Die neue deutsche Leitlinie zur peripartalen Hämorrhagie - Wichtige Aspekte für die Gerinnungs- und Kreislauftherapie

Anästhesiol Intensivmed Notfallmed Schmerzther 2016; 51: 526-535
DOI: 10.1055/s-0042-105937

Die peripartale Blutung (PPH) ist weltweit weiterhin eine der führenden Gründe mütterlicher Sterblichkeit. Die Deutsche Gesellschaft für Gynäkologie und Geburtshilfe hat zusammen mit der Gesellschaft für Thrombose- und Hämostaseforschung, dem deutschen Hebammenverband und der DGAI die alte Leitlinie aktualisiert. Die Empfehlungen dieser Leitlinie stellen das Ergebnis einer umfassenden Literaturanalyse und eines formalen Konsensusprozesses dar (Konsensus-basierte Leitlinie, S2K) und umfassen alle Aspekte der peripartalen Blutung einschließlich Definition, Ursachen, Risikofaktoren und Therapie. Kernpunkt der anästhesiologisch-hämostaseologischen Behandlung ist die Entwicklung einer interdisziplinären Standard Operating Procedure (SOP), welche die medikamentöse Behandlung inkl. der Transfusion von Blutprodukten in Abhängigkeit von Ursache und Schwere der Blutung und der chirurgischen Behandlung beinhaltet. Die Leitlinie betont dabei die Bedeutung klinischer und laborgestützter Diagnostik, wenn eine peripartale Blutung vermutet wird, da nur diese die frühe Erkennung der Blutungsursachen und ursachengerechte Therapie ermöglicht. Die Empfehlungen zum anästhesiologisch-hämostaseologischen Management umfassen die evidenzbasierte Gabe von Uterotonika im Falle der atonen Blutung sowie die Gabe von Tranexamsäure und Blutprodukten wie Faktorenkonzentraten, gerinnungsaktivem Frischplasma ,Thrombozytenkonzentraten, Erythrozytenkonzentraten als auch in Ausnahmefällen rekombinantem aktivierten Faktor VII und Desmopressin. In Ergänzung der genannten Behandlungsoptionen werden – basierend auf verfügbaren Daten aus der Literatur - Empfehlungen zur blutsparenden Therapie mit dem Einsatz des Cell Savers, der kontrollierten Hypotension und restriktiven Transfusionstriggern gegeben.
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© Georg Thieme Verlag Stuttgart · New York

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Dokumentation chronischer Schmerzen online möglich

Anästhesiol Intensivmed Notfallmed Schmerzther 2016; 51: 582-582
DOI: 10.1055/s-0042-115331

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© Georg Thieme Verlag Stuttgart · New York

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Kontrolle der Hämodynamik und Hirnperfusion bei Kindern - Welches Monitoring sollte genutzt werden?

Anästhesiol Intensivmed Notfallmed Schmerzther 2016; 51: 536-539
DOI: 10.1055/s-0041-103632

Die Möglichkeiten des Monitorings der Hämodynamik und zerebralen Perfusion sind in der Kinderanästhesie aufgrund der geringen technischen Vielfalt eingeschränkt. Dieses Monitoring sollte jedoch vor dem Hintergrund des potenziellen Schadens einer langanhaltenden Hypotension und zerebralen Minderperfusion zum Einsatz kommen. So steht derzeit für die breite Anwendung die nicht invasive Blutdruckmessung und für Risikopatienten v. a. die Nahinfrarot-Spektroskopie zur Verfügung. Die frühzeitige Messung des Blutdrucks und die Beachtung der Grenzen standen in der Vergangenheit in der Kinderanästhesie im Hintergrund. Das ist aufgrund der aktuellen Datenlage nicht mehr state of the art.
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© Georg Thieme Verlag Stuttgart · New York

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Rettungsgasse: gesetzliche Klarstellung begrüßt

Anästhesiol Intensivmed Notfallmed Schmerzther 2016; 51: 582-582
DOI: 10.1055/s-0042-115333

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© Georg Thieme Verlag Stuttgart · New York

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Organersatzverfahren - Zwischen Verheißung und Verantwortung

Anästhesiol Intensivmed Notfallmed Schmerzther 2016; 51: 540-542
DOI: 10.1055/s-0042-110367

Die Intensivmedizin mit den Zielen des Monitorings, der Unterstützung bei Versagen der Vitalfunktionen sowie der Behandlung vorliegender Grunderkrankungen ist seit Anbeginn eng mit technischen Möglichkeiten sowie Herausforderungen verknüpft gewesen.
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© Georg Thieme Verlag Stuttgart · New York

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Mund-Nasen-Maske statt invasiver Beatmung

Anästhesiol Intensivmed Notfallmed Schmerzther 2016; 51: 583-583
DOI: 10.1055/s-0042-115330

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© Georg Thieme Verlag Stuttgart · New York

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Organersatzverfahren - Nierenersatzverfahren in der Intensivmedizin

Anästhesiol Intensivmed Notfallmed Schmerzther 2016; 51: 544-553
DOI: 10.1055/s-0041-109833

Schwer kranke, intensivmedizinisch behandelte Patienten haben ein hohes Risiko, ein akutes Nierenversagen zu entwickeln. Jedes Nierenversagen verkürzt die weitere Lebenserwartung. Ein akutes Nierenversagen führt aber nicht mehr unmittelbar zum Tod, weil die vielfältigen Funktionen der Niere medikamentös oder maschinell ersetzt werden können. Hämodialyse und Hämofiltration sind die grundlegenden Verfahren der maschinellen Nierenersatztherapie; sie können kontinuierlich oder intermittierend durchgeführt werden. Die Entscheidung für ein bestimmtes Verfahren muss vom Einzelfall abhängig gemacht werden. Die Peritonealdialyse ist eine Alternative zur Blutwäsche, stellt aber besondere personelle und institutionelle Anforderungen. Röntgenkontrastmittel und Rhabdomyolyse sind häufige Ursachen eines toxischen akuten Nierenversagens auf der Intensivstation, können durch Nierenersatzverfahren aber nicht verhindert werden.
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© Georg Thieme Verlag Stuttgart · New York

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Keeping Clubhouses Open: Toward a Roadmap for Sustainability

Abstract

Clubhouses are recovery centers that help persons with serious mental illness obtain and maintain community-based employment, education, housing, social integration, and other services. Key informants from U.S. clubhouses were interviewed to create a conceptual framework for clubhouse sustainability. Survival analyses tested this model for 261 clubhouses. Clubhouses stayed open significantly longer if they had received full accreditation, had more administrative autonomy, and received funding from multiple rather than sole sources. Cox regression analyses showed that freestanding clubhouses which were accredited endured the longest. Budget size, clubhouse size, and access to managed care did not contribute significantly to sustainability.

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Mental Health Service Use Among Young Adults: A Communication Framework for Program Development

Abstract

Research on mental health service engagement has been dominated by attempts to identify determinants of engagement. Such knowledge is important but incomplete. Once identified, program designers need to use evidence-based principles to design programs to bring about changes in the empirically identified determinants. Research is relatively silent on such principles. This article develops a framework to guide program designers' as they address factors that constrain and/or facilitate engagement. The framework is grounded in communication theory and evidence from related behavioral science research. The literature is summarized and used to generate a check-list of questions to consider when structuring engagement programs.

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Eccentric Exercise: Physiological Characteristics and Acute Responses

Abstract

An eccentric contraction involves the active lengthening of muscle under an external load. The molecular and neural mechanisms underpinning eccentric contractions differ from those of concentric and isometric contractions and remain less understood. A number of molecular theories have been put forth to explain the unexplained observations during eccentric contractions that deviate from the predictions of the established theories of muscle contraction. Postulated mechanisms include a strain-induced modulation of actin-myosin interactions at the level of the cross-bridge, the activation of the structural protein titin, and the winding of titin on actin. Accordingly, neural strategies controlling eccentric contractions also differ with a greater, and possibly distinct, cortical activation observed despite an apparently lower activation at the level of the motor unit. The characteristics of eccentric contractions are associated with several acute physiological responses to eccentrically-emphasised exercise. Differences in neuromuscular, metabolic, hormonal and anabolic signalling responses during, and following, an eccentric exercise bout have frequently been observed in comparison to concentric exercise. Subsequently, the high levels of muscular strain with such exercise can induce muscle damage which is rarely observed with other contraction types. The net result of these eccentric contraction characteristics and responses appears to be a novel adaptive signal within the neuromuscular system.

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Children’s Media Use and Self-Regulation Behavior: Longitudinal Associations in a Nationwide Japanese Study

Abstract

Objective The effect of media use on child behavior has long been a concern. Although studies have shown robust cross-sectional relations between TV viewing and child behavior, longitudinal studies remain scarce. Methods We analyzed the Longitudinal Survey of Babies, conducted by Japan's Ministry of Health, Labour and Welfare since 2001. Among 53,575 families, 47,010 responded to the baseline survey; they were followed up every year for 8 years. Complete data were available for longitudinal analysis among 32,439 participants. Daily media use (TV viewing and video game-playing hours at ages 3, 4, and 5 years) was used as the main exposure. We employed an index of the children's self-regulatory behavior as the outcome variable. Odds ratios and 95 % confidence intervals (CIs) were estimated. Results Among boys, longer TV-viewing times at ages 4 and 5 were related to problematic self-regulatory behavior. Compared with boys who watched just 1–2 h of TV a day, those who watched it 4–5 h had a 1.79-fold greater risk (CI 1.22–2.64) of problematic self-regulatory behavior, according to parental report. Among girls, similar results were evident at ages 4 and 5 (e.g., adjusted odds ratios for 4–5 h daily viewing versus 1–2 h at age 4: 2.59; 95 % CI 1.59–4.22). Video games may have a protective effect on the risk of problematic self-regulatory behavior at ages 3 and 5. Conclusion Longer daily exposure to TV during early childhood (age 4–5) may be associated with subsequent problematic child self-regulatory behavior.

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The Effectiveness of a Physical Activity Educational Campaign in a Rural Obstetrics and Gynecology Office

Abstract

Objectives The objective of this study was to evaluate the effectiveness of an early intervention health education campaign to positively influence physical activity (PA) knowledge, intention, and performance among prenatal women and women of reproductive age. Methods This study employed a quantitative, quasi-experimental, control-group comparison design with nonprobability sampling methodology. Implemented in rural healthcare settings located in the Southeastern portion of the United States, participants included prenatal patients and patients of reproductive age (n = 325) from two separate obstetrics and gynecology (OB/GYN) offices. While the intervention group was solicited from an OB/GYN office where the information-based health education campaign was implemented, the comparison group was solicited from a comparable OB/GYN office that did not implement the health education campaign. Results The women exposed to the PA health education campaign were significantly more likely to report that PA information was provided at their physician's office, scored higher on PA knowledge, and were more likely to meet the guidelines for vigorous PA and strength training (p < 0.05). Conclusions Physical activity educational campaigns are a cost effective intervention that can be implemented in healthcare settings to promote maternal and child health.

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The Influence of Infant Feeding Practices on Infant Mortality in Southern Africa

Abstract

Objective To examine the adjusted and unadjusted effects of infant feeding practices on infant mortality in Southern Africa. Methods A merged dataset from the most recent Demographic and Health Surveys for Lesotho, Swaziland, Zambia and Zimbabwe was analysed using the Cox Proportional Hazard Model. A total number of 13,218 infants born in 5 years preceding all the surveys with information on infant feeding practices constituted the study population. Infant mortality was the outcome variable and infant feeding practices categorised into; no breastfeeding, partial breastfeeding and exclusive breastfeeding were the main explanatory variables. Maternal demographic and socio-economic characteristics and infants' bio-demographic characteristics were also studied. Results Although, exclusive breastfeeding was quite low (12 %), exclusively breastfed infants exhibited a 97 % lower risk of dying during infancy compared to infants not breastfed in the region. Variations existed by country in the levels and patterns of both infant mortality and infant feeding practices. Mother's country, highest level of education and marital status; child's sex, birth weight and preceding birth interval were the significant predictors of infant mortality in Southern Africa. Conclusions Any form of breastfeeding whether exclusive or partial breastfeeding greatly reduces the risk of infant mortality with the greatest mortality reduction effect observed among exclusively breastfed infants in Southern Africa. To reduce the upsurge of infant mortality, there is the need to step up the effectiveness of child nutrition programmes that promote breastfeeding and put emphasis on exclusive breastfeeding of infants in the region.

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Perceptions of Body Size in Mothers and Their Young Children in the Galapagos Islands

Abstract

Introduction Little specific information has been published about the health of people who live in the Galapagos Islands. As part of determining the status of the nutrition transition that may be occurring in the islands mothers of young children in the Galapagos perceptions of their child's body size and therefore health status was evaluated along with actual body size. Methods This paper presents data collected as part of a pilot study that used a mixed methods approach to identify and describe health and nutrition issues for mother–child pairs on Isla Isabela in Galapagos, Ecuador. It includes participant anthropometric assessment and self-perception of body size using silhouettes for themselves and one of their children along with open-ended questions to elicit further understanding of body size perceptions. Twenty mothers of children greater than 6 months of age but less than 6 years of age were interviewed. Results The women preferred a smaller body size for themselves but a larger body size for their children. Findings of different body size combinations between mothers and children in the same household demonstrated that the island is undergoing or may be post the nutrition transition. Discussion This dual burden of body weights (especially overweight or obese mothers) in the same household with underweight, normal and overweight or obese children and the potential nutrition related chronic disease burden in the future will require more educational resources and innovative health services than are currently available for the people of the Galapagos.

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Association Between Caregiver Stress and Behavioral Problems in the Children of Incarcerated Fathers in Hong Kong

Abstract

Objectives Caregivers of children with incarcerated parents have received little attention in the literature, though they face unique incarceration-related challenges. General caregiver research has highlighted associations between caregiver distress and children's behavioral problems, even implying that the depressive tendencies of caregivers can be 'transmitted'. The current study investigated the applicability of this notion to caregivers responsible for children of incarcerated fathers. Methods Fifty-four female caregivers of children with incarcerated parents were recruited via collaboration with a non-governmental organization. Their levels of stress and depression were measured using questionnaires, as were the behavioral problems of children under their care. The relationships between the variables were examined. Results The results firstly suggest that these caregivers are vulnerable to psychological distress, with around 57 % of them suffering from borderline to severe depression. Obtained socio-demographic characteristics were not found to have any bearing on the psychosocial functioning of caregivers or children—rather, all psychosocial variables were interlinked, and further analyses revealed that the depression of caregivers mediated the relationship between their perceived stress and internalizing/externalizing behavioral problems of the child (β = .628 and β = .468 respectively), implicating depression as a mechanism via which adversity can be transferred from a caregiver to a child. Conclusions Increasing the focus on a caregiver's mental health may be an efficacious strategy in research and practice, perhaps by providing more support for caregivers and implementing joint caregiver-child interventions to more holistically alleviate problems in families affected by parental incarceration. Limitations of the current study and further recommendations are also discussed.

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IgG Autoantibodies Induced by T. cruzi During Pregnancy: Correlation with Gravidity Complications and Early Outcome Assessment of the Newborns

Abstract

Objective The aim of the present research was to evaluate the correlation of vertically transmitted IgG antibodies induced by T. cruzi and newborn early outcome assessment, mainly birth weight and gestational age. Methods We performed a cross-sectional study with 183 pregnant women (64 with asymptomatic Chagas disease) and their newborns. Both were subjected to complete clinical examination. Peripheral parasitemia was assessed in mother and neonates by parasite detection through microscopic examination of the buffycoat from mother's peripheral and cord blood. Antibodies induced by T. cruzi, such as anti-FRA, anti-B13, anti-p2β and anti-T. cruzi were assessed by immunoassay. Birth weight, general condition evaluation by APGAR Score and gestational age by Capurro Score, were determined in newborns. Results The rate of stillbirth background and pregnancy-induced hypertension were higher in patients with Chagas disease (p = 0.01 and p = 0.02, respectively). Parasitemia was detectable in 17 mothers and 4 newborns. The newborns of mothers with detectable parasitemia presented decreased gestational age (p = 0.006) and body weight (p = 0.04). Mostly all the mothers with Chagas disease and all their newborns have positive values of antibodies induced by T. cruzi; however, only anti-p2β showed to be related to the presence of complication during pregnancy (OR 2.35, p = 0.036), and to low birth weight (OR 1.55, p = 0.02). Conclusions Low birth weight and decreased postnatal estimation of maturity were related to detectable parasitemia in the mother. Also, vertical transmission of T. cruzi-induced autoantibodies might have clinical implication in newborns given the negative association between anti-p2β values and weight.

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Relationship Between Common Mental Disorder Symptoms During Pregnancy and Preterm Birth Among Chinese Women in Wuhan

Abstract

Objectives Few studies focus on the symptoms of common mental disorders during pregnancy (CMDP) and risk of preterm birth subtypes (PTB). The purpose of this study was to estimate the association between CMDP and PTB, and to examine whether or not the association between CMDP and PTB varies with the subtype of PTB in Chinese. Methods This population-based case control study, conducted in Wuhan, China, defined cases as every pregnant woman who had a PTB among all births in Wuhan, from June 10, 2011, to June 9, 2013. The same number of pregnant women who had term births was randomly selected as controls. The Electronic Perinatal Health Care Information System, a questionnaire designed for the study, provided data about the participants. Logistic regression analyses were used to model associations between CMDP and PTB, and to test associations between CMDP and two subtypes of PTB. Results The study recruited 8616 cases and an equal number of controls. We successfully collected maternal information on 6656 cases and controls for a response rate of 77.3 %. The incidence of PTB in Wuhan was 4.5 %. Spontaneous preterm births (SPTB) accounted for 60.1 %, and medically induced preterm births (IPTB) accounted for 39.9 % of preterm births. The prevalence rate of CMDP was 15.8 %. CMDP was slightly associated with PTB (crude OR 1.16, 95 % CI 1.01–1.32; adjusted OR 1.15, 95 % CI 1.00–1.32), further analyses showed CMDP was associated with IPTB (aOR 1.25, 95 % CI 1.04–1.50), but not with SPTB. Conclusion Our data suggest that CMDP is related to an increased risk of PTB, and that this association is primarily due to IPTB rather than SPTB.

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Screening for Post-traumatic Stress Disorder in Prenatal Care: Prevalence and Characteristics in a Low-Income Population

Abstract

Objectives Investigate the feasibility of using a brief, 4-item PTSD screening tool (PTSD-PC) as part of routine prenatal care in two community health care settings serving ethnically and linguistically diverse low-income populations. Report prevalence and differences by sub-threshold and clinical levels, in demographic, health, mental health, risk behaviors, and service use. Methods Women were screened as part of their prenatal intake visit over a 2-year period. Those screening positive at clinical or sub-threshold levels were recruited if they spoke English, Spanish, Portuguese, Vietnamese or Arabic. Enrolled women were interviewed about psychosocial risk factors, prior traumas, PTSD symptoms, depression, anxiety, substance use, health and services, using validated survey instruments. Results Of 1362 women seen for prenatal intakes, 1259 (92 %) were screened, 208 (17 %) screened positive for PTSD at clinical (11 %) or sub-threshold levels (6 %), and 149 (72 % of all eligible women) enrolled in the study. Those screening positive were significantly younger, had more prior pregnancies, were less likely to be Asian or black, and were more likely to be non-English speakers. Enrolled women at clinical as compared to sub-threshold levels showed few differences in psychosocial risk, but had significantly more types of trauma, more trauma before age 18, more interpersonal trauma, and had greater depression, anxiety, and PTSD symptoms. Only about 25 % had received mental health treatment. Conclusions The PTSD-PC was a feasible screening tool for use in prenatal care. While those screening in at clinical levels were more symptomatic, those at subthreshold levels still showed substantial symptomology and psychosocial risk.

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From Postpartum Haemorrhage Guideline to Local Protocol: A Study of Protocol Quality

Abstract

Objective Postpartum hemorrhage (PPH) has a continuously rising incidence worldwide, suggesting suboptimal care. An important step in optimizing care is the translation of evidence-based guidelines into comprehensive hospital protocols. However, knowledge about the quality of these protocols is lacking. The objective of this study was to evaluate the quality of PPH-protocols on structure and content in the Netherlands. Methods We performed an observational multicenter study. Eighteen PPH-protocols from 3 University Hospitals (UH), 8 Teaching Hospitals (TH) and 7 Non-Teaching hospitals (NTH) throughout the Netherlands were acquired. The structure of the PPH-protocols was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) Instrument. The content was appraised using previously developed quality indicators, based on international guidelines and Advance-Trauma-Life-Support (ATLS)-based course instructions. Results The quality of the protocols for postpartum hemorrhage for both structure and content varied widely between different hospitals, but all of them showed room for improvement. The protocols scored mainly below average on the different items of the AGREE-II instrument (8 of the 10 items scored <4 on a 1–7 scale). Regarding the content, adoption of guideline recommendations in protocols was 46 %. In addition, a timely indication of 'when to perform' a recommendation was lacking in three-fourths of the items. Conclusion This study shows that the quality of the PPH-protocols for both structure and content in the Netherlands is suboptimal. This makes adherence to the guideline and ATLS-based course instructions difficult.

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Subjective Social Status and Psychological Distress in Mothers of Young Children

Abstract

Introduction Perceptions of social standing have increasingly well-documented relationships with health. Higher subjective social status (SSS) is associated with better psychological well-being among women, and mothers of newborns. The relationship between SSS and psychological distress among mothers of young children, however, is largely unknown. SSS may provide insight into aspects of maternal functioning that are relevant to parenting capacity, as well as insight into future health; in addition, SSS is brief, and may be perceived as less intrusive than other measures of socioeconomic status or mental health. We evaluated the relationship between SSS and psychological distress among mothers of 5-year-old children from diverse socioeconomic backgrounds. Methods One hundred and sixty-two mothers of 5-year old children, who participated in a study of child self-regulation, completed surveys that assessed sociodemographics, mental health, and perceived social support. The MacArthur Scale of SSS used pictures of ten-rung ladders to assess respondents' social position in relation to the US (SES ladder) and their community (community ladder). Quantile regression models were used to assess the relationship between maternal psychological distress (perceived social support, depressive symptoms, anxiety) and the ladders (individually and together), adjusting for maternal age, race, education, and number of children. To examine whether the SSS–health relationships differed by race, the models were also stratified by race. Results Community ladder ranking was positively associated with social support (β = 1.34, SE = 0.33, p < .001), and negatively associated with depressive symptoms (β = −1.34, SE = 0.52, p < .05). SES ladder ranking was positively associated with social support (β = 1.17, SE = 0.52, p < .05). Findings in the full sample were driven by more robust relationships between psychological distress and community SSS among Black/African-American mothers. Discussion The findings suggest that perceived social standing in one's community is associated with maternal psychological well-being. Community SSS may be particularly influential for Black/African-American mothers' well-being.

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Rate of Second and Third Trimester Weight Gain and Preterm Delivery Among Underweight and Normal Weight Women

Abstract

Objectives Low gestational weight gain (GWG) in the second and third trimesters has been associated with increased risk of preterm delivery (PTD) among women with a body mass index (BMI) < 25 mg/m². However, few studies have examined whether this association differs by the assumptions made for first trimester gain or by the reason for PTD. Methods We examined singleton pregnancies during 2000–2008 among women with a BMI < 25 kg/m² who delivered a live-birth ≥28 weeks gestation (n = 12,526). Women received care within one integrated health care delivery system and began prenatal care ≤13 weeks. Using antenatal weights measured during clinic visits, we interpolated GWG at 13 weeks gestation then estimated rate of GWG (GWG_rate) during the second and third trimesters of pregnancy. We also estimated GWG_rate using the common assumption of a 2-kg gain for all women by 13 weeks. We examined the covariate-adjusted association between quartiles of GWG_rate and PTD (28–36 weeks gestation) using logistic regression. We also examined associations by reason for PTD [premature rupture of membranes (PROM), spontaneous labor, or medically indicated]. Results Mean GWG_rate did not differ among term and preterm pregnancies regardless of interpolated or assumed GWG at 13 weeks. However, only with GWG_rate estimated from interpolated GWG at 13 weeks, we observed a U-shaped relationship where odds of PTD increased with GWG_rate in the lowest (OR 1.36, 95 % CI 1.10, 1.69) or highest quartile (OR 1.49, 95 % CI 1.20, 1.85) compared to GWG_rate within the second quartile. Further stratifying by reason, GWG_rate in the lowest quartile was positively associated with spontaneous PTD while GWG_rate in the highest quartile was positively associated with PROM and medically indicated PTD. Conclusions Accurate estimates of first trimester GWG are needed. Common assumptions applied to all pregnancies may obscure the association between GWG_rate and PTD. Further research is needed to fully understand whether these associations are causal or related to common antecedents.

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Prenatal Stress and the Cortisol Awakening Response in African-American and Caucasian Women in the Third Trimester of Pregnancy

Abstract

Objectives Prior studies have shown significant racial disparities in psychosocial stressors for pregnant women. One physiological mechanism by which prenatal stress is expressed is via the stress-sensitive hormone cortisol, which itself differs by race. In this study, we examine differences in cortisol awakening response (CAR) for African-American and Caucasian pregnant women during late pregnancy, particularly whether racial disparities are evident after accounting for measures of psychosocial stress. Methods During their third trimester of pregnancy (32–40 weeks of gestation), we asked women to self-collect salivary samples at home over 2 days. We then measured salivary cortisol across the day for 30 pregnant women (18 Caucasian; 12 African-American) to examine the CAR by race and by multiple measures of self-reported psychosocial stress, including perceived discrimination. Results Although the women in our sample showed normative cortisol diurnal rhythms (high on waking, peak 30 min post-waking, lowest at bedtime), we found that African-American women had blunted (smaller) awakening responses compared to Caucasian women (p < 0.05). The CAR was significantly larger in Caucasian women compared to African-American women even after accounting for covariates in a multivariate equation. However, when we added measures of psychosocial stress to the multivariate equation, higher levels of stress were significantly associated with a smaller CAR (p < 0.05), and the association between maternal race and CAR was no longer significant. Conclusions Our results add to a growing body of evidence that racial differences in the activity of the hypothalamic–pituitary–adrenal axis are associated with psychosocial stress during pregnancy.

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Risk of Preeclampsia in Pregnancies After Assisted Reproductive Technology and Ovarian Stimulation

Abstract

Objective To compare the risk of preeclampsia among spontaneously conceived pregnancies to those after hyperestrogenic ovarian stimulation (hyperestrogenic OS) with and without assisted reproductive technology (ART), and stimulation with non-hyperestrogenic aromatase inhibitor stimulation (non-hyperestrogenic OS). Methods Live-born singleton deliveries among women 20–49 years were identified in the 2004–2012 Truven Health MarketScan Commercial Claims and Encounters Databases using ICD-9 and CPT codes. Maternal characteristics were compared using Chi squared and Fisher exact tests. We performed multilevel multivariable logistic regression, controlling for maternal age, parity, comorbid conditions, and region of delivery, and calculated adjusted odds ratios (aOR) and 95 % confidence intervals for mild and severe preeclampsia. Results 1,014,526 spontaneously conceived, 6881 hyperestrogenic OS with ART, 27,516 hyperestrogenic OS without ART, and 2117 non-hyperestrogenic OS pregnancies were identified. The adjusted odds of developing preeclampsia were increased for deliveries after hyperestrogenic OS with ART (mild preeclampsia aOR 1.42, 1.24–1.62; severe preeclampsia aOR 1.83, 1.59–2.11) and without ART (mild preeclampsia aOR 1.32, 1.24–1.42; severe preeclampsia aOR 1.53, 1.41–1.66). Adjusted odds of preeclampsia were similar between spontaneously conceived and non-hyperestrogenic OS pregnancies. Conclusions for Practice Risk of preeclampsia after ART may in part be related to supraphysiologic estrogen associated with hyperestrogenic OS.

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Severe Neonatal Morbidity Among Births to Refugee Women

Abstract

Background Despite being considered high risk, little is known about the perinatal health of refugees in developed countries. Our objectives were to examine whether: (1) the healthy migrant effect applies to infants born to refugee women with respect to severe neonatal morbidity (SNM); (2) refugee status was a risk factor for SNM among immigrants; (3) refugee sponsorship status was a risk factor for SNM by comparing asylum-seekers to sponsored refugees; and (4) refugees were at greater risk of specific SNM subtypes. Methods Immigration records (1985–2010) linked to Ontario hospital data (2002–2010) were used to examine SNM. We calculated adjusted risk ratios (ARR) with 95 % confidence intervals (95 % CI) for SNM and unadjusted risk ratios with 99 % CI for SNM subtypes using log-binomial regression. Results There were borderline differences in SNM among refugees (N = 29,755) compared to both non-immigrants (N = 860,314) (ARR = 0.94, 95 % CI 0.89, 0.99) and other immigrants (N = 230,847) (ARR = 1.10, 95 % CI 1.04, 1.18) with a larger difference comparing other immigrants to non-immigrants (ARR = 0.83, 95 % CI 0.81, 0.85). Asylum-seekers did not differ from sponsored refugees (ARR = 1.07, 95 % CI 0.90, 1.27). Though rare, several SNM subtypes were significant with large effect sizes. Conclusion With respect to SNM risk, the healthy migrant effect clearly applies to non-refugee immigrants, but is weaker for refugees and may not apply. Among immigrants, refugee status was a weak risk factor for SNM and may not be clinically important. Sponsorship status was not associated with greater risk of SNM. Further investigation of several SNM subtypes is warranted.

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Undernutrition Among Infants and Children in Nepal: Maternal Health Services and Their Roles to Prevent it

Abstract

Objectives Appropriate infant and young child feeding (IYCF) for children aged 6–23 months includes adequate dietary diversity, appropriate meal frequency, and continued breastfeeding. Mothers receiving antenatal care (ANC) and postnatal care (PNC) may adopt better IYCF. This study examined the association of ANC or PNC attendance with IYCF and child nutrition status. Methods A cross-sectional study was performed on 400 mother–child pairs in rural Nepal. Mothers were interviewed about their history of ANC and PNC attendance and IYCF; the height and weight of their children were measured. IYCF was measured with infant and child feeding index (ICFI) aggregating scores of dietary diversity, meal frequency, continued breastfeeding, and dietary variety. Lower ICFI scores indicated poorer IYCF practices. Multiple regression and logistic regression examined the association of ANC and PNC attendance with ICFI scores and undernutrition, respectively. Results Absence of ANC (β = −1.01, P = 0.011) and absence of PNC (β = −1.01, P = 0.011) were negatively associated with ICFI scores. Additionally, absence of ANC was positively associated with underweight (AOR 3.37; 95 % CI 1.42–9.92 for children 6–11 months, AOR 3.43; 95 % CI 1.41–8.32 for children 12–23 months) and stunting (AOR 6.51; 95 % CI 2.11–20.10 for children 6–11 months, AOR 3.32; 95 % CI 1.50–7.31 for children 12–23 months). Similarly, children tended to be underweight and stunted if their mothers did not receive any PNC. Conclusion Absence of ANC and PNC were associated with poor IYCF, underweight, and stunting in children.

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Provision of Lipid-Based Nutrient Supplements from Age 6 to 18 Months Does Not Affect Infant Development Scores in a Randomized Trial in Malawi

Abstract

Objectives Undernutrition during early life contributes to more than 200 million children globally not fulfilling their developmental potential. Our objective was to determine whether dietary supplementation with several formulations of lipid-based nutrient supplements (LNS), which differed in dose per day and milk content, positively affect infant development in Malawi. Methods We randomly assigned 1932 infants age 6 months to receive one of the following for 12 months: 10, 20 g, or 40 g/day milk-containing LNS, 20 g or 40 g/day milk-free LNS, or no supplement until 18 months of age (control group). We assessed motor, language, socio-emotional, and executive function at age 18 months. Primary analysis was by intention-to-treat and we also examined 13 potential effect modifiers, including the child's initial nutritional status and level of developmental stimulation. The study is registered as clinical trial NCT00945698. Results We found no significant differences between intervention groups in any scores. The difference in mean z-scores between children in the control group and children in the intervention groups ranged from −0.08 to 0.04 for motor development (p = 0.76), −0.05 to 0.01 for language development (p = 0.97), −0.15 to 0.11 for socio-emotional development (p = 0.22), and −0.02 to 0.20 for executive function (p = 0.24). We did not find that initial nutritional status, developmental stimulation, or other factors modified the effect LNS versus control group. Conclusions for Practice Our results suggest that in a population such as this one, provision of LNS from age 6 to 18 months would not affect motor, language, socio-emotional, or executive function skills at age 18 months.

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Maternal Pre-pregnancy BMI and Reproductive Health of Daughters in Young Adulthood

Abstract

Objective To investigate the possible associations between maternal pre-pregnancy body mass index (BMI) and daughters' age of menarche and subsequent markers of reproductive health. Methods Nine hundred eighty-five pregnant women (80 %) were enrolled at their routine 30th week examinations in 1988–1989. In 2008, a follow-up questionnaire was completed for 365 daughters (83 %), while 267 daughters (61 %) participated in a subsequent clinical examination. Main outcome measures were age of menarche, reproductive hormone profile, and ovarian follicle count in daughters. Results Daughters of mothers in the highest pre-pregnancy BMI tertile (BMI ≥ 22.0 kg/m²) had an adjusted 4.1 (0.3; 8.0) months earlier menarche compared with the middle tertile group (BMI 20.0–21.9 kg/m²). Among non-users of hormonal contraceptives, daughters of mothers in the highest pre-pregnancy BMI tertile had non-significantly lower dehydroepiandrosterone-sulphate (DHEAS), estradiol, and free estrogen index (FEI), compared to the middle BMI tertile. This was supported by a sub-analysis using the WHO classification (underweight, BMI < 18.50; normal range, BMI 18.50–24.99; overweight/obese, BMI ≥ 25.00 kg/m²) as exposure groups, in which daughters of overweight mothers had lower levels of DHEAS and estradiol, and lower FEI compared to daughters of normal weight mothers. No associations were found for ovarian follicle count in any of the groups. Conclusions for Practice We found that higher maternal BMI is associated with earlier age of menarche in daughters. A possible impact of maternal pre-pregnancy BMI on DHEAS and estradiol serum levels, and FEI in non-users of hormonal contraceptives was indicated, but the results were not statistically significant.

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Effect of a Best Practice Alert on Gestational Weight Gain, Health Services, and Pregnancy Outcomes

Abstract

Objective To examine whether an electronic medical record "best practice alert" previously shown to improve antenatal gestational weight gain patient education resulted in downstream effects on service delivery or patient health outcomes. Methods This study involved secondary analysis of data from an intervention to improve provider behavior surrounding gestational weight gain patient education. Data were from retrospective chart reviews of patients who received care either before (N = 333) or after (N = 268) implementation of the intervention. Pre-post comparisons and multivariable logistic regression were used to analyze downstream effects of the intervention on health outcomes and obesity-related health services while controlling for potential confounders. Results The intervention was associated with an increase in the proportion of prenatal patients who gained weight within Institute of Medicine guidelines, from 28 to 35 % (p < .05). Mean total gestational weight gain did not change, but variability decreased such that post-intervention women had weight gains closer to their gestational weight gain targets. The intervention was associated with a 94 g decrease in mean infant birth weight (p = .03), and an increase in the proportion of overweight and obese women screened for undiagnosed Type 2 diabetes before 20 weeks gestation, from 13 to 25 % (p = .01). Conclusions for Practice The electronic medical record can be leveraged to promote healthy gestational weight gain and early screening for undiagnosed Type 2 diabetes. Yet most patients still need additional support to achieve gestational weight gain within Institute of Medicine guidelines.

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Inside EMS Podcast: Would you want your kids to have an EMS career?

Download this podcast on iTunes, SoundCloud or via RSS feed

​​In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson answer a question from a podcast listener. Matt Burns, 22, has been in the welding field for almost three years. He's thinking about leaving his current career for one in EMS and asks the hosts their opinion on if he should make the change.

Chris shares that his daughter recently asked him about going into EMS. He explains how he told her more of the bad side and then the good. "If I think this is the best career field in the world, why don't I want my daughter to do it" Does that make me a hypocrite"" Chris asks.

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EMS Artwork: Fighting off the reaper

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A Slap on the Back and a Pat on the Head

Someone deserves a congratulatory slap on the back. A quick look at the list of papers in this issue of The Spine Journal reveals several systematic reviews on the treatment of neck pain. (1-5) The Ontario Protocol for Traffic Injury Management Collaboration deserves our recognition for the hard work that went into these reviews and for updating all of us on topics last published in 2008 by the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force [NPTF]).

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Comparison of peritendinous hyaluronan injections versus extracorporeal shock wave therapy in the treatment of painful Achilles tendinopathy: A randomized clinical efficacy and safety study

Publication date: Available online 14 September 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Nils Lynen, Thierry De Vroey, Imke Spiegel, Frederik Van Ongeval, Niels-Jan Hendrickx, Gaëtane Stassijns
ObjectiveTo compare the safety and efficacy of hyaluronan (HA) injections with standard extracorporeal shock wave therapy (ESWT) in the treatment of painful midportion Achilles tendinopathy.DesignMultinational, prospective, randomized controlled, blinded-observer trial.SettingAmbulatory care.ParticipantsAdults presenting Achilles midportion tendinopathy for at least 6 weeks and a pain score of at least 40 mm (Huskisson, visual analogue scale (VAS), 100 mm). 62 participants were randomized and 59 analyzed in the ITT-data set. No withdrawals due to adverse effects.InterventionsTwo peritendinous HA injections versus three ESWT applications at weekly intervals.Main Outcome MeasuresPrimary efficacy criterion was changed from VISA-A score to percent change in pain (VAS) at 3 months post-treatment, compared to baseline values. Main secondary parameters were VISA-A, Clinical Global Impression (CGI) and clinical parameters.ResultsHA treatment provided a clinically relevant improvement in Achilles midportion tendinopathy. A large superiority of the HA-group, compared to ESWT application, was observed for percent change in pain (VAS) and this superiority was proven to be statistically significant (Mann-Whitney statistic (MW) = 0.7507 with p = 0.0030 lower than required alpha = 0.025 significance level one-sided; Mann-Whitney-U test) at 3 months post-treatment. Similar findings for HA were also observed at 4 weeks (MW = 0.6425, p = 0.0304) and 6 months (MW = 0.7172, p = 0.0018). Advantage of HA treatment was confirmed by VISA-A, CGI and clinical parameters. Ten adverse events, 4 in HA-group and 6 in ESWT-group were reported, but none were classified as serious.ConclusionsTwo peritendinous HA injections showed greater treatment success in Achilles midportion tendinopathy compared to standard ESWT.



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Easily Administered Patient Reported Outcome Measures: Adolescents’ Perceived Functional Changes after Completing an Intensive Chronic Pain Rehabilitation Program

Publication date: Available online 14 September 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Heidi Kempert, Ethan Benore, Rachel Heines
ObjectiveTo discuss whether patient reported measures would be clinically sensitive and useful for identifying functional change within an intensive chronic pain program setting. Children and adolescents' perception of their abilities is a natural target of rehabilitation therapies. Perceived functioning is often impaired when experiencing chronic pain and is a meaningful goal of rehabilitation therapy. This study examines two patient reported measures administered as part of physical therapy for chronic pain. It was hypothesized that children and adolescents completing an interdisciplinary pain rehabilitation program would report gains in perceived physical functioning from admission to discharge, and that perceived gains in function would be associated with a reduction in pain intensity.DesignThe study was a retrospective data analysis of 109 children and adolescents with chronic pain treated over a single calendar year. Paired t-tests evaluated change in perceived function measures and pain over time. Standardized residual change scores were used in subsequent regression to assess associations between change scores.SettingAn interdisciplinary pediatric pain rehabilitation program that supports children and adolescents with chronic pain by increasing strength, flexibility and endurance, facilitating a return to daily life activities, and using appropriate self-directed coping and pain management skills.Participants109 children and adolescents (ages 8-19, 83% female) with various chronic pain diagnoses that were admitted to a three- to four-week intensive pain rehabilitation program.InterventionsParticipants were involved in physical and occupational therapy for three hours daily, as well as recreation therapy, psychology, school, aquatics, art and music therapy for a total of 8 hours daily. Parents were involved in parent education with therapists from all disciplines in conjunction with their child's programming.Main Outcome MeasuresLower Extremity Functional Scale (LEFS); Upper Extremity Functional Index (UEFI); self-reported pain severity rating on 0-10 numerical rating scale.ResultsData demonstrated significant gains in LEFS and UEFI during the program. Improvement in perceived functioning was significantly correlated with reduction in pain.ConclusionsThe LEFS and UEFI provide a meaningful way to track progress in chronic pain rehabilitation. Using self-perceived measures, children and adolescents noted significant functional improvement, associated with less pain intensity. These findings increase our understanding of the rehabilitation process and point to goals for clinical improvement.



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Inside EMS Podcast: Would you want your kids to have an EMS career?

Download this podcast on iTunes, SoundCloud or via RSS feed

​​In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson answer a question from a podcast listener. Matt Burns, 22, has been in the welding field for almost three years. He's thinking about leaving his current career for one in EMS and asks the hosts their opinion on if he should make the change.

Chris shares that his daughter recently asked him about going into EMS. He explains how he told her more of the bad side and then the good. "If I think this is the best career field in the world, why don't I want my daughter to do it? Does that make me a hypocrite?" Chris asks.

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EMS Artwork: Fighting off the reaper

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Genomic, Transcriptomic and Proteomic Analysis Provide Insights into the Cold Adaptation Mechanism of the Obligate Psychrophilic Fungus Mrakia psychrophila

Mrakia psychrophila is an obligate psychrophilic fungus. The cold adaptation mechanism of psychrophilic fungi remains unknown. Comparative genomics analysis indicated that M. psychrophila had a specific codon usage preference, especially for codons of Gly and Arg and its major facilitator superfamily (MFS) transporter gene family was expanded. Transcriptomic analysis revealed that genes involved in ribosome and energy metabolism were upregulated at 4°C, while genes involved in unfolded protein binding, protein processing in the endoplasmic reticulum, proteasome, spliceosome and mRNA surveillance were upregulated at 20°C. In addition, genes related to unfolded protein binding were alternatively spliced. Consistent with other psychrophiles, desaturase and glycerol 3-phophate dehydrogenase which are involved in biosynthesis of unsaturated fatty acid and glycerol respectively were upregulated at 4°C. Cold adaptation of M. psychrophila is mediated by synthesizing unsaturated fatty acids to maintain membrane fluidity and accumulating glycerol as a cryoprotectant. The proteomic analysis indicated that the correlations between the dynamic patterns between transcript level changes and protein level changes for some pathways were positive at 4°C, but negative at 20°C. The death of M. psychrophila above 20°C might be caused by an unfolded protein response.

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Transcriptome Analysis Reveals that Vitamin A Metabolism in the Liver Affects Feed Efficiency in Pigs

Feed efficiency (FE) is essential for pig production. In this study, 300 significantly differentially expressed (DE) transcripts, including 232 annotated genes, 28 cis- natural antisense transcripts (cis-NATs), and 40 lncRNAs, were identified between the liver of Yorkshire pigs with extremely high and low FE. Among these transcripts, 25 DE lncRNAs were significantly correlated with 125 DE annotated genes at a transcriptional level. These DE genes were primarily enriched in Vitamin A (VA), fatty acid, and steroid hormone metabolism. VA metabolism is regulated by energy status, and the active derivative of VA metabolism can regulate fatty acids metabolism and steroid hormones metabolism. The key genes of VA metabolism (CYP1A1, ALDH1A2, and RDH16), fatty acid biosynthesis (FASN, SCD, CYP2J2, and ANKRD23), and steroid hormone metabolism (CYP1A1, HSD17B2, and UGT2B4) were significantly up-regulated in the liver of high-FE pigs. Previous study with the same samples as in this study indicated that the mitochondrial function and energy expenditure were reduced in the muscle tissue of high-FE pigs. In conclusion, VA metabolism in liver tissues plays important roles in the regulation of FE in pigs by affecting energy metabolism, which may mediate fatty acid biosynthesis and steroid hormone metabolism. Furthermore, our results identified novel transcripts, such as cis-NATs and lncRNAs, which are also involved in the regulation of FE in pigs.

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Multiple Transcript Properties Related to Translation Affect mRNA Degradation Rates in Saccharomyces cerevisiae

Degradation of mRNA contributes to variation in transcript abundance. Studies of individual mRNAs have shown that both cis and trans factors affect mRNA degradation rates. However, the factors underlying transcriptome-wide variation in mRNA degradation rates are poorly understood. We investigated the contribution of different transcript properties to transcriptome-wide degradation rate variation in the budding yeast, Saccharomyces cerevisiae, using multiple regression analysis. We find that multiple transcript properties are significantly associated with variation in mRNA degradation rates and that a model incorporating these properties explains ~50% of the genome-wide variance. Predictors of mRNA degradation rates include transcript length, abundance, ribosome density, biased codon usage and GC content of the third position in codons. To experimentally validate these factors we studied individual transcripts expressed from identical promoters. We find that decreasing ribosome density by mutating the first translational start site of a transcript increases its degradation rate. Using coding sequence variants of GFP that differ only at synonymous sites, we show that increased GC content of the third position of codons results in decreased rates of mRNA degradation. Thus, in steady-state conditions, a large fraction of genome-wide variation in mRNA degradation rates is determined by inherent properties of transcripts, many of which are related to translation, rather than specific regulatory mechanisms.

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Risk factors for failed reactivation of a labor epidural for postpartum tubal ligation: a prospective, observational study

To determine specific risk factors that increase the failure rate of labor epidurals reactivated for use as a surgical block for postpartum tubal ligation.

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Continuum introduced as new active data monitoring solution

LAKEVILLE, Minn. ImageTrend, Inc. announced the arrival of Continuum™ -the solution for active data monitoring and automated delivery of information. Organizations using Continuum can realize immediate awareness with real-time updates uponposting information.Subscribers will be able to select what is monitored, when the information is received and how it will be viewed. Active data and ...

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EMS Artwork: Fighting off the reaper

Artist's image shows a behind-the-scenes look at EMS personnel trying to save a patient's life

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Vital signs are only one component of fireground rehab

This article first appeared on FireRehab.com, sponsored by Masimo.

By Jay MacNeal with Todd Daniello, Ken Hanson, Mitch Li, Sean Marquis, John Pakiela, Matt Smetana and Chris Wistrom

Many rehab protocols direct the EMS provider to monitor vitals during the on-scene rehab process; however, they don't usually give safe vital sign parameters. This vagueness has caused considerable frustration to those going through rehab, EMS providers and incident commanders. Without parameters, how do we know who is safe to return to the incident"

Unfortunately, there is no universal set of vital signs that indicate it is safe for an individual to be released from rehab. A recent study done by Barr and colleagues suggested that vital signs of firefighters with medical symptoms were not significantly different from vital signs of firefighters who had an unremarkable recovery.

They studied firefighters over five years on various incidents. The researchers found that of the 13 subjects reporting a medical complaint, the vital signs were similar to those that had not registered a medical complaint [1]. Perhaps showing vital signs may not be the telltale marker for firefighter medical issues in rehab.

The Barr study caused some questioning of our EMS system's protocols that did in fact have vital sign parameters as part of our rehab process.

So, do vital signs matter in rehab" The answer is we don't know.

Given that sometimes we don't know what we don't know, we as the medical directors for an EMS system in southern Wisconsin have chosen to continue a conservative stance on firefighter rehab. Here is our rationale for this.

Firefighting is an Olympic sport
Firefighting is one of the most physiologically demanding careers possible. Our ramp-up tone study demonstrated that going from a resting state to a full response causes considerable strain on the human body, especially when startled suddenly [2]. Our alerts happen with little warning and many times while a firefighter is sleeping.

On the heels of this alarm stress is the rapidly added psychological and thermal stress of response operations. It is a physiologic perfect storm that can precipitate disaster with any underlying health problem. Firefighting is an Olympic sport – without the warm-up or cool-down phase.

Managing and monitoring risk
In our EMS system, we are trying to break the physiologic disaster cycle. We have worked on reducing the adrenaline and physiologic stress at alert time with ramp-up tones [2]. We aim to manage risk to the individual through on-scene monitoring for signs of physiologic stress by an EMS provider and EMS physician. We have a formal climate-controlled and nutrition-stocked rehab vehicle and rehab team to support major incidents.

Vital signs in rehab are mentioned in NFPA 1584, which states, "Currently, there are no studies that quantify vital sign measurements with the length of rehabilitation or with the need to direct members to a treatment area. Visual signs and symptoms remain the best method to evaluate members in the rehabilitation area. Vital sign measurements can be used as a baseline and can assist to identify other health or safety concerns [3]."

NFPA 1584 recommends these vital signs for release from the rehab area [3]:

• Temperature: <100.6 F
• Heart Rate: <100
• Respiratory Rate: 12-20
• Blood Pressure: <160 systolic and <100 diastolic
• Pulse Oximetry: >94 percent

The NFPA vitals serve as a reasonable baseline but should only be seen as a reference. In our EMS system rehab protocols, we have followed NFPA fairly closely. We use our rehab vital sign measurements for on-scene rehab discharge decisions and as a tool to screen our firefighters for undiagnosed hypertension.

Understanding that the fireground is stressful, we do not implement any medical treatment for hypertension, but we do have criteria for the firefighter to have a primary care follow-up appointment and hypertension recheck.

Blood Pressure

Recommended Action

<140 systolic
<90 diastolic

Discharge from rehab.

140-160 systolic
90-100 diastolic

Discharge from rehab.
Primary care physician follow up for recheck.

160-180 systolic

Removed from active scene work. Light duty until cleared by primary care physician.

>180 systolic
>120 diastolic

Transport to emergency department.

Mercyhealth EMS Blood Pressure Guidelines

Vital signs provide guidance and a baseline to detect abnormalities. They should not be seen as absolutes. Any responder with normal vitals should still receive a thorough medical evaluation if he or she experienced a significant exposure or injury, show any signs of fatigue, have abnormal neurological symptoms or fail to perform duties related to overexertion.

For more information on Masimo's RAD-57, submit your information here.

References

1. Medical Monitoring During Firefighter Incident Scene Rehabilitation. David A. Barr , PhD, Craig A. Haigh , MS, CFO, EFO, MIFireE, NRP, Jeannie M. Haller , MS & Denise L. Smith , PhD. Prehospital Emergency Care Volume 20, 2016. Issue 4. Page 467-476 | Published online: 08 Mar 2016. http://ift.tt/2cbmybc

2. Effect of station-specific alerting and ramp-up tones on firefighters' alarm time heart rates. MacNeal JJ, Cone DC, Wistrom CL. J Occup Environ Hyg. 2016 May 12:1-17. http://ift.tt/2cdrOQg

3. NFPA 1584 2015 Edition Annex A. National Fire Protection Association. http://ift.tt/2cbkVdu"icid=B484

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Community paramedicine program proves potential value

Northwell Health (N.Y.) has published preliminary results of the impact their community paramedicine program had within an advanced illness management program. "Providing Acute Care at Home: Community Paramedics Enhance an Advanced Illness Management Program — Preliminary Data" was published in the Journal of American Geriatric Society on August 30, 2016.

Of the 1,602 patients enrolled in advanced illness management, see the workflow diagram, over the first 16 months, just under 50 percent required an emergency response. Of those "404 patients used community paramedicine at least once, and 369 patients used only traditional EMS."

There were a total of 1,755 responses for the 773 patients, of which nearly 38 percent were community paramedicine responses. Patients that were seen by the community paramedics remained at home 78 percent of the time and only nine those patients were subsequently transported to the emergency department within 24 hours of the community paramedic visit.

When patients that were initially seen by community paramedics required treatment at the ED, their chance of being admitted to the hospital was significantly higher than those transported via traditional EMS, however there was no difference in the length of stay between the two groups.

Community paramedics were utilized for respiratory complaints in 23.6 percent of responses, neurological and psychiatric issues were 17.9 percent of responses, generalized discomfort or weakness was seen 15.2 percent of the time and cardiac or blood pressure concerns were addressed in 10.1 percent of the responses.

One hundred and sixteen patients and caregivers completed a survey on their experiences. All felt that community paramedicine delivered a high-quality service, almost all agreed that they would use the service again, and just over 90 percent admitted that they would have pursued traditional emergency care had the community paramedicine program been unavailable.

Memorable quotes:
Here are four memorable quotes from the article about the Northwell Health community paramedicine (CP) program:

• "This program is designed to honor individuals' goals of care."
• "Preventing even a few admissions could offset the cost of a CP program and generate revenue in risk-based arrangements."
• "The significantly higher admission rate for individuals transported by CP shows that paramedic-physician teams can identify the sickest individuals who need and want inpatient treatment."
• "This report shows the potential feasibility and benefits of a CP model in which paramedics and physicians move from risk-avoidant towards risk-tolerant care and supports the model's further evaluation."

Key takeaways on the Northwell Health preliminary data
Here are the key takeaways for EMS leaders and community paramedics.

1. Significance of peer review
This is one of the first peer-reviewed publications based within the U.S. to show that community paramedicine programs can be effective. Although a number of community paramedicine programs openly publicize their results on the internet and at EMS trade shows, the decision by the authors to seek out peer review is significant for the advancement of the science of EMS.

2. Build awareness of EMS
The authors' decision to publish in a non-EMS specific journal is also significant. It means that providers and researchers with no prior exposure to the utility of EMS are reading about it.

3. Observational study
This study was a prospective observational study, meaning there was no true control group. The results can only be taken at face value in the context of Northwell Health, an organization that has openly demonstrated high-institutional support for such a novel care delivery model.

Other EMS organizations hoping to duplicate the success seen here must recognize there are a variety of factors to be considered before starting such a program.

What are your top takeaways after reading the research on the Northwell Health community paramedic program?

Workflow diagram for the Northwell Health advanced illness management program that included a community paramedicine response component.  

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Community paramedicine program proves potential value

Northwell Health (N.Y.) has published preliminary results of the impact their community paramedicine program had within an advanced illness management program. "Providing Acute Care at Home: Community Paramedics Enhance an Advanced Illness Management Program — Preliminary Data" was published in the Journal of American Geriatric Society on August 30, 2016.

Of the 1,602 patients enrolled in advanced illness management, see the workflow diagram, over the first 16 months, just under 50 percent required an emergency response. Of those "404 patients used community paramedicine at least once, and 369 patients used only traditional EMS."

There were a total of 1,755 responses for the 773 patients, of which nearly 38 percent were community paramedicine responses. Patients that were seen by the community paramedics remained at home 78 percent of the time and only nine those patients were subsequently transported to the emergency department within 24 hours of the community paramedic visit.

When patients that were initially seen by community paramedics required treatment at the ED, their chance of being admitted to the hospital was significantly higher than those transported via traditional EMS, however there was no difference in the length of stay between the two groups.

Community paramedics were utilized for respiratory complaints in 23.6 percent of responses, neurological and psychiatric issues were 17.9 percent of responses, generalized discomfort or weakness was seen 15.2 percent of the time and cardiac or blood pressure concerns were addressed in 10.1 percent of the responses.

One hundred and sixteen patients and caregivers completed a survey on their experiences. All felt that community paramedicine delivered a high-quality service, almost all agreed that they would use the service again, and just over 90 percent admitted that they would have pursued traditional emergency care had the community paramedicine program been unavailable.

Memorable quotes:

Here are four memorable quotes from the article about the Northwell Health community paramedicine (CP) program:

• "This program is designed to honor individuals' goals of care."
• "Preventing even a few admissions could offset the cost of a CP program and generate revenue in risk-based arrangements."
• "The significantly higher admission rate for individuals transported by CP shows that paramedic-physician teams can identify the sickest individuals who need and want inpatient treatment."
• "This report shows the potential feasibility and benefits of a CP model in which paramedics and physicians move from risk-avoidant towards risk-tolerant care and supports the model's further evaluation."

Key takeaways on the Northwell Health preliminary data
Here are the key takeaways for EMS leaders and community paramedics.

1. Significance of peer review
This is one of the first peer-reviewed publications based within the U.S. to show that community paramedicine programs can be effective. Although a number of community paramedicine programs openly publicize their results on the internet and at EMS trade shows, the decision by the authors to seek out peer review is significant for the advancement of the science of EMS.

2. Build awareness of EMS
The authors' decision to publish in a non-EMS specific journal is also significant. It means that providers and researchers with no prior exposure to the utility of EMS are reading about it.

3. Observational study
This study was a prospective observational study, meaning there was no true control group. The results can only be taken at face value in the context of Northwell Health, an organization that has openly demonstrated high-institutional support for such a novel care delivery model.

Other EMS organizations hoping to duplicate the success seen here must recognize there are a variety of factors to be considered before starting such a program.

What are your top takeaways after reading the research on the Northwell Health community paramedic program"

Workflow diagram for the Northwell Health advanced illness management program that included a community paramedicine response component.

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World of Warships: Wargaming weighs anchor with this action-packed combat game

The following is paid content sponsored by Wargaming.

World of Warships is a free, historical combat game from Wargaming, an award-winning online game developer, and publisher. This massively multiplayer online game allows players to command a massive naval fleet featuring some of history's most iconic war vessels from the mid-20th century. Open beta testing for World of Warships launched in 2015 and countless upgrades have been made since the beta stage.

Now, as World of Warships celebrates its one year anniversary, the game is better than ever.

World of Warships offers four classes of ships; each ship has a unique strength that fulfills a different role for the team. Experienced gamer, Aditya Janitra, broke down the differences between the four types of ships offered in the game: destroyers, cruisers, battleships and aircraft carriers.

Destroyers
These are the smallest, fastest and most stealthy class of ships in the game. Destroyers can easily spot the enemy team and contend with other destroyers. Due to the destroyer's compact size, the largest caliber gun it can handle is a 130mm, which can be the primary downfall of this ship as it has less damage than other classes. Destroyers are, however, equipped with a torpedo tube feature, which helps offset the lack of large artillery.

Cruisers
This ship offers the most force, and the game hosts a variety of cruisers from around the world. While cruisers have varying characteristics depending on the nation you choose to go to battle with, most cruisers are reasonably quick, well-armed and powerful.

For example, Imperial Japanese Navy cruisers are equipped with large-caliber guns and a decent level of armor. They are also equipped with torpedo tubes, which makes them very dangerous in close-range combat. Meanwhile, U.S. Navy cruisers are loaded with anti-aircraft guns, so they serve a different purpose for your team.

Battleships
The battleship is the behemoth of the seas. The battleship's size allows it to carry the biggest and longest-range guns of any ship in the game making it the most powerful ship in the game. The downside of a battleship, however, is its mobility. Battleships aren't quick, their turrets turn slowly, and their rudders shift slowly (which means they need to make wide turns). This ship must be driven with tactical awareness. Once you commit yourself to a part of the game's map in a battleship, turning back or changing course will take some time so strategy is imperative.

Aircraft carriers
For those who want something a little different, this carrier is unique to the game because you don't actually drive this ship. When you're playing as an aircraft carrier, the game suddenly turns into a real-time strategy game, and you will be controlling each fighter and bomber squadron that is available to you.

Currently, only two nations in the game have carriers: the United States and Japan. Japanese Navy carriers possess a large number of torpedo and dive bomber squadrons, which mean they are a force to be reckoned with. The U.S. Navy carriers are geared toward achieving air superiority, so they have a higher amount of fighter squadrons compared to bomber squadrons.

Wargaming introduced a new "Epicenter" game mode to encourage more aggressive, close range encounters.

Technical features of the game
The immersion features in World of Warships have been well-received. Janitra said, "Wargaming did a great job replicating what it would be like to drive something that weighs a couple million pounds in the seas, or at least how you may imagine it."

"The tactical combat features should be applauded, too," Janitra said.

"You are actually required to plan your next move ahead of time, a strategy feature many computer games haven't focused on in the past."

Wargaming's most recent update (0.5.11) introduced armor maps to clearly define where each ship's strong and weak points are - further enhancing the game's strategic planning. A new map – "Archipelago" – was also added with significant updates to two additional maps.

The strategically designed environments make each match a completely unique experience.

An ever-evolving process
From a development standpoint, the process to design and implement a new ship in the game requires extensive research, design and technical work. It takes an average of six months for a new ship to be introduced to the game, according to Wargaming. So as the game matures, more ships will turn up in the game's inventory.

Insider's tip: Gamers who felt under-represented by the lack of British Warships, you're in luck. These warships have been going through the extensive design process, and will be arriving later this year.

Get a feel for the game's features in this trailer from World of Wargaming.

World of Warships is free to play online, with the option to make in-game purchases that allow you to buy new ships and modules or game intelligence. If you haven't played World of Warships yet, enter NEWCAPT2016 when signing up for a free premium ship to receive exclusive in-game goods.

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EMS conferences: 10 reasons for volunteers to attend

By Nancy Magee

EMS conferences provide outstanding education and CE opportunities and reinforce how far emergency medical care has progressed. No longer is EMS simply kicking the can down the road to definitive care. How effectively prehospital care is provided can make a difference in the course of care for many of the sickest patients. Other roles for EMS in caring for the community are on the horizon and embracing them will be critical to the survival of local volunteer and non-profit EMS agencies.

Here are 10 reasons for volunteers to attend an EMS conference.

1. Get out of your comfort zone.
Human beings are inherently tribalistic. It is our tendency to be convinced that our own beliefs, habits and culture are right and that we are normal.

Volunteer EMS agencies share this trait with nearly every other type of civic or community group. Networking and hearing new ideas from EMS educators who are from other parts of your state and around the nation will give you a fresh, more objective perspective about EMS.

2. Be inspired
Keynote speakers usually aim to relight the flame for EMTs who are frustrated, burned out and bored with everyday calls. Reinforcing that you are a part of a profession that makes a difference, is important and is much bigger than your local service can help turn crispy responders into positive force multipliers.

3. Meet influential people
Myth and dogma tends to surround discussions of protocol, law and best practice. Conferences typically offer the opportunity to meet state officials, medical directors and subject matter experts.

Have your questions answered accurately by leading experts and top decision makers. Start a relationship and exchange contact information for future issues or questions.

4. Try before you buy
Many volunteer agencies purchase new equipment to keep pace with neighboring agencies. Sometimes they refuse to try anything new because they don't see a reason to change from the devices they are familiar with.

Ask the sales representatives in the exhibit hall to demonstrate their products and convince you why it is both the best and the most fiscally responsible choice for your agency. Often you can have samples and literature sent directly to your station.You can even schedule a follow-up visit at the station for other members.

5. Hear strategies that work
Most volunteer agencies nationwide suffer from the same issues of recruitment, retention, funding and maintaining clinical competence. EMS conferences usually offer education tracks focused on leadership, operations and education. Often there are tracks for volunteer and rural EMS.

The way we've always done it doesn't work anymore. Instead of re-inventing the wheel, take away ideas and innovative solutions presented by administrators and consultants that have worked for them or they have observed at successful agencies.

6. Progress and impact
What may seem like new treatment practices such as pit crew CPR, reduction of oxygen administration, reduced lights and siren use and limited spinal immobilization were being discussed and debated at EMS conferences as far back as 10 years ago. Evidence-based medicine has replaced theory.

Progressive agencies who were willing to slay some sacred cows and document the results have made a huge impact on how EMS is provided today. Getting ahead of trends can minimize the cognitive dissonance caused by sudden changes to traditional patient care modalities and make getting buy-in for future initiatives much easier.

7. Stewardship
Stewardship is the responsible overseeing and protection of something considered worth caring for and preserving. Volunteers have been providing emergency medical care in their communities for almost 90 years. More than half of all EMS providers are volunteers today.

As ambassadors of the profession, actively pursuing a commitment to both excellent and compassionate care is an undertaking that requires teamwork and unity. Spending time at an EMS conference with positive and like-minded people who share your passion for EMS and volunteering helps you recharge your batteries.

8. Invest in yourself and your agency
High-quality education provided by dynamic, entertaining and experienced presenters can help renew a love of learning. Attending a conference will immediately create better educated, involved and confident providers. Being a competent, confident and engaged EMT makes the volunteer EMS experience even more rewarding

The greater the number of members attending, the more you strengthen the agency through greater retention. Members of successful volunteer agencies can be consistently found proudly representing their service at state and national conferences year after year.

9. Hear the latest clinical research topics
Listening to what may be in store for the future of prehospital medicine is interesting as it teaches you to challenge your basic assumptions. It also highlights the need for continuing education and fosters an understanding of the need for a continuous evolution of the EMS profession.

10. Join an association or work to launch a new one
Representatives from the National Registry of EMTs, the National Association of EMTs, National Association of EMS Educators and the National Volunteer Fire Council can be found at national conferences and some of the larger state conferences. If your state has an EMS association or a volunteer EMS Association find out what they are working on, and how you can get involved. If there is no state or local association, plan a meet and greet event and work on getting one started. Bring the latest news and information from the associations back to your agency and create a sense of excitement and inclusion in the greater EMS community.

Having a seat at the table where the future of EMS is being researched, imagined and designed requires volunteers be informed of and included at major EMS events. Encouraging volunteers to attend conferences, providing scholarships, eliciting feedback and getting involved will yield tremendous long-term benefits for the individual EMS providers, their departments and help ensure a successful future for volunteer EMS.

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Copy-number variant analysis of classic heterotaxy highlights the importance of body patterning pathways

Abstract

Classic heterotaxy consists of congenital heart defects with abnormally positioned thoracic and abdominal organs. We aimed to uncover novel, genomic copy-number variants (CNVs) in classic heterotaxy cases. A microarray containing 2.5 million single-nucleotide polymorphisms (SNPs) was used to genotype 69 infants (cases) with classic heterotaxy identified from California live births from 1998 to 2009. CNVs were identified using the PennCNV software. We identified 56 rare CNVs encompassing genes in the NODAL (NIPBL, TBX6), BMP (PPP4C), and WNT (FZD3) signaling pathways, not previously linked to classic heterotaxy. We also identified a CNV involving FGF12, a gene previously noted in a classic heterotaxy case. CNVs involving RBFOX1 and near MIR302F were detected in multiple cases. Our findings illustrate the importance of body patterning pathways for cardiac development and left/right axes determination. FGF12, RBFOX1, and MIR302F could be important in human heterotaxy, because they were noted in multiple cases. Further investigation into genes involved in the NODAL, BMP, and WNT body patterning pathways and into the dosage effects of FGF12, RBFOX1, and MIR302F is warranted.

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Online EMS Educator - Virtual Instructor Led Education - Code3 CME

General Functions/Duties: Instructs and facilitates EMT and Paramedic Refresher curriculum online in accordance with DOT, NREMT and CECBEMS standards in an online, live virtual classroom or in classroom presentations. Assignments may include Emt or Paramedic continuing medical education courses in an online, virtual classroom to students. Duties and Responsibilities: Prepares and delivers instruction ...

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Discriminating RNA variants with single-molecule allele-specific FISH

Publication date: Available online 14 September 2016
Source:Mutation Research/Reviews in Mutation Research
Author(s): Martyna O. Urbanek, Wlodzimierz J. Krzyzosiak
DNA mutations of various types often affect the cellular localization and function of gene products. The role of mutant transcripts in the pathogenesis of human disease is increasingly recognized. Among the pathogenic RNA variants are transcripts with single nucleotide substitutions, small insertions or deletions, aberrantly or alternatively spliced transcripts and RNAs derived from fused genes. To discriminate among transcripts, particularly those of low abundance, showing small or large sequence differences, a highly sensitive and specific RNA imaging method is required. The method that fulfills these criteria is single-molecule fluorescence in situ hybridization (smFISH) combined with probes discriminating among RNA variants. With this method, RNA transcripts produced from individual alleles can be imaged, and differences in their transcription, processing, cellular localization and decay can be revealed. In addition to its applications for studying physiological processes involving RNA variants, smFISH offers several advantages for disease related mutation research. Further development of allele-specific microscopic methods may broaden group of RNA variants analyzed, including RNAs with expanded repeat tract, different variants of 3'UTR, RNAs differing in length of polyA tract or transcripts produced from alternative start codons. Moreover, first attempts for allele-specific RNA live imaging were made adding time-lapse analysis. In this review, we discuss important aspects of the variant-specific smFISH methodology and present examples of its applications in deciphering RNA-mediated pathogenic mechanisms in a variety of human diseases, including cancer, neurological, immunological and cardiovascular diseases.



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Indications and complications of endoscopic retrograde cholangiopancreatography procedures in a tertiary care centre

2016-09-15T08-00-53Z
Source: International Journal of Advances in Medicine
Parvesh Kumar Jain, Vinay B. N..
Background: ERCP is commonly performed for the management of choledocholithiasis, diagnosis and management of biliary and pancreatic neoplasms, and postoperative management of biliary perioperative complications. The aim of this study was to review the indications and complications of endoscopic retrograde cholangiopancreatography (ERCP) procedures in a tertiary care centre. Methods: From April 2012 to March 2016, consecutive patients undergoing ERCP procedure in medical and surgical gastroenterology department were included in the study. Patients with any previous papillary intervention like papillotomy, sphincterotomy or stent placement were excluded from the study. Patients demographic characters, ERCP indications and post-ERCP complications were reviewed. Results: Four hundred and ninety patients were included in the study. Among them male patients were 240 and females were 250. Mean age was 44.6 years and the age range was 18 to 82 years. Most common indication for ERCP was choledocholithiasis (N=377, 76.93%). and malignant obstructive jaundice (N=57, 11.63%). Post ERCP complications developed in 29 patients (5.91%). Pancreatitis was the most common post-ERCP complication. Conclusions: ERCP is a safe procedure. ERCP complications in our center are similar to those reported from other centres.


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Cancer genomics: A fluid route to gene expression

Nature Reviews Genetics 17, 582 (2016). doi:10.1038/nrg.2016.120

Author: Linda Koch

Liquid biopsies — such as the sequencing-based analysis of cell-free DNA (cfDNA) circulating in blood — have garnered increasing interest in oncology as a minimally invasive method to obtain information on cancer-associated genetic and epigenetic aberrations. A new study suggests that sequencing of plasma cfDNA

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DNA elements: Sequence and shape help target the X chromosome

Nature Reviews Genetics 17, 583 (2016). doi:10.1038/nrg.2016.126

Author: Linda Koch

A newly discovered DNA motif determined by its sequence and shape, named PionX (pioneering sites on the X), allows the dosage compensation machinery in Drosophila melanogaster to distinguish X chromosomes from autosomes. In fruitflies, the male-specific lethal dosage compensation complex (MSL-DCC) doubles gene expression

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Genetic variation: ExAC boosts clinical variant interpretation in rare diseases

Nature Reviews Genetics 17, 584 (2016). doi:10.1038/nrg.2016.121

Author: Orli G. Bahcall

The largest catalogue of protein-coding genetic variation to date is reported by the Exome Aggregation Consortium (ExAC). This project includes aggregation, harmonization and joint analysis of exome sequence data for 60,706 individuals from more than 20 research studies. ExAC's openly accessible genetic variation database has

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Prenatal and pre-implantation genetic diagnosis

Nature Reviews Genetics 17, 643 (2016). doi:10.1038/nrg.2016.97

Authors: Joris Robert Vermeesch, Thierry Voet & Koenraad Devriendt

The past decade has seen the development of technologies that have revolutionized prenatal genetic testing; that is, genetic testing from conception until birth. Genome-wide single-cell arrays and high-throughput sequencing analyses are dramatically increasing our ability to detect embryonic and fetal genetic lesions, and have substantially

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Targeting the cancer epigenome for therapy

Nature Reviews Genetics 17, 630 (2016). doi:10.1038/nrg.2016.93

Authors: Peter A. Jones, Jean-Pierre J. Issa & Stephen Baylin

Next-generation sequencing has revealed that more than 50% of human cancers harbour mutations in enzymes that are involved in chromatin organization. Tumour cells not only are activated by genetic and epigenetic alterations, but also routinely use epigenetic processes to ensure their escape from chemotherapy and

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Chromatin: Xist as a recruitment tool

Nature Reviews Genetics 17, 580 (2016). doi:10.1038/nrg.2016.116

Author: Denise Waldron

In female mammals, one of the two X chromosomes is transcriptionally silenced in a process called X chromosome inactivation (XCI). A study published in Science provides important new insights into the mechanisms that underlie this process, identifying a new role for the long non-coding

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Specification and epigenetic programming of the human germ line

Nature Reviews Genetics 17, 585 (2016). doi:10.1038/nrg.2016.88

Authors: Walfred W. C. Tang, Toshihiro Kobayashi, Naoko Irie, Sabine Dietmann & M. Azim Surani

Primordial germ cells (PGCs), the precursors of sperm and eggs, are established in perigastrulation-stage embryos in mammals. Signals from extra-embryonic tissues induce a unique gene regulatory network in germline-competent cells for PGC specification. This network also initiates comprehensive epigenome resetting, including global DNA demethylation and

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Evolution to the rescue: using comparative genomics to understand long non-coding RNAs

Nature Reviews Genetics 17, 601 (2016). doi:10.1038/nrg.2016.85

Author: Igor Ulitsky

Long non-coding RNAs (lncRNAs) have emerged in recent years as major players in a multitude of pathways across species, but it remains challenging to understand which of them are important and how their functions are performed. Comparative sequence analysis has been instrumental for studying proteins

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