent insurmountable barriers. Other factors, however, may be addressed more readily. These include: absence of a medical response culture, discomfort with the role of medical intervention, insecurity with the use of medical devices, a lack of proactive medical direction, infrequent refresher training, and dependence on EMS intervention. Panelists agreed that successful LEA-D programs possess ten key attributes (Table 6). In the end, the goal remains "early" defibrillation, not "police" defibrillation. It does not matter whether the rescuer wears a blue uniform--or any uniform, for that matter--so long as the defibrillator reaches the victim quickly. If LEA personnel routinely arrive at medical emergencies after other emergency responders or after 8 minutes have elapsed from the time of collapse, an LEA-D program will be unlikely to provide added value. Similarly, if police frequently arrive first, but the department is unwilling or unable to cultivate the attributes of successful LEA-D programs, efforts to improve survival may not be realized. In most communities, however, LEA-D programs have tremendous lifesaving potential and are well worth the investment of time and resources. Law enforcement agencies considering adoption of AED programs should review the frequency with which police arrive first at medical emergencies and LEA response intervals to determine whether AED programs might help improve survival in their communities. It is time for law enforcement agency defibrillation to become the rule, not the exception.

Cost reductions for pretreatment and bioconversion processes are key objectives necessary to the successful deployment of a bioethanol industry. These unit operations have long been recognized for their impact on the production cost of ethanol. One strategy to achieve this objective is to improve the pretreatment process to produce a pretreated substrate resulting in reduced bioconversion time, lower cellulase enzyme usage, and/or higher ethanol yields. Previous research produced a highly digestible pretreated yellow poplar substrate using a multistage, continuously flowing, very dilute sulfuric acid (0.07% (w/v)) pretreatment. This process reduced the time required for the bioconversion of pretreated yellow poplar sawdust to ethanol. This resulted in a substantially improved yield of ethanol from cellulose. However, the liquid volume requirements, steam demand, and complexity of the flow-through reactor configuration were determined to be serious barriers to commercialization of that process. A reconfigured process to achieve similar performance has been developed using a single-stage batch pretreatment followed by a separation of solids and liquids and washing of the solids at a temperatures between 130 and 150 degrees C. Separation and washing at the elevated temperature is believed to prevent a large fraction of the solubilized lignin and xylan from reprecipitating and/or reassociating with the pretreated solids. This washing of the solids at elevated temperature resulted in both higher recovered yields of soluble xylose sugars and a more digestible pretreated substrate for enzymatic hydrolysis. Key operating variables and process performance indicators included acid concentration, temperature, wash volume, wash temperature, soluble xylose recovery, and performance of the washed, pretreated solids in bioconversion via simultaneous saccharification and fermentation (SSF). Initial results indicated over a 50% increase in ethanol yield at 72 h for the hot washed material as compared to the control (no washing, no separation) and a 43% reduction of in the bioconversion time required for a high ethanol yield from cellulose

Issues and Purpose: Pediatric nurses do not consistently use the anesthetic cream for children. This study examined availability, use, and perception of driving and restraining forces for use of EMLA cream for venipuncture and i.v. catheter insertion., Design and Methods: In this descriptive study, surveys were sent to 400 randomly selected pediatric RNs. Surveys were returned by 211 nurses from 36 states., Results: Driving forces for EMLA usage included ease of use and increased patient rapport. Restraining forces were focused on barriers to accessing EMLA. Positive perceptions of EMLA were affected by ease of accessibility., Practice Implications: Use of EMLA may be enhanced by standard orders, inservice instruction, and stocking EMLA on the patient care unit.

Simultaneous saccharification and cofermentation (SSCF) was carried out at approximately 15% total solids using conditioned dilute-acid pretreated yellow poplar feedstock, an adapted variant of National Renewable Energy Laboratory (NREL) xylose-fermenting Zymomonas mobilis and either commercial or NREL-produced cellulase enzyme preparations. In 7 d, at a cellulase loading of 12 filter paper units per gram cellulose (FPU/g), the integrated system produced more than 3% w/v ethanol and achieved 54% conversion of all potentially available biomass sugars (total sugars) entering SSCF. A control SSCF employing Sigmacell cellulose and a commercial cellulase at an enzyme loading of 14 FPU/g achieved 65% conversion of total sugars to ethanol.

Nutrient cost is an important aspect in the fermentation of biomass to ethanol. With a goal of developing a cost-effective fermentation medium, several industrially available nutrient sources were evaluated for their effectiveness in the simultaneous saccharification and fermentation of pretreated poplar with Saccharomyces cerevisiae D5A. These studies showed that a low-cost medium containing 0.3% corn steep liquor and 2.5 mM MgSO4 7H2O was similar in performance to a nutrient-rich medium. Besides its low cost, this alternative medium consists of components that are available on a commercial scale, thereby making it industrially relevant.

Traditional classroom-based instruction of cardiopulmonary resuscitation (CPR) has failed to achieve desired rates of bystander CPR. Video self-instruction (VSI) is a more accessible alternative to traditional classroom instruction (TRAD), and it achieves better CPR skill performance. VSI employs a 34-min training tape and an inexpensive manikin. VSI combines simplified and reordered content focusing on the delivery of one-rescuer CPR with the 'practice-as-you-watch' approach of an exercise video. Performance of CPR skills immediately following VSI was compared to performance immediately following TRAD using an instrumented manikin, a valid and reliable skill checklist, and an overall competency rating. Compared with TRAD subjects, VSI subjects performed more compressions correctly (P < 0.001), more ventilations correctly (P < 0.001), and more assessment and sequence skills correctly (P < 0.001). TRAD subjects delivered twice as many compressions that were too shallow, and underinflated the lungs twice as often. VSI subjects were rated 'competent' or better 80.0% of the time, compared with TRAD subjects, who achieved this rating only 45.1% of the time (P < 0.001). TRAD subjects were rated to be 'not competent' in performing CPR nearly 10 times more often than VSI subjects (P < 0.001). Subjects 40 years of age and older performed better after VSI than after TRAD. Superior skill performance among subjects exposed to VSI persisted 60 days following training. VSI has the potential to reach individuals unlikely to participate in TRAD classes because of its greater convenience, lower cost, and training in about 0.50 h compared with 3-4 h for TRAD classes.

Objective: To determine the gender-based career obstacles for women in an academic department of medicine and to report the interventions to correct such obstacles (resulting from the evaluation) and the results of these interventions., Design: Intervention study, before-after trial, with assessment of faculty concerns and perceived change through structured, self-administered questionnaires., Setting: The Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md., Participants: Full-time faculty., Interventions: Multifaceted intervention from 1990 through 1995 to correct gender-based career obstacles reported by women faculty, including problem identification, leadership, and education of faculty, and interventions to improve faculty development, mentoring, and rewards and to reduce isolation and structural career impediments., Main Outcome Measures: Retention and promotion of deserving women faculty, salary equity, quality of mentoring, decreased isolation from information and colleagues, integration of women faculty into the scientific community, and decreased manifestations of gender bias., Results: Junior women were retained and promoted, reversing previous experience, with a 550% increase in the number of women at the associate professor rank over 5 years (from 4 in 1990 to 26 in 1995). Interim 3-year follow-up showed a 183% increase in the proportion of women faculty who expected they would still be in academic medicine in 10 years (from 23% [7/30] in 1990 to 65% [30/46] in 1993). One half to two thirds of women faculty reported improvements in timeliness of promotions, manifestations of gender bias, access to information needed for faculty development, isolation, and salary equity. Men also reported improvements in these areas., Conclusions: The outcomes reported here indicate that it is possible to make substantive improvements in the development of women's careers, that an institutional strategy to this end can be successful in retaining women in academic medicine, and that such interventions are likely to benefit all faculty. Long-term interventions appear essential.

From its beginnings 15 years ago as a small, grassroots group of volunteers, Hospice Services of Howard County has grown into a thriving business organization serving clients in one of the fastest growing counties in the state. Having gained Medicare certification this fall, the organization has finally realized its dream of becoming a full-service hospice.

The toxicity/oncogenicity of refractory ceramic fibres have been tested in chronic inhalation studies in rodents. Because these studies are time consuming and expensive, there is a need to develop and validate short-term models to screen fibres for their toxicological potential. In the present study, the toxic effects of four different compositions of refractory ceramic fibres were determined using Chinese hamster ovary cells grown in culture. These refractory ceramic fibres were the same size-selected fibres that had been used in animal inhalation studies, thus facilitating a direct comparison of findings in the two systems. Chinese hamster ovary cells were treated with refractory ceramic fibres 24 hr after seeding into 60-mm culture dishes in Ham's F12 medium with 10% serum. Inhibition of cell proliferation and colony formation were determined after 3-5 days of fibre exposure. Crocidolite and chrysotile asbestos were used as positive controls. Concentration-dependent inhibition of both cell proliferation and colony formation was observed after treatment with refractory ceramic fibres. The LC(50) for the different refractory ceramic fibres ranged from 10 to 30 mug/cm(2). The LC(50)s for crocidolite and chrysotile were 5 mug/cm(2) and 1 mug/cm(2), respectively. To assess the genotoxic potential of these fibres, fibre-exposed Chinese hamster ovary cell cultures were stained with acridine orange and scored for the incidence of micronuclei and other nuclear abnormalities. The incidence of nuclear abnormalities for refractory ceramic fibres at 20 mug/cm(2) ranged from 20 to 40%. Toxic endpoints of the in vitro studies were compared with those of the chronic animal inhalation studies. The latter included induction of lung fibrosis and pleural and airway tumours. A correlation was observed between the in vitro and in vivo toxicological potencies of the respective four refractory ceramic fibres: the fibres that were most toxic in vitro were also the most toxic in the chronic animal inhalation studies. A direct relationship was also observed, both in vitro and in vivo, between average fibre length and the severity of the toxic effect.

Pyloric exclusion with gastrojejunostomy has been shown to be an effective adjuvant in the treatment of severe duodenal and pancreatic trauma. The authors have successfully applied this technique to the treatment of two patients with complicated pancreatic pseudocysts drained by cyst duodenostomy. A third patient with malignant duodenocolic fistula was palliated with this modality but eventually succumbed to his advanced disease.

A 43-year-old woman, a long-term intrauterine contraceptive device (IUD) wearer with a history of Actinomyces organisms seen in cervicovaginal smears, developed hepatic actinomycosis 13 months after removal of the IUD. The liver involvement was diagnosed by fine needle aspiration (FNA) cytology and the use of immunocytochemical techniques. Histopathologic examination of a right pelvic mass removed at surgical exploration revealed an Actinomyces tuboovarian abscess, the primary lesion in this case. The importance of cytologic detection of Actinomyces in cervicovaginal smears for the prevention of IUD-related pelvic inflammatory disease (PID) is discussed, as is the usefulness of FNA cytology in the diagnosis of systemic actinomycosis.

Considerable evidence exists of hypothalamic dysfunction in patients with anorexia nervosa and bulimia nervosa. This dysfunction is reflected in disturbances of endocrine function including abnormalities of gonadotropin, growth hormone, and corticotropin-releasing hormone secretion. Whereas these disturbances are generally reversed with nutritional rehabilitation and weight restoration, it is not evident to what extent nutritional factors are the primary etiology or whether they unmask an otherwise existing but compensated central disturbance. Similarly, endocrine disturbances may be a final common pathway in which disturbances of diet, weight, activity, stress, and mood as well as hypothalamic dysfunction are expressed.

Dual photon absorptiometry was used to assess the risk of developing osteoporosis in patients with anorexia nervosa and patients of normal weight with bulimia nervosa. Anorectic patients had significantly lower vertebral bone mineral densities compared with healthy controls. Bulimic patients had values similar to those of controls, and the differences between bulimics and anorectics narrowly missed significance. No significant difference was found between patient groups in measurements of serum estradiol, but anorectics, compared with bulimics, had significantly higher values of 24-hour urinary free cortisol. Hypercortisolemia, by diminishing bone formation and increasing bone resorption, is likely to contribute to the development of osteoporosis in patients with eating disorders.

Caloric requirements for weight gain in subgroups of anorectic patients (anorectic restrictors, anorectic binge-purgers) and weight maintenance in subgroups of anorectic and bulimic patients (bulimics with and without a prior history of anorexia nervosa) were studied in a total of 36 patients. No significant differences were found between subgroups of anorectic patients either in calories to gain weight or to maintain a normal weight. Bulimic patients, as a group, were found to require significantly fewer [corrected] calories than the group of anorectic patients to maintain a normal weight. Bulimic patients with a prior history of anorexia nervosa were found to require more calories for weight maintenance than bulimics with no such prior history. In the entire eating disorder population, there was a significant negative correlation between highest premorbid body mass index (BMI) and calories required to maintain weight. These findings suggest that differences in energy metabolism may be present in the eating disorder subgroups.

Porous samples of cellulose diacetate/nitrate CAN (millipore filter), polycarbonate PC (nuclepore filter), cellulose diacetate Ca, and polydimethyl siloxane SR of various pore sizes were immersed in stirred heparinized human blood while being perfused with lactated Ringer's solution at various rates. Control samples were exposed to the blood in the absence of perfusion. The control tests showed that CAN and PC adhered platelets rapidly to plateau levels of 1--5 X 10(6)/cm2 in approximately 4 min, while CA and SR remained platelet-free. The critical perfusion rate vp* to prevent adhesion of platelets (and all formed elements) to the CAN and PC was approximately 0.1 cc/min cm2 at a shear rate of approximately 620 sec-1 independent of pore size tested. vp* increased slightly with stirring rate. A simplified diffusion-convection model was used to qualitatively account for the effects observed.

An apparatus is described which permitted a perfusant (lactated Ringer's solution) to be passed through a porous sample in a pulsatile manner with a square wave pressure profile. The "on" time, "off" time, number of cycles and pressure amplitude were separately controllable. Using this apparatus and immersing the sample in stirred, heparinized, human blood, there was a certain "off" time below which platelet adhesion to the sample abruptly ceased. The values of this "off" time, termed the activation time ta for platelet adhesion were approximately 0.5 sec for 0.2 micrometers pore size cellulose diacetate/nitrate (millipore filter) and approximately 0.3 sec for 0.2 micrometers polycarbonated (nuclepore filter). After a single cycle with a 5 sec "off" time, adhered platelets on both these materials showed pseudopodia, varying degrees of spreading and membrane perforation.

Effective emergency systems using emergency medical technicians (EMTs) trained to defibrillate or paramedics can save more lives from out-of-hospital cardiac arrest due to ventricular fibrillation than can emergency systems staffed with basic EMTs who cannot defibrillate. This article focuses on the cost-effectiveness of systems staffed with each type of EMT. Data were collected from all 50 states and from the District of Columbia to determine the number of hours and estimated cost of initial training for the three types of EMTs in the United States in 1986. The median initial training hours for basic EMTs, EMTs trained in defibrillation, and paramedics were 110, 129, and 700, respectively. Median costs for initial training at each EMT level were +123, +150, and +1580/student. According to published survival data for emergency medical systems staffed with EMTs at each level, the total initial training personnel and equipment cost per life saved from ventricular fibrillation was +7687, +2126, and +2289 for systems staffed by the respective EMTs. The initial cost per life saved from ventricular fibrillation is more than three times greater in systems staffed by basic EMTs than in systems staffed by EMTs trained in defibrillation or paramedics. From a medical and a cost-effective standpoint, all communities served by basic EMTs should consider upgrading them to at least the defibrillation-trained EMT level.

Cats, anesthetized with sodium pentobarbital, were cannulated to measure pulmonary, systemic, and left atrial pressures and pulmonary ventilation, compliance, and resistance. Intracranial pressure was elevated to 30 mm Hg by injecting silicone oil into the extradural space. After an average time of 56 minutes, pulmonary systolic and diastolic pressures more than doubled, systemic systolic pressure sometimes rose and sometimes fell, and diastolic pressure rose 5%. Left atrial pressure never exceeded 8 cm of saline. Pulmonary compliance decreased by one-half, but airway resistance was unchanged. Pulmonary edema was estimated from histological sections. The pulmonary hypertension may be the result of a sympathetic discharge confined to the lung, since no remarkable changes in heart rate or systemic blood pressure occurred. The decrease in pulmonary compliance followed the rise in pulmonary arterial pressure, and is interpreted as the result of interstitial edema. There was no evidence that left heart failure or elevated left atrial pressure caused the pulmonary edema.