Πέμπτη, 17 Νοεμβρίου 2016

Tissue and peripheral eosinophilia as predictors for disease outcome in children with ulcerative colitis

Eosinophils are implicated in the pathogenesis of ulcerative colitis.

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Transient Elastography in patients with implanted cardiac rhythm devices

At present the use of transient elastography (TE) in patients with pacemaker (PM) or implantable cardioverter defibrillator (ICD) devices is not recommended, since the safety due to the electromagnet embarked in the vibrator for producing the shearwave has not been evaluated. However, no adverse events of sonographic examinations in this patient group have been reported.

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Non-harmonicity in high-frequency components of the intra-operative corticogram to delineate epileptogenic tissue during surgery

Epilepsy is a dynamic condition as seizures occur intermittently and in most cases unexpectedly. This suggests that the underlying processes responsible for the generation and cessation of seizures are non-harmonic, i.e. non-linear and non-stationary. A high level of non-linearity in the system is needed to initiate seizures (Helling et al., 2015). The epileptiform EEG contains several biomarkers which all have a strong non-linear component (Elger et al., 2000; Andrzejak et al., 2012). This holds true for epileptiform inter-ictal spikes, for the recently discovered high-frequency oscillations (HFOs; >80 Hz) and for seizures themselves.

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Atypical brain activation in children who stutter in a visual Go/Nogo task: An ERP study

The ability to communicate is an essential part of our everyday lives and any problem in this area can have a harmful effect on the quality of life. In developmental stuttering, speech is characterized with repetitions, prolongations and blocks that make the speech dysfluent thus affecting communication negatively. According to current theories stuttering may arise from neurobiological and neurophysiological differences in brain areas related to speech and auditory processing (Giraud et al., 2008; Jansson-Verkasalo et al., 2014; Watkins et al.,2008; for an overview, see review by Alm, 2004).

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Non-harmonicity in high-frequency components of the intra-operative corticogram to delineate epileptogenic tissue during surgery

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Publication date: Available online 17 November 2016
Source:Clinical Neurophysiology
Author(s): Evelien E. Geertsema, Maryse A. van 't Klooster, Nicole E.C. van Klink, Frans S.S. Leijten, Peter C. van Rijen, Gerhard H. Visser, Stiliyan N. Kalitzin, Maeike Zijlmans
ObjectiveWe aimed to test the potential of auto-regressive model residual modulation (ARRm), an artefact-insensitive method based on non-harmonicity of the high-frequency signal, to identify epileptogenic tissue during surgery.MethodsIntra-operative electrocorticography (ECoG) of 54 patients with refractory focal epilepsy were recorded pre- and post-resection at 2048 Hz. The ARRm was calculated in one-minute epochs in which high-frequency oscillations (HFOs; fast ripples, 250-500 Hz; ripples, 80-250 Hz) and spikes were marked. We investigated the pre-resection fraction of HFOs and spikes explained by the ARRm (h2-index). A general ARRm threshold was set and used to compare the ARRm to surgical outcome in post-resection ECoG (Pearson X2).ResultsARRm was associated strongest with the number of fast ripples in pre-resection ECoG (h2=0.80, P<0.01), but also with ripples and spikes. An ARRm threshold of 0.47 yielded high specificity (95%) with 52% sensitivity for channels with fast ripples. ARRm values >0.47 were associated with poor outcome at channel and patient level (both P<0.01) in post-resection ECoG.ConclusionsThe ARRm algorithm might enable intra-operative delineation of epileptogenic tissue.SignificanceARRm is the first unsupervised real-time analysis that could provide an intra-operative, 'on demand' interpretation per electrode about the need to remove underlying tissue to optimize the chance of seizure freedom.



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Atypical brain activation in children who stutter in a visual Go/Nogo task: An ERP study

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Publication date: Available online 17 November 2016
Source:Clinical Neurophysiology
Author(s): Johanna Piispala, Sara Määttä, Ari Pääkkönen, Risto Bloigu, Mika Kallio, Eira Jansson-Verkasalo
[Objective]The aim of the study was to investigate inhibitory control by evaluating possible differences in the strength and distribution of the brain activity in a visual Go/Nogo task in children who stutter (CWS) compared to typically developing children (TDC).[Methods]Eleven CWS and 19 TDC participated. Event related potentials (ERP) were recorded using a 64-channel EEG-cap during an equiprobable visual Go/Nogo task. The global field power (GFP) as well as the mean amplitudes in the P3 time frame were compared between groups. Additionally, the potential maps of the groups were investigated visually in the N2 and P3 time windows.[Results]The groups differed significantly in the right frontal area especially in the Nogo condition (p<.001) with CWS showing smaller (less positive) mean amplitudes, most likely due to a prolonged and asymmetrical N2 component. Also the fronto-central Nogo P3 component was rather indistinct in CWS, but easily recognizable in TDC in the potential maps.[Conclusions]The CWS show atypical brain activation compared to the TDC in a Go/Nogo task as indexed by the excessive N2-related activity in both conditions and reduced P3-related activity in Nogo condition.[Significance]These findings indicate atypical stimulus evaluation and response inhibition processes in CWS.



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The effects of dynamic airway photographs on preoperative airway planning among a panel of anesthetists

To determine whether having preoperative airway photographs will change the preanesthetic airway plan.

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Perioperative anesthetic management for renal cell carcinoma with vena caval thrombus extending into the right atrium: case series

Renal cell carcinoma has a tendency for vascular invasion and may extend into the inferior vena cava and even into the right-sided cardiac chambers. It has been reported that nephrectomy with thrombectomy can provide immediate palliation of symptoms with 5-year survival rates of up to 72% in the absence of nodal or distant metastasis. The location of the tumor dictates the anesthetic and surgical approach, as extension into the heart often necessitates cardiac surgical involvement. Renal cell carcinoma with vena cava tumor thrombus extending into the right cardiac chamber usually requires cardiopulmonary bypass and occasionally deep hypothermic circulatory arrest for surgical resection, and anesthetic approach should be tailored to each individual case.

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Glycopyrrolate: It's time to review

Medication shortages have become an all-too-common inconvenience that has forced anesthesia providers to examine our administering practices. Because of these shortages, commonly used medications are at the greatest risk. Glycopyrrolate (Robinul), which has been in short supply in recent years, is one of the most widely used anticholinergic agents, especially in conjunction with the anticholinesterase neostigmine, for reversal of neuromuscular blockade (NMB) drugs. Here we review multiple studies from 1972 through 1986 that used varying methods of patient selection and dosage and drug combination criteria, and which noted that glycopyrrolate had a superior efficacy and adverse effect profile when compared with atropine in NMB reversal.

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Choreoathetotic syndrome following cardiac surgery

Movement disorders following heart surgery are very unusual. Post-pump chorea is mainly a pediatric complication of heart surgery, typically manifesting after a latent period of normality and is usually related with long extracorporeal circulation time and deep hypothermia. We report a 73-year-old woman, without risk factors predisposing to paroxysmal movement disorders, presenting acute choreoathetoid movements 5 days after aortic valvular replacement with normal extracorporeal circulation time and perioperative normothermia.

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Cervical sympathetic blockade for the management of electrical storm

A 75-year-old man presented with dizziness and fatigue secondary to ventricular and supraventricular arrhythmias. He underwent an elective ablation but continued to suffer from ventricular tachycardia with cardiovascular instability despite antiarrhythmic therapy with multiple agents. The patient continued to develop episodes of ventricular tachycardia and an episode of ventricular fibrillation.Electrical storm encompasses a situation of cardiac instability which may present as several episodes of ventricular tachycardia or ventricular fibrillation in a short period.

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Menthol: A Fresh Ergogenic Aid for Athletic Performance

Abstract

The application of menthol has recently been researched as a performance-enhancing aid for various aspects of athletic performance including endurance, speed, strength and joint range of motion. A range of application methods has been used including a mouth rinse, ingestion of a beverage containing menthol or external application to the skin or clothing via a gel or spray. The majority of research has focussed on the use of menthol to impart a cooling sensation on athletes performing endurance exercise in the heat. In this situation, menthol appears to have the greatest beneficial effect on performance when applied internally. In contrast, the majority of investigations into the external application of menthol demonstrated no performance benefit. While studies are limited in number, menthol has not yet proven to be beneficial for speed or strength, and only effective at increasing joint range of motion following exercise that induced delayed-onset muscle soreness. Internal application of menthol may provoke such performance-enhancing effects via mechanisms related to its thermal, ventilatory, analgesic and arousing properties. Future research should focus on well-trained subjects and investigate the addition of menthol to nutritional sports products.



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Assessing and Conceptualizing Frontal EEG Asymmetry: An Updated Primer on Recording, Processing, Analyzing, and Interpreting Frontal Alpha Asymmetry

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Publication date: Available online 17 November 2016
Source:International Journal of Psychophysiology
Author(s): Ezra E. Smith, Samantha J. Reznik, Jennifer L. Stewart, John J.B. Allen
Frontal electroencephalographic (EEG) alpha asymmetry is widely researched in studies of emotion, motivation, and psychopathology, yet it is a metric that has been quantified and analyzed using diverse procedures, and diversity in procedures muddles cross-study interpretation. The aim of this article is to provide an updated tutorial for EEG alpha asymmetry recording, processing, analysis, and interpretation, with an eye towards improving consistency of results across studies. First, a brief background in alpha asymmetry findings is provided. Then, some guidelines for recording, processing, and analyzing alpha asymmetry are presented with an emphasis on the creation of asymmetry scores, referencing choices, and artifact removal. Processing steps are explained in detail, and references to MATLAB-based toolboxes that are helpful for creating and investigating alpha asymmetry are noted. Then, conceptual challenges and interpretative issues are reviewed, including a discussion of alpha asymmetry as a mediator/moderator of emotion and psychopathology. Finally, the effects of two automated component-based artifact correction algorithms—MARA and ADJUST—on frontal alpha asymmetry are evaluated.



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The Independent Influence of Concussive and Sub-concussive Impacts on Soccer Players' Neurophysiological and Neuropsychological Function

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Publication date: Available online 17 November 2016
Source:International Journal of Psychophysiology
Author(s): R. Davis Moore, Julien Lepine, Dave Ellemberg
Accumulating research demonstrates that repetitive sub-concussive impacts can alter the structure, function and connectivity of the brain. However, the functional significance of these alterations as well as the independent contribution of concussive and sub-concussive impacts to neurophysiological and neuropsychological health are unclear. Accordingly, we compared the neurophysiological and neuropsychological function of contact athletes with (concussion group) and without (sub-concussion group) a history of concussion, to non-contact athletes. We evaluated event-related brain potentials (ERPs) elicited during an oddball task and performance on a targeted battery of neuropsychological tasks. Athletes in the sub-concussion and concussion groups exhibited similar amplitude reductions in the ERP indices of attentional resource allocation (P3b) and attentional orienting (P3a) relative to non-contact athletes. However, only athletes in the concussion group exhibited reduced amplitude in the ERP index of perceptual attention (N1). Athletes in the sub-concussion and concussion groups also exhibited deficits in memory recall relative to non-contact athletes, but athletes in the concussion group also exhibited significantly more recall errors than athletes in the sub-concussion group. Additionally, only athletes in the concussion group exhibited response delays during the oddball task. The current findings suggest that sub-concussive impacts are associated with alterations in the neurophysiological and neuropsychological indices of essential cognitive functions, albeit to a lesser degree than the combination of sub-concussive and concussive impacts.



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Paramedic I,II,III,IV, or V - Presbyterian Healthcare Services

Type of Opportunity: Full Time FTE: 1.000000 Exempt: No Work Schedule: Varied Days and Hours Shift: 1 Location: US:NM:Albuquerque Education: Essential: * High School Diploma or GED Credentials: Essential: * Emerg Med Tech/Paramedic-NM * Cardiopulmonary Resuscitation-Other Source * Advanced Cardiac Life Support-AHA Other Requirements: Paramedic I • Paramedics without either an Associate's ...

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Paramedic - Yellow Ambulance

Job Summary: Promptly responds to requests for medical transportation, both emergency and non-emergency, and provides appropriate medical evaluation and care to the limit of his/her certification and training. Professionally interacts with other medical personnel and performs tasks to expedite the transport of the patient where appropriate. Provides accurate written and verbal reports and participates ...

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Emergency Medical Technician - Yellow Ambulance

Job Summary: Promptly responds to requests for medical transportation, both emergency and non-emergency, and provides appropriate medical evaluation and care to the limit of his/her certification and training. Professionally interacts with other medical personnel and performs tasks to expedite the transport of the patient where appropriate. Provides accurate written and verbal reports and participates ...

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Ghost of Christmas Present has holiday wisdom for an EMT

"Who, are you!"

"I am the Ghost of Christmas Present. And you are a weird little man!"

He was small, but looked tall, dressed in a flowing robe, standing by the pay phone, a bottle of wine cleverly covered with a brown paper bag in one hand, a box of Chicken McNuggets in the other.

"And why did you call me"" I grumbled.

"Because I am intoxicated, and you are not! Come with me you miserable creature, I have only one hour to spend on this puny little planet!"

"Fine then, be done with it," I said, and tugged his robe.

We sped through the city streets toward our destination. I sat in the Captain's seat, trying to ignore the apparition before me. He watched me, wise eyes shining, and laughed heartily as we bounced along.

"You don't even see it, do you""

"What do I not see."

"Life man! It's all around you, and it's passing you by. Look at me! I have nothing but am full of the Milk of Human Kindness!"

"You're full of something, that much is true."

"See outside these windows!"

He pointed to the rear of the truck, through the dirty glass. Lights blurred past, white ones, colored ones, some blinking some not.

"Tell me what you see."

"I see a bunch of morons who can't afford to put food on their table putting up stupid lights to celebrate something they cannot pay for!"

"You cannot "pay for" happiness you wretched creature! You sit there, on your throne of discontentment and judge these happy souls, these brothers and sisters who want nothing more that the chance to work, and be with their families, and put a goose on their table at Christmastime. And you wallow in self pity, and wish you could do more, and have more, and spend more so that your own family will appreciate you! Good God, man have you learned nothing! Life is passing you by, and you are letting it!

"I'll have you know, I am a man of utmost character, well respected in the community! And you are a bum!"

"A bum I may be, but my soul is light from the knowledge that my fellow man is good, and generous and kind. I am not weighed down by the chains you have forged these forty years passed. You see no cell phone, no vehicle to pay for, no mortgage to tie me to this existence."

He passed the paper bag toward me.

"Now drink, man and know how it feels to be free!"

--

Captain Scrooge and other Holiday tales: stories about life during the holidays as told by a first responder
Copyright © 2016 by Michael Morse
Available on Amazon.



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Ghost of Christmas Present has holiday wisdom for an EMT

Read an excerpt from "Captain Scrooge and other holiday tales" which is a collection of life during the holidays as told by an EMT

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15 books for EMTs and paramedics

Looking for a gift, a weekend read, or a resource? Check out our recent favorites.

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New VC, Responder Ventures, launches investments to focus on public safety technology innovation

Jupiter, FL (November, 2016) – Responder Ventures, LLC announces the formal launch of its industry-leading venture capital firm dedicated to investing in innovative products and solutions for the public safety sector. Responder aims to identify and support the top technologies available to assist first responder ventures within law enforcement, EMS, fire safety and military. Responder Ventures ...

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Inside EMS Podcast: How important is developing a culture of safety in EMS?

Download this podcast on iTunes, SoundCloud or via RSS feed

​​In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson discuss the importance of developing a culture of safety from the responsibility of the workforce to the responsibility of the organization. We want to know: how important is culture in reaching organizational strategic goals" Join the discussion and sound off in the comments.



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Editorial Board

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Publication date: December 2016
Source:Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms, Volume 1859, Issue 12





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News from the plant world: Listening to transcription

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Publication date: Available online 16 November 2016
Source:Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms
Author(s): Erich Grotewold, Nathan M. Springer




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La. paramedic, EMT meet baby they helped deliver

By EMS1 Staff

COVINGTON, La. — A paramedic and an EMT were reunited this week with the family and newborn baby they helped deliver. 

First responders arrived at the home of Christopher and Chermaine Laurent last August, and found Chermaine on the floor attempting to delay birth. 

Paramedic Capt. Mike Guillot and EMT Brent Pearson quickly stabilized and transported her to the ambulance, reported WDSU

"Within 10 seconds of me getting in the back of the med unit, that was it. It was on. I'd say by the time we got on the call, within two minutes she was delivering the baby in the back of the med unit," Capt. Guillot said. 

After Laurent delivered her daughter, she was transported to the hospital. 

Capt. Guillot and EMT Pearson met the Laurent's and their daughter Caliste Wednesday at a hospital event that recognizes first responders and reconnects them with patients they've helped. 

"It's almost like your family because you did a big event in their life," Capt. Guillot said. 



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CPR skills: Use it or lose it

It's unfair to our patients to let professional bravado blind us from the need to maintain low-frequency high-criticality skill proficiency.

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Topography of Activity Evoked in the Human Brain during Discrimination of Moving Sound Stimuli

The aim of the present work was to assess interhemisphere asymmetry of the N1, P2, and N250 components of auditory event-related potentials (ERP) and mismatch negativity (MMN) in passive discrimination between moving sound stimuli in an oddball paradigm. Stimulus movement was created using a linear increase in the interaural time delay ΔT in dichotically presented signals. The amplitudes of the N1 and P2 components were greater in the right hemisphere, this being particularly clear in the frontolateral area. The amplitude of the N250 component in the frontolateral and frontomedial areas was greater in the hemisphere contralateral to the sound stimulus. The direction of movement of sound stimuli had no effect on the asymmetry of ERP and MMN components. The right-hemisphere asymmetry of N1 increased with increases in stimulus speed, while asymmetry of P2 was maximal for short movement trajectories. Asymmetry of N250 and MMN was identified in terms of differences between standards and deviants, i.e., a higher-order feature. Thus, these studies demonstrated differences in the nature of interhemisphere asymmetry for the early and late ERP components, reflecting differences in the neural structures supporting primary analysis of the stimulus and higher cognitive processes.



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First Detection of GES-5 Carbapenemase-Producing Acinetobacter baumannii Isolate

Microbial Drug Resistance , Vol. 0, No. 0.


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Response of Escherichia coli to Prolonged Berberine Exposure

Microbial Drug Resistance , Vol. 0, No. 0.


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Antimicrobial Resistance Mechanisms and Genetic Diversity of Multidrug-Resistant Acinetobacter baumannii Isolated from a Teaching Hospital in Malaysia

Microbial Drug Resistance , Vol. 0, No. 0.


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Dissemination of Trimethoprim–Sulfamethoxazole Drug Resistance Genes Associated with Class 1 and Class 2 Integrons Among Gram-Negative Bacteria from HIV Patients in South India

Microbial Drug Resistance , Vol. 0, No. 0.


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Funding Opportunities for Building Data Connections Between EMS and Healthcare Partners



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Laparoscopic management of large hiatus hernia: five-year cohort study and comparison of mesh-augmented versus standard crura repair

Abstract

Objectives

To evaluate objective and subjective outcomes of patients undergoing laparoscopic repair of large hiatal hernia, either with or without resorbable mesh augmentation. The primary outcome of the study was anatomical recurrence rate as measured by endoscopy. Secondary outcomes were safety, efficacy, and long-term quality of life.

Methods

This was an observational cohort study. Patients who underwent laparoscopic repair of large (≥5 cm) type III hiatal hernia were included. Criteria of exclusion were previously failed hiatus hernia repair and emergency procedures. Patients were stratified into mesh group (mesh-augmented crura repair plus fundoplication) and non-mesh group (standard crura repair plus fundoplication). Preoperative and postoperative symptoms were assessed using the GERD-HRQL questionnaire. Upper gastrointestinal endoscopy was routinely performed between 6 and 12 months postoperatively and was repeated over the follow-up every 1–2 years or as needed. Anatomical hernia recurrence was defined as the maximum vertical length of stomach being at least 2 cm above the diaphragm.

Results

A total of 84 patients, 41 in the mesh group and 43 in the non-mesh group, operated between October 2009 and October 2014, were included in the study. All surgical procedures were completed laparoscopically. The median follow-up was 24 (IQR 29) months. There were 12 endoscopic recurrences, 4 in the mesh group and 8 in the non-mesh group. The five-year recurrence-free probability was similar in the two groups, but an earlier failure rate was noted in the non-mesh group at 12 months (p = 0.299). Three of the 12 patients with anatomical recurrence were symptomatic but did not require a reoperation. Univariate Cox proportional hazard analysis indicated that Toupet fundoplication may reduce the recurrence rate compared to Nissen fundoplication. No mesh-related complications occurred.

Conclusions

Laparoscopic repair of large hiatal hernia is effective and durable. Crura reinforcement with a resorbable synthetic mesh is safe and may protect from early anatomical recurrence.



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Comparison of the long-term outcomes of robotic radical gastrectomy for gastric cancer and conventional laparoscopic approach: a single institutional retrospective cohort study

Abstract

Background

Robotic gastrectomy (RG) for gastric cancer (GC) has been increasingly performed over the last decade. The technical feasibility and safety of RG for GC, predominantly early GC, have previously been reported; however, few studies have evaluated the oncological outcomes. This study aimed to determine the long-term outcomes of RG for GC compared with those of conventional laparoscopic gastrectomy (LG).

Methods

Of the 521 consecutive patients with GC who underwent radical gastrectomy at our institution between 2009 and 2012, 84 consecutive patients who underwent RG and 437 patients who received LG were enrolled in this study. Long-term outcomes including the 3-year overall survival (3yOS) and 3-year recurrence-free survival rates (3yRFS) were examined retrospectively.

Results

In the RG group, the 3yOS rates stratified by pathological stage according to the Japanese classification of gastric carcinoma (IA, IB, II, and III) were 94.7, 90.9, 89.5, and 62.5 %, respectively. No differences in 3yOS (RG, 86.9 % vs. LG, 88.8 %; p = 0.636) or 3yRFS (RG, 86.9 % vs. LG, 86.3 %; p = 0.905) were observed between the groups. 3yOS was strongly associated with cancer recurrence within 3 years (p < 0.001), while 3yRFS was associated with tumor size ≥ 30 mm (p < 0.001), clinical stage ≥ IB (p < 0.001), estimated blood loss ≥ 50 mL (p = 0.033), and postoperative pancreatic fistula CD grade ≥ III) (p = 0.035).

Conclusions

RG for GC was feasible and safe from the oncological point of view in a cohort including a considerable number of patients with advanced GC.



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Outcome of bariatric surgery in patients with type 1 diabetes mellitus: our experience and review of the literature

Abstract

Background

The beneficial effect of bariatric surgery (BS) in type 2 diabetes mellitus patients is well established. Conversely, little is known about the efficacy of BS in type 1 diabetes mellitus (T1DM) patients, despite the increasing prevalence of obesity in this population.

Methods

A retrospective review was carried out on a prospectively collected bariatric surgery registry of all patients undergoing BS at two university hospitals between 2010 and 2015. Patients with T1DM were identified, and detailed chart reviews were obtained.

Results

In this time period, we operated on thirteen patients with T1DM. Eight were female (61.5 %). Median age at time of surgery was 38 ± 8.3 (range 28–53) years. The procedures performed were laparoscopic sleeve gastrectomy (n = 10) and laparoscopic Roux-en-Y gastric bypass (n = 3). On median postoperative follow-up of 24 (range 2.5–51) months, mean body mass index significantly decreased from 39.9 ± 4.1 to 30.1 ± 3.9 kg/m2 (P < 0.0001) and insulin requirements were significantly reduced from 83.7 ± 40.4 to 45.7 ± 33.1 U/day (P < 0.01). However, there was no significant change in glycemic control assessed by HbA1C (P = 0.2). During the first months following surgery, three patients (21.4 %) experienced diabetic ketoacidosis, and four patients (28.6 %) reported more frequent episodes of hypoglycemia.

Conclusions

Bariatric surgery in morbidly obese T1DM patients is an effective method for weight loss, leading to a remarkable improvement in insulin requirements. Larger prospective studies are still needed to confirm these findings, assess long-term effects of BS and better delineate its risk-to-benefit ratio in this growing population of morbidly obese patients with T1DM.



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Laparoscopic Puestow: lateral pancreaticojejunostomy

Abstract

Introduction

Chronic pancreatitis is a painful inflammatory disease that leads to progressive and irreversible destruction of pancreatic parenchyma [1]. A lateral pancreaticojejunostomy, also known as the Puestow procedure, is performed for symptomatic chronic pancreatitis associated with a dilated pancreatic duct secondary to calcifications or strictures [4]. An open approach is used traditionally due to the complexity of the case, and there have only been a handful of laparoscopic case reports [2]. This video depicts a laparoscopic lateral pancreaticojejunostomy for chronic pancreatitis.

Methods

A 45-year-old gentleman with a 20-year history of chronic alcohol abuse presented with diffuse abdominal pain. His pain was worse postprandially and associated with loose stools. A computed tomography scan revealed multiple calcified deposits within the body and tail of the pancreas, and a dilated pancreatic duct measuring 1.4 cm with a proximal obstructing calcified stone. A 5-port foregut technique was used, and a 15-cm pancreatic ductotomy was performed with an ultrasonic scalpel. Calcified stones were cleared from the duct, and a roux-en-y pancreaticojejunostomy was performed using a hand-sewn technique.

Results

The patient had a relatively uncomplicated hospital course with return of bowel function on postoperative day 4. His patient-controlled analgesic device was discontinued on post operative day 3. He was ambulating, tolerating a regular diet and discharged home on postoperative day 5. At 12- and 26-month follow-up, he remains off narcotics, but still requires 1–2 tabs of pancreatic enzyme replacement per meal. Most importantly, he has not had any alcohol for over 2 years.

Conclusion

The two primary goals in treating chronic pancreatitis include long-term pain relief and improvements in quality of life [3]. For patients with chronic pancreatitis and a dilated pancreatic duct, a laparoscopic lateral pancreaticojejunostomy may be an effective approach to decrease pain and improve quality of life.



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Gender differences in both the pathology and surgical outcome of patients with esophageal achalasia

Abstract

Background

Esophageal achalasia is a relatively rare disease that occurs usually in middle-aged patients. The laparoscopic Heller–Dor (LHD) procedure is the gold-standard surgical treatment for esophageal achalasia. There are many studies on the pathology and surgical outcome of esophageal achalasia from various perspectives, but there are no studies on gender differences in both the pathology and surgical outcome.

Aims

This study aimed to evaluate gender differences in the surgical outcome with the LHD procedure and in the pathology of esophageal achalasia patients.

Methods

The study included 474 LHD-treated patients who were postoperatively followed up for 6 months or more. The patients were divided into 2 groups by gender, to compare the preoperative pathology, surgical outcome, symptom scores before and after LHD, symptom score improvement frequency, and patient satisfaction with the surgery.

Results

The study population consisted of 248 male and 226 female, having a mean age of 45.1 years. There were no gender differences in the preoperative pathology, but a significantly lower BMI (p < 0.0001) and a smaller esophageal dilation (p = 0.0061) were observed in the female group. The frequency and severity of chest pain before the surgery were significantly higher in the female group (p = 0.0117 and p = 0.0103, respectively), and the improvement in both the frequency and severity of chest pain was significantly higher in the female group (p = 0.0005 and p = 0.003, respectively). No differences were identified in the surgical outcomes and postoperative course. The patient satisfaction with the surgery was high in both groups and comparable (p = 0.6863).

Conclusions

The female patients with esophageal achalasia were characterized by low BMI, less esophageal dilation, and increased frequency and severity of chest pain. LHD improved the chest pain in the female patients, whereas the surgical outcome and satisfaction with the surgery were excellent regardless of gender.



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Peri-incisional and intraperitoneal ropivacaine administration: a new effective tool in pain control after laparoscopic surgery in gynecology: a randomized controlled clinical trial

Abstract

Background

A proportion of patients undergoing laparoscopic gynecological surgery experiences excessive post-operative pain, which results in high rescue analgesic treatment and prolonged hospitalization. The aim of our study was to evaluate the efficacy of intraoperative topical ropivacaine in the control of post-operative pain in the first 48 h after operative laparoscopy for benign adnexal or uterine pathologies .

Methods

We conducted a prospective, randomized, double-blind, placebo-controlled clinical trial. Patients received a standard dose of topical ropivacaine (injected at the three portal sites and atomized in the abdominal cavity) or placebo. The primary outcome was the evaluation of post-operative pain intensity 6 h after surgery. Secondary outcomes included the intensity of pain during the 48 h after surgery, shoulder tip pain and the request for rescue analgesics during the first 48 h after surgery, time to discharge from recovery room, time to mobilizing on the ward and time to return to daily activities. Patients were divided in two groups (Group_A: benign adnexal pathologies; Group_B: benign uterine diseases) and assigned to Subgroup_1 (receiving ropivacaine) and Subgroup_2 (receiving placebo).

Results

A total of 187 women were included: 93 in Group_A and 94 in Group_B. Forty-seven patients entered Subgroup_A1, 46 Subgroup_A2, 48 Subgroup_B1 and 46 Subgroup_B2. Subgroup_A1 experienced lower post-operative pain at 4 (p = 0.008) and 6 h (p = 0.001) as well as a faster return to daily activities (p = 0.01) in comparison with Subgroup_A2. Both Subgroup_A1 and Subgroup_B1 showed lower shoulder tip pain (respectively, p = 0.032 and p = 0.001) as well as shorter time to mobilizing on the ward after surgery (respectively, p = 0.001 and p = 0.01). The remaining variables analysis did not show significant results.

Conclusions

Combined topical analgesia with ropivacaine could represent a new safe and effective tool in the control of post-operative pain in gynecological laparoscopic surgery. Given the greater benefits for adnexal surgery, this strategy may be more suitable for this class of patients.



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Stenosis rates after endoscopic submucosal dissection of large rectal tumors involving greater than three quarters of the luminal circumference

Abstract

Background

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment option for large rectal tumors. There are limited data available on stenosis rates following ESD of large rectal lesions. We aimed to evaluate the stenosis rate following ESD of large rectal tumors with rectal mucosal defects greater than three quarters of the circumference.

Methods

We retrospectively identified patients who underwent rectal ESD between January 1998 and July 2014. Patients with rectal mucosal defects greater than three quarters the luminal circumference were included for analysis. Clinicopathologic characteristics, treatment outcomes and adverse events were assessed. Stenosis was defined as an inability to pass a pediatric colonoscope into the sigmoid colon. None of the patients underwent prophylactic balloon dilation.

Results

A total of 363 patients with 370 rectal lesions were treated by ESD. Among these, 26 patients had 26 lesions with rectal mucosal defects greater than three quarters of the luminal circumference. Median tumor size (range) was 80 (47–150) mm. Four lesions (15 %) required between 90 and <100 % circumferential dissection, while complete circumferential ESD was performed in two lesions (8 %). Dissection extended to the anal canal in six patients. The median procedure time was 220 min. En bloc resection and curative resection were achieved in 88.5 and 65.4 %, respectively. Delayed bleeding rates and perforation rates were 7.7 and 0 %, respectively. During a median follow-up period of 9.8 (0–59) months, there were no patients with complaints of constipation or fecal incontinence. One patient (4.2 %) was noted to have rectal stenosis, but was clinically asymptomatic. Endoscopic balloon dilation was not required in any patients.

Conclusions

Stenosis may rarely occur after ESD of large rectal lesions with rectal mucosal defects greater than three quarters of the circumference, even without prophylactic endoscopic balloon dilation.



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Single hospital visit day case laparoscopic hernia repair without prior outpatient consultation is safe and acceptable to patients

Abstract

Background

For some common conditions, pre-operative clinic visits are often of little value to the patient or surgeon with transfer to the waiting list being predictable. In response to local patient feedback, we introduced a single hospital visit laparoscopic hernia surgery pathway with focus on informed consent, patient-reported outcomes and post-operative interaction with primary care services.

Methods

A single hospital visit service for elective hernia repairs was created. Patients were not excluded on age, BMI or co-morbidity. Following referral, patients were telephoned by a surgeon. If considered appropriate, a symptom assessment tool, procedure information and consent form were sent. All patients were operated without attending clinic or pre-operative assessment. Surgeon-led telephone follow-up was made at either 2 or 7 days post-operatively and patient satisfaction assessed at 3 months.

Results

A total of 517 patients were referred for single-stop surgery between 2012 and 2015. Median age was 58 (range 20–92), 91 % were male, and mean BMI was 25.6 (17.4–52.0). No patient refused the single-visit pathway. Single-stop patients had higher knowledge questionnaire scores (mean 16 vs. 10, p = 0.01) than patients who had attended clinic. Nine (1.7 %) were requested to attend clinic to confirm diagnosis, and three (0.8 %) were cancelled by their surgeon on the operative day. A total of 393 hernia repairs (331 TEP, 63 open) were performed under general anaesthetic. 92 % were discharged on day zero. Telephone follow-up day two rather than seven decreased attendance to primary care services (25 % vs. 57 %, p = 0.001). At 3 months, 95 % were satisfied and symptom scores were reduced (median 5–0, p < 0.0001).

Conclusion

Single-visit surgery appears to extend the patient benefits of laparoscopy by reducing hospital visits without compromising safety. Single hospital visit hernia surgery for unselected primary care referrals is possible and acceptable to patients.



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Is preoperative withdrawal of aspirin necessary in patients undergoing elective inguinal hernia repair?

Abstract

Background

Antiplatelets such as aspirin are widely used to reduce thrombotic events in patients with various cardiovascular comorbidities. Continuing aspirin through noncardiac surgery has been shown to reduce risk of major adverse cardiac events (MACE) but may lead to higher bleeding complications. Inguinal hernia repair is a commonly performed surgical procedure among such patients, but no guideline exists regarding perioperative use of aspirin.

Objective

We aim to investigate the safety profile of aspirin continuation in the perioperative period in patients undergoing elective primary inguinal hernia repair.

Methods

All patients who underwent elective primary inguinal hernia repair from 2008 to 2015 and were on aspirin preoperatively were identified. The patients were divided into two groups: those who continued aspirin through the morning of the operation and those who were advised to stop aspirin therapy 3–7 days prior to operation. All patients underwent either open Lichtenstein mesh repair or laparoscopic total extra-peritoneal mesh repair. Outcomes measured include intraoperative blood loss, operative time, bleeding complications, wound site complications and MACE.

Results

Among 1841 patients who underwent elective primary inguinal hernia mesh repair, 142 (7.7 %) patients were on preoperative aspirin. Fifty-seven patients underwent laparoscopic repair, while 85 underwent open mesh repair. Twenty-seven out of fifty-seven (47.3 %) from the laparoscopic group and 55/85 (64.7 %) from the open group were instructed to stop aspirin (p = 0.040). There were no significant differences between those who stopped aspirin and those who continued in terms of intraoperative blood loss and operative timing. Immediate postoperative bleeding complications and follow-up wound complications were also similar between the two groups. Overall, there were no MACE among those who underwent laparoscopic repair. Three MACE were recorded in the open group (2 stopped vs. 1 continued; p = 0.943). There was no perioperative mortality.

Conclusion

Continuation of aspirin is safe and should be preferred in patients with higher cardiovascular risk.



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Endoscopic submucosal dissection versus surgical resection for early gastric cancer: a retrospective multicenter study on immediate and long-term outcome over 5 years

Abstract

Background

Endoscopic submucosal dissection (ESD) is an alternative to surgical resection for treating early gastric cancer (EGC). However, there have been limited reports on the long-term outcome of ESD compared to that of surgical resection. The aim of this study was to evaluate the immediate and long-term clinical and oncologic outcomes of ESD compared to surgical resection.

Method

We retrospectively reviewed data of patients in five centers who were treated with ESD or surgical resection for EGC within expanded criteria for ESD from 2006 to 2008.

Result

ESD group had significantly shorter procedure times, shorter fasting period, and shorter hospital stay than the surgical resection group. Immediate complications in the surgical resection group were more common compared to those in the ESD group. Five-year cancer recurrence rate of the ESD group was 12.3 % and significantly higher than 2.1 % of the surgical resection group (P = 0.001). Five-year disease-free survival rate of the surgical resection group was 97 %, which was significantly higher than 85 % of the ESD group (P = 0.001). Metachronous lesions were equally found every year during the follow-up period in the ESD group. Five-year overall survival rates were 100 % for both groups.

Conclusion

ESD might be an acceptable and effective treatment for EGC considering overall survival rates with fewer early complication rates and shorter duration of hospital stay compared to surgical resection. However, intensive and persistent endoscopic surveillance should be performed after ESD for early detection of metachronous lesions.



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Face and content validation of a Virtual Translumenal Endoscopic Surgery Trainer (VTEST™)

Abstract

Background

Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical paradigm, where peritoneal access is achieved through one of the natural orifices of the body. It is being reported as a safe and feasible surgical technique with significantly reduced external scarring. Virtual Translumenal Endoscopic Surgical Trainer (VTEST™) is the first virtual reality simulator for the NOTES. The VTEST™ simulator was developed to train surgeons in the hybrid transvaginal NOTES cholecystectomy procedure. The initial version of the VTEST™ simulator underwent face validation at the 2013 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) summit. Several areas of improvement were identified as a result, and the corresponding modifications were implemented in the simulator. This manuscript outlines the results of the subsequent evaluation study, performed in order to assess the face and content validity of the latest VTEST™ simulator.

Methods

Twelve subjects participated in an institutional review board-approved study that took place at the 2014 NOSCAR summit. Six of the 12 subjects, who are experts with NOTES experience, were used for face and content validation. The subjects performed the hybrid transvaginal NOTES cholecystectomy procedure on VTEST™ that included identifying the Calot's triangle, clipping and cutting the cystic duct/artery, and detaching the gallbladder. The subjects then answered five-point Likert scale feedback questionnaires for face and content validity.

Results

Overall, subjects rated 12/15 questions as 3.0 or greater (60 %), for face validity questions regarding the realism of the anatomical features, interface, and the tasks. Subjects also highly rated the usefulness of the simulator in learning the fundamental NOTES technical skills (3.50 ± 0.84). Content validity results indicate a high level of usefulness of the VTEST™ for training prior to operating room experience (4.17 ± 0.75).



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Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage: predictors of successful outcome in patients who fail endoscopic retrograde cholangiopancreatography

Abstract

Background

Patients with failed endoscopic retrograde cholangiopancreatography (ERCP) are conventionally offered percutaneous transhepatic biliary drainage (PTBD). While PTBD is effective, it is associated with catheter-related complications, pain, and poor quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a minimally invasive endoscopic option increasingly offered as an alternative to PTBD. We compare outcomes of EUS-BD and PTBD in patients with biliary obstruction at a single tertiary care center.

Methods

A retrospective review was performed in patients with biliary obstruction who underwent EUS-BD or PTBD after failed ERCP from June 2010 through December 2014 at a single tertiary care center. Patient demographics, procedural data, and clinical outcomes were documented for each group. The aim was to compare efficacy and safety of EUS-BD and PTBD and evaluate predictors of success.

Results

A total of 60 patients were included (mean age 67.5 years, 65 % male). Forty-seven underwent EUS-BD, and thirteen underwent PTBD. Technical success rates of PTBD and EUS-BD were similar (91.6 vs. 93.3 %, p = 1.0). PTBD patients underwent significantly more re-interventions than EUS-BD patients (mean 4.9 versus 1.3, p < 0.0001), had more late (>24-h) adverse events (53.8 % vs. 6.6 %, p = 0.001) and experienced more pain (4.1 vs. 1.9, p = 0.016) post-procedure. In univariate analysis, clinical success was lower in the PTBD group (25 vs. 62.2 %, p = 0.03). In multivariable logistic regression analysis, EUS-BD was the sole predictor of clinical success and long-term resolution (OR 21.8, p = 0.009).

Conclusion

Despite similar technical success rates compared to PTBD, EUS-BD results in a lower need for re-intervention, decreased rate of late adverse events, and lower pain scores, and is the sole predictor for clinical success and long-term resolution. EUS-BD should be the treatment of choice after a failed ERCP.



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Risk of anastomotic leak after laparoscopic versus open colectomy

Abstract

Background

Anastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With the widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic when compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopic versus open colorectal resection using a nationwide database with standardized definitions.

Methods

The 2012–2013 ACS-NSQIP targeted colectomy data were queried for all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by a propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak.

Results

Of 23,568 patients, 3.4 % developed an anastomotic leak. Laparoscopic surgery was associated with a leak rate of 2.8 % (n = 425) and open surgery, 4.5 % (n = 378, p < 0.0001). Patients who developed a leak were more likely to die within 30 days of surgery (5.7 vs. 0.6 %, p < 0.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs. 63 years, p = 0, p = 0.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, p < 0.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95 % CI 0.58–0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak.

Conclusion

Laparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease- and procedure-related factors.



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How to position an EMS patient after a fall

Syncope is a temporary loss of consciousness resulting from decreased blood flow to the brain. While the idea is simple, the mechanics of syncope can be more complex.

Near syncope, another term EMS providers are likely to hear, is loosely defined as an episode of dizziness or weakness associated with the same temporary loss of blood to the brain.

Aside from the potential traumatic injury to his hip, the assessment of Mr. Stevens should focus on a potential cause of his near syncope. In this case, measuring a blood glucose (if within your scope of practice) would rule out potential complications of his diabetes.

Otherwise, evaluating possible cardiovascular causes should be high on the differential diagnosis list. In Mr. Stevens' case, there are three clues indicating syncope of cardiovascular origin:

  1. Abrupt position change
  2. Poor oral intake
  3. Beta-blocker medication

Near syncope when standing
Mr. Stevens' hypertension is treated with beta-blockers, which lower blood pressure by decreasing heart rate and contractility. These effects combine to decrease overall cardiac output. A recent illness with poor fluid intake can cause mild dehydration leaving less overall circulating volume in the body. Finally, a rapid change in posture — supine to standing — changes the demands on the body as it attempts to maintain homeostasis against gravity.

All three of these effects can combine to cause syncope or near syncope as seen with Mr. Stevens. When the patient stands quickly the body attempts to compensate by accelerating the heart rate; in this case, however, beta-blockers keep the heart rate artificially low and don't allow for a rapid response to changing needs. Additionally, mild dehydration reduces preload and, along with bradycardia, reduces cardiac output. As gravity pulls blood from the brain the patient's cardiac output is unable to compensate and cerebral perfusion is decreased to the point where syncope occurs. In Mr. Stevens' case, this is also associated with a loss of muscle tone and a fall.

Positioning based on patient findings
A patient who has suffered a syncope related to a change in position may or may not be hypotensive when lying down. Symptoms may be exacerbated when moved from lying to sitting or standing and a thorough assessment should include evaluation of orthostatic vital signs. In Mr. Stevens' case, however, a change in position to sitting or standing is not feasible because of his potential hip injury.

He may tolerate elevating his legs, however, into Trendelenburg position but is there any benefit to doing this" While this was traditionally taught to EMS providers as a way of "forcing" blood to the brain, a review of available peer-reviewed literature demonstrates that while more research is needed, Trendelenburg position "does not reveal beneficial or sustained changes in systolic blood pressure, preload, afterload, or cardiac output."[1]

At best, use of Trendelenburg is subject to competing expert opinions and while it has not been shown to broadly benefit patients it also has not been shown to cause harm. In Mr. Stevens' case, his injured and painful hip contraindicates use of Trendelenburg.

Conclusion
Because Mr. Stevens' weakness symptoms are absent went lying down and because his pain increases when sitting upright, you elect to leave him in a supine position. The paramedic from the ambulance starts an IV and gives the patient pain medication and fluid prior to moving him. Careful to keep him flat, you lift Mr. Stevens over to the stretcher and pad his affected leg to keep him comfortable. Mr. Stevens is transported to the emergency department without issue.

References
1. Bridges, N., & Jarquin-Valdivia, A. A. (2005). Use of the Trendelenburg Position as the resuscitation position: To T or not to T" American Journal of Critical Care,14(5), 364–368.



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CPR skills: Use it or lose it

EMS providers perform a wide variety of technical tasks during the course of their duties. Skills like measuring vital signs, performing a physical assessment or auscultating lung sounds are common tasks. Gaining vascular access, administering a fluid bolus or injecting a medication is less common. Creating airway access through a surgical cricothyrotomy may be a once in a career intervention.

The upshot is that EMS providers must maintain competency and proficiency in their complete scope of practice. Whether it's a high-frequency low-criticality procedure of measuring a pulse rate, to a low-frequency high-criticality skill of pediatric intubation, it is assumed that we are proficient in the entire range of skills.

It's also known that in the low-frequency interventional skills, that if you don't use it, you lose it. Previous studies have shown that many paramedics intubate only once a year. Advanced life support providers on engine companies rarely start IVs due to time constraints. Some systems only see a handful of working cardiac arrests annually.

It's abundantly clear that ongoing training is necessary to maintain proficiency. It's no different than a law enforcement officer having to regularly qualify on firearm use. To maintain "muscle memory" of a technical procedure, you have to perform it regularly.

The key point is "regularity." Many of us have experienced the trauma of taking a mandatory in-service class once a year, where much of the time is spent talking about procedures and very little time spent is spent practicing them. And since we are "on the same team" so to speak, there is unspoken pressure to "pass" everyone on skill proficiency and pencil whip the competency forms, which are then put away in employee files to show the world that we "do" training.

As this study on high-quality CPR proficiency shows, it doesn't have to be this way. Quarterly training sessions in CPR using feedback mechanisms can be effective in maintaining high-quality technique. In another words, training can be brief, targeted and effective in skill maintenance. Using short, but intense scenarios to simulate real-world conditions promotes motor skill retention and by permeating those scenarios with high-level stress the quality of the training is elevated many fold. Providers are better prepared to function under formidable conditions.

No matter how well designed training can be, none of it will be helpful if you're not into it. The machismo and bravado side of our profession can often blind us from the need to stay current and proficient. That's simply not fair to our patients.

Next time, instead of sulking in the back of the classroom, take the time — and the energy — to make sure you are prepared to perform the procedures and techniques that are demanded of you at the most critical time.



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How EMS agencies can participate in Health Information Exchanges

The Center for Medicare and Medicaid Services released a letter in early 2016 to expand the eligibility of funds to encourage the adoption and use of Health Integration Exchanges through 2021 [1]. These funds are directed through the Health Information Technology for Economic and Clinical Health Act of 2009. The HITECH act can directly address many of the challenges that EMS faces daily and reduces the obstacles in creating successful community medicine programs.

What is a Health Integration Exchange"
An electronic Health Information Exchange allows all providers of care to appropriately access and share patient information timely and securely. For example, instead of faxing or dropping off EMS patient care records at the hospital an HIE allows the patient care record to immediately be placed inside the hospital's records of care. An HIE greatly improves the completeness of a patient's record as treatments and evaluations are jointly reviewed to reduce readmissions, avoid medication errors, improve diagnoses and decrease duplication testing.

What are the advantages of an HIE for EMS"
Here are five advantages of an HIE for EMS agencies to be aware of.

Read full story on EMSGrantsHelp.com



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Funding Opportunities for Building Data Connections Between EMS and Healthcare Partners



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Funding Opportunities for Building Data Connections Between EMS and Healthcare Partners



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