Τετάρτη 11 Ιανουαρίου 2017

Long term neurobehavioral symptoms and return to productivity in Operation Enduring Freedom/Operation Iraqi Freedom Veterans with and without traumatic brain injury

Publication date: Available online 11 January 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Marianne H. Mortera, Stacy A. Kinirons, Jessie Simantov, Heidi Klingbeil
ObjectivesTo describe Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans who underwent the Comprehensive Traumatic Brain Injury Evaluation (CTBIE), differences between the traumatic brain injury (TBI) and non- traumatic brain injury (non-TBI) subgroups, and factors associated with return to productivity (RTP).DesignRetrospective medical record review.SettingVeterans Affairs Medical Center, Polytrauma/TBI Network Site.ParticipantsMedical records of 236 OEF/OIF Veterans who underwent the CTBIE between 2009-2013.InterventionsNot applicable.Main Outcome MeasuresDemographic characteristics, injury history, clinical presentation, and factors associated with RTP.ResultsVeterans (n=236) were male (90.7%), White (45.3%) or Black (34.7%), with half of Hispanic origin, and a mean age of 33 years. The mean time since injury was approximately 4 years. Reported symptoms were high, with greater than 90% reporting anxiousness, irritability, sleep difficulty, forgetfulness, and headaches.TBI diagnosis was found in 163 (69%) Veterans. The TBI subgroup was younger (TBI 32.5 years versus non-TBI 34.9 years, p=0.02), reported a greater number of injuries (p= 0.000), and had significantly higher rates of half of the reported symptoms. Greatest differences were noted with forgetfulness (TBI 95.7% versus non-TBI 79.5%, p=0.000), poor concentration (TBI 90.2% versus non-TBI 76.7%, p=0.007), and headaches (TBI 93.9% versus non-TBI 83.6%, p=0.014).RTP was 60.6% for the total Veteran population. Factors associated with RTP were race (white) (OR=2.00; 95%CI:1.13-3.55, p=0.018), sensitivity to light (OR=2.58; 95%CI:1.17-5.66, p=0.018), and fatigue (OR=3.68; 95%CI:1.51-8.95, p=0.004). Veterans that did RTP wessre three times less likely to report depression (OR=0.323; 95%CI:0.12-.85, p=0.022).ConclusionsVeterans reported a substantial number of lingering symptoms, with a higher prevalence in Veterans with TBI. Veterans with reported depression were less likely to RTP. Future research should focus on the relationship between depression and non-RTP and the effectiveness of VA services.



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Functional Electrical Stimulation for foot drop in Multiple Sclerosis: A Systematic Review and Meta-Analysis of the impact on gait speed

Publication date: Available online 11 January 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Linda Miller, Angus McFadyen, Anna C. Lord, Rebecca Hunter, Lorna Paul, Danny Rafferty, Roy Bowers, Paul Mattison
ObjectiveTo review the efficacy of functional electrical stimulation (FES) used for foot drop in people with multiple sclerosis (pwMS) on gait speed in short and long walking performance tests.Data sourcesFive databases (Cochrane Library, CINAHL, Embase, MEDLINE, Pubmed) and reference lists were searched.Study selectionStudies of both observational and experimental design where gait speed data in pwMS could be extracted were included.Data extractionData were independently extracted and recorded. Methodological quality was assessed using the Effective Public Health Practice Project (EPHPP) tool.Data synthesisNineteen studies (described in 20 articles) recruiting 490 pwMS were identified and rated moderate or weak, with none gaining a strong rating. All studies rated weak for blinding. Initial and ongoing orthotic and therapeutic effects were assessed with regards to the impact of FES on gait speed in short and long walking tests. Meta-analyses of the short walk tests revealed a significant initial orthotic effect (t = 2.14, p = 0.016) with a mean increase in gait speed of 0.05 meters per second (m/s) and ongoing orthotic effect (t = 2.81, p = 0.003) with a mean increase of 0.08m/s. There were no initial or ongoing effect on gait speed in long walk tests and no therapeutic effect on gait speed in either short or long walk tests.ConclusionsFES used for foot drop has a positive initial and ongoing effect on gait speed in short walking tests. Further fully-powered randomized controlled trials comparing FES with alternative treatments are required.



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Aquatic Exercise Therapy for People with Parkinson’s disease: a Randomized Controlled Trial

Publication date: Available online 12 January 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Louise M. Carroll, Daniele Volpe, Meg E. Morris, Jean Saunders, Amanda M. Clifford
ObjectiveTo evaluate the effects of aquatic exercise therapy on gait variability and disability compared to usual care for people with Parkinson's disease (PD).DesignSingle-blind randomized control trial (RCT).SettingA community based hydrotherapy pool in Ireland.ParticipantsTwenty one individuals with PD (Hoehn-Yahr Stages I-III).InterventionsParticipants were randomly assigned to either an aquatic exercise therapy group (45 minutes, twice a week for 6 weeks) or a control group that received usual care.Main Outcome Measure(s)The primary outcome measure was gait variability as measured using a Coda CX1 motion capture system. Secondary outcomes were quality of life measured on the Parkinson's Disease Questionnaire-39, freezing of gait and motor disability quantified by the Unified Parkinson Disease Rating Scale (UPDRS III). Feasibility was evaluated by measuring safety, adverse events and participant satisfaction.ResultsPeople in the aquatic therapy group and control group showed similar small improvements in gait variability. The aquatic therapy group showed greater improvements in disability than the control group (P<0.01). No differences between groups or over time were identified for freezing of gait or quality of life. Aquatic therapy sessions were safe and enjoyable with no adverse events.ConclusionsAquatic therapy appears feasible and safe for some people in the early stages of Parkinson's disease.



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The emotive nature of conflict monitoring in the medial prefrontal cortex

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Publication date: Available online 11 January 2017
Source:International Journal of Psychophysiology
Author(s): Blair Saunders, Hause Lin, Marina Milyavskaya, Michael Inzlicht
The detection of conflict between incompatible impulses, thoughts, and actions is a ubiquitous source of motivation across theories of goal-directed action. In this overview, we explore the hypothesis that conflict is emotive, integrating perspectives from affective science and cognitive neuroscience. Initially, we review evidence suggesting that the mental and biological processes that monitor for information processing conflict—particularly those generated by the anterior midcingulate cortex—track the affective significance of conflict and use this signal to motivate increased control. In this sense, variation in control resembles a form of affect regulation in which control implementation counteracts the aversive experience of conflict. We also highlight emerging evidence proposing that states and dispositions associated with acceptance facilitate control by tuning individuals to the emotive nature of conflict, before proposing avenues for future research, including investigating the role of affect in reinforcement learning and decision making.



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Adapting Genotyping-by-Sequencing for Rice F2 Populations

Rapid and cost-effective genotyping of large mapping populations can be achieved by sequencing a reduced representation of the genome of every individual in a given population and using that information to generate genetic markers. A customized genotyping-by-sequencing (GBS) pipeline was developed to genotype a rice F2 population from a cross of Oryza sativa ssp. japonica cv. Nipponbare and the African wild rice species Oryza longistaminata. While most GBS pipelines aim to analyze mainly homozygous populations we attempted to genotype a highly heterozygous F2 population. We show how species- and population-specific improvements of established protocols can drastically increase sample throughput and genotype quality. Using as few as 50,000 reads for some individuals (134,000 reads on average) we were able to generate up to 8,154 informative SNP markers in 1,081 F2 individuals. Additionally, the effects of enzyme choice, read coverage and data post-processing are evaluated. Using GBS-derived markers we were able to assemble a genetic map of 1,536 cM. To demonstrate the usefulness of our GBS pipeline we determined QTL for the number of tillers. We were able to map four QTLs to chromosomes 1, 3, 4 and 8 and partially confirm their effects using introgression lines. We provide an example of how to successfully use GBS with heterozygous F2 populations. By using the comparatively low-cost MiSeq platform we show that the GBS method is flexible and cost-effective even for smaller laboratories.



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Genetic Dissection of a QTL Affecting Bone Geometry

Parameters of bone geometry such as width, length, and cross-sectional area are major determinants of bone strength. Though these traits are highly heritable, few genes influencing bone geometry have been identified. Here, we dissect a major quantitative trait locus (QTL) influencing femur size. This QTL was originally identified in an F2 cross between the C57BL/6J-hg/hg (HG) and CAST/EiJ strains and was referred to as femur length in high growth mice 2 (Feml2). Feml2 was located on Chromosome (Chr.) 9 at ~20 cM. Here, we show that the HG.CAST-(D9Mit249-D9Mit133)/Ucd congenic strain captures Feml2. In an F2 congenic cross, we fine-mapped the location of Feml2 to an ~6 Mbp region extending from 57.3 to 63.3 Mbp on Chr. 9. We have identified candidates by mining the complete genome sequence of CAST/EiJ and through allele specific expression analysis of growth plates in C57BL/6J x CAST/EiJ F1 hybrids. Interestingly, we also find that the refined location of Feml2 overlaps a cluster of six independent genome-wide associations for human height. This work provides the foundation to identify novel genes affecting bone geometry.



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When angiogenesis is not good enough

Abstract

Growing a functional microvascular network undoubtedly entails the coordination of multiple cellular and molecular dynamics across the different vessel types that span the hierarchy of the network.

This article is protected by copyright. All rights reserved



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THE ROLE OF THE CEREBELLUM IN HIGH STAGES OF MOTOR PLANNING HIERARCHY

Motor planning is not a monolithic process, and distinct stages of motor planning are responsible for encoding different levels of abstractness. However, how these distinct components are mapped into different neural substrates remains an open question. We studied one of these high-level motor planning components, defined as second-order motor planning, in a patient (R.G.) with an extremely rare case of cerebellar agenesis but without any other cortical malformations. Second-order motor planning dictates that when two acts have to be performed sequentially, planning of the second act can influence the execution of the first. We used an optoelectronic system for kinematic analysis to compare R.G.'s performance with age-matched controls in a second-order motor planning task. The first act was to reach for an object and the second was to place it into a small or large container. Our results showed that despite the expected difficulties in fine-motor skills, second-order motor planning (i.e., the ability to modulate the first act as a function of the nature of the second act) was preserved even in the patient with congenital absence of the cerebellum. These results open new intriguing speculations about the role of the cerebellum in motor planning abilities. Although prudence is imperative when suggesting conclusions based on single-case findings, this evidence suggests fascinating hypotheses about the neural circuits that support distinct stages of the motor planning hierarchy, and regarding the functional role of second-order motor planning in motor cognition and its potential dysfunction in autism.



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Preparatory alpha-band oscillations reflect spatial gating independently of predictions regarding target identity

Preparatory modulations of cortical alpha-band oscillations are a reliable index of the voluntary allocation of covert spatial attention. It is currently unclear whether attentional cues containing information about a target's identity (such as its visual orientation), in addition to its location, might additionally shape preparatory alpha modulations. Here, we explore this question by directly comparing spatial and feature-based attention in the same visual detection task while recording brain activity using magneto-encephalography (MEG). At the behavioural level, preparatory feature-based and spatial attention cues both improved performance, and did so independently of each other. Using MEG, we replicated robust alpha lateralisation following spatial cues: in preparation for a visual target, alpha power decreased contralaterally, and increased ipsilaterally to the attended location. Critically, however, preparatory alpha lateralisation was not significantly modulated by predictions regarding target identity, as carried via the behaviourally effective feature-based attention cues. Furthermore, non-lateralised alpha power during the cue-target interval did not differentiate between uninformative cues and cues carrying feature-based predictions either. Based on these results we propose that preparatory alpha modulations play a role in the gating of information between spatially segregated cortical regions, and are therefore particularly well suited for spatial gating of information.



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Auditory adaptation improves tactile frequency perception

Our ability to process temporal frequency information by touch underlies our capacity to perceive and discriminate surface textures. Auditory signals, which also provide extensive temporal frequency information, can systematically alter the perception of vibrations on the hand. How auditory signals shape tactile processing is unclear: perceptual interactions between contemporaneous sounds and vibrations are consistent with multiple neural mechanisms. Here we used a crossmodal adaptation paradigm, which separated auditory and tactile stimulation in time, to test the hypothesis that tactile frequency perception depends on neural circuits that also process auditory frequency. We reasoned that auditory adaptation effects would transfer to touch only if signals from both senses converge on common representations. We found that auditory adaptation can improve tactile frequency discrimination thresholds. This occurred only when adaptor and test frequencies overlapped. In contrast, auditory adaptation did not influence tactile intensity judgments. Thus, auditory adaptation enhances touch in a frequency- and feature-specific manner. A simple network model in which tactile frequency information is decoded from sensory neurons that are susceptible to auditory adaptation recapitulates these behavioral results. Our results imply that the neural circuits supporting tactile frequency perception also process auditory signals. This finding is consistent with the notion of supramodal operators performing canonical operations, like temporal frequency processing, regardless of input modality.



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Stability and plasticity in neural encoding of linguistically-relevant pitch patterns

While life-long language experience modulates subcortical encoding of pitch patterns, there is emerging evidence that short-term training introduced in adulthood also shapes subcortical pitch encoding. Here, we use a cross-language design to examine the stability of language experience-dependent subcortical plasticity over multiple days. We then examine the extent to which behavioral relevance induced by speech sound-to-category training leads to plastic changes in subcortical pitch encoding in adulthood relative to adolescence, a period of ongoing maturation of subcortical and cortical auditory processing. Frequency-following responses (FFRs), which reflect phase-locked activity from subcortical neural ensembles, were elicited while participants passively listened to pitch patterns reflective of Mandarin tones. In experiment 1, FFRs were recorded across three consecutive days from native Chinese-speaking (n = 10) and English-speaking (n = 10) adults. In experiment 2, FFRs were recorded from native English-speaking adolescents (n = 20) and adults (n = 15) before, during, and immediately after a session of speech sound-to-category training, as well as a day after training ceased. Experiment 1 demonstrated the stability of language experience-dependent subcortical plasticity in pitch encoding across multiple days of passive exposure to linguistic pitch patterns. In contrast, Experiment 2 revealed an enhancement in subcortical pitch encoding that emerged a day after the sound-to-category training, with some developmental differences observed. Taken together, these findings suggest that behavioral relevance is a critical component for the observation of plasticity in the subcortical encoding of pitch.



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Spatial cognition in a virtual reality home-cage extension for freely moving rodents

Virtual reality environments are part of a powerful tool set to investigate brain mechanisms of behavior in animals. For this, animals are mostly head-fixed or in a harness, and training for cognitively more complex VR paradigms is time consuming. A virtual reality apparatus allowing free animal movement and 24/7 operator-independent training of tasks would enable many new applications. Key prospective usages include brain imaging in behaving animals carrying a miniaturized mobile device such as a fluorescence microscope, or an optetrode. Here we introduce the servoball, a spherical virtual reality treadmill that is connected to the home cage from where single individuals can voluntarily enter through an RFID automated access control. We automatically trained rats that demonstrated use of visual or acoustic cues to solve spatial cognitive tasks, and recorded spatially modulated entorhinal cells. This integrated home cage with VR-arena experimental system permits highly efficient experimentation for complex cognitive experiments.



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Temporally precise control of single neuron spiking by juxtacellular nanostimulation

Temporal patterns of action potentials influence a variety of activity-dependent intra- and inter-cellular processes and play an important role in theories of neural coding. Elucidating the mechanisms underlying these phenomena requires imposing spike trains with precisely defined patterns, but this has been challenging due to the limitations of existing stimulation techniques. Here we present a new nanostimulation method providing control over the action potential output of individual cortical neurons. Spikes are elicited through the juxtacellular application of short-duration fluctuating currents ('kurzpulses'), allowing for the sub-millisecond precise and reproducible induction of arbitrary patterns of action potentials at all physiologically relevant firing frequencies (<120 Hz), including minute-long spike trains recorded in freely moving animals. We systematically compared our method to whole-cell current injection as well as optogenetic stimulation and show that nanostimulation performance compares favorably with these techniques. This new nanostimulation approach is easily applied, can be readily performed in awake behaving animals, and thus promises to be a powerful tool for systematic investigations into the temporal elements of neural codes as well as the mechanisms underlying a wide variety of activity-dependent cellular processes.



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Motor plan differs for young and older adults during similar movements.

Older adults exhibit altered activation of the agonist and antagonist muscles during goal-directed movements compared with young adults. However, it remains unclear whether the differential activation of the antagonistic muscles in older adults results from an impaired motor plan or an altered ability of the muscle to contract. The purpose of this study, therefore, was to determine whether the motor plan differs for young and older adults. Ten young (26.1 ± 4.3 yrs, 4 females) and sixteen older (71.9 ± 6.9 yrs, 9 females) adults participated in the study. Participants performed 100 trials of fast goal directed movements with ankle dorsiflexion while we recorded the EMG activity of the primary agonist (Tibialis Anterior; TA) and antagonist (Soleus; SOL) muscles. From those 100 trials we selected 5 trials in each of 3 movement endpoint categories (Fast, Accurate, and Slow). We investigate age-associated differences in the motor plan by quantifying the individual activity and coordination of the agonist and antagonist muscles. During similar movement endpoints, older adults exhibited similar activation of the agonist (TA) and antagonist (SOL) muscles compared to young adults. In addition, the coordination of the agonist and antagonist muscles (TA and SOL) was different between the two age groups. Specifically, older adults exhibited lower TA-SOL overlap (F1,23=41.2, P<.001) and greater TA-SOL Peak EMG delay (F1,25=35.5, P<0.001). This finding suggests that while both age groups displayed similar movement endpoints, they exhibited a different motor plan, as demonstrated by altered coordination between the agonist and antagonist muscles.



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In Monkeys Making Value-Based Decisions Amygdala Neurons Are Sensitive to Cue Value as Distinct from Cue Salience

Neurons in area LIP of macaque monkey parietal cortex respond to cues predicting rewards and penalties of variable size in a manner that depends on the motivational salience of the predicted outcome (strong for both large reward and large penalty) rather than on its value (positive for large reward and negative for large penalty). This finding suggests that LIP mediates the capture of attention by salient events and does not encode value in the service of value-based decision making. It leaves open the question whether neurons elsewhere in the brain encode value in the identical task. To resolve this issue, we recorded neuronal activity in the amygdala in the context of the task employed in the LIP study. We found that responses to reward-predicting cues were similar between areas, with the majority of reward-sensitive neurons responding more strongly to cues that predicted large reward than to those that predicted small reward. Responses to penalty-predicting cues were, however, markedly different. In the amygdala, unlike LIP, few neurons were sensitive to penalty size, few penalty-sensitive neurons favored large over small penalty, and the dependence of firing rate on penalty size was negatively correlated with its dependence on reward size. These results indicate that amygdala neurons encoded cue value under circumstances in which LIP neurons exhibited sensitivity to motivational salience. However, the representation of negative value, as reflected in sensitivity to penalty size, was weaker than the representation of positive value, as reflected in sensitivity to reward size.



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Muscle spindles in human tibialis anterior encode muscle fascicle length changes

Muscle spindles provide exquisitely sensitive proprioceptive information regarding joint position and movement. Through passively driven length changes in the muscle-tendon unit (MTU), muscle spindles detect joint rotations because of their in-parallel mechanical linkage to muscle fascicles. In human microneurography studies, muscle fascicles are assumed to follow the MTU and, as such, fascicle length is not measured in such studies. However, under certain mechanical conditions compliant structures can act to decouple the fascicles, and therefore the spindles, from the MTU. Such decoupling may reduce the fidelity by which muscle spindles encode joint position and movement. The aim of the present study was to measure, for the first time, both the changes in firing of single muscle spindle afferents and changes in muscle fascicle length in vivo from the tibialis anterior muscle (TA) during passive rotations about the ankle. Unitary recordings were made from 15 muscle spindle afferents supplying TA via a microelectrode inserted into the common peroneal nerve. Ultrasonography was used to measure the length of an individual fascicle of TA. We saw a strong correlation between fascicle length and firing rate during passive ankle rotations of varying rates (0.1-0.5Hz) and amplitudes (1-9°). In particular, we saw responses observed at relatively small changes in muscle length that highlight the sensitivity of the TA muscle to small length changes. This study is the first to measure spindle firing and fascicle dynamics in vivo and provides an experimental basis for further understanding the link between fascicle length, MTU length and spindle firing patterns.



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Characterizing differential post-stroke corticomotor drive to the dorsi- and plantarflexor muscles during resting and volitional muscle activation

Imbalance of corticomotor excitability between the paretic and nonparetic limbs has been associated with the extent of upper extremity motor recovery post-stroke, is greatly influenced by specific testing conditions such as the presence or absence of volitional muscle activation, and may vary across muscle groups. However, despite its clinical importance, post-stroke corticomotor drive to lower extremity muscles has not been thoroughly investigated. Additionally, while conventional gait rehabilitation strategies for stroke survivors focus on paretic limb foot drop and dorsiflexion impairments, most contemporary literature has indicated that paretic limb propulsion and plantarflexion impairments are the most significant limiters to post-stroke walking function. The purpose of this study was to compare corticomotor excitability of the dorsi- and plantarflexor muscles during resting and active conditions in individuals with good and poor post-stroke walking recovery and in neurologically-intact controls. We found that plantarflexor muscles showed reduced corticomotor symmetry between paretic and nonparetic limbs compared to dorsiflexor muscles in individuals with poor post-stroke walking recovery during active muscle contraction but not during rest. Reduced plantarflexor corticomotor symmetry during active muscle contraction was a result of reduced corticomotor drive to the paretic muscles and enhanced corticomotor drive to the nonparetic muscles when compared to the neurologically-intact controls. These results demonstrate that atypical corticomotor drive exists in both the paretic and nonparetic lower limbs and implicate greater severity of corticomotor impairments to plantarflexor versus dorsiflexor muscles during muscle activation in stroke survivors with poor walking recovery.



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The mammalian efferent vestibular system plays a crucial role in vestibulo-ocular reflex compensation after unilateral labyrinthectomy

The α9 nicotinic acetylcholine receptor (α9-nAChR) subunit is expressed in the vestibular and auditory periphery, and its loss of function could compromise peripheral input from the predominantly-cholinergic efferent vestibular system (EVS). A recent study has shown that α9-nAChRs play an important role in short-term vestibulo-ocular reflex (VOR) adaptation. We hypothesise that α9-nAChRs could also be important for other forms of vestibular plasticity, such as that needed for VOR recovery after vestibular organ injury. We measured the efficacy of VOR compensation in α9 knockout mice. These mice have deletion of most of the gene (chrna9) encoding the nAChR and thereby lack α9-nAChRs. We measured the VOR gain (eye-velocity/head-velocity) in 20 α9 knockout mice and 16 cba129 controls. We measured the sinusoidal (0.2-10Hz, 20-100°/s) and transient (1500-6000°/s2) VOR in complete darkness before (baseline) unilateral labyrinthectomy (UL), and then 1, 5 and 28 days after UL. On day 1 after UL, cba129 mice retained ~50% of their initial function for contralesional rotations, whereas α9 knockout mice only retained ~20%. After 28 days, α9 knockout mice had ~50% lower gain for both ipsilesional and contralesional rotations compared to cba129 mice. Cba129 mice regained ~75% of their baseline function for ipsilesional and ~90% for contralesional rotations. In contrast, α9 knockout mice only regained ~30% and ~50% function, respectively, leaving the VOR severely impaired for rotations in both directions. Our results show that loss of α9-nAChRs severely affects VOR compensation, suggesting that complimentary central and peripheral EVS-mediated adaptive mechanisms might be affected by this loss.



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Rates of performance loss and neuromuscular activity in men and women during cycling: evidence for a common metabolic basis of muscle fatigue

The durations that muscular force and power outputs can be sustained until failure fall predictably on an exponential decline between an individual's 3-s burst maximum to the maximum performance they can sustain aerobically. The exponential time constants describing these rates of performance loss are similar across individuals, suggesting that a common metabolically based mechanism governs muscle fatigue; however, these conclusions come from studies mainly on men. To test whether the same physiological understanding can be applied to women, we compared the performance-duration relationships and neuromuscular activity between seven men [23.3 ± 1.9 (SD) yr] and seven women (21.7 ± 1.8 yr) from multiple exhaustive bouts of cycle ergometry. Each subject performed trials to obtain the peak 3-s power output (Pmax), the mechanical power at the aerobic maximum (Paer), and 11–14 constant-load bouts eliciting failure between 3 and 300 s. Collectively, men and women performed 180 exhaustive bouts spanning an ~6-fold range of power outputs (118–1116 W) and an ~35-fold range of trial durations (8–283 s). Men generated 66% greater Pmax (956 ± 109 W vs. 632 ± 74 W) and 68% greater Paer (310 ± 47 W vs. 212 ± 15 W) than women. However, the metabolically based time constants describing the time course of performance loss were similar between men (0.020 ± 0.003/s) and women (0.021 ± 0.003/s). Additionally, the fatigue-induced increases in neuromuscular activity did not differ between the sexes when compared relative to the pedal forces at Paer. These data suggest that muscle fatigue during short-duration dynamic exercise has a common metabolically based mechanism determined by the extent that ATP is resynthesized by anaerobic metabolism.

NEW & NOTEWORTHY Although men and women differed considerably in their absolute cycling performances, there was no sex difference in the metabolically based exponential time constant that described the performance-duration relationship. Similarly, the fatigue-induced increases in neuromuscular activity were not different between the sexes when compared from a metabolic perspective. These data suggest that men and women have similar rate-limiting mechanisms for short-duration dynamic exercise that are determined by the extent the exercise is supported by anaerobic metabolism.



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Renal sympathetic denervation attenuates hypertension and vascular remodeling in renovascular hypertensive rats

Li P, Huang P, Yang Y, Liu C, Lu Y, Wang F, Sun W, Kong X. Renal sympathetic denervation attenuates hypertension and vascular remodeling in renovascular hypertensive rats. J Appl Physiol 122: 121–129, 2017. First published October 14, 2016; doi:10.1152/japplphysiol.01019.2015.—Sympathetic activity is enhanced in patients with essential or secondary hypertension, as well as in various hypertensive animal models. Therapeutic targeting of sympathetic activation is considered an effective antihypertensive strategy. We hypothesized that renal sympathetic denervation (RSD) attenuates hypertension and improves vascular remodeling and renal disease in the 2-kidney, 1-clip (2K1C) rat model. Rats underwent 2K1C modeling or sham surgery; then rats underwent RSD or sham surgery 4 wk later, thus resulting in four groups (normotensive-sham, normotensive-RSD, 2K1C-sham, and 2K1C-RSD). Norepinephrine was measured by ELISA. Echocardiography was used to assess heart function. Fibrosis and apoptosis were assessed by Masson and TUNEL staining. Changes in mean arterial blood pressure in response to hexamethonium and plasma norepinephrine levels were used to evaluate basal sympathetic nerve activity. The 2K1C modeling success rate was 86.8%. RSD reversed the elevated systolic blood pressure induced by 2K1C, but had no effect on body weight. Compared with rats in the 2K1C-sham group, rats in the 2K1C-RSD group showed lower left ventricular mass/body weight ratio, interventricular septal thickness in diastole, left ventricular end-systolic diameter, and left ventricular posterior wall thickness in systole, whereas fractional shortening and ejection fraction were higher. Right kidney apoptosis and left kidney hypertrophy were not changed by RSD. Arterial fibrosis was lower in animals in the 2K1C-RSD group compared with those in the 2K1C-sham group. RSD reduced plasma norepinephrine and basal sympathetic activity in rats in the 2K1C-RSD group compared with rats in the 2K1C-sham group. These results suggest a possible clinical efficacy of RSD for renovascular hypertension.

NEW & NOTEWORTHY The effects of renal sympathetic denervation (RSD) on hypertension, cardiac function, vascular fibrosis, and renal apoptosis were studied in the 2K1C rat model. Results showed that RSD attenuated hypertension, improved vascular remodeling, and reduced vascular fibrosis through decreased sympathetic activity in the 2K1C rat model, but it did not change the kidney size, renal apoptosis, or renal caspase-3 expression. These results could suggest possible clinical efficacy of RSD for renovascular hypertension.



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Effect of hypohydration on thermoregulatory responses in men with low and high body fat exercising in the heat

It is unclear whether men with low body fat (LO-BF) have impaired thermoregulation during exercise heat stress compared with those with high body fat (HI-BF) when euhydration (EU) is maintained. Furthermore, in LO-BF individuals, hypohydration (HY) impairs thermoregulatory responses during exercise heat stress, but it is unknown whether this occurs in HI-BF counterparts. The purpose of this study was to test the hypotheses that men with HI-BF have impaired thermoregulatory responses to exercise heat stress and that HY further exacerbates these impairments vs. LO-BF. Men with LO-BF [n = 11, body mass (BM) 73.9 ± 8.5 kg, BF% 13.6 ± 3.8] and HI-BF (n = 9, BM 89.6 ± 6.9 kg, BF% 30.2 ± 4.1), in a randomized crossover design, performed 60 min of upright cycling in a hot environment (40.3 ± 0.4°C, relative humidity 32.5 ± 1.9%) at a metabolic heat production rate of 6 W/kg BM and finished exercise either euhydrated (EU; 0.3 ± 1.2 vs. 0.3 ± 0.9% BM loss) or HY (–2.5 ± 1.1 vs. –1.7 ± 1.5% BM loss). Changes in rectal temperature (Trec), local sweat rate (LSR), and cutaneous vascular conductance (CVC; %max) were measured throughout. When EU, LO-BF and HI-BF had similar CVC and LSR responses (P > 0.05); however, LO-BF had a lower Trec vs. HI-BF (0.92 ± 0.35 vs. 1.31 ± 0.32°C, P = 0.021). Compared with EU, HY increased end-exercise Trec in LO-BF (0.47 ± 0.37°C, P < 0.01) but not in HI-BF (–0.06 ± 0.29°C, P > 0.05). HY, compared with EU, did not affect LSR and CVC in either group (P > 0.05). We conclude that, when euhydrated, men with HI-BF have a greater increase in Trec vs. LO-BF but similar CVC and LSR. HY exacerbates increases in Trec in LO-BF but not HI-BF.

NEW & NOTEWORTHY This is the first known investigation to compare thermoregulatory responses to exercise heat stress between men with high and low body fat (BF) in a physiologically uncompensable environment while simultaneously examining the confounding influence of hydration status. Both groups demonstrated similar sweating and cutaneous vasodilatory responses when euhydrated, despite vast differences in rectal temperature. Furthermore, in contrast to low BF, individuals with high BF demonstrated similar increases in core body temperature when either euhydrated or hypohydrated.



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Intraoperative Hypotonie: Pathophysiologie und klinische Relevanz

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 16-27
DOI: 10.1055/s-0042-106052



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
Table of contents  |  CME online  |  Full text



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Mechanische Reanimationshilfen innerklinisch genutzt

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 6-6
DOI: 10.1055/s-0042-121862



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Praxisbuch Beatmung

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 13-13
DOI: 10.1055/s-0042-103729



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Eine Geschichte von Nervenblockaden und Ergebnissen

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 6-7
DOI: 10.1055/s-0042-121865



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Muss Metformin wegen der Gefahr der Laktatazidose 48 h vor OP abgesetzt werden?

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 66-69
DOI: 10.1055/s-0042-121635



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Infektionen: Molekulargenetischer Test statt Blutkulturen

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 7-8
DOI: 10.1055/s-0042-121861



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Medikamente im Rettungsdienst

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 13-13
DOI: 10.1055/s-0042-109764



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Schlaganfall: Anästhesie bei endovaskulärer Therapie

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 8-9
DOI: 10.1055/s-0042-121863



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Intraoperative Hypotonie: Therapie

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 45-54
DOI: 10.1055/s-0042-106074



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Personalisierte Antibiotikatherapie

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 10-10
DOI: 10.1055/s-0042-122171



Georg Thieme Verlag KG Stuttgart · New York

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Stark überlastete Notaufnahmen und Rettungsdienste

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 12-12
DOI: 10.1055/s-0042-122174



Georg Thieme Verlag KG Stuttgart · New York

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Notfalldaten auf elektronischer Gesundheitskarte

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 10-11
DOI: 10.1055/s-0042-122172



Georg Thieme Verlag KG Stuttgart · New York

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Weiterbildung Schmerzmedizin

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 13-13
DOI: 10.1055/s-0042-104432



Georg Thieme Verlag KG Stuttgart · New York

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DIVI unterstützt Bundesmedikationsplan für mehr Patientensicherheit

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 10-10
DOI: 10.1055/s-0042-122175



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Intraoperative Hypotonie: Werden Sie Homöostatiker!

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 14-15
DOI: 10.1055/s-0042-121853



Georg Thieme Verlag KG Stuttgart · New York

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Europaweite Studie zu Antibiotikaresistenz in Krankenhäusern

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 11-12
DOI: 10.1055/s-0042-122176



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Intraoperative Hypotonie: Bedeutung und Monitoring in der klinischen Praxis

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 29-44
DOI: 10.1055/s-0042-107915



Georg Thieme Verlag KG Stuttgart · New York

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Reform der Notfallambulanzen bedroht Kliniken

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 12-12
DOI: 10.1055/s-0042-122173



Georg Thieme Verlag KG Stuttgart · New York

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Notfälle im Rettungsdienst und in der Klinik: Gefäßzugänge bei Kindern

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 55-64
DOI: 10.1055/s-0042-104853

Der i. v. Gefäßzugang ist im Notfall zwingend notwendig, um Medikamente und/oder Flüssigkeiten zuführen zu können. Gerade aber bei kleinen Kindern oder Säuglingen ist die Punktion peripherer Venen mitunter schwierig und in einer zeitkritischen Situation häufig auch sehr stressbelastet. In solchen Situationen muss der Anwender Alternativen zur etablierten Venenpunktion kennen und Hilfsmittel beherrschen können. Im Rettungsdienst sind die intraossären (i. o.) Gefäßzugänge ohne Verzögerung anzuwenden, falls die peripheren Venenpunktion nicht zügig garantiert werden kann. Obwohl inzwischen zahlreiche transportable Ultraschallgeräte auf dem Markt sind, die auch im Rettungsdienst eingesetzt werden können, sind diese zurzeit noch nicht flächendeckend im außerklinischen Alltag verfügbar. Nach Stabilisierung der Vitalfunktionen und Transport ins Krankenhaus kann die Anlage eines periphervenösen (PVK) oder zentralvenösen Katheters (ZVK) erwogen werden, um einen bereits liegenden i. o. Zugang zu ersetzen. In dieser Übersicht sollen die gängigen Gefäßzugänge bei Kindern und Säuglingen besprochen, Alternativen diskutiert und zentrale Punktionstechniken beschrieben werden. Die Anwendung des Ultraschalls zu Gefäßpunktion nimmt einen immer größeren Stellenwert ein. Daher werden auch ultraschallbasierte Techniken vorgestellt. Die Sonografie kann die Anlage von peripheren Verweilkanülen und/oder zentralvenösen Kathetern beim pädiatrischen Patienten in innerklinischen Notfallsituationen oder bei schwierigen Venenverhältnissen erheblich erleichtern.Abstract: Vascular access is necessary for the administration of medication and for the collection of blood samples in an emergency. Peripheral venous access is occasionally difficult in infants and younger children, particularly during emergencies. However, reliable vascular access and prompt treatment are required in these circumstances to successfully treat the patient. During the rescue service, immediate establishment of the intraosseous vascular access is very important, in case peripheral vascular access cannot be established rapidly. Although numerous transportable ultrasound machines have been developed, which may be utilized during rescue service, relatively difficult access hampers their application during the rescue service. After stabilizing vital functions and transportation to the hospital, peripheral venous access or central venous access can be attempted again in order to replace intraosseous vascular access. In this manuscript, we first discuss intraosseous vascular access as an alternative vascular access technique, which can be attempted during the rescue service. Next, we introduce ultrasound-guided and other techniques for peripheral and central vascular access as potential alternatives for pediatric patients with difficult vascular access or in-hospital emergency situations. Timely decision-making and prompt utilization of alternative procedures to achieve unimpeded vascular access is essential for the treatment and survival of pediatric patients in an emergency.
[...]

Georg Thieme Verlag KG Stuttgart · New York

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Pssst … AINS-Secrets: Heute aus der Gynäkologie

Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 70-74
DOI: 10.1055/s-0042-101637



Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Diet-induced dysmotility and neuropathy in the gut precedes endotoxemia and metabolic syndrome: the chicken and the egg revisited

Abstract

Neuropathy of the enteric nervous system (ENS) is one of the major underlying causes of debilitating gastrointestinal (GI) motility disorders in diabetic patients.

This article is protected by copyright. All rights reserved



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Mitochondrial adaptations to exercise in human skeletal muscle: a possible role for cristae density as a determinant of muscle fitness

Abstract

Skeletal muscle possesses a remarkable plasticity in response to repeated exercise challenges (i.e. exercise 'training'). A hallmark phenotypic change is an increase in the ability to sustain contraction and resist fatigue. Such increased muscle endurance is linked, in part, to an improved ability to sustain ATP synthesis aerobically through coordinated enhancements in the delivery of oxygen (e.g. cardiorespiratory, vascular adaptations) and its utilization within skeletal muscle mitochondria for the oxidation of fat and carbohydrates.

This article is protected by copyright. All rights reserved



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Ghrelin ameliorates blood brain barrier disruption in the systemic hypoxia

Abstract

The blood brain barrier (BBB), which serves to protect homeostasis of the central nervous system, is formed by tight junction proteins. Several studies have indicated that systemic hypoxia leads to cerebral edema through disruption of the tight junction proteins such as occludin and zonula occludens-1 (ZO-1). According to our previous studies ghrelin attenuates cerebral edema in the hypoxic brain. However, its mechanisms are not completely understood. The present study was aimed to determine the effect of ghrelin on occludin and Zo-1 in the hypoxic brain. Adult male Wistar rats were divided into acute and chronic controls, acute or chronic hypoxia, and ghrelin- treated acute or chronic hypoxia groups. Hypoxic groups were kept in a hypoxic chamber (O2 10–11%) for two days (acute) or ten days (chronic). Effects of ghrelin on occludin and ZO-1 protein levels were assessed using western blotting. Western blot analysis revealed that ZO-1 and occludin protein expression significantly decreased in acute and chronic hypoxia. Ghrelin significantly increased ZO-1 protein expression in both acute and chronic hypoxia (P < 0.05). Ghrelin also increased occludin protein expression in chronic hypoxia (P < 0.05), but did not effectively change it in acute hypoxia. Our data showed that ghrelin injection maintains occludin and ZO-1 tight junction proteins which may improve the integrity of the BBB in hypoxic condition.

This article is protected by copyright. All rights reserved



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Slower but not faster unilateral fatiguing knee extensions alter contralateral limb performance without impairment of maximal torque output

Abstract

Purpose

The purpose of the present study was to examine the effects of unilateral fatigue of the knee extensors at different movement velocities on neuromuscular performance in the fatigued and non-fatigued leg.

Methods

Unilateral fatigue of the knee extensors was induced in 11 healthy young men (23.7 ± 3.8 years) at slower (60°/s; FAT60) and faster movement velocities (240°/s; FAT240) using an isokinetic dynamometer. A resting control (CON) condition was included. The fatigue protocols consisted of five sets of 15 maximal concentric knee extensions using the dominant leg. Before and after fatigue, peak isokinetic torque (PIT) and time to PIT (TTP) of the knee extensors as well as electromyographic (EMG) activity of vastus medialis, vastus lateralis, and biceps femoris muscles were assessed at 60 and 240°/s movement velocities in the fatigued and non-fatigued leg.

Results

In the fatigued leg, significantly greater PIT decrements were observed following FAT60 and FAT240 (11–19%) compared to CON (3–4%, p = .002, d = 2.3). Further, EMG activity increased in vastus lateralis and biceps femoris muscle following FAT240 only (8–28%, 0.018 ≤ p ≤ .024, d = 1.8). In the non-fatigued leg, shorter TTP values were found after the FAT60 protocol (11–15%, p = .023, d = 2.4). No significant changes were found for EMG data in the non-fatigued leg.

Conclusion

The present study revealed that both slower and faster velocity fatiguing contractions failed to show any evidence of cross-over fatigue on PIT. However, unilateral knee extensor fatigue protocols conducted at slower movement velocities (i.e., 60°/s) appear to modulate torque production on the non-fatigued side (evident in shorter TTP values).



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Developing a Quality Assurance System for Multiple Evidence Based Practices in a Statewide Service Improvement Initiative

Abstract

Efforts to implement evidence based practices (EBP) are increasingly common in child-serving systems. However, public systems undertaking comprehensive improvement efforts that aim to increase availability of multiple practices at the same time may struggle to build comprehensive and user-friendly strategies to develop the workforce and encourage adoption, faithful implementation, and sustainability of selected EBPs. Given that research shows model adherence predicts positive outcomes, one critical EBP implementation support is systematic quality, fidelity, and compliance monitoring. This paper describes the development and initial implementation of a quality assurance framework for a statewide EBP initiative within child welfare. This initiative aimed to improve provider practice and monitor provider competence and compliance across four different EBPs, and to inform funding and policy decisions. The paper presents preliminary data as an illustration of lessons learned during the quality monitoring process and concludes with a discussion of the promise and challenges of developing and applying a multi-EBP quality assurance framework for use in public systems.



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The Consistencies and Vagaries of the Washington State Inventory of Evidence-Based Practice: The Definition of “Evidence-Based” in a Policy Context

Abstract

As states increasingly establish the importance of evidence-based practice through policy and funding mandates, the definition of evidence-based practice can have a significant impact on investment decisions. Not meeting established criteria can mean a loss of funding for established programs and the implementation disruption of programs without a strong research base. Whether the definition of "evidence-based" is influenced by these high stakes contexts is an interesting question that can inform the larger field about the value and utility of evidence-based practice lists/inventories for disseminating knowledge. In this paper we review the development of the Washington State Inventory of Evidence-Based, Research-Based and Promising Practices as a case study for the process of defining evidence-based practice in a policy context. As part of this study we also present a comparison of other well-known evidence-based practice inventories and examine consistencies and differences in the process of identifying and developing program ratings.



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Community-Sourced Intervention Programs: Review of Submissions in Response to a Statewide Call for “Promising Practices”

Abstract

This study was initiated to add to the nascent literature on locally-grown intervention programs in the youth mental health, child welfare, and juvenile justice service sectors, many of which demonstrate practice-based or community-defined evidence, but may not have been subjected to empirical evaluation. Characteristics of applications submitted in response to three public calls for additions to an inventory of research-supported intervention programs were reviewed on evidence for effectiveness, the use of key quality assurance (QA) elements (e.g., clearly specified training or integrity monitoring procedures), and cultural specificity. Findings indicate that four QA processes were identified in approximately half of all submissions: a specific initial training process, the existence of intervention integrity measures, routine outcome monitoring, and ongoing support post-training. An initial training process and integrity measurement were more commonly described among programs determined to have greater research evidence for their effectiveness. Overall, cultural elements were described relatively infrequently and most often reflected surface-level program delivery characteristics (e.g., offering services in languages other than English). Discussion is focused on the alignment of submitted programs with the larger literatures focused on implementation science and cultural competence.



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Introduction to the Special Issue: Legislation Related to Children’s Evidence-Based Practice



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Community Engagement Strategies for Implementation of a Policy Supporting Evidence-Based Practices: A Case Study of Washington State

Abstract

After nearly two decades of cultivating an evidence based practice milieu in Washington State, the 2012 legislature passed House Bill 2536 (HB 2536) to promote the increased uptake and use of evidence based practices in the child welfare, juvenile justice and child behavioral health systems. The current paper examines stakeholder participation and engagement in HB 2536 during the first year of its implementation. The current paper describes the community response, influence, and engagement during the drafting of the bill language. It then describes initial policy implementation and community engagement efforts within a framework of implementation strategies (Powell et al. in Medical Care Research and Review 69:123–57, 2012). Analysis includes common concerns, statements of support, and suggestions from diverse stakeholder groups. Discussion reviews the lessons learned and future directions, including opportunities for additional collaborations with community stakeholders in the subsequent years of HB 2536 implementation.



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Red light runners: Worst of 2016

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Prescription opioid facts

The Centers for Disease Control and Prevention discuss prescription opioids and the serious risks and side effects they have.

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Prescription opioid facts

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Red light runners: Worst of 2016

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Prescription opioid facts

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Prescription opioid facts

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Paramedic I - Louisville Metro Emergency Services

ESSENTIAL FUNCTIONS Provides emergency medical treatment including the injections of drugs and medications and intravenous fluids to injured, sick, or incapacitated persons Operates an emergency medical vehicle Lifts, carries and transports injured, sick or incapacitated persons from residential or accident scenes to medical facilities EXAMPLES OF WORK Restores, defibrillates and stabilizes heart rhythm ...

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EMT - Louisville Metro Emergency Services

ESSENTIAL FUNCTIONS Operates an emergency medical vehicle Lifts, carries and transports injured, sick or incapacitated persons from residential or accident scenes to medical facilities Provides emergency medical treatment to injured, sick or incapacitated persons EXAMPLES OF WORK Communicates with professional medical personnel at emergency treatment facility to obtain instructions regarding treatment ...

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Red light runners: Worst of 2016

This video features some of the worst clips of drivers running red lights in 2016.

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Prescription opioid facts

The Centers for Disease Control and Prevention discuss prescription opioids and the serious risks and side effects they have.

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Prescription opioid facts

The Centers for Disease Control and Prevention discuss prescription opioids and the serious risks and side effects they carry.

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Prescription opioid facts

The Centers for Disease Control and Prevention discuss prescription opioids and the serious risks and side effects they have.

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Red light runners: Worst of 2016

This video features some of the worst clips of drivers running red lights in 2016.

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Prescription opioid facts

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Circulating Endothelial Progenitor Cells in Crohn’s Disease: An EPiC in the Making?



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Effectiveness and Safety of Entecavir or Tenofovir in a Spanish Cohort of Chronic Hepatitis B Patients: Validation of the Page-B Score to Predict Hepatocellular Carcinoma

Abstract

Background

Long-term antiviral therapy has resulted in viral suppression and biochemical response in chronic hepatitis B, although the risk of hepatocellular carcinoma has not been abolished. The Page-B score could be useful to estimate the probability of HCC.

Aims

To analyze the effectiveness and safety of entecavir or tenofovir for more than 4 years and the usefulness of Page-B score in the real-world setting.

Methods

Analysis of Caucasian chronic hepatitis B subjects treated with entecavir or tenofovir from the prospective, multicenter database CIBERHEP.

Results

A total of 611 patients were enrolled: 187 received entecavir and 424 tenofovir. Most were men, mean age 50 years, 32% cirrhotic and 16.5% HBeAg-positive. Mean follow-up was 55 (entecavir) and 49 (tenofovir) months. >90% achieved HBV DNA <69 IU/mL and biochemical normalization by months 12 and 36, respectively. Cumulative HBeAg loss and anti-HBe seroconversion were achieved by 33.7 and 23.8%. Four patients lost HBsAg; three HBeAg-positive. Renal function remained stable on long-term follow-up. Fourteen (2.29%) developed HCC during follow-up all of them with baseline Page-B ≥10. Nine were diagnosed within the first 5 years of therapy. This contrasts with the 27 estimated by Page-B, a difference that highlights the importance of regular HCC surveillance even in patients with virological suppression.

Conclusions

Entecavir and tenofovir achieved high biochemical and virological response. Renal function remained stable with both drugs. A Page-B cut-off ≥10 selected all patients at risk of HCC development.



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Decreased Risk of Preeclampsia After the Introduction of Universal Voucher Scheme for Antenatal Care and Birth Services in the Republic of Korea

Abstract

Objectives A number of interventions to reduce disparities in maternal health have been introduced and implemented without concrete evidence to support them. In Korea, a universal voucher scheme for antenatal care and birth services was initiated in December 2008 to improve Korea's fertility rate. This study explores the risk of preeclampsia after the introduction of a universal voucher scheme. Methods Population-based cohort data from the National Health Insurance Service–National Sample Cohort (NHIS-NSC) covering 2002–2013 were analysed. A generalized linear mixed model (GLMM) was used to estimate the relationship between the risk of preeclampsia and voucher scheme introduction. Results The annual age-adjusted incidence of preeclampsia showed no significant unidirectional change during the study period. In the GLMM analysis, the introduction of a voucher scheme was associated with a reduced risk of preeclampsia, controlling for potential confounding factors. The interaction between household income level and voucher scheme was not significant. Conclusions for Practice This finding suggests that the introduction of a voucher scheme for mothers is related to a reduced risk of preeclampsia even under universal health coverage.



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Self-Care for Health in Rural Hispanic Women at Risk for Postpartum Depression

Abstract

Objective

To determine factors that affect self-care of rural Hispanic women at risk for postpartum depression (PPD).

Methods

This study was a descriptive cross-sectional design based on the key concepts of Orem's Self-care Deficit Nursing theory. Data were collected from 223 Hispanic postpartum women residing in Mecca, North Shore, and Thermal in California by an interviewer-administered survey. Four instruments were utilized: Edinburgh Postnatal Depression Scale (EPDS) for PPD, Multidimensional Scale of Perceived Social Support for social support, Duke University Religion Index (DUREL) for spirituality, and Self Rated Abilities for Health Practices for self-care.

Results

The prevalence of women at risk for PPD was about 43 %. Social support, spirituality, and self-care ability were significantly correlated in women with PPD. Social support was a strong factor in predicting self-care ability for 'Nutrition', 'Psychological well-being', 'Exercise', and 'Responsible Health Practices' in the rural Hispanic women at risk for PPD.

Conclusions

The study findings can enable nurses and healthcare professionals to develop effective tailored interventions to assist rural Hispanic women's abilities to perform self-care for health, and in particular, during the postpartum period.



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State-Level Immunization Information Systems: Potential for Childhood Immunization Data Linkages

Abstract

Objectives Sources of immunization data include state registries or immunization information systems (IIS), medical records, and surveys. Little is known about the quality of these data sources or the feasibility of using IIS data for research. We assessed the feasibility of collecting immunization information for a national children's health study by accessing existing IIS data and comparing the completeness of these data against medical record abstractions (MRA) and parent report. Staff time needed to obtain IIS and MRA data was assessed. Methods We administered a questionnaire to state-level IIS representatives to ascertain availability and completeness of their data for research and gather information about data formats. We evaluated quality of data from IIS, medical records, and reports from parents of 119 National Children's Study participants at three locations. Results IIS data were comparable to MRA data and both were more complete than parental report. Agreement between IIS and MRA data was greater than between parental report and MRA, suggesting IIS and MRA are better sources than parental report. Obtaining IIS data took less staff time than chart review, making IIS data linkage for research a preferred choice. Conclusions IIS survey results indicate data can be obtained by researchers using data linkages. IIS are an accessible and feasible child immunization information source and these registries reduce reliance on parental report or medical record abstraction. Researchers seeking to link IIS data with large multi-site studies should consider acquiring IIS data, but may need strategies to overcome barriers to data completeness and linkage.



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Attachment to Conventional Institutions and Adolescent Rapid Repeat Pregnancy: A Longitudinal National Study Among Adolescents in the United States

Abstract

Introduction There is limited research on rapid repeat pregnancies (RRP) among adolescents, especially using nationally representative samples. We examine distal factors—school, family, peers, and public/private religious ties—and their associations with RRP among adolescent mothers. Methods Guided by social development theory, we conducted multivariate logistic regression analyses, adjusted for sociodemographic characteristics, to examine associations between RRP and attachment to school, family, peers, and religion among 1158 female respondents from the National Longitudinal Study of Adolescent to Adult Health (Add Health) who reported at least one live birth before age 20. Results Attachments to conventional institutions were associated with lower likelihood of RRP. Adolescent mothers who had a stronger relationship with their parents had reduced odds of RRP (adjusted odds ratio [aOR] 0.83, 95 % CI 0.71–0.99). Increased odds of RRP were associated with anticipating fewer negative social consequences of sex (aOR 1.18, 95 % CI 1.02–1.35), never praying (versus praying daily; aOR 1.47, 95 % CI 1.10–1.96), and never participating in church-related youth activities (versus participating once a week; 1.04, 95 % CI 1.01–1.07). Discussion After an adolescent birth, social support from family, peers, and the community can benefit young mothers. Private aspects of religiosity may be especially important. Understanding the processes by which these distal factors are linked to the likelihood of RRP is needed to create multifaceted intervention programs that provide diverse methods of support customized to specific circumstances of adolescent mothers.



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Barriers in the Uptake and Delivery of Preconception Care: Exploring the Views of Care Providers

Abstract

Objectives To examine health care professionals' views of their role and responsibilities in providing preconception care and identify barriers that affect the delivery and uptake of preconception care. Methods Twenty health care professionals who provide preconception care on a regular basis were interviewed using semi-structured interviews. Results We interviewed twelve community midwives, three General Practitioners, three obstetricians, one cardiologist specialized in congenital heart diseases and one gastroenterologist.We identified four barriers affecting the uptake and delivery of preconception care (PCC): (1) lack of a comprehensive preconception care program; (2) limited awareness of most future parents about the benefits of preconception care, hesitance of GP's about the necessity and effectiveness of PCC; (3) poor coordination and organization of preconception care; (4) conflicting views of health care professionals on pregnancy, reproductive autonomy of patients and professional responsibility. Conclusion We have identified four barriers in the uptake and delivery of preconception care. Our findings support the timely implementation of a comprehensive program of PCC (already advocated by the Health Council of the Netherlands) and increasing awareness and knowledge of PCC from care providers and future parents. We emphasize the need for further research on how organizational barriers lead to suboptimal PCC and how interdisciplinary collaboration and referral can lead to optimally tailored intervention approaches.



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Weight-Gain Velocity in Newborn Infants Managed with the Kangaroo Method and Associated Variables

Abstract

Objectives The Kangaroo method helps promote maternal breastfeeding and adequate growth of low birthweight preterm infants. The objective of this study was to analyze the association between weight-gain velocity during use of the Kangaroo method and maternal and infant variables. Methods A nested cross-sectional study in a cohort of newborn infants managed using the Kangaroo method was carried out at a reference center for the method in Brazil. Data on low birthweight and preterm infants managed using the Kangaroo Method (n = 78) and on their respective mothers (n = 70) was collected between January and July 2014. Maternal and infant variables were associated and correlated with weight-gain velocity (g/kg/day) at each phase of the method (p < 0.05). Results Mean weight-gain velocity increased from 0.12 ± 11.11 g/kg/day in the first phase to 13.47 ± 4.84 g/kg/day in the third phase (p < 0.001), and percentage of adequate weight increased at phase 3 (p < 0.001). Birthweight was inversely correlated with weight-gain velocity at phases 1 and 2 of the Kangaroo method. Birthweight of under 1500 g was associated with a lower likelihood of inadequate weight-gain velocity of the newborn at phase 1 (OR = 0.1; 95 % CI 0.01–0.78; p = 0.012). In phase 3, maternal age was directly correlated with weight-gain velocity. Conclusions Weight-gain velocity was associated with maternal (age) and infant (gestational age at birth, birthweight, weight for gestational age at birth, length of hospital stay and five-minute Apgar score) variables. Knowledge of the factors influencing weight-gain velocity and its behavior at each phase of the method can help guide conduct toward potentializing factors that promote adequate weight-gain.



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Weight Misperception and Health-Related Quality of Life in Appalachian Adolescents in the United States

Abstract

Introduction There is limited research on the relation between weight misperceptions and health-related quality of life (HRQoL) among U.S. adolescents. Methods Baseline data (n = 1509) collected in 2012 from the Team Up for Healthy Living project were used. Measures included BMI percentiles calculated from measured height and weight; self-perception of weight status; and the 23-item PedsQL™ Inventory. Multiple linear regression was performed after adjustment for covariates to examine associations between weight misperception and HRQoL. Results Compared to accurate weight perception, weight underestimation was associated with higher total HRQoL (β = 2.41), physical health (β = 2.77), and emotional (β = 2.83), social (β = 2.47) and psychosocial functioning (β = 2.38) (all p < 0.05). Weight overestimation was associated with lower social functioning (β = −13.13, p < 0.05). Stratified by gender, associations were observed only in males. Discussion Weight underestimation had greater association with HRQoL than weight overestimation; and varied by gender. Better understanding of these associations will assist in improving the health of adolescents in Southern Appalachia.



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Can Discipline Education be Culturally Sensitive?

Abstract

Objectives Inappropriate discipline such as harsh physical punishment is a social determinant of health. The objective was to determine if a brief parent training intervention that teaches discipline strategies is culturally sensitive. Methods English or Spanish-speaking parents of 1–5 year old children viewed a multimedia program that teaches appropriate discipline strategies. The intervention, Play Nicely, was viewed in the exam room before the physician's visit. Parents viewed 4 of 20 discipline strategies of their choosing; the average viewing time was 7 min. Results Of 204 parents eligible to participate, 197 (96 %) completed the study; 41 % were Black, 31 % were White, and 21 % were Hispanic. At least 80 % of parents from each racial/ethnic group reported that the program built their confidence to care for their child, addressed their family needs, explained things in a way they could understand, respected their family values, and was sensitive to their personal beliefs. Overall, 80 % of parents reported that the program answered individual questions. One parent (0.5 %) reported that the program did not respect her family values. Conclusions for Practice Discipline education can be integrated into the pediatric primary care clinic in a way that is family-centered and culturally sensitive for the majority of parents. The results have implications for the development and implementation of population-based parenting programs and the primary prevention of child abuse and violence.



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Motor Skill Competence and Physical Activity in Preschoolers: A Review

Abstract

Objectives Preschoolers 3–5 years of age are in a crucial stage of motor skill competence. While preschoolers develop their motor skill competence through engagement in physical activity, a majority of them fail to meet guideline-recommended physical activity level. This study reviews scientific evidence on the relationship between motor skill competence and physical activity among preschoolers. Methods This systematic review followed the PRISMA framework. Keyword and reference search were conducted in PubMed, Cochrane Library, PsycINFO, Web of Science, and Google Scholar. Inclusion criteria included—age: 3–5 years of age; setting: preschool environment (e.g., preschool, childcare, head start); main outcomes: motor skill competence and physical activity; study design: cross-sectional study, case–control study, retrospective cohort study, prospective cohort study, or randomized controlled trial; language: English; and article type: peer-reviewed publication. Results Eleven studies met the inclusion criteria, including 6 randomized controlled trials and 5 cross-sectional studies. Studies were conducted in 5 countries: United States (5), United Kingdom (2), Australia (2), Switzerland (1), and Finland (1). Eight out of the 11 studies included in the review reported a significant relationship between motor skill competence and physical activity. The specific pattern and strength of the relationship tend to differ by gender, physical activity intensity, motor skill type, and day of the week (weekdays versus weekends). Conclusions An association has been consistently documented between motor skill competence and physical activity. Future research is warranted to elucidate the underlining causal link, examine potential heterogeneity, and determine the role of environment in the relationship between motor skill competence and physical activity among preschoolers.



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Disparities in Quality and Access to Care for Children with Developmental Disabilities and Multiple Health Conditions

Abstract

Background

The Maternal Child Health Bureau identified six indicators of quality and accessibility essential in achieving coordinated, family-centered, community-based care for children with special healthcare needs (CSHCN). Previous research examined associations between children with single conditions and individual indicators. We sought to identify disparities in meeting quality and accessibility indicators for children with different condition types.

Methods

The 2009–2010 National Survey of CSHCN is a nationally representative cross-sectional study with caregiver's reports on 40,242 children (0–17 years). Children were categorized into one of seven conditions groups: physical health (PHC), mental health (MHC), developmental disability (DD), physical and mental (PHC and MHC), physical and developmental (PHC and DD), mental and developmental (MHC and DD) and physical, mental and developmental (PHC, MHC, and DD). Unadjusted and adjusted analyses determined associations between condition group and quality and access indicators.

Results

Children with DD, alone or in combination with another condition, were significantly less likely to meet each indicator (p < 0.01) after adjusting for individual demographic, child's activity limitations and family-related characteristics. Compared with children with PHC, those with all three conditions (PHC, MHC, and DD) had the lowest odds of access to medical home (61 % decreased odds (DO)), community services (67 % DO), and adequate insurance (26 % DO); MHC and DD had the lowest odds of partnering in decision making (51 % DO); DD had the lowest odds of healthcare transition service (66 % DO).

Conclusions

Children with DD and multiple conditions experience disparities in quality and access to healthcare services, meeting most indictors half as often as other CSHCN.



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Tenn. ambulance overturns on highway, 1 ejected

Officials said it is unclear if the man was ejected from the ambulance or another vehicle

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Wrong-way driver killed after crashing into Wash. ambulance

Two EMS providers and a patient were transported to the hospital for minor injuries

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Oral tactile sensitivity and masticatory performance are impaired in stroke patients

Abstract

Background

Orofacial impairment following stroke frequently involves reduced chewing performance, i.e., oral phase dysphagia.

Objective

To investigate the sensitivity of oral tissues following stroke and its potential impact on masticatory function.

Methods

Hospitalized post-stroke patients were recruited and compared to healthy controls. Outcome measures comprised masticatory performance employing a colour-mixing ability-, i.e. bolus-kneading test, maximum lip and bite force, and the one-point and two-point tactile thresholds. Food hoarding and prevalence of dry mouth were evaluated with ordinal scales.

Results

Twenty-seven stroke patients (age 64.3±14.1 years) and 27 healthy controls (age 60.8±14.3 years, p=0.254) participated in this study. The groups had similar numbers of occluding units, but stroke patients reported more frequently dry mouth sensations and food hoarding. The intra-oral tactile sensitivity on the contra-lesional side was significantly lower in stroke patients compared to controls (0.0001<p<0.0002), and significant intra-group side differences were found only in the stroke group (0.0001<p<0.0010). For the lip, both sides were less sensitive in the stroke group compared with controls. The experiments confirmed lower masticatory performance and lip force in the stroke group, but the bite force was similar compared to healthy controls. Oral sensitivity was correlated with masticatory performance when a global correlation model was applied.

Conclusions

A stroke may affect the sensitivity of the intra-oral tissues contra-lesionally, thus potentially affecting chewing function. Rehabilitation should therefore not only focus on motor impairment, but equally stimulate the sensitivity of the oral tissues, employing dry ice application or similar specific treatments.



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Remember 2 Things: Piercings and airway management

Steve Whitehead, host of Remember 2 Things, breaks down two things to think about when you encounter a patient with piercings in their airway while you're trying to manage it.

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Remember 2 Things: Two pieces of PPE you're not using enough

Steve Whitehead, host of Remember 2 Things, explains why eye and ear protection should be used on every single call.

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Remember 2 Things: Self-motivated learners

Steve Whitehead, host of Remember 2 Things, encourages and explains how self-motivated learners can positively influence and expand their organization.

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Remember 2 Things: Piercings and airway management

Steve Whitehead, host of Remember 2 Things, breaks down two things to think about when you encounter a patient with piercings in their airway while you're trying to manage it.

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Remember 2 Things: Two pieces of PPE you're not using enough

Steve Whitehead, host of Remember 2 Things, explains why eye and ear protection should be used on every single call.

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Remember 2 Things: Self-motivated learners

Steve Whitehead, host of Remember 2 Things, encourages and explains how self-motivated learners can positively influence and expand their organization.

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Remember 2 Things: Piercings and airway management

Steve Whitehead, host of Remember 2 Things, breaks down two things to think about when you encounter a patient with piercings in their airway while you're trying to manage it.

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Remember 2 Things: Two pieces of PPE you're not using enough

Steve Whitehead, host of Remember 2 Things, explains why eye and ear protection should be used on every single call.

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Remember 2 Things: Self-motivated learners

Steve Whitehead, host of Remember 2 Things, encourages and explains how self-motivated learners can positively influence and expand their organization.

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Remember 2 Things: Piercings and airway management

Steve Whitehead, host of Remember 2 Things, breaks down two things to think about when you encounter a patient with piercings in their airway while you're trying to manage it.

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Remember 2 Things: Two pieces of PPE you're not using enough

Steve Whitehead, host of Remember 2 Things, explains why eye and ear protection should be used on every single call.

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Remember 2 Things: Self-motivated learners

Steve Whitehead, host of Remember 2 Things, encourages and explains how self-motivated learners can positively influence and expand their organization.

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How to use SALT to triage MCI patients

When needs outstrip resources it is appropriate to call for help, but rather than to wait for the resources to come to you, EMS providers can use SALT to move patients forward to resources.

SALT, which stands for Sort, Assess, Lifesaving interventions, Treatment and/or transport is the four step process for responders to manage mass casualty incidents proposed by the National Association of EMS Physicians as part of a Centers for Disease Control and Prevention sponsored project to use the best available science and expert opinion to develop a standard guideline for mass casualty management [2]. SALT, endorsed by more than a dozen national emergency medicine and EMS organizations, along with the Model Uniform Core Criteria for Triage, provides a framework of clear, simple steps that field providers can use to bring order to chaos and help improve patient outcome [2].

Establish command and control

The heart of SALT is the idea that providers focus on the prioritized movement of patients away from the incident that is making more patients and towards safety and the resources to care for them. For SALT to work, a mass casualty incident must first be identified and declared. Because MCI identification differs for every EMS service, each provider must know the MCI threshold for their system.

Regardless of whether they are an MCI officer or a caregiver, each responder must focus on their role in facilitating the movement of patients away from the patient generator, which is the thing that is making more patients or making them sicker. Move patients forward to a casualty collection point, which is a safer place where they can be sorted and prioritized for further forward movement to treatment areas and transport to receiving facilities.

As command and control is established, EMS providers should grab their mass casualty triage tags and any MCI equipment that they intend to use to begin patient triage. Here is how to apply SALT.

Sort the Walkers, the Wavers and the Still

Rapidly prioritize the patients using global sorting. This will help efficiently assess, administer lifesaving interventions and ultimately treat and transport the patients.

Announce to all involved, using a public address system or loudspeaker, "Everyone who can hear me, move to [the safe area you have designated] and we will help you."

Give strong, loud and clear visual and verbal commands. Those who respond first will be the last patients to assess, but they may be able to assist with moving more critical patients forward. These patients are the Walkers.

To the patients who remain in place say, "If you need help, wave your arm or move your leg and we will be there to help you as soon as we can."

These patients who can follow commands but cannot move themselves are the Wavers and the second priority for assessment.

Remember that some patients may be ambulatory, yet opt to stay with another injured patient. Other patients may be able to move and decide to assist a non-ambulatory patient. This is okay. Sorting is simply an easy way for the first arriving EMS units to begin moving patients forward to care.

Those who are Still and have not yet moved or responded to you are the first patients that you need to assess and possibly care for.

Assessment/Lifesaving interventions

With the SALT system, assessment and lifesaving interventions go hand in hand. There is no timing radial pulses or counting respirations in a SALT assessment, only answering simple yes-and-no questions.

When you assess and find a life threat you should provide a lifesaving intervention as long as it does not take longer than a minute and does not require you or another EMS provider to stay with the patient. For example, if you find that a patient has massive hemorrhage, provide rapid bleeding control with a tourniquet.

If a patient's airway is closed, open it. If that patient is a child or infant, consider giving them two breaths.

If you are an ALS provider, it may be appropriate to provide needle decompression, auto-injector chemical toxin antidotes or other lifesaving interventions that take less than a minute to administer and do not require you to stay with the patient.

Remember, to maintain forward movement of patients, you must also maintain forward movement of EMS providers. That is, if a patient needs lifesaving interventions and you are immediately ready to give them, do so and move on to the next patient. Do not stop during assessment and lifesaving interventions to fetch a piece of equipment or restock supplies. Patients must continue to move forward to the casualty collection point next, then to the treatment area and eventually to transport to receiving facilities.

As you assess and provide lifesaving interventions, categorize or tag patients by priority. SALT and MUCC triage works as follows.

Dead (black triage tape or tag)

Patients with injuries incompatible with life or without spontaneous respirations are triaged as deceased. Assess the following:

  • Adult patient is not breathing after opening airway.
  • Child is not breathing after opening airway and giving 2 breaths.

Patients tagged Dead do not move forward from the point of injury to the casualty collection point.

Immediate (red triage tape or tag)

Patients with severe injuries, but high potential for survival with treatment such as victims of tension pneumothorax, assess the following:

  • Does the patient have a peripheral pulse"
  • Is the patient not in respiratory distress"
  • Is hemorrhage controlled"
  • Does the patient follow commands or make purposeful movements"

A "no" answer to any of these questions and a field provider judgement that the patient is likely to survive given the available resources means the patient should be tagged Immediate.

Immediate patients move forward to the casualty collection point first.

Expectant (gray triage tape or tag)

A "no" response to any of the questions about pulse, breathing, hemorrhage and mental status, but the patient is unlikely to survive given the available resources means the patient should be tagged Expectant. These patients should receive treatment resources only after the Immediate patients have been moved forward.

Examples of expectant patients include head injury with exposed brain matter, carotid artery hemorrhage or burns to 90 percent of the total body surface area.

Delayed (yellow triage tape or tag)

Patients with serious injuries, such as a long bone fracture, that will require eventual forward movement to definitive treatment, but not immediate forward movement and care are tagged Delayed. To determine if a patient is Delayed assess the following:

  • Does the patient have a peripheral pulse"
  • Is the patient not in respiratory distress"
  • Is hemorrhage controlled"
  • Does the patient follow commands or make purposeful movements"

A "yes" response to all of these, but the injuries are still significant, such as a proximal long bone fracture, then the patient should be tagged Delayed.

Minimal (green triage tap or tag)

"Yes" to all of the same questions about pulse, breathing, hemorrhage and mental status, but the patient's injuries are minor, such as minor abrasions and lacerations and the patient should be tagged Minimal.

Most Minimal patients should have moved forward during the sort of Walkers from the Wavers and the Still. Remaining Minimal patients are the last to move forward and they may help move other patients forward to treatment and transport.

Treatment and Transport

As patients receive their tags from the SALT process, they should move forward to a casualty collection point. Patients continue to move forward from there to a treatment area and eventually to an ambulance for transport to a receiving facility..

The treatment area is the destination for all incoming personnel and equipment from responding EMS agencies. It is also only to temporarily hold patients until they can be transported forward to receiving facilities.

Still a long way to travel

Even though the SALT and MUCC MCI recommendations have been around for years, the change from older triage systems proceeds slowly. As SALT is adopted by additional agencies, more EMS providers will find this simple, straight-forward, easy to learn system helpful to manage mass casualty incidents of all sizes.

References
1. Robertson-Steel, I. Evolution of triage systems. Emergency Medicine Journal 23, 154–155 (2006).

2. Federal Interagency Committee on EMS. National Implementation Of the Model Uniform Core Criteria for Mass Casualty Incident Triage. (2014).



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Information sharing will drive EMS growth, improvement

For the typical EMS provider, data may be one of the least sexy topics to discuss around the station dinner table or while sitting at a post. The mention of the word makes most of us imagine spreadsheets, calculators and back office staff entering data into computers — not very relevant to what we do with patients in the field.

In reality, nothing could be further from the truth. Data and information analytics permeates everything that we do as field providers, including better patient care, more targeted services toward the community and increased reimbursement for what do provide. In fact, the National Highway Traffic Safety Administration's Office of EMS has just issued a report on the need to create a culture of information-driven EMS systems to drive future growth and development of the industry. While it's not very likely that you'll be reading this document to your partner in between calls, you should take notice that such reports will impact how you may provide field care.

Data shapes the EMS elephant

There have been concerted efforts to collect data at local, regional and national levels since the mid 1990s. However we still define EMS by what we do locally, on the unit every day. As a result, each of us has a specific opinion as to what we feel is "true" regarding the EMS industry.

It's very much like the old story about blind individuals trying to describe what an elephant is. One man touches the trunk and says one thing, while another woman touches the tail and describes the elephant in a totally different way. Given how systems have developed over the past fifty years, the variability in describing the EMS elephant is huge.

Data can remove the mask of blindness and allow us to see EMS for what it is. The more we know about what we do, how we do it, and most critically, the outcomes associated with our care, the better we are able to adapt our operational tactics and plan for better success.

Better outcomes mean better EMS

You would think that it is self-evident, but consider how much we do in EMS that is not grounded in evidence: transporting patients to the hospital with lights and sirens activated; ALS first responders; myriad of medications we administer in the field. Indeed many interventions and tactics in EMS have been driven by best guesses and so-called expert opinion, with little or no understanding of the outcomes of such interventions.

One area that has seen improvement is in cardiac resuscitation. Many EMS systems are reporting better ROSC and discharge from hospital rates due to better chest compressions, increased bystander CPR and public access AEDs. While we may debate about the specifics and nuances of different interventions, the needle is moving in the right direction.

Significant barriers to data collection, sharing

The EMS industry has a problem sharing information. Some of the reluctance to share is warranted — proprietary data influences the bottom line and the potential for litigation exposure. Pretty much everything else can be blinded or otherwise made anonymous, so that the aggregated dataset becomes large enough to establish true benchmarks for quality.

Because EMS systems have developed independently of each other since the beginning, it's no surprise that data collection has also been kept in siloes. It'll take willingness to participate, effort — and money — to create data collection systems that are universal and therefore, applicable to the entire industry.

Moving forward from here

NHTSA has already started the process for the next iteration of field care services in the United States. I suspect that there will be a greater emphasis on evidence-based processes that will underlie the EMS safety net. For those of us coming into the profession, these are the developments to pay attention to, as unsexy as it is; your future is wrapped up within their outcomes.



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