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Παρασκευή 6 Ιανουαρίου 2017
The plausible association of MTHFR and ADORA2A polymorphisms with nodules in rheumatoid arthritis patients treated with methotrexate
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A novel ABCC6 haplotype is associated with azathioprine drug response in myasthenia gravis
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Rituximab response in follicular lymphoma is associated with the rs20575 polymorphism in TRAILR1 extrinsic apoptosis trigger
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A comprehensive contribution of genes for aryl hydrocarbon receptor signaling pathway to hypertension susceptibility
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Persistency of Prediction Accuracy and Genetic Gain in Synthetic Populations Under Recurrent Genomic Selection
Recurrent selection (RS) has been used in plant breeding to successively improve synthetic and other multiparental populations. Synthetics are generated from a limited number of parents (Np), but little is known about how Np affects genomic selection (GS) in RS, especially the persistency of prediction accuracy and genetic gain. Synthetics were simulated by intermating Np= 2 to 32 parent lines from an ancestral population with short- or long-range linkage disequilibrium (LDA) and subjected to multiple cycles of GS. We determined accuracy and genetic gain across 30 cycles for different training set (TS) sizes, marker densities, and generations of recombination before model training. Contributions to accuracy and genetic gain from pedigree relationships as well as from co-segregation and LDA between QTL and markers were analyzed via four scenarios differing in (i) the relatedness between TS and selection candidates and (ii) whether selection was based on markers or pedigree records. Persistency of accuracy was high for small N_p, where predominantly co-segregation contributed to accuracy, but also for large Np, where LDA replaced co-segregation as dominant information source. Together with increasing genetic variance, this compensation resulted in relatively constant long- and short-term genetic gain for increasing Np larger than 4, given long-range LDA in the ancestral population. Although our scenarios suggest that information from pedigree relationships contributed only for very few generations to accuracy in GS, we expect a longer contribution than in pedigree BLUP, because capturing Mendelian sampling by markers reduces selective pressure on pedigree relationships. Larger TS and higher marker density improved persistency of accuracy and hence genetic gain, but additional recombinations could not increase genetic gain.
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Novel Resampling Improves Statistical Power for Multiple-Trait QTL Mapping
Multiple-trait analysis typically employs models that associate a quantitative trait locus (QTL) with all of the traits. As a result, statistical power for QTL detection may not be optimal if the QTL contributes to the phenotypic variation only in a small proportion of the traits. Excluding QTL effects that contribute little to the test statistic can improve statistical power. In this article, we show that an optimal power can be achieved when the number of QTL effects is best estimated and that a stringent criterion for QTL effect selection may improve power when the number of QTL effects is small but can reduce power otherwise. We investigate strategies for excluding trivial QTL effects and propose a method that improves statistical power when the number of QTL effects is relatively small and fairly maintains the power when the number of QTL effects is large. The proposed method first uses resampling techniques to determine the number of non-trivial QTL effects and then selects QTL effects by the backward elimination procedure for significance test. We also propose a method for testing QTL-trait associations which are desired for biological interpretation in applications. We validate our methods using simulations and Arabidopsis thaliana transcript data.
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Cytoplasmic-Nuclear Incompatibility Between Wild-Isolates of Caenorhabditis nouraguensis
How species arise is a fundamental question in biology. Species can be defined as populations of interbreeding individuals that are reproductively isolated from other such populations. Therefore, understanding how reproductive barriers evolve between populations is essential for understanding the process of speciation. Hybrid incompatibility (for example, hybrid sterility or lethality) is a common and strong reproductive barrier in nature. Here we report a lethal incompatibility between two wild isolates of the nematode Caenorhabditis nouraguensis. Hybrid inviability results from the incompatibility between a maternally inherited cytoplasmic factor from each strain and a recessive nuclear locus from the other. We have excluded the possibility that maternally inherited endosymbiotic bacteria cause the incompatibility by treating both strains with tetracycline and show that hybrid death is unaffected. Furthermore, cytoplasmic-nuclear incompatibility commonly occurs between other wild isolates, indicating that this is a significant reproductive barrier within C. nouraguensis. We hypothesize that the maternally inherited cytoplasmic factor is the mitochondrial genome and that mitochondrial dysfunction underlies hybrid death. This system has the potential to shed light on the dynamics of divergent mitochondrial-nuclear coevolution and its role in promoting speciation.
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upSET, the Drosophila Homologue of SET3, Is Required for Viability and the Proper Balance of Active and Repressive Chromatin Marks
Chromatin plays a critical role in faithful implementation of gene expression programs. Different post-translational modifications of histone proteins reflect the underlying state of gene activity, and many chromatin proteins write, erase, bind, or are repelled by these histone marks. One such protein is UpSET, the Drosophila homolog of yeast Set3 and mammalian KMT2E (MLL5). Here we show that UpSET is necessary for the proper balance between active and repressed states. Using CRISPR/Cas-9 editing, we generated S2 cells which are mutant for upset. We found that loss of UpSET is tolerated in S2 cells, but that heterochromatin is misregulated, as evidenced by a strong decrease in H3K9me2 levels assessed by bulk histone post-translational modification quantification. To test whether this finding was consistent in the whole organism, we deleted the upset coding sequence using CRISPR/Cas-9, which we found to be lethal in both sexes in flies. We were able to rescue this lethality using a tagged upSET transgene, and found that UpSET protein localizes to transcriptional start sites of active genes throughout the genome. Misregulated heterochromatin is apparent by suppressed position effect variegation of the wm4 allele in heterozygous upset-deleted flies. We show that this result applies to heterochromatin genes generally using nascent-RNA sequencing in the upset-mutant S2 lines. Our findings support a critical role for UpSET in maintaining heterochromatin, perhaps by delimiting the active chromatin environment.
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Genetics and Adaptation of Soybean Cyst Nematode to Broad Spectrum Soybean Resistance
The soybean cyst nematode (SCN) Heterodera glycines is a major threat to soybean production made more challenging by the current limitations of natural resistance for managing this pathogen. The use of resistant host cultivars is effective but over time results in the generation of virulent nematode populations able to robustly parasitize the resistant host. In order to understand how virulence develops in SCN we utilized a single backcrossed BC1F2 strategy to mate a highly virulent inbred population (TN20) capable of reproducing on all current sources of resistance with an avirulent one (PA3) unable to reproduce on any of the resistant soybean lines. The offspring were then investigated to determine how virulence is inherited on the main sources of SCN resistance, derived from soybean lines Peking, PI 88788, PI 90763, and the broad spectrum resistance source PI 437654. Significantly, our results suggest virulence on PI 437654 is a multigenic recessive trait that allows the nematode to reproduce on all current sources of resistance. In addition, we examined how virulence on different sources of resistance interact by placing virulent SCN populations under secondary selection and identified a strong counter-selection between virulence on PI 88788- and PI 90763-derived resistances, while no such counter-selection existed between virulence on Peking and PI 88788 resistance sources. Our results suggest that the genes responsible for virulence on PI 88788 and PI 90763 may be different alleles at a common locus. If so, rotation of cultivars with resistance from these two sources may be an effective management protocol.
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Central and peripheral responses to static and dynamic stretch of skeletal muscle: mechano- and metaboreflex implications
Passive static stretching (SS), circulatory cuff occlusion (CCO), and the combination of both (SS + CCO) have been used to investigate the mechano- and metaboreflex, respectively. However, the effects of dynamic stretching (DS) alone or in combination with CCO (DS + CCO) on the same reflexes have never been explored. The aim of the study was to compare central and peripheral hemodynamic responses to DS, SS, DS + CCO, and SS + CCO. In 10 participants, femoral blood flow (FBF), heart rate (HR), cardiac output (CO), and mean arterial pressure (MAP) were assessed during DS and SS of the quadriceps muscle with and without CCO. Blood lactate concentration [La–] in the lower limb undergoing CCO was also measured. FBF increased significantly in DS and SS by 365 ± 98 and 377 ± 102 ml/min, respectively. Compared with baseline, hyperemia was negligible during DS + CCO and SS + CCO (+11 ± 98 and +5 ± 87 ml/min, respectively). DS generated a significant, sustained increase in HR and CO (~40s), while SS induced a blunted and delayed cardioacceleration (~20 s). After CCO, [La–] in the lower limb increased by 135%. Changes in HR and CO during DS + CCO and SS + CCO were similar to DS and SS alone. MAP decreased significantly by ~5% during DS and SS, did not change in DS + CCO, and increased by 4% in SS + CCO. The present data indicate a reduced mechanoreflex response to SS compared with DS (i.e., different HR and CO changes). SS evoked a hyperemia similar to DS. The similar central hemodynamics recorded during stretching and [La–] accumulation suggest a marginal interaction between mechano- and metaboreflex.
NEW & NOTEWORTHY Different modalities of passive stretching administration (dynamic or static) in combination with circulatory cuff occlusion may reduce or amplify the mechano- and metaboreflex. We showed a reduced mechanoreflex response to static compared with dynamic stretching. The lack of increase in central hemodynamics during the combined mechano- and metaboreflex stimulation implicates marginal interactions between these two pathways.
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Relationship between obstructive sleep apnea and endogenous carbon monoxide
Endogenous carbon monoxide (CO) levels are recognized as a surrogate marker for activity of heme oxygenase-1, which is induced by various factors, including hypoxia and oxidative stress. Few reports have evaluated endogenous CO in patients with obstructive sleep apnea (OSA). Whether OSA more greatly affects exhaled or blood CO is not known. Sixty-nine patients with suspected OSA were prospectively included in this study. Exhaled and blood CO were evaluated at night and morning. Blood and exhaled CO levels were well correlated both at night and morning (r = 0.52, P < 0.0001 and r = 0.61, P < 0.0001, respectively). Although exhaled CO levels both at night and morning significantly correlated with total sleep time with arterial oxygen saturation < 90% ( = 0.41, P = 0.0005 and = 0.27, P = 0.024, respectively), blood CO levels did not correlate with any sleep parameter. Seventeen patients with an apnea and hypopnea index (AHI) < 15 (control group) were compared with 52 patients with AHI ≥ 15 (OSA group). Exhaled CO levels at night in the OSA group were significantly higher than in the control group (3.64 ± 1.2 vs. 2.99 ± 0.70 ppm, P < 0.05). Exhaled CO levels at night decreased after 3 mo of continuous positive airway pressure (CPAP) therapy in OSA patients (n = 36; P = 0.016) to become nearly the same level as in the control group (P = 0.21). Blood CO levels did not significantly change after CPAP therapy. Exhaled CO was positively related to hypoxia during sleep in OSA patients, but blood CO was not. Exhaled CO might better correlate with oxidative stress associated with OSA than blood CO.
NEW & NOTEWORTHY Endogenous carbon monoxide (CO) levels are recognized to be a surrogate marker of oxidative stress. No study has evaluated both exhaled and blood CO at the same time in obstructive sleep apnea (OSA) patients. Here we provide evidence that exhaled CO levels positively correlated with hypoxia during sleep in OSA patients, but blood CO levels did not, and that continuous positive airway pressure therapy significantly decreased exhaled CO levels in the OSA group, but did not significantly affect blood CO.
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Metabolic adaptations in skeletal muscle after 84 days of bed rest with and without concurrent flywheel resistance exercise
As metabolic changes in human skeletal muscle after long-term (simulated) spaceflight are not well understood, this study examined the effects of long-term microgravity, with and without concurrent resistance exercise, on skeletal muscle oxidative and glycolytic capacity. Twenty-one men were subjected to 84 days head-down tilt bed rest with (BRE; n = 9) or without (BR; n = 12) concurrent flywheel resistance exercise. Activity and gene expression of glycogen synthase, glycogen phosphorylase (GPh), hexokinase, phosphofructokinase-1 (PFK-1), and citrate synthase (CS), as well as gene expression of succinate dehydrogenase (SDH), vascular endothelial growth factor (VEFG), peroxisome proliferator-activated receptor gamma coactivator-1 (PGC-1α), and myostatin, were analyzed in samples from m. vastus lateralis collected before and after bed rest. Activity and gene expression of enzymes controlling oxidative metabolism (CS, SDH) decreased in BR but were partially maintained in BRE. Activity of enzymes regulating anaerobic glycolysis (GPh, PFK-1) was unchanged in BR. Resistance exercise increased the activity of GPh. PGC-1α and VEGF expression decreased in both BR and BRE. Myostatin increased in BR but decreased in BRE after bed rest. The analyses of these unique samples indicate that long-term microgravity induces marked alterations in the oxidative, but not the glycolytic, energy system. The proposed flywheel resistance exercise was effective in counteracting some of the metabolic alterations triggered by 84-day bed rest. Given the disparity between gene expression vs. enzyme activity in several key metabolic markers, posttranscriptional mechanisms should be explored to fully evaluate metabolic adaptations to long-term microgravity with/without exercise countermeasures in human skeletal muscle.
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CORP: Minimizing the chances of false positives and false negatives
Statistics is essential to the process of scientific discovery. An inescapable tenet of statistics, however, is the notion of uncertainty which has reared its head within the arena of reproducibility of research. The Journal of Applied Physiology's recent initiative, "Cores of Reproducibility in Physiology," is designed to improve the reproducibility of research: each article is designed to elucidate the principles and nuances of using some piece of scientific equipment or some experimental technique so that other researchers can obtain reproducible results. But other researchers can use some piece of equipment or some technique with expert skill and still fail to replicate an experimental result if they neglect to consider the fundamental concepts of statistics of hypothesis testing and estimation and their inescapable connection to the reproducibility of research. If we want to improve the reproducibility of our research, then we want to minimize the chance that we get a false positive and—at the same time—we want to minimize the chance that we get a false negative. In this review I outline strategies to accomplish each of these things. These strategies are related intimately to fundamental concepts of statistics and the inherent uncertainty embedded in them.
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Does the sensorimotor system minimize prediction error or select the most likely prediction during object lifting?
The human sensorimotor system is routinely capable of making accurate predictions about an object's weight, which allows for energetically efficient lifts and prevents objects from being dropped. Often, however, poor predictions arise when the weight of an object can vary and sensory cues about object weight are sparse (e.g., picking up an opaque water bottle). The question arises, what strategies does the sensorimotor system use to make weight predictions when one is dealing with an object whose weight may vary? For example, does the sensorimotor system use a strategy that minimizes prediction error (minimal squared error) or one that selects the weight that is most likely to be correct (maximum a posteriori)? In this study we dissociated the predictions of these two strategies by having participants lift an object whose weight varied according to a skewed probability distribution. We found, using a small range of weight uncertainty, that four indexes of sensorimotor prediction (grip force rate, grip force, load force rate, and load force) were consistent with a feedforward strategy that minimizes the square of prediction errors. These findings match research in the visuomotor system, suggesting parallels in underlying processes. We interpret our findings within a Bayesian framework and discuss the potential benefits of using a minimal squared error strategy.
NEW & NOTEWORTHY Using a novel experimental model of object lifting, we tested whether the sensorimotor system models the weight of objects by minimizing lifting errors or by selecting the statistically most likely weight. We found that the sensorimotor system minimizes the square of prediction errors for object lifting. This parallels the results of studies that investigated visually guided reaching, suggesting an overlap in the underlying mechanisms between tasks that involve different sensory systems.
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The relationship between ERP components and EEG spatial complexity in a visual Go/Nogo task
The ERP components and variations of spatial complexity or functional connectivity are two distinct dimensions of neurophysiological events in the visual Go/Nogo task. Extensive studies have been conducted on these two distinct dimensions; however, no study has investigated whether these two neurophysiological events are linked to each other in the visual Go/Nogo task. The relationship between spatial complexity of electroencephalographic (EEG) data, quantified by the measure omega complexity, and event-related potential (ERP) components in a visual Go/Nogo task was studied. We found that with the increase of spatial complexity level, the latencies of N1 and N2 component were shortened and the amplitudes of N1, N2, and P3 components were decreased. The anterior Go/Nogo N2 effect and the Go/Nogo P3 effect were also found to be decreased with the increase of EEG spatial complexity. In addition, the reaction times in high spatial complexity trials were significantly shorter than those of medium and low spatial complexity trials when the time interval used to estimate the EEG spatial complexity was extended to 0~1,000 ms after stimulus onset. These results suggest that high spatial complexity may be associated with faster cognitive processing and smaller postsynaptic potentials that occur simultaneously in large numbers of cortical pyramidal cells of certain brain regions. The EEG spatial complexity is closely related with demands of certain cognitive processes and the neural processing efficiency of human brain.
NEW & NOTEWORTHY The reaction times, the latencies/amplitudes of event-related potential (ERP) components, the Go/Nogo N2 effect, and the Go/Nogo P3 effect are linked to the electroencephalographic (EEG) spatial complexity level. The EEG spatial complexity is closely related to demands of certain cognitive processes and could reflect the neural processing efficiency of human brain. Obtaining the single-trial ERP features through single-trial spatial complexity may be a more efficient approach than traditional methods.
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Innocuous warming enhances peripheral serotonergic itch signaling and evokes enhanced responses in serotonin-responsive dorsal horn neurons in the mouse
Itch is often triggered by warming the skin in patients with itchy dermatitis, but the underlying mechanism is largely unknown. We presently investigated if warming the skin enhances histamine- or serotonin (5-HT)-evoked itch behavior or responses of sensory dorsal root ganglion (DRG) cells, and if responses of superficial dorsal horn neurons to innocuous warming are enhanced by these pruritogens. In a temperature-controlled environmental chamber, mice exhibited greater scratching following intradermal injection of 5-HT, but not histamine, SLIGRL, or BAM8-22, when the skin surface temperature was above 36°C. Calcium imaging of DRG cells in a temperature-controlled bath revealed that responses to 5-HT, but not histamine, were significantly greater at a bath temperature of 35°C vs. lower temperatures. Single-unit recordings revealed a subpopulation of superficial dorsal horn neurons responsive to intradermal injection of 5-HT. Of these, 58% responded to innocuous skin warming (37°C) prior to intradermal injection of 5-HT, while 100% responded to warming following intradermal injection of 5-HT. Warming-evoked responses were superimposed on the 5-HT-evoked elevation in firing and were significantly larger compared with responses pre-5-HT, as long as 30 min after the intradermal injection of 5-HT. Five-HT-insensitive units, and units that either did or did not respond to intradermal histamine, did not exhibit any increase in the incidence of warmth sensitivity or in the mean response to warming following intradermal injection of the pruritogen. The results suggest that 5-HT-evoked responses of pruriceptors are enhanced during skin warming, leading to increased firing of 5-HT-sensitive dorsal horn neurons that signal nonhistaminergic itch.
NEW & NOTEWORTHY Skin warming often exacerbates itch in patients with itchy dermatitis. We demonstrate that warming the skin enhanced serotonin-evoked, but not histamine-evoked, itch behavior and responses of sensory dorsal root ganglion cells. Moreover, serotonin, but not histamine, enhanced responses of superficial dorsal horn neurons to innocuous warming. The results suggest that skin warming selectively enhances the responses of serotonin-sensitive pruriceptors, leading to increased firing of serotonin-sensitive dorsal horn neurons that signal nonhistaminergic itch.
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Contractile function and motor unit firing rates of the human hamstrings
Neuromuscular properties of the lower limb in health, aging, and disease are well described for major lower limb muscles comprising the quadriceps, triceps surae, and dorsiflexors, with the notable exception of the posterior thigh (hamstrings). The purpose of this study was to further characterize major muscles of the lower limb by comprehensively exploring contractile properties in relation to spinal motor neuron output expressed as motor unit firing rates (MUFRs) in the hamstrings of 11 (26.5 ± 3.8) young men. Maximal isometric voluntary contraction (MVC), voluntary activation, stimulated contractile properties including a force-frequency relationship, and MUFRs from submaximal to maximal voluntary contractile intensities were assessed in the hamstrings. Strength and MUFRs were assessed at two presumably different muscle lengths by varying the knee joint angles (90° and 160°). Knee flexion MVCs were 60–70% greater in the extended position (160°). The frequency required to elicit 50% of maximum tetanic torque was 16–17 Hz. Mean MUFRs at 25–50% MVC were 9–31% less in the biceps femoris compared with the semimembranosus-semitendinosus group. Knee joint angle (muscle length) influenced MUFRs such that mean MUFRs were greater in the shortened (90°) position at 50% and 100% MVC. Compared with previous reports, mean maximal MUFRs in the hamstrings are greater than those in the quadriceps and triceps surae and somewhat less than those in the tibialis anterior. Mean maximal MUFRs in the hamstrings are influenced by changes in knee joint angle, with lower firing rates in the biceps femoris compared with the semimembranosus-semitendinosus muscle group.
NEW & NOTEWORTHY We studied motor unit firing rates (MUFRs) at various voluntary contraction intensities in the hamstrings, one of the only major lower limb muscles to have MUFRs affected by muscle length changes. Within the hamstrings muscle-specific differences have greater impact on MUFRs than length changes, with the biceps femoris having reduced neural drive compared with the semimembranosus-semimembranosus. Comparing our results to other lower limb muscles, flexors have inherently higher firing rate compared with extensors.
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Improved production of doubled haploids of winter and spring triticale hybrids via combination of colchicine treatments on anthers and regenerated plants
Abstract
Double haploids (DH), obtained during androgenesis in vitro or by genome diploidisation in regenerated haploids, are one type of basic materials used in triticale breeding programmes. The aim of this study was to improve DH production by a combination of colchicine treatment methods on a sample of five winter and five spring triticale hybrids. Colchicine was applied in vitro either in the C17 medium to induce embryo-like structures (ELS) or in the 190-2 medium for green plant (GP) development. Regenerants which remained haploid were immersed in a colchicine solution either when placed on the medium prior to transferring to soil or when growing in pots, followed by the application or absence of cooling. Colchicine treatment during anther culture affected neither ELS nor GP development, but significantly increased the number of DH plants in comparison to spontaneous chromosome doubling. The highest efficiency was recorded when colchicine was applied in the induction medium (55%) versus the regeneration medium (44.5%) or no colchicine treatment (30%). The effectiveness of chromosome duplication in haploid plants ranged from 32 to 64.5% and it was the highest for the treatment on the medium followed by cooling. Individual hybrids differed regarding their capability of regeneration and chromosome doubling, which were consistent only to a low or moderate extent. However, taken together, winter and spring hybrids did not differ significantly. Combined colchicine application resulted in a high yield of DH production, 82.6% for all triticale hybrids, and can provide a considerable number of fertile DH lines for triticale breeding programmes.
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Annals of Cardiac Anesthesia: Beacon journey toward excellence: 2015-2017
Annals of Cardiac Anaesthesia 2017 20(1):1-3
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Demonstration of blood flow by color doppler in the femoral artery distal to arterial cannula during peripheral venoarterial-extracorporeal membrane oxygenation
Annals of Cardiac Anaesthesia 2017 20(1):108-109
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Iatrogenic vocal cord paralysis after cardiac surgery: evocative note for surgeon and anesthesiologist
Annals of Cardiac Anaesthesia 2017 20(1):117-118
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Anesthesiology and the difficult airway - Where do we currently stand?
Annals of Cardiac Anaesthesia 2017 20(1):4-7
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Outcome of four pretreatment regimes on hemodynamics during electroconvulsive therapy: A double-blind randomized controlled crossover trial
Annals of Cardiac Anaesthesia 2017 20(1):93-99
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Comparison of two doses of heparin on outcome in off-pump coronary artery bypass surgery patients: A prospective randomized control study
Annals of Cardiac Anaesthesia 2017 20(1):8-13
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Extracorporeal membrane oxygenation in severe influenza infection with respiratory failure: A systematic review and meta-analysis
Annals of Cardiac Anaesthesia 2017 20(1):14-21
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Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass
Annals of Cardiac Anaesthesia 2017 20(1):83-89
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Incidence and progression of cardiac surgery-associated acute kidney injury and its relationship with bypass and cross clamp time
Annals of Cardiac Anaesthesia 2017 20(1):22-27
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An unusual cause of postpartum heart failure
Annals of Cardiac Anaesthesia 2017 20(1):102-103
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Selection of an appropriate left-sided double-lumen tube size for one-lung ventilation among Asians
Annals of Cardiac Anaesthesia 2017 20(1):28-32
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Nucleic acid-based methods for early detection of sepsis
Annals of Cardiac Anaesthesia 2017 20(1):112-113
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Remifentanil prevents increases of blood glucose and lactate levels during cardiopulmonary bypass in pediatric cardiac surgery
Annals of Cardiac Anaesthesia 2017 20(1):33-37
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Percutaneous tracheostomy
Annals of Cardiac Anaesthesia 2017 20(1):121-121
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Assessment of limited chest x-ray technique in postcardiac surgery management
Annals of Cardiac Anaesthesia 2017 20(1):38-41
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Delirium after cardiac surgery: A pilot study from a single tertiary referral center
Annals of Cardiac Anaesthesia 2017 20(1):76-82
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Acute effect of treatment of mitral stenosis on left atrium function
Annals of Cardiac Anaesthesia 2017 20(1):42-44
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Prayer sign as a marker of increased ventilatory hours, length of intensive care unit and hospital stay in patients undergoing coronary artery bypass grafting surgery
Annals of Cardiac Anaesthesia 2017 20(1):90-92
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Comparative effect of grape seed extract (Vitis vinifera) and ascorbic acid in oxidative stress induced by on-pump coronary artery bypass surgery
Annals of Cardiac Anaesthesia 2017 20(1):45-51
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Misdirected minitracheostomy tube
Annals of Cardiac Anaesthesia 2017 20(1):100-101
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The who-when-why triangle of CAM use among Portuguese IBD patients
The use of complementary and alternative medicines is increasing among chronic patients, particularly those afflicted with inflammatory bowel diseases.
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Clinical utility of the SMSA grading tool for the management of colonic neoplastic lesions
Whilst polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty.
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The who-when-why triangle of CAM use among Portuguese IBD patients
The use of complementary and alternative medicines is increasing among chronic patients, particularly those afflicted with inflammatory bowel diseases.
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Clinical utility of the SMSA grading tool for the management of colonic neoplastic lesions
Whilst polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty.
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Rapid reaction: 3 active shooter, mass killing truths
What: A single gunman killed five and wounded eight at the Fort Lauderdale-Hollywood International Airport, earlier today. A series of photos of a bystander assisting a victim with bleeding before receive medical care by EMS confirms the injury pattern we know to expect — hemorrhage.
Why it's significant: The Fort Lauderdale airport mass shooting reaffirms the continuing need for EMS providers, as well as our partners in law enforcement and fire and rescue, to continue preparing for and training to respond to mass shootings.
Top takeaways: As I watched this incident unfold, viewed the initial press conference and read early news reports, I am reminded of three truths about mass shooting preparedness and response.
Truth 1: Mass shootings can happen anywhere
Night clubs, schools, churches, businesses, restaurants and movie theaters are among the soft targets recently chosen by lone gunmen for committing horrific killings. Airports are not a new target. In 2013, a gunman killed a TSA agent at LAX. Before, and even moreso since that incident, airports have had a heavy security presence. But that hasn't deterred gunmen from seeking out vulnerable airport visitors and employees. In March 2016, dozens of people were killed at the Brussels airport and metro stations.
Attacks outside of secure screening areas, like those found at every airport and sports stadium, are especially worrisome as there is a funneling and concentration of potential victims entering or leaving the secure area. Many of those areas also have the added complexity of difficult ingress for emergency responders coming from outside the airport or stadium.
Continue to recognize these soft targets, plan to respond to them and partner with local law enforcement to best understand the potential threats.
Truth 2: Stand up, practice and prepare to deploy a rescue task force
An increasing number of jurisdictions have recognized the importance of collaborating with law enforcement to stand up a rescue task force, practice entering and moving through the warm zone and preparing personnel with additional personnel protective equipment. Continue making this a priority in station and all-company level training.
At any mass shooting incident emergency responders have two priorities; stop the killing and stop the dying. After the gunman at the Fort Lauderdale airport was taken into custody, immediate actions included, as needed, hemorrhage control, airway management, assuring adequate ventilation and rapid transit to definitive care.
Truth 3: Everyone needs to know how to "stop the bleed"
Once the threat of additional killing is neutralized, or moved away from victims, everyone has an obligation to stop the dying. EMS personnel, police officers and bystanders play a critical role in stopping the dying by identifying the most severely injured, controlling severe bleeding with commercial or improvised tourniquets, using basic maneuvers to maintain an open airway and moving patients towards casualty collection points.
EMS has unlimited choices to teach injury prevention and emergency response procedures to their community. In my opinion, three of the most important are:
1. Compression only CPR and AED use for victims of cardiac arrest.
2. Move, escape, or attack for active shooter incidents.
3. Stop the bleed for severe, uncontrolled hemorrhage.
We want bystanders to take action, like this Twitter user sharing how his wife was able to give verbal instructions to a victim bleeding somewhere outside the Fort Lauderdale airport. From the photo, it looks like a bystander was assisting with direct pressure. I don't know if the police officer had a tourniquet on his belt for self-care, buddy care or victim care, but it would be great if every police officer in your response area was carrying a tourniquet.
Fortunately my wife told the woman to raise victim's hand up to slow the bleeding http://pic.twitter.com/Vh5q0ba4z6
— Maxwill Solutions (@MxWllSolutions) January 6, 2017
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5 things to know about traveling with a gun
After an active shooter killed five people and wounded eight at the Fort Lauderdale airport Friday, the Associated Press cited an official as saying the shooter had arrived from a flight with his gun checked in a bag. After he claimed the bag, he allegedly loaded the gun in a bathroom and began shooting. This prompted one main question: Can you check and transport a gun at an airport"
According to the Transportation Security Administration (TSA), you can transport a checked unloaded firearm in a locked hard-sided container.
Guns are not allowed in carry-on bags, even though that doesn't stop some from trying. Last week, the TSA discovered 53 firearms in carry-on bags around the nation. Shockingly, 42 of the firearms were loaded and 15 had a round chambered.
Here's an overview of what to keep in mind when traveling with and transporting a gun from an airport.
1. What are the regulations regarding firearm transport"
First, you must declare the firearm to the airline when checking your bag. The container, according to TSA, must be securely locked. You must declare the firearm orally each time you present it for transport.
2. What about ammunition"
When checking firearms, you must unload them. Ammunition can be transported in checked baggage. Magazines, ammunition clips, bolts and firing pins must be securely boxed or in a hard-sided case with the firearm. Small arms ammunition can be carried inside the hard-sided case. Airlines, according to Beretta, allow up to 11 pounds of ammunition.
3. Does federal law protect airline travelers with firearms"
Yes. However, these four things must be present: the person must lawfully possess and carry a firearm; the firearm must be unloaded and inaccessible from the passenger compartment of the person's vehicle en route to the airport; the firearm must be transported directly from a personal vehicle to an airline check-in desk without interruption in the transport; the firearm must be carried to the check-in desk unloaded and in a locked container.
In case of questioning, it's important to always bring printed out documents with airline and TSA policies regarding firearms transportation.
4. Do any airports frown upon firearm travelers"
According to the NRA, New York and New Jersey airports, including JFK, La Guardia, Newark and Albany, enforce state and local firearm laws against airline travelers.
5. Can law enforcement officers fly on an airplane armed"
According to the TSA, the law enforcement officer must be employed as a federal officer and armed in accordance with an agency-wide policy. They must also be sworn and commissioned to enforce criminal or immigration statues, authorized to have the weapon in regard to an assigned duty and must have completed the TSA Law Enforcement Officer Flying Armed Training Course.
For additional requirements and examples of officers that would not meet the standards, check the TSA website for further information.
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Low-dose maintenance steroid treatment could reduce the relapse rate in patients with type 1 autoimmune pancreatitis: a long-term Japanese multicenter analysis of 510 patients
Abstract
Background
The effect of maintenance steroid treatment (MST) in reducing the risk of relapse in patients with autoimmune pancreatitis (AIP) remains under debate. The aim of this study was to validate the effect of MST on AIP administered in accordance with the 2010 Japanese consensus guidelines.
Methods
The clinical data of patients with (n = 510) from 22 high-volume centers in Japan were studied. The primary endpoints were the relapse rates (RRs) in patients administered MST versus those not administered MST. The secondary endpoints were the optimal dose and duration of MST in terms of steroid toxicity and the predictors of relapse.
Results
The RRs were 10.0% within 1 year, 25.8% within 3 years and 35.1% within 5 years. The RR in the steroid therapy group reached a plateau at 42.7% at 7 years. In terms of the optimal dosage, the overall RR in the MST 5 mg/day group was 26.1%, which was significantly lower than that in the group which had discontinued steroid therapy (45.2%; p = 0.023) or was receiving MST at 2.5 mg/day (43.4%, p = 0.001). The RRs in the group receiving MST at ≥5 mg/day versus the patient group receiving MST at <5 mg/day were 10.6 vs. 10.3% within 1 year, 23.5 vs. 32.9% within 3 years and 32.2 vs. 41.3% within 5 years, respectively (log-rank, p = 0.028). The best cutoff value of the total steroid dose for serious steroid toxicity was 6405 mg, with a moderate accuracy of 0.717 determined using the area under the curve. Presence of diffuse pancreatic swelling [odds ratio OR) 1.745; p = 0.008) and MST at >5 mg/day were identified as predictors of relapse (OR 0.483; p = 0.001).
Conclusions
The RR could continue to increase for 7 years even under MST. Based on our analysis of the side effects of steroid therapy, MST at 5 mg/day for 2 (total 4625 mg) to 3 (total 6425 mg) years might be a rational and safe therapeutic strategy in terms of keeping the RR to <30% while avoiding potential steroid toxicity.
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Upregulated absorption of dietary palmitic acids with changes in intestinal transporters in non-alcoholic steatohepatitis (NASH)
Abstract
Background
Palmitic acid is an important risk factor for the pathogenesis of non-alcoholic steatohepatitis (NASH), but changes in palmitic acid intestinal absorption in NASH are unclear. The aim of this study was to clarify changes in palmitic acid intestinal absorption and their association with the pathogenesis of NASH.
Methods
A total of 106 participants were recruited to the study, of whom 33 were control subjects (control group), 32 were patients with NASH Brunt stage 1–2 [early NASH (e-NASH)], and 41 were patients with NASH Brunt stage 3–4 [advanced NASH (a-NASH)]. 13C-labeled palmitate was administered directly into the duodenum of all participants by gastrointestinal endoscopy. Breath 13CO2 levels were measured to quantify palmitic acid absorption, and serum Apolipoprotein B-48 (ApoB-48) concentrations were measured after a test meal to quantify absorbed chylomicrons. Expressions of fatty acid (FA) transporters were also examined. The associations of breath 13CO2 levels with hepatic steatosis, fibrosis and insulin resistance was evaluated using laboratory data, elastography results and liver histology findings.
Results
Overall, 13CO2 excretion was significantly higher in e-NASH patients than in the control subjects and a-NASH patients (P < 0.01). e-NASH patients had higher serum ApoB-48 levels, indicating increased palmitic acid transport via chylomicrons in these patients. Jejunal mRNA and protein expressions of microsomal triglyceride transfer protein and cluster of differentiation 36 were also increased in both NASH patient groups. The 13CO2 excretion of e-NASH patients was significantly correlated with the degree of hepatic steatosis, fibrosis and insulin resistance (P = 0.005, P < 0.001, P = 0.019, respectively).
Conclusions
Significantly upregulated palmitic acid absorption by activation of its transporters was evident in patients with NASH, and clinical progression of NASH was related to palmitic acid absorption. These dietary changes are associated with the onset and progression of NASH.
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Size Exponents for Scaling Maximal Oxygen Uptake in Over 6500 Humans: A Systematic Review and Meta-Analysis
Abstract
Background
Maximal oxygen uptake ( \({\dot{\text{V}}\text{O}}\) 2max) is conventionally normalized to body size as a simple ratio or using an allometric exponent < 1. Nevertheless, the most appropriate body size variable to use for scaling and the value of the exponent are still enigmatic. Studies tend to be based on small samples and can, therefore, lack precision.
Objective
The objective of this systematic review was to provide a quantitative synthesis of reported static allometric exponents used for scaling \({\dot{\text{V}}\text{O}}\) 2max to whole body mass and fat-free mass.
Methods
Eight electronic databases (CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, PubMed, Scopus, SPORTDiscus and Web of Science) were searched for relevant studies published up to January 2016. Search terms included 'oxygen uptake', 'cardiorespiratory fitness', ' \({\dot{\text{V}}\text{O}}\) 2max', ' \({\dot{\text{V}}\text{O}}\) 2peak', 'scaling' and all interchangeable terms. Inclusion criteria included human cardiorespiratory fitness data; cross-sectional study designs; an empirical derivation of the exponent; reported precision statistics; and reported information regarding participant sex, age and sports background, \({\dot{\text{V}}\text{O}}\) 2max protocol, whole body composition protocol and line-fitting methods. A random-effects model was used to quantify weighted pooled exponents and 95% confidence limits (Cls). Heterogeneity was quantified with the tau-statistic (τ). Meta-regression was used to quantify the impact of selected moderator variables on the exponent effect size. A 95% prediction interval was calculated to quantify the likely range of true fat-free mass exponents in similar future studies, with this distribution used to estimate the probability that an exponent would be above theorised universal values of \(\frac{2}{3}\text{and}\frac{3}{4}\) .
Results
Thirty-six studies, involving 6514 participants, met the eligibility criteria. Whole body mass and fat-free mass were used as the scaling denominator in 27 and 15 studies, respectively. The pooled allometric exponent (95% Cls) was found to be 0.70 (0.64 to 0.76) for whole body mass and 0.90 (0.83 to 0.96) for fat-free mass. The between-study heterogeneity was greater for whole body mass (τ = ±0.15) than for fat-free mass (τ = ±0.11). Participant sex explained 30% of the between-study variability in the whole body mass exponent, but the influence on the fat-free mass exponent was trivial. The whole body mass exponent of 0.52 (0.40 to 0.64) for females was substantially lower than the 0.76 (0.70 to 0.83) for males, whereas the fat-free mass exponent was similar for both sexes. The effects of all other moderators were trivial. The 95% PI for fat-free mass ranged from 0.68 to 1.12. The estimated probability of a true fat-free mass exponent in a future study being greater than \(\frac{2}{3}\,\text{or}\,\frac{3}{4}\) power scaling is 0.98 (very likely) and 0.92 (likely), respectively.
Conclusions
In this quantitative synthesis of published studies involving over 6500 humans, the whole body mass exponent was found to be spuriously low and prone to substantial heterogeneity. We conclude that the scaling of \({\dot{\text{V}}\text{O}}\) 2max in humans is consistent with the allometric cascade model with an estimated prediction interval for the fat-free mass exponent not likely to be consistent with the \(\frac{2}{3}\text{and}\frac{3}{4}\) power laws.
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Prevalence and Quality of Individual Placement and Support (IPS) Supported Employment in the United States
Abstract
The individual placement and support (IPS) model of supported employment for people with serious mental illness is an evidence-based practice. Factors including a national learning community promoting IPS and enforcement of the Supreme Court's Olmstead decision have spurred the growth of IPS nationwide. In this study we first evaluated the national prevalence and quality of IPS programs. We then evaluated the impact of learning community membership and Olmstead settlements on IPS program penetration and quality across the United States. We interviewed representatives from 48 state behavioral health agencies and 51 state vocational rehabilitation agencies. Survey questions examined the number of IPS programs in each state, the presence of an Olmstead settlement mandating employment services for people with serious mental illness, and the presence of three indicators of quality in IPS programs: collaboration between state behavioral health and vocational rehabilitation agencies, regular, independent fidelity monitoring, and technical assistance and training for IPS programs. Respondents from 38 (75%) states, including 19 states in the IPS Learning Community and 19 outside the learning community, reported a total of 523 IPS programs nationwide (M = 14, SD = 16). The state IPS program penetration rate (number of IPS programs per 1,000,000 people) ranged from 0.05 to 16.62 (M = 3.61, SD = 3.62) among states with IPS. The penetration rate was similar for learning community and non-learning community states with IPS, but learning community states were much more likely than non-learning community states with IPS to report the presence of each of three quality indicators. Eleven states reported Olmstead or other settlements that positively impacted employment services for people with serious mental illness, but among the 38 states with IPS programs, Olmstead states did not differ from non-Olmstead states in IPS program penetration or on the quality indicators. Nationally, most states provide IPS programs, but the within-state penetration rate and quality of implementation vary widely. While learning community and non-learning community states with IPS do not differ in the prevalence of IPS programs, learning community states are much more likely to report key quality indicators, which may enhance these states' potential for sustaining and expanding IPS. Olmstead settlements have not yet shown a direct impact on the penetration and quality of IPS, but as the Department of Justice continues to enforce the Supreme Court's Olmstead decision, their significance may increase.
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Mo. flight paramedic, pilot celebrate milestone
By EMS1 Staff
WEST PLAINS, Mo. — Flight paramedics may cover many miles while on the job, but this week one paramedic and a pilot reached a new milestone.
Flight paramedic Donald Laughary completed his 250th flight, and his pilot, Steve McClure, completed his 750th flight, reported the West Plains Daily Quill.
"The best part of my job is having an opportunity to help people on what could be the worst day of their lives," Laughary said. He served as a paramedic and EMS supervisor prior to joining the West Plains Air Evac Lifeteam in 2014.
McClure joined the service in 2007, and he said he loves to fly while also helping those in need. He formerly served as a pilot in the Army National Guard.
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Paramedic Chief Q&A: A new way to train public safety officers
In the metropolitan Richmond, Va. area, regional cooperation by public safety agencies means more than just sharing personnel and equipment to manage emergency incidents.
Almost three years ago, 33 students from 11 fire, law enforcement and EMS agencies came together as the first class for the Metro Richmond Public Safety Leadership Academy.
When the academy's third class commences in February, there will be 56 students representing 18 public safety agencies from across the region. Recently, I spoke with Police Lt. Mike Phibbs of the Richmond Police Department, who was one of the program's founders.
Paramedic Chief: Where did the idea for the program come from"
Mike Phibbs: It started out as a conversation between me and my captain at the time, John O'Kleasky. I had completed my ICS 305 [Basic Incident Management Team] training and had joined a Type III incident management team, and John was a student in the Naval Post Graduate Program. We ended up talking about how most everything about leadership cuts across public safety regardless if you're law enforcement, fire, EMS or sheriff.
So, John and I started making some calls and sending out some e-mails to the public safety agencies in the area. And we got this amazing response: people were really interested in having their first-line supervisors learn about leadership in a collaborative environment.
What came next"
In August 2014, we invited colleagues from nine agencies to meet and discuss the idea of a regional leadership school designed by and for public safety professionals. We developed an initial mission for the school — which remains the mission today —to bring together members from EMS, fire and law enforcement to learn leadership and communication skills from the very best instructors in public safety.
Out of that initial meeting we kept the ball rolling through phone calls, e-mails and other scheduled meetings where we saw each other. We were designing a completely new program with a whole set of challenges including who would host the first class, how many students could we have, setting a date, creating a curriculum and selecting instructors and students. Through a lot of work by many people we could launch the first class in February 2015.
What, if any, models did you look at when forming the course"
We knew that we didn't want an academy where the students came and sat through lectures all day. Everyone in that initial group had similar thoughts; we wanted to create not just a learning situation, but also an experience where students could build lasting professional relationships.
That was important because our target audience for the first year was the first-line supervisor in your public safety agency. In the February 2016 class, we also began to have second-level supervisors attend.
We drew both inspiration and ideas for the academy from ICS 305, the Naval Post Graduate Program and the Virginia Fire Officer Academy. Those programs had group exercises, group projects and blended learning — the kind of things we were looking to create the most impact.
How did you settle on the program's length"
That was one of the first challenges the development group had to overcome. A few days is too short to have a lasting impact and many agencies can't afford a two-week in-class program. We decided to make it a week and get the best instructors for the topics we thought were the most important.
Here's what that week looks like. When people come into the class they are put into groups. Each group is an equal mix of police, fire and EMS personnel; we do not put multiple people from the same agency into one group. First thing Monday morning the instructors run the class through a unified command level exercise as an icebreaker activity.
In that exercise most students will stay in their public safety silo. Most groups struggle at first and that quickly helps students develop a mind-set that from small incidents to the big one, everyone in public safety must be able to effectively work together.
Following the exercise, we do a comprehensive debrief where we help the students see where they could have done a better job of connecting the dots, whether those dots involved situational awareness, decision making, communications, logistics or resource management.
Initially, most of the groups have different expectations on how the other public safety services respond to the incident. We then use group discussion built around that used by the Navy's Blue Angels. The goal is not to point fingers, which we don't allow, but to get people to effectively communicate across groups and professions and see incidents from all perspectives.
For the rest of the week, we bring in the best instructors in the area to deliver presentations pertinent to leadership, management, project management, human relations, liability and performance management. We match up instructors from different public safety agencies to work together in a team-teaching approach.
So, if I've got a police officer who has developed a good delivery on effective communication in the workplace, I'm going to match him or her with an instructor from, say fire, that has a similar background. That way we avoid, or at least minimize, the student who's sitting there thinking, "I'm a fire guy. What does this police guy know about life in the fire station""
Where do the instructors come from and who pays them"
All the instructors have given their time pro bono. In most cases, they are on-duty and on the clock back in their home department; teaching at the academy is their work assignment for the day.
From that first class back in 2015, we've had tremendous support from both the instructors and their departments. The agency heads are all on board with the program, and every year we have line of excellent people who want to instruct.
It's the support of those participating departments and their local governments that has enabled us to run each of those first two classes for about $1,000 each. Whether it's Chesterfield Police Department printing up the student notebooks, Hanover County Fire or Henrico Division of Fire bringing food or sending a couple of their officers down for the day to manage logistics, every participating department makes contributions in some way.
What else happens during the week"
We also have a chief's luncheon where the department chiefs who have students in the academy come in and have lunch with their students. Students get to hear from their chief and other chiefs as they speak about "What keeps me up at night"" The students really see the 30,000-foot view of their agencies and how they fit in and make an impact on the agency today and going into the future.
The key is to not only build leadership skills but lasting relationships with the other members. Because remember, our students are those police, fire and EMS first-line supervisors. They are the ones making tough decisions at 3 a.m. that can have either a good outcome or a bad outcome for themselves and their department.
On Friday we run the students through what we call the "decision house." The students go through several scenarios with their groups. The group members decide who goes first, second and so forth for the scenarios presented to them in the decision house.
Committee members do their research to come up with real-life leadership and management situations for the students to solve. The topics include a disgruntled and unmotivated employee, possible violations of anti-harassment or sexual harassment policies, employees who openly challenge supervisor's authority, challenges in supervising friends and those who arrived for their shift unfit for duty.
The student goes into the scenario where they're being observed by a panel of evaluators. The students are given the background of the employee and underlying issues; a role player will then choose one of two options to respond to the student's actions to resolve the issue.
If at any time the student feels they can't handle the situation, or they're just stumped, they can tap out and one of their colleagues in their group steps into the scenario in their place. By keeping the groups together, students learn different strategies.
That part of the program wraps up around 3 p.m. Friday. They are given certificates and are free to work on their capstone projects, which were assigned to each group on the first day of class.
What is the capstone project"
We solicit ideas for capstone projects from those departmental chiefs — projects that would have impact back in their organizations. Maybe it's a better understanding of a problem or a solutions to a problem; it could be anything.
For this year's project, one of the chiefs has given us a problem that potentially has many different facets. We're going to give the same topic to all the groups and challenge them to explore what one or more of those facets might be.
These are not individual projects"
No. Those same groups stay together to work on their group project. We give them an additional two weeks to complete their project with the outcome being a written report and oral presentation to a panel of chiefs — as if they were reporting out on a work task back in their department.
So starting late Monday afternoon, each group must figure out how they're going to manage the completion of their project. It's up to each group to decide who's going to present, who's doing the PowerPoint slides and who is doing research — but all must contributes to the project. It's also up to them to figure out schedules and how they're going to manage their time to get the work done.
We have instructors who teach problem solving and file sharing the first day of class, before the topics are assigned. We want people to concentrate on the classes, not trying to get a jump on the project at the expense of learning the classroom material.
What does that report-out presentation look like"
Each group gets 15 minutes to deliver their presentation and they have to allow five minutes for questions from the chiefs to whom they're presenting. So, their research and preparation has to include thinking about what kinds of questions they might get asked and what their response will be.
What other resources are available to the groups"
We think this is one of the best parts of the program — our mentors. When we give them their project, we also provide each group with two or three mentors to help them in getting organized and staying focused on their projects.
These mentors are lieutenants or higher rank within their department or they've graduated from one of the previous academies. We've only got two classes of previous students, but the gratifying thing is that many of them want to come back and be mentors.
In reality, the academy is a three-week program when you add one week of classroom work to the two weeks the students are working on their group projects. And those two weeks is where a tremendous amount of learning and relationship building takes place.
The reality of life in public safety is we all work different schedules. As one moves up in an agency, being able to effectively work with people on different shifts becomes a big deal.
Their research for their project helps them learn skills and technologies that will help them now and in the future. The mentors and students communicate by e-mail, texting and phone calls to get the necessary work done to complete their project on time. They also meet up as a group or use file sharing to work out the details of their presentation in cyberspace.
But more importantly, as we've already learned from our first two academies, working on their project is where the development of professional working relationships really takes off. We've heard it from the mentors themselves and we've heard it from what the mentors tell their groups.
What advice do you have for other public safety groups that want to build their own academy"
Excellent question. You and I could spend another whole hour or so just talking about this question.
OK, give me your top-three pieces of advice.
Overall, you must understand that this thing [the academy] has a lot of moving parts. Developing the curriculum, registering students, lining up instructors, instructors preparing their material for delivery and I could go on and on.
The first year you need to develop a check list as you go along to prepare you for subsequent years. It is easy to overlook something. We now have a great system, but I always ask at the end our meetings if we are missing something.
Have hard dates for all of your benchmark activities. This goes back to that moving parts thing. You have to have those dates set, communicate them to everyone and stay on top of things. Everybody in this thing, students and instructors alike, already have full-time jobs, so it's very easy for this stuff to fall through the cracks.
Get your instructors locked into their assignments. We give them the date and time for their delivery, along with goals and objectives for their presentation, and then we pretty much stay out of their way.
But we're real sticklers for them being there on time and ready to go when they get there. They have to stay on time. If they go over it impacts the next instructor. You must also be prepared to step in if something comes up. Our cadre always has an emergency contingency class ready to go. If you are prepared, the students should never know there was a problem.
And last, but not least, everybody must remember the academy is about the students and what will it take to help them to be successful in this program.
How can someone learn more about the academy"
They can call me, Lt. Mike Phibbs, at 804-646-8143 during my office hours with the Richmond Police Department, which are typically 8 a.m. to 4 p.m. EST. They can also contact me through e-mail at William.Phibbs@richmondgov.com.
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Improve EMS performance like a champion
By Mike Taigman and Tony Sorensen
My most vivid Olympic memory is the 1996 women's gymnastics all-around competition. The Russians had dominated the sport and going into the final rotation it looked like it would be possible for the U.S. to win for the first time in Olympic history. The last U.S. event was the vault. U.S. team member Dominique Moceanu had fallen twice when Kerri Strug, the last U.S. competitor, lined up to vault. Strug under-rotated the landing of her first attempt and injured her ankle.
With the point difference smaller than a blood cell, she asked the coach, "Do we need this""
He said, "Kerri, we need you to go one more time. We need you one more time for the Gold. You can do it; you better do it."
She limped to the end of the runway and then landed the vault on both feet long enough to register a 9.712 before collapsing in pain, cementing the Olympic gold medal for the U.S.
Olympic inspiration for EMS improvement
Inspired by champions like Strug, the team from Life EMS Ambulance, established in Grand Rapids, Mich. in 1980 and proudly serving over 3,700 square miles of west Michigan with paramedic response, decided to have some fun and see if they could make some meaningful improvements at the same time. Their theory was that if they focused on a handful of measurable opportunities for improvement, added in a dose of friendly competition, and offered prizes for the winners, that they would make meaningful improvements.
Their quality improvement-focused version of the Olympics was held last summer in the months before, during and after the Rio Olympics. The Life EMS Ambulance organization is naturally segmented into three teams — central, north/east, and south — for friendly competition. They created four events:
1. Vital Sign Sprint: Did we obtain two sets of vital signs on each patient"
2. Breath Stroke: Did we use capnography on patients receiving ventilatory assistance"
3. Last Normal Backstroke: Did we record the last seen normal time for patients with CVA"
4. Data Sync Dive: Was the data from the monitor uploaded into the ePCR"
Their aim was to make tangible improvements in these four areas. Baseline data provided a starting point. The company provided feedback on team performance every two weeks in company newsletters. Individual employees got regular feedback on their performance through FirstPass, a clinical quality measurement and protocol monitoring tool. Gold medal winners got $25 gift cards, silver got a pizza party and bronze got an ice cream social.
A spirit of camaraderie, competition and fun spread throughout the organization. Crew members started coaching each other on ways to improve.
Significant and sustained performance improvement
Life EMS Ambulance saw significant and sustained improvement in two of the target areas. These two charts are Shewhart charts, which are a type of statistical process control charts to display data for performance improvement.
The other two target areas saw no change. They had no decrease in performance anywhere in their system. And probably the most surprising thing is that they saw widespread sustained improvement in several areas that were not on the target list. These included improvements to:
- Time to 12-lead ECG acquisition.
- Time to nitroglycerin administration and time to aspirin administration for patients with acute coronary syndrome.
- Recording of two pain scores.
- ROSC for people with cardiac arrest.
- Temperature and ETCO2 assessed for possible sepsis patients.
7 performance improvement lessons
The team at Life EMS ambulance learned valuable lessons about quality improvement that are applicable to any EMS agency. Here is what they learned:
1. A friendly competition focused on quality improvement can result in improvements.
2. These improvements appear to be sustainable, at least in the few months after the competition ended.
3. Not everything that is focused on for measurement will improve with the first effort.
4. Providing regular feedback, close in time to the actual patient care, to the team and individuals on performance helps people keep on track.
5. Focused improvement in a few areas has the potential to overflow and cause improvement in other areas.
6. It's possible to have a lot of fun while engaged in serious improvement work.
7. A dedicated and talented team of front line medics are able to implement widespread improvements in a short period of time.
There are some performance improvement theorists that suggest competition might not be a good idea — that competition has the potential to erode self-esteem, especially in young people. The leadership team addressed this concern by ensuring that 80-90 percent of the focus was on improving care for their patients with a lighthearted playful sense of competition.
Other experts will tell you the use of rewards like prizes undermines the joy in work. Their theory is that when people are too focused on the prize they might actually care less about the work they are doing and any improvements will be short lived. For this competition, the prizes were not luxury Caribbean cruises or fancy sports cars. Prizes were modest, but real. And we know that the prizes were not the primary focus, because the improvements have sustained well past the awarding of gift cards, pizza and ice cream.
Who could possibly top the Olympics" Bond. James Bond. Yes, their next quality improvement competition will have a 007 theme. The target areas will be:
- Serial 12 lead EKG's … One is not enough.
- Pain scores are forever.
- Doctor Know … for base physician contact.
- Morphine and fentanyl weight-based dosing … for your weight only.
- Trauma scene time … license to live.
About the co-author
Tony Sorensen is the vice president of resource performance for Life EMS Ambulance and a paramedic I/C with 31 years of EMS experience in both rural and urban systems. In addition to his EMS clinical experience he has taught MFR, EMT, EMT-S and paramedic programs through Montcalm County EMS, Montcalm Community College and Life EMS Ambulance. Tony is active in many local, regional and state level EMS activities. He is the past president of the Society of Michigan EMS Instructor Coordinators and the current president of the Michigan EMS Practitioners Association. Tony also represents MiEMSPA as a member of the State of Michigan EMS Coordination Committee. He has held leadership positions with Montcalm County, State of Michigan EMS Section as the EMS Education Coordinator.
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5 steps to create an EMS culture of continuous learning
By Sean Caffrey, NEMSMA
EMS is a practice of medicine. As a result, it doesn't matter if you are an EMT that graduated yesterday or a 20-year veteran of critical care transport, you are a medical professional and you have an obligation to provide the best care possible for your patients. To do so, you cannot simply rely on what you were taught in school. Practicing medicine involves constantly improving your practice, keeping up with the latest information and periodically refreshing your knowledge.
As an EMS leader, however, you have an added obligation to support the practice of the medical professionals within your organization. The quality of care your EMS providers deliver is dependent on you creating the systems and culture necessary to support the delivery of high-quality patient care, and the continuous improvement of that care. Here are five steps necessary to create a culture of continuous learning:
Step 1: Partner with your medical director
The highest-performing EMS organizations almost always have a well-established partnership between the head of the organization and their physician medical director. The role of the medical director is to lend their medical expertise and judgment to the development and implementation of the care protocols used by your organization. The medical director also has a lead role in supervising and monitoring the clinical practice of EMTs and paramedics. The best medical directors are also an accessible resource for provider questions, a mentor for the effective practice of medicine, a teacher and a partner in high-level patient care decision making.
While not every medical director has all of these traits, the more of them they have, and the less your medical director simply serves as a rubber stamp for clinical practice compliance, the better off your organization will be. The National Association of EMS Physicians has taken a strong leadership role with other physician organizations to develop the EMS subspecialty of emergency medicine with its own knowledge base, fellowship requirements and testing. Every year more and more physician EMS specialists become available. The advantages a physician board certified in EMS brings to your organization are:
- A thorough understanding of the application of emergency medicine in the field.
- A knowledge of EMS systems, operations and regulations.
- A strong background in EMS protocols and related research.
- An understanding of quality improvement methods.
EMS physicians come with 10 or more years of post-graduate training and experience in emergency medicine. If you can team one up with an experienced supervisory team, it's a combination that's hard to beat for creating a culture of continuous learning.
Step 2: Don't focus just on compliance
EMS operates through the use of protocol-based medicine. Hopefully, you hire well-qualified providers to deliver clinical care in an unpredictable and often difficult environment. If your providers go through their workday worrying about if they will get in trouble for not following the protocols, you have probably created the wrong culture.
Protocols are guidelines that help standardize the delivery of care. EMS providers are the skilled professionals employed to interpret them in highly dynamic and complex situations. On the whole, EMS should be celebrated among medical specialties for doing a great deal of protocol-based care in comparison to many other areas of medicine.
Your providers, however, must also exercise judgment in their application. Great leaders are always looking to improve their protocols and look for ways to improve them as tools that their providers can use to increase the quality of care. Failure to follow protocols can be a system, provider or even a protocol issue. Work to understand what is causing protocol compliance issues before you assume the provider is at fault.
Just culture principles offer a great set of tools to improve performance in your organization by better understanding the types of error and how to address them. Quality improvement methodologies, such as Lean and Six Sigma, further help you understand how your systems function and when they are working effectively.
Taken together, you will often find that improving the performance of your organization is often more about fixing systems and processes than it is about individual performance issues. It is likely the management team of an EMS organization that will have the most responsibility to improve clinical performance through optimization of policies, procedures and protocols.
Step 3: Choose your best personnel to lead QI efforts
The secret to an effective quality improvement program is understanding that providers want to do a better job of providing patient care. If your QI program works well, it will help your people recognize gaps in care and make them partners in addressing those gaps.
Of course, if you run a "gotcha" compliance program you can rest assured your clinicians will probably avoid giving you any feedback on what could be better for fear it will lead to punishment. As a general rule, if you have an angry and frustrated leader of your QI program, and your providers hate getting QI related messages, your QI program needs better leadership.
Tap your best clinicians to do QI, teach them about just culture, statistical process control, normal and special cause variation and other key improvement science concepts that make them well qualified and curious about how to improve care, and less likely to be cranky disciplinarians.
Step 4: Mistakes are your best opportunity to improve so don't waste them
Mistakes will be made in clinical care for a variety of reasons. Sometimes they are unavoidable due to circumstances or unclear information. Sometimes mistakes are the result of provider error, but most of them they are the result of poorly functioning systems. Don't waste the opportunity to learn from these mistakes.
A wasted mistake usually starts with the assumption that the mistake was due to a lazy or stupid provider. If you act on that assumption before digging deeper, then your providers will learn to effectively hide mistakes. Since the hiding will frequently work, you will no longer have frontline partners in solving problems and your systems will operate poorly. You will also have to spend a lot more time and effort finding problems.
Big mistakes are often the result of multiple smaller mistakes that go unrecognized or uncorrected. As a result, every mistake is an opportunity to fine tune systems and prevent catastrophes.
Don't waste mistakes by ignoring or hiding from them. Instead, use them as a tool to support learning throughout your organization in a non-punitive way. If you do it well, your team might even start telling you about problems and potential fixes even before you know the problem exists.
Step 5: Commit to communication and education
One of the biggest tragedies in modern organizations is that things go wrong or improvements are not realized because no one bothered to broadly communicate issues or changes. If you find problems, you need to communicate them to your team so they can have the benefit of heading them off where they can. Telling one person not to repeat a mistake is fine, but telling everyone how to anticipate, recognize and prevent one is much better.
Asking for help from field providers to evaluate and improve processes is also a critical feedback loop to managers responsible for how things are done. Develop good mechanisms to communicate in both directions.
Finally, continuing education is more than a requirement to maintain a certification. It is a benefit that employees and volunteers appreciate to help them do their jobs better. It is essential that EMS organizations offer some continuing education in-house or in partnership with other health care organizations. Ideally, continuing education should be tied back to gaps identified by quality improvement efforts. This could be topics that you don't encounter often, high-risk skills or known problem areas. Regardless, take steps to address these areas through education and training to constantly improve performance and to create a culture of continuous improvement.
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Improve EMS performance like a champion
By Mike Taigman and Tony Sorensen
My most vivid Olympic memory is the 1996 women's gymnastics all-around competition. The Russians had dominated the sport and going into the final rotation it looked like it would be possible for the U.S. to win for the first time in Olympic history. The last U.S. event was the vault. U.S. team member Dominique Moceanu had fallen twice when Kerri Strug, the last U.S. competitor, lined up to vault. Strug under-rotated the landing of her first attempt and injured her ankle.
With the point difference smaller than a blood cell, she asked the coach, "Do we need this?"
He said, "Kerri, we need you to go one more time. We need you one more time for the Gold. You can do it; you better do it."
She limped to the end of the runway and then landed the vault on both feet long enough to register a 9.712 before collapsing in pain, cementing the Olympic gold medal for the U.S.
Olympic inspiration for EMS improvement
Inspired by champions like Strug, the team from Life EMS Ambulance, established in Grand Rapids, Mich. in 1980 and proudly serving over 3,700 square miles of west Michigan with paramedic response, decided to have some fun and see if they could make some meaningful improvements at the same time. Their theory was that if they focused on a handful of measurable opportunities for improvement, added in a dose of friendly competition, and offered prizes for the winners, that they would make meaningful improvements.
Their quality improvement-focused version of the Olympics was held last summer in the months before, during and after the Rio Olympics. The Life EMS Ambulance organization is naturally segmented into three teams — central, north/east, and south — for friendly competition. They created four events:
1. Vital Sign Sprint: Did we obtain two sets of vital signs on each patient?
2. Breath Stroke: Did we use capnography on patients receiving ventilatory assistance?
3. Last Normal Backstroke: Did we record the last seen normal time for patients with CVA?
4. Data Sync Dive: Was the data from the monitor uploaded into the ePCR?
Their aim was to make tangible improvements in these four areas. Baseline data provided a starting point. The company provided feedback on team performance every two weeks in company newsletters. Individual employees got regular feedback on their performance through FirstPass, a clinical quality measurement and protocol monitoring tool. Gold medal winners got $25 gift cards, silver got a pizza party and bronze got an ice cream social.
A spirit of camaraderie, competition and fun spread throughout the organization. Crew members started coaching each other on ways to improve.
Significant and sustained performance improvement
Life EMS Ambulance saw significant and sustained improvement in two of the target areas. These two charts are Shewhart charts, which are a type of statistical process control charts to display data for performance improvement.
The other two target areas saw no change. They had no decrease in performance anywhere in their system. And probably the most surprising thing is that they saw widespread sustained improvement in several areas that were not on the target list. These included improvements to:
- Time to 12-lead ECG acquisition.
- Time to nitroglycerin administration and time to aspirin administration for patients with acute coronary syndrome.
- Recording of two pain scores.
- ROSC for people with cardiac arrest.
- Temperature and ETCO2 assessed for possible sepsis patients.
7 performance improvement lessons
The team at Life EMS ambulance learned valuable lessons about quality improvement that are applicable to any EMS agency. Here is what they learned:
1. A friendly competition focused on quality improvement can result in improvements.
2. These improvements appear to be sustainable, at least in the few months after the competition ended.
3. Not everything that is focused on for measurement will improve with the first effort.
4. Providing regular feedback, close in time to the actual patient care, to the team and individuals on performance helps people keep on track.
5. Focused improvement in a few areas has the potential to overflow and cause improvement in other areas.
6. It's possible to have a lot of fun while engaged in serious improvement work.
7. A dedicated and talented team of front line medics are able to implement widespread improvements in a short period of time.
There are some performance improvement theorists that suggest competition might not be a good idea — that competition has the potential to erode self-esteem, especially in young people. The leadership team addressed this concern by ensuring that 80-90 percent of the focus was on improving care for their patients with a lighthearted playful sense of competition.
Other experts will tell you the use of rewards like prizes undermines the joy in work. Their theory is that when people are too focused on the prize they might actually care less about the work they are doing and any improvements will be short lived. For this competition, the prizes were not luxury Caribbean cruises or fancy sports cars. Prizes were modest, but real. And we know that the prizes were not the primary focus, because the improvements have sustained well past the awarding of gift cards, pizza and ice cream.
Who could possibly top the Olympics? Bond. James Bond. Yes, their next quality improvement competition will have a 007 theme. The target areas will be:
- Serial 12 lead EKG's … One is not enough.
- Pain scores are forever.
- Doctor Know … for base physician contact.
- Morphine and fentanyl weight-based dosing … for your weight only.
- Trauma scene time … license to live.
About the co-author
Tony Sorensen is the vice president of resource performance for Life EMS Ambulance and a paramedic I/C with 31 years of EMS experience in both rural and urban systems. In addition to his EMS clinical experience he has taught MFR, EMT, EMT-S and paramedic programs through Montcalm County EMS, Montcalm Community College and Life EMS Ambulance. Tony is active in many local, regional and state level EMS activities. He is the past president of the Society of Michigan EMS Instructor Coordinators and the current president of the Michigan EMS Practitioners Association. Tony also represents MiEMSPA as a member of the State of Michigan EMS Coordination Committee. He has held leadership positions with Montcalm County, State of Michigan EMS Section as the EMS Education Coordinator.
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