Πέμπτη, 31 Αυγούστου 2017

The Accuracy of a Handheld Ultrasound Device for Neuraxial Depth and Landmark Assessment: A Prospective Cohort Trial.

This study investigated the accuracy of a wireless handheld ultrasound with pattern recognition software that recognizes lumbar spine bony landmarks and measures depth to epidural space (Accuro, Rivanna Medical, Charlottesville, VA) (AU). AU measurements to epidural space were compared to Tuohy needle depth to epidural space (depth to loss of resistance at epidural placement). Data from 47 women requesting labor epidural analgesia were analyzed. The mean difference between depth to epidural space measured by AU versus needle depth was -0.61 cm (95% confidence interval, -0.79 to -0.44), with a standard deviation of 0.58 (95% confidence interval, 0.48-0.73). Using the AU-identified insertion point resulted in successful epidural placement at first attempt in 87% of patients, 78% without redirects. (C) 2017 International Anesthesia Research Society

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Patients Undergoing Cesarean Delivery After Exposure to Oxytocin During Labor Require Higher Postpartum Oxytocin Doses.

BACKGROUND: Experts recommend postpartum oxytocin to prevent uterine atony and hemorrhage, but oxytocin may be associated with dose-dependent adverse effects, and the correct dose of postpartum oxytocin has yet to be determined. The effective dose in 90% of patients (ED90) of oxytocin after cesarean delivery may be higher in patients exposed to oxytocin during labor compared to patients unexposed. We therefore undertook this study to compare postpartum oxytocin requirements in patients exposed to oxytocin prior to cesarean delivery versus those not exposed, when all were treated according to a specific institutional protocol. METHODS: In this retrospective chart review, we reviewed medical records of patients who underwent cesarean delivery under neuraxial anesthesia and noted demographic data, relevant comorbidities, and oxytocin exposure, infusion rate, and duration prior to delivery. Patients exposed to oxytocin before cesarean (OXY+ group) were compared to those not exposed (OXY- group). The primary outcome variable was highest infusion rate of postpartum oxytocin required per institutional protocol. Secondary outcomes included estimated blood loss, proportion of patients with postpartum hemorrhage, and proportions who received other uterotonic medications or red blood cell transfusion. RESULTS: OXY+ patients were more likely to be nulliparous and had higher estimated gestational age and neonatal weight than OXY- patients. They also had higher incidence of chorioamnionitis and lower incidence of multiple gestation. OXY+ patients required a high postpartum oxytocin infusion rate more often than OXY- patients (adjusted odds ratio 1.94 [95% confidence interval, 1.19-3.15; P = .008]). They also received other uterotonic agents more commonly. Estimated blood loss, hemorrhage rates, and transfusion rates did not differ between groups. CONCLUSIONS: Reported increases in the ED90 of postpartum oxytocin after oxytocin exposure during labor appear to be clinically significant. We have therefore altered our institutional protocol so that women preexposed to oxytocin routinely receive higher initial postpartum oxytocin infusion rates. (C) 2017 International Anesthesia Research Society

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Trends in the Prevalence of Intraoperative Adverse Events at 2 Academic Hospitals After Implementation of a Mandatory Reporting System.

BACKGROUND: Anesthesia information management systems (AIMSs) have been effectively used to improve quality in anesthesia care, and have enabled the development of mandatory quality assurance (QA) reporting systems for adverse events (AEs). While this approach has been shown to increase event reporting over time, the long-term effect of such a system on quality is unknown. We investigated the trends in AE reporting over time after implementing AIMS-based mandatory reporting systems at 2 academic medical centers. METHODS: At Thomas Jefferson University Hospital, AEs were retrieved after implementation of a mandatory QA process in 2013. These AEs were categorized as preventable and unpreventable. The rates of overall preventable and unpreventable AEs were analyzed over time. At Vanderbilt University Medical Center, the rates of AEs were analyzed after establishing a mandatory QA process in 2002. Data were binned by quarter, and trends over time were analyzed using the Mann-Kendall test. RESULTS: At Thomas Jefferson University Hospital, over a period of 2 years after implementation of a mandatory QA process, the documented AE rate decreased from 1.23% to 0.64% (P

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Medical Statistics: For Beginners, 1st ed.

No abstract available

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Huntington Mice Demonstrate Diminished Pain Response in Inflammatory Pain Model.

BACKGROUND: Huntington disease (HD) affects the nervous system and leads to mental and motor dysfunction. Previous studies have shown that HD is caused by the exon 1 region of the huntingtin (HTT) gene having expanded CAG trinucleotide repeats. However, few studies have focused on the relationship between HD and pain. The purpose of this study is to investigate the relationship between HD and pain response. METHODS: We used clinical similar transgenic HD mice carrying a mutant HTT exon 1 containing 84 CAG trinucleotide repeats to evaluate the relationship between HD and pain. Inflammatory pain models were induced by either formalin or complete Freund adjuvant injection over the hind paw. Spinal cord, dorsal root ganglion, and paw skin tissues were harvested at the end of the behavioral inflammatory pain studies. Immunofluorescence assay, Western blotting, and enzyme-linked immunosorbent assay were used to identify changes in cells and cytokines. RESULTS: Our data demonstrate that preonset HD mice exhibited less pain behavior than wild-type (WT) mice in both young (n = 11 [WT], 13 [HD]) and aged (n = 8 [WT], 9 [HD]) mice. Western blotting and immunohistological examination of lumbar spinal cord tissue and dorsal root ganglion indicate less activation of glial cells and astrocytes in young HD mice (n = 6-7) compared to that in WT mice (n = 6-7). The production levels of tumor necrosis factor-[alpha], interleukin-1[beta], and substance P were also lower in young HD mice (n = 6-7). CONCLUSIONS: Our data demonstrate less pain behavior and pain-related cytokine response at the spinal cord level for HD mice compared to those for WT mice. Further studies are needed for determining the mechanism as to how mutant HTT leads to altered pain behavior and pain-related cytokine response. (C) 2017 International Anesthesia Research Society

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Understanding Infusion Pumps.

Infusion systems are complicated electromechanical systems that are used to deliver anesthetic drugs with moderate precision. Four types of systems are described-gravity feed, in-line piston, peristaltic, and syringe. These systems are subject to a number of failure modes-occlusion, disconnection, siphoning, infiltration, and air bubbles. The relative advantages of the various systems and some of the monitoring capabilities are discussed. A brief example of the use of an infusion system during anesthetic induction is presented. With understanding of the functioning of these systems, users may develop greater comfort. (C) 2017 International Anesthesia Research Society

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Tranexamic Acid Administration During On-Pump Cardiac Surgery: A Survey of Current Practices Among Canadian Anesthetists Working in Academic Centers.

BACKGROUND: Tranexamic acid (TXA) is commonly administered during on-pump cardiac surgery to minimize bleeding. However, an optimal dosing regimen has not been described, and recent studies suggest that higher doses may be associated with seizure. Little is known about current practice among cardiac anesthetists. METHODS: We contacted all academic anesthesia departments in Canada to identify cardiac anesthetists, who represent the majority of practitioners. This group constituted our sampling frame. Information regarding participant demographics, TXA dose, and administration details were obtained by electronic survey. Responses were analyzed descriptively. To compare dose, we assumed an 80-kg patient and 3 hours of infusion time. The Kruskal-Wallis test was used to compare average dose across provinces. RESULTS: Among 341 Canadian academic cardiac anesthetists, 234 completed the survey (68.2% response rate). Among respondents, 86.3% administer TXA to all patients; 13.7% administer it to some. Most (68.4%) administer an infusion after a bolus; other modes included infusion (4.7%), single bolus (13.2%), 2 or more boluses (12.0%), or another regimen (1.7%). The mean (standard deviation) dose given was 49 mg/kg (24), with a range from 10 to 100 mg/kg. The mean dose varied across provinces from 23 to 55 mg/kg (P = .001). CONCLUSIONS: TXA is given to nearly all patients undergoing on-pump cardiac surgery at academic hospitals in Canada. However, there is significant heterogeneity in practice between individuals and across provinces. Further research is needed to determine the TXA dose that maximizes efficacy and minimizes side effects. (C) 2017 International Anesthesia Research Society

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Anesthetic Considerations for Patients Undergoing Bronchial Thermoplasty.

Bronchial thermoplasty (BT) is a novel, Food and Drug Administration-approved nondrug treatment for patients whose asthma remains uncontrolled despite traditional pharmacotherapy. BT involves application of controlled radiofrequency energy to reduce airway smooth muscle in large- and medium-sized airways. Although BT is often performed under general anesthesia, anesthetic management strategies for BT are poorly described. We describe the anesthetic management of 7 patients who underwent 19 BT treatments in a tertiary academic medical center. (C) 2017 International Anesthesia Research Society

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Electrical pulse stimulation: an in vitro exercise model for the induction of human skeletal muscle cell hypertrophy. A proof-of-concept study

Abstract

Electrical Pulse Stimulation (EPS) of muscle cells has previously been used as an in vitro exercise model. The present study aims to establish an EPS protocol promoting the hypertrophy of human muscle cells, which represents a major physiological endpoint to resistance exercise in humans. We hypothesized that adding a resting period after EPS would be critical for the occurrence of the morphological change. Myoblasts obtained from human muscle biopsies (n = 5) were differentiated into multinucleated myotubes and exposed to 8 h EPS consisting of 2 ms pulses at 12 V with a frequency of 1 Hz. Myotube size was assessed using immunohistochemistry immediately, 4 h and 8 h after completed EPS. Gene expression and phosphorylation status of selected markers of hypertrophy were assessed using RT-PCR and western blotting, respectively. Release of the myokine IL-6 in culture medium was measured using ELISA. We demonstrate a significant increase (31 ± 14%; P = 0.03) in the size of myotubes when EPS is followed by 8 h resting period, but not immediately or 4 h after completed EPS. The response was supported by downregulation (P = 0.04) of myostatin gene expression, a negative regulator of muscle mass and increased phosphorylated mTOR (P = 0.03) and 4E-BP1 (P = 0.01), which are important factors in the cellular growth signalling cascade. The present work demonstrates that EPS is an in vitro exercise model promoting the hypertrophy of human muscle cells, recapitulating a major physiological endpoint to resistance exercise in human skeletal muscle.

This article is protected by copyright. All rights reserved



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Genomic Relatedness Strengthens Genetic Connectedness Across Management Units

Genetic connectedness refers to a measure of genetic relatedness across management units (e.g., herds and flocks). With the presence of high genetic connectedness in management units, best linear unbiased prediction (BLUP) is known to provide reliable comparisons between genetic values. Genetic connectedness has been studied for pedigree-based BLUP; however, relatively little attention has been paid to using genomic information to measure connectedness. In this study, we assessed genome-based connectedness across management units by applying prediction error variance of difference (PEVD), coefficient of determination (CD), and prediction error correlation (r) to a combination of computer simulation and real data (mice and cattle). We found that genomic information (G) increased the estimate of connectedness among individuals from different management units compared to that based on pedigree (A). A disconnected design benefited the most. In both datasets, PEVD and CD statistics inferred increased connectedness across units when using G- rather than A-based relatedness suggesting stronger connectedness. With r once using allele frequencies equal to one-half or scaling G to values between 0 and 2, which is intrinsic to A, connectedness also increased with genomic information. However, PEVD occasionally increased, and r decreased when obtained using the alternative form of G, instead suggesting less connectedness. Such inconsistencies were not found with CD. We contend that genomic relatedness strengthens measures of genetic connectedness across units and has the potential to aid genomic evaluation of livestock species.



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A Bimolecular Fluorescence Complementation Tool for Identification of Protein-Protein Interactions in Candida albicans

Investigation of protein-protein interactions (PPI) in Candida albicans is essential for understanding the regulation of the signal transduction network that triggers its pathogenic lifestyle. Unique features of C. albicans, such as the alternative codon usage and incomplete meiosis, have enforced the optimization of standard genetic methods as well as development of novel approaches. Since the existing methods for detection of PPI are limited for direct visualization of the interacting complex in vivo, we have established a bimolecular fluorescence complementation (BiFC) in C. albicans, a powerful technique for studying PPI. We have developed an optimized set of plasmids that allows for N- and C-terminal tagging of proteins with split yeast-enhanced monomeric Venus fragments, so that all eight combinations of fusion orientations can be analyzed. With the use of our BiFC assay we demonstrate three interaction complexes in vivo, which were also confirmed by two-hybrid analysis. Our Candida optimized BiFC assay represents a useful molecular tool for PPI studies and shows great promise in expanding the knowledge on molecular mechanisms of protein functions.



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Single-Step qPCR and dPCR Detection of Diverse CRISPR-Cas9 Gene Editing Events in Vivo

CRISPR-Cas9 based technology is currently the most flexible means to create targeted mutations by recombination or indel mutations by non-homologous end joining. During mouse transgenesis, recombinant and indel alleles are often pursued simultaneously. Multiple alleles can be formed in each animal to create significant genetic complexity that complicates the CRISPR-Cas9 approach and analysis. Currently, there are no rapid methods to measure the extent of on-site editing with broad mutation sensitivity. In this study, we demonstrate the allelic diversity arising from targeted CRISPR-editing in founder mice. Using this DNA sample collection, we validated specific, quantitative, and digital PCR methods (qPCR and dPCR, respectively) for measuring the frequency of on-target editing in founder mice. We found that locked nucleic acid (LNA) probes combined with an internal reference probe (Drop-Off Assay) provide accurate measurements of editing rates. The Drop-Off LNA Assay also detected on-target CRISPR-Cas9 gene editing in blastocysts with a sensitivity comparable to PCR-clone sequencing. Lastly, we demonstrate that the allele-specific LNA probes used in qPCR competitor assays can accurately detect recombinant mutations in founder mice. In summary, we show that LNA-based qPCR and dPCR assays provide a rapid method for quantifying the extent of on-target genome editing in vivo, testing RNA guides, and detecting recombinant mutations.



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Performance on a clinical quadriceps activation battery is related to a laboratory measure of activation and recovery after total knee arthroplasty

Publication date: Available online 31 August 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Michael Bade, Tamara Struessel, Roger Paxton, Joshua Winters, Carol Baym, Jennifer Stevens-Lapsley
ObjectiveTo determine the relationship between performance on a clinical quadriceps activation battery (QAB) with 1) activation measured by doublet interpolation and 2) recovery of quadriceps strength and functional performance following total knee arthroplasty (TKA).DesignThis was a planned secondary analysis of a randomized controlled trialSettingUniversity research laboratoryParticipantsOne hundred sixty-two patients (aged 63 ± 7 (mean ± sd) years; 89 females) undergoing TKA participated.Outcome MeasuresPatients were classified as HIGH (QAB ≥ 4/6) or LOW (QAB ≤3/6) based upon performance on the QAB measured 4 days after TKA. Differences between groups in activation and recovery at 1, 2, 3, 6, and 12 months after TKA were compared using a repeated measures maximum likelihood model.ResultsThe LOW QAB group demonstrated poorer quadriceps activation via doublet interpolation (p=0.01), greater quadriceps strength loss (p=0.01), and greater functional performance decline (all p<0.001) at 1 month after TKA compared to the HIGH QAB group. Differences between LOW and HIGH QAB groups on all measures did not persist at 3 and 12 months (all p>0.05).ConclusionPoor performance on the QAB early after TKA is related to poor quadriceps activation and poor recovery in the early postoperative period. Patients in the LOW QAB group took 3 months to recover to the same level as the HIGH QAB group. The QAB may be useful in identifying individuals who need specific interventions to target activation deficits or different care pathways in the early postoperative period to speed recovery after TKA.



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Shifting gears: dynamic muscle shape changes and force-velocity behaviour in the medial gastrocnemius

When muscles contract, they bulge in thickness or in width to maintain a (nearly) constant volume. These dynamic shape changes are tightly linked to the internal constraints placed on individual muscle fibres and play a key functional role in modulating the mechanical performance of skeletal muscle by increasing its range of operating velocities. Yet to date, we have a limited understanding of the nature and functional implications of in vivo dynamic muscle shape change under submaximal conditions. This study determined how the in vivo changes in medial gastrocnemius (MG) fascicle velocity, pennation angle, muscle thickness and subsequent muscle gearing varied as a function of force and velocity. To do this, we obtained recordings of MG tendon length, fascicle length, pennation angle, and thickness using B-mode ultrasound, and muscle activation, using surface electromyography during cycling at a range of cadences and loads. We found that that increases in contractile force were accompanied by reduced bulging in muscle thickness, reduced increases in pennation angle, and faster fascicle shortening. Although the force and velocity of a muscle contraction are inversely related due to the force-velocity effect, this study has shown how dynamic muscle shape changes are influenced by force, and not influenced by velocity.



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Single passive leg movement assessment of vascular function: The contribution of nitric oxide

The assessment of passive leg movement (PLM)-induced leg blood flow (LBF) and vascular conductance (LVC) is a novel approach to assess vascular function, which has recently been simplified to only a single PLM (sPLM), thereby increasing the clinical utility of this technique. As the physiological mechanisms mediating the robust increase in LBF and LVC with sPLM are currently unknown, we tested the hypothesis that nitric oxide (NO) is a major contributor to the sPLM-induced LBF and LVC response. In nine healthy men, sPLM was performed with and without the inhibition of nitric oxide synthase (NOS) via intra-arterial infusion of NG-monomethyl-L-arginine (L-NMMA). Doppler ultrasound and femoral arterial pressure were used to determine LBF and LVC, which were characterized by the peak change (LBFpeak and LVCpeak) and area under the curve (LBFAUC and LVCAUC). L-NMMA significantly attenuated the LBFpeak (L-NMMA: 492 ± 153 vs. control: 719 ± 238 ml·min-1), LBFAUC (L-NMMA: 57 ± 34 vs. control: 147 ± 63 ml), LVCpeak (L-NMMA: 4.7 ± 1.1 vs. control: 8.0 ± 3.0 ml·min-1·mmHg-1), and the LVCAUC (L-NMMA: 0.5 ± 0.3 vs. control: 1.6 ± 0.9 ml·mmHg-1). The magnitude of NO contribution to LBF and LVC was significantly correlated with the magnitude of the control responses (LBFpeak: r = 0.94; LBFAUC: r = 0.85; LVCpeak: r = 0.94; LVCAUC: r = 0.95). These data establish that the sPLM-induced hyperemic and vasodilatory response is predominantly (~65%) NO-mediated. As such, sPLM appears to be a promising, simple, in vivo assessment of NO-mediated vascular function and NO bioavailability.



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Additive Effects of Heating and Exercise on Baroreflex Control of Heart Rate in Healthy Males

This study assessed the additive effects of passive heating and exercise on cardiac baroreflex sensitivity (cBRS) and heart rate variability (HRV). Twelve healthy young men (25±1 yrs, 23.8±0.5 kg/m2) randomly underwent two experimental sessions: heat stress (HS; whole-body heat stress using a tube-lined suit to increase core temperature by ~1°C) and normothermia (NT). Each session was composed of a: pre-intervention rest (REST1); HS or NT interventions; post-intervention rest (REST2); and 14 min of cycling exercise [7 min at 40%HRreserve (EX1) and 7 min at 60%HRreserve (EX2)]. Heart rate and finger blood pressure were continuously recorded. cBRS was assessed using the sequence (cBRSSEQ) and transfer function (cBRSTF) methods. HRV was assessed using the indices SDNN (standard deviation of RR intervals) and RMSSD (root mean square of successive RR intervals). cBRS and HRV were not different between sessions during EX1 and EX2 (i.e. matched heart rate conditions: EX1=116±3 vs. 114±3, EX2=143±4 vs. 142±3 bpm; but different workloads: EX1=50±9 vs. 114±8, EX2=106±10 vs. 165±8 Watts; for HS and NT, respectively; P<0.01). However, when comparing EX1 of NT with EX2 of HS (i.e. matched workload conditions, but with different heart rates), cBRS and HRV were significantly reduced in HS (cBRSSEQ = 1.6±0.3 vs. 0.6±0.1 ms/mmHg, P<0.01; SDNN = 2.3±0.1 vs. 1.3±0.2 ms, P<0.01). In conclusion, in conditions matched by HR, the addition of heat stress to exercise does not affect cBRS and HRV. Alternatively, in workload-matched conditions, the addition of heat to exercise results in reduced cBRS and HRV compared to exercise in normothermia.



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Creatine (methyl-d3) dilution in urine for estimation of total body skeletal muscle mass-accuracy and variability vs. MRI and DXA

A noninvasive method to estimate muscle mass based on creatine (methyl-d3) dilution (D3-creatine) using fasting morning urine was evaluated for accuracy and variability over a 3-4 mo period. Healthy older (67-80 y) subjects (n=14) with muscle wasting secondary to aging and 4 patients with chronic disease (58-76 y) fasted overnight, then received an oral 30-mg dose of D3-creatine at 8 am (day 1). Urine was collected during 4 h of continued fast then at consecutive 4-8-h intervals through day 5. Repeat assessment was performed 3-4 mo later in 13 healthy subjects and 1 patient with congestive heart failure. Deuterated and unlabeled creatine and creatinine were measured using liquid chromatography-tandem mass spectrometry. Total body creatine pool size and muscle mass were calculated from D3-creatinine enrichment in urine. Muscle mass was also measured by whole-body MRI and 24-h urine creatinine, and lean body mass (LBM) by dual-energy x-ray absorptiometry (DXA). D3-creatinine urinary enrichment from day 5 provided muscle mass estimates that correlated with MRI for all subjects (r=0.88, P<0.0001), with less bias (mean±SD difference from MRI: –3.00±2.75 kg) compared with total LBM assessment by DXA, which overestimated muscle mass vs MRI (+22.5±3.7 kg). However, intra-individual variability was high with the D3-creatine dilution method, with intra-subject SD for estimated muscle mass of 2.5 kg vs MRI (0.5 kg) and DXA (0.8 kg). This study supports further clinical validation of the D3-creatine method for estimating muscle mass.



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Skeletal Muscle Contractile Properties in a Novel Murine Model for Limb Girdle Muscular Dystrophy 2i

Limb-girdle muscular dystrophy (LGMD) 2i results from mutations in fukutin-related protein and aberrant α-dystroglycan glycosylation. Although this significantly compromises muscle function and ambulation, the comprehensive characteristics of contractile dysfunction are unknown. We therefore quantified the in situ contractile properties of the medial gastrocnemius in young adult P448L mice, an affected muscle and novel model of LGMD2i, respectively. Maximal twitch force, tetanic force and power normalized to physiological cross-sectional area were significantly smaller in P448L mice, compared to sex-matched wild-type mice. These differences were consistent with the replacement of contractile fibers by passive tissue. The shape of the active force-length relationships were similar in both groups, regardless of sex, consistent with intact sarcomere homogeneity in P448L mice. Passive force-length curves normalized to maximal isometric force were steeper in P448L mice and passive elements contribute disproportionately more to total contractile force in P448L mice. Sex differences were mostly noted in the force-velocity curves as normalized values for maximal and optimal velocities were significantly slower in P448L males, compared to wild-type, but not in P448L females. This suggests that the dystrophic phenotype, which may include possible changes in cross-bridge kinetics and fiber type proportions, progresses more quickly in P448L males. These results together indicate that active force and power generation are compromised in both sexes of P448L mice while passive forces increase. More importantly, the results identified several functional markers of disease pathophysiology that could aid in developing and assessment of novel therapeutics for LGMD2i and possibly other dystroglycanopathies as well.



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The Effect of Inert Gas Choice on Multiple Breath Washout in Healthy Infants - Differences in Lung Function Outcomes and Breathing Pattern

Detrimental effects on breathing pattern during multiple breath inert gas washout (MBW) have been described with different inhaled gases (100% oxygen, O2, and sulfur hexafluoride, SF6) but detailed comparisons are lacking. N2 and SF6 based tests were performed during spontaneous quiet sleep in 10 healthy infants aged 0.7-1.3 years using identical hardware. Differences in breathing pattern pre and post 100% O2 and 4% SF6 exposure were investigated, and the results obtained compared (FRC and Lung Clearance Index, LCI). During 100% O2 exposure mean inspiratory flow ("respiratory drive") decreased transiently by mean (SD) 28 (9)% (p<0.001), and end-tidal CO2 (carbon dioxide) increased by mean (SD) 0.3 (0.4)% units (p<0.05), vs. air breathing pre-phase. During subsequent N2 washin (i.e. recovery phase) pattern of change reversed. No significant effect on breathing pattern was observed during SF6 testing. In vitro testing confirmed that technical artifacts did not explain these changes. Mean (SD) FRC and LCI in vivo were significantly higher with N2 vs. SF6 washout: 216 (33) vs. 186 (22) mL (p<0.001) and 8.25 (0.85) vs. 7.55 (0.57) turnovers (p=0.021). Based on these results, SF6 based MBW is the preferred methodology for tests in this age range.



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UBC-Nepal Expedition: Acute alterations in sympathetic nervous activity do not influence brachial artery endothelial function at sea-level and high-altitude

Evidence indicates that increases in sympathetic nervous activity (SNA), and acclimatization to high-altitude (HA), may reduce endothelial function as assessed by brachial artery flow-mediated dilatation (FMD); however, it is unclear whether such changes in FMD are due to direct vascular constraint, or consequential altered hemodynamics (e.g. shear stress) associated with increased SNA as a consequence of exposure to HA. We hypothesized that: 1) at rest, SNA would be elevated and FMD would be reduced at HA compared to sea-level (SL); and 2) at SL and HA, FMD would be reduced when SNA was acutely increased, and elevated when SNA was acutely decreased. Using a novel, randomized experimental design, brachial artery FMD was assessed at SL (344m) and HA (5050m) in 14 participants during mild lower-body negative pressure (LBNP; -10 mmHg) and lower-body positive pressure (LBPP; +10 mmHg). Blood pressure (finger photoplethysmography), heart rate (electrodcardiogram), oxygen saturation (pulse oximetry), and brachial artery blood flow and shear rate (Duplex ultrasound) were recorded during LBNP, control, and LBPP trials. Muscle SNA was recorded (via microneurography) in a subset of participants (n=5). Our findings were: 1) at rest, SNA was elevated (P<0.01), and absolute FMD was reduced (P=0.024), but relative FMD remained unaltered (P=0.061), at HA compared to SL, and 2) despite significantly altering SNA with LBNP (+60.3±25.5%) and LBPP (-37.2±12.7%) (P<0.01), FMD was unaltered at SL (P=0.448), and HA (P=0.537). These data indicate that acute and mild changes in SNA do not directly influence brachial artery FMD at SL or HA.



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Effects of vehicle microdialysis solutions on cutaneous vascular responses to local heating

Microdialysis is a minimally invasive technique often paired with laser Doppler flowmetry to examine cutaneous microvascular function, yet presents with several challenges, including incompatibility with perfusion of highly lipophilic compounds. The present study addresses this methodological concern, with an emphasis on the independent effects of commonly used vehicle dialysis solutions to improve solubility of pharmacological agents with otherwise low aqueous solubility. Four microdialysis fibers were placed in the ventral forearm of eight subjects (4 men, 4 women; 25 ± 1 years) with sites randomized to serve as 1) control (lactated Ringer's), 2) Sodium carbonate-bicarbonate buffer administered at physiological pH (SCB-HCL; pH 7.4, achieved via addition of hydrochloric acid (HCL)), 3) 0.02% Ethanol, and 4) 2% dimethyl sulfoxide (DMSO). Following baseline (34°C), vehicle solutions were administered throughout a standardized local heating protocol to 42°C. Laser Doppler flowmetry provided an index of blood flow. Cutaneous vascular conductance was calculated and normalized to maximum (%CVCmax, sodium nitroprusside and 43°C local heat). The SCB-HCL solution increased baseline %CVCmax (control: 9.7 ± 0.8, SCB-HCL: 21.5 ± 3.5 %CVCmax; p=0.03) but no effects were observed during heating or maximal vasodilation. There were no differences with perfusion of ethanol or DMSO at any stage of the protocol (p>0.05). These data demonstrate the potential confounding effects of some vehicle dialysis solutions on cutaneous vascular function. Notably, this study provides evidence that 2% DMSO and 0.02% ethanol are acceptable vehicles with no confounding local vascular effects to a standardized local heating protocol at the concentrations presented.



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Glucose transport across lagomorph jejunum epithelium is modulated by AMP-activated protein kinase (AMPK) under hypoxia

The gastrointestinal epithelium possesses adaptation mechanisms to cope with huge variations in blood flow and subsequently oxygenation. Since sufficient energy supply is crucial under hypoxic conditions, glucose uptake especially must be regulated by these adaptation mechanisms. Therefore, we investigated glucose transport under hypoxic conditions. Jejunal epithelia of rabbits were incubated in Ussing chambers under short- circuit current conditions. Hypoxia was simulated by gassing with 1% O2 instead of 100% O2. The activity of SGLT1 (sodium-coupled glucose transporter 1) was assessed by measuring the increase of short circuit current (Isc) after the addition of 2 mM glucose to the mucosal buffer solution. We observed decreased activity of SGLT1 after hypoxia compared to control conditions. To investigate underlying mechanisms, epithelia were exposed to agonists and antagonists of AMP-activated protein kinase (AMPK), before assessing SGLT1-mediated transport and the pAMPK/AMPK protein ratio. Preincubation with the antagonist restored SGLT1 activity under hypoxic conditions to the level of control conditions, indicating an involvement of AMPK in the (down-)regulation of SGLT1 activity under hypoxia which was confirmed in western blot analysis of pAMPK/AMPK. Transepithelial flux studies using radioactively labelled glucose, ortho-methyl-glucose, fructose and mannitol revealed no changes after hypoxic incubation. Therefore, we could exclude a decreased transepithelial glucose transport rate and increased paracellular conductance under hypoxia. In conclusion, our study hints at a decreased activity of SGLT1 under hypoxic conditions in an AMPK-dependent manner. However, transepithelial transport of glucose is maintained. Therefore, we suggest other transport mechanisms, especially glucose transporter 1 and/or 2 to substitute SGLT1 under hypoxia.



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INFLUENCE OF NUTRIENT INGESTION ON AMINO ACID TRANSPORTERS AND PROTEIN SYNTHESIS IN HUMAN SKELETAL MUSCLE AFTER SPRINT EXERCISE

Nutrient ingestion is known to increase the exercise-induced stimulation of muscle protein synthesis following resistance exercise. Less is known about the effect of nutrients on muscle protein synthesis following sprint exercise. At two occasions separated by one month, twelve healthy subjects performed three 30-s sprints with 20-min rest between bouts. In randomized order, they consumed a drink with essential amino acids and maltodextrin (nutrient) or flavored water (placebo). Muscle biopsies were obtained 80 and 200 min after the last sprint and blood samples were taken repeatedly during the experiment. Fractional synthetic rate (FSR) was measured by continuous infusion of L-[2H5]-phenylalanine up to 200 min postexercise. The mRNA and protein expression of SNAT2 were both 1.4-fold higher (P < 0.05) after nutrient intake compared to placebo at 200 min postexercise. Phosphorylated Akt, mTOR and p70S6k was 1.7- to 3.6-fold higher (P<0.01) 80 min after the last sprint with nutrient ingestion as compared to placebo. In addition, FSR was higher (P<0.05) with nutrients when plasma phenylalanine (FSRplasma) was used as a precursor, but not when intracellular phenylalanine (FSRmuscle) was used. Significant correlations were also found between FSRplasma on the one hand and plasma leucine and serum insulin on the other hand in the nutrient condition. The results show that nutrient ingestion induces the expression of the amino acid transporter SNAT2, stimulates Akt/mTOR signaling and most likely the rate of muscle protein synthesis following sprint exercise.



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Measuring high-altitude adaptation

High altitudes (>8000 ft or 2500 m) provide an experiment of nature for measuring adaptation and the physiological processes involved. Studies conducted over the past ~25 years in Andeans, Tibetans, and less often Ethiopians show varied but distinct O2 transport traits from those of acclimatized newcomers, providing indirect evidence for genetic adaptation to high altitude. Short-term (acclimatization, developmental) and long-term (genetic) responses to high altitude exhibit a temporal gradient such that, while all influence O2 content, the latter also improve O2 delivery and metabolism. Much has been learned concerning the underlying physiological processes but additional studies are needed on the regulation of blood flow and O2 utilization. Direct evidence of genetic adaptation comes from single nucleotide polymorphism (SNP)-based genome scans and whole-genome sequencing studies that have identified gene regions acted upon by natural selection. Efforts have begun to understand the connections between the two with Andean studies on the genetic factors raising uterine blood flow, fetal growth, and susceptibility to Chronic Mountain Sickness and Tibetan studies on genes serving to lower hemoglobin and pulmonary arterial pressure. Critical for future studies will be the selection of phenotypes with demonstrable effects on reproductive success, the calculation of actual fitness costs, and greater inclusion of women among the subjects being studied. The well-characterized nature of the O2 transport system, the presence of multiple long-resident populations, and relevance for understanding hypoxic disorders in all persons underscore the importance of understanding how evolutionary adaptation to high altitude has occurred.



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Effects of anti-inflammatory (NSAID) treatment on human tendinopathic tissue

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat tendinopathy, but evidence for this treatment is lacking, and little is known regarding effects of NSAIDs on human tendinopathic tendon. This study investigated effects of NSAID treatment (ibuprofen) on human tendinopathic tendon, with changes in gene expression as the primary outcome, and tendon pain, function and blood flow as secondary outcomes. Twenty-six adults (16 male, 10 female) diagnosed with chronic Achilles tendinopathy were randomized to one-week treatment with ibuprofen (600mgx3/day) (n=13) or placebo (n=13) (double-blinded). Ibuprofen content in blood, visual analog scale (VAS) score for tendon pain at rest and activity, Victorian Institute of Sports Assessment-Achilles (VISA-A) scores for tendon function, tendon thickness (with ultrasonography) and color Doppler were measured pre- and one hour post-treatment. After the last post-test, a full-width tendon biopsy was taken from the affected area. Real-time-RT-PCR was used to assess expression of collagen I, collagen III, transforming growth factor (TGF-ß) isoforms, cyclooxygenase-2 (COX-2), Angiopoietin-like 4 (ANGPTL4) and Cyclic AMP-dependent transcription factor (ATF3) in tendon tissue. Expression of collagens and TGF-ß isoforms showed relatively low variation and was unaffected by ibuprofen treatment. Further, no changes were seen in tendon thickness or VISA-A score. The placebo treatment reduced the color Doppler (in tendon plus surrounding tissue) compared to the ibuprofen group, and also increased the perception of pain at rest. In conclusion, there was no indication that short-term ibuprofen treatment affects gene expression in human chronic tendinopathic tendon or leads to any clear changes in tendon pain or function.



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The endothelium in hypoxic pulmonary vasoconstriction

Hypoxic pulmonary vasoconstriction (HPV) in combination with hypercapnic pulmonary vasoconstriction redistributes pulmonary blood flow from poorly aerated to better ventilated lung regions by an active process of local vasoconstriction. Impairment of HPV results in ventilation-perfusion mismatch and is commonly associated with various lung diseases including pneumonia, sepsis, or cystic fibrosis. Although several regulatory pathways have been identified, considerable knowledge gaps persist, and a unifying concept of the signaling pathways that underlie HPV and their impairment in lung diseases has not yet emerged. In the past, conceptual models of HPV have focused on pulmonary arterial smooth muscle cells (PASMC) acting as sensor and effector of hypoxia in the pulmonary vasculature. In contrast, the endothelium was considered a modulating bystander in this scenario. For an ideal design, however, the oxygen sensor in HPV should be located in the region of gas exchange, i.e. in the alveolar capillary network. This concept requires the retrograde propagation of the hypoxic signal along the endothelial layer of the vascular wall and subsequent contraction of PASMC in upstream arterioles that is elicited via a temporospatially tightly controlled endothelial-smooth muscle cell crosstalk. The present review summarizes recent work that provides proof-of-principle for the existence and functional relevance of such signaling pathway in HPV that involves important roles for connexin 40, epoxyeicosatrienoic acids, sphingolipids, and cystic fibrosis transmembrane conductance regulator. Of translational relevance, implication of these molecules provides for novel mechanistic explanations for impaired ventilation/perfusion matching in patients with pneumonia, sepsis, cystic fibrosis and presumably various other lung diseases.



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Effect of zileuton on osteoporotic bone and its healing, expression of bone and brain genes in rats

Estrogen deficiency and aging are associated with osteoporosis, impaired bone healing and lower cognitive performance. Close functional and physical connections occur between bone and the central nervous system. An anti-inflammatory drug, zileuton, is known to have a positive effect on bone and ischemic brain. We studied the effect of zileuton on bone, its healing and on the genes for bone-brain cross-talks. Three-month-old Sprague-Dawley rats were ovariectomized or left untreated. After 8 weeks, bilateral metaphyseal tibia osteotomy with plate osteosynthesis was performed in all rats. Ovariectomized rats were fed with food containing zileuton (1, 10 or 100 mg/kg body weight) for 5 weeks. In tibiae, bone volume, callus and cortical volume, gene expression of osteocalcin and alkaline phosphatase were enhanced by zileuton (10 mg, 100 mg); biomechanical properties and bone density were not changed. In femur, zileuton enlarged cortical volume distal and trabecular volume proximal decreasing their density. The expression level of brain Sema3a, known to positively regulate bone mass, was downregulated after ovariectomy, while bone Sema4d, a negative regulator of bone mass, was upregulated in the tibia callus after ovariectomy while zileuton treatment (10 mg, 100 mg) reversed these effects. Here, we describe for the first time, the expression of Rbbp4 mRNA and its increase in tibia after ovariectomy. Zileuton caused downregulation of Rbbp4 in the hippocampus and had an effect on bone healing, changed the expression of genes involved in crosstalk between bones and brain and may be a potent drug for further examination in estrogen deficiency-related dysfunction(s).



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Erratum to: The effect of a performance-based intra-procedural checklist on a simulated emergency laparoscopic task in novice surgeons



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Erratum to: EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction



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Infrahepatic inferior vena cava clamping with Pringle maneuvers for laparoscopic extracapsular enucleation of giant liver hemangiomas

Abstract

Background

This study aimed to determine the feasibility of the extracapsular enucleation method for giant liver hemangiomas by infrahepatic inferior vena cava (IVC) clamping and the Pringle maneuver to control intraoperative bleeding under laparoscopic hepatectomy.

Methods

From January 2012 to January 2016, 36 patients underwent laparoscopic extracapsular enucleation of giant liver hemangiomas. Patients were divided into two groups: infrahepatic IVC clamping + Pringle maneuvers group (IVCP group, n = 15) and the Pringle maneuvers group (Pringle group, n = 21). Operative parameters, postoperative laboratory tests, and morbidity and mortality were analyzed.

Results

The mean size of liver hemangiomas was 13.3 cm (range 10–25 cm). Infrahepatic IVC clamping + the Pringle maneuvers with laparoscopic extracapsular enucleation significantly reduced intraoperative blood loss (586.7 vs 315.3 mL, p < 0.001) and transfusion rates (23.8 vs 6.7%, p = 0.001), compared with the Pringle maneuver alone. The gallbladder was retained in both groups. The mean arterial pressure (MAP) in Pringle group remained virtually stable before and after clamping of hepatic portal, while it was significantly decreased after IVC clamping in IVCP group than that pre-clamping (p < 0.001). The heart rate of all patients was significantly increased after clamping when compared to pre-clamping heart rates (p < 0.001). Once vascular occlusion was released, MAP returned to normal levels within a few minutes. There were no significant differences in postoperative complications between two groups. The vascular occlusion techniques in both groups had no serious effect on postoperative of hepatic and renal function.

Conclusions

Extracapsular enucleation with infrahepatic IVC clamping + the Pringle maneuver is a safe and effective surgical treatment to control bleeding for giant liver hemangiomas in laparoscopic hepatectomy.



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The SmartOR: a distributed sensor network to improve operating room efficiency

Abstract

Background

Despite the significant expense of OR time, best practice achieves only 70% efficiency. Compounding this problem is a lack of real-time data. Most current OR utilization programs require manual data entry. Automated systems require installation and maintenance of expensive tracking hardware throughout the institution. This study developed an inexpensive, automated OR utilization system and analyzed data from multiple operating rooms.

Study design

OR activity was deconstructed into four room states. A sensor network was then developed to automatically capture these states using only three sensors, a local wireless network, and a data capture computer. Two systems were then installed into two ORs, recordings captured 24/7. The SmartOR recorded the following events: any room activity, patient entry/exit time, anesthesia time, laparoscopy time, room turnover time, and time of preoperative patient identification by the surgeon.

Results

From November 2014 to December 2015, data on 1003 cases were collected. The mean turnover time was 36 min, and 38% of cases met the institutional goal of ≤30 min. Data analysis also identified outlier cases (>1 SD from mean) in the domains of time from patient entry into the OR to intubation (11% of cases) and time from extubation to patient exiting the OR (11% of cases). Time from surgeon identification of patient to scheduled procedure start time was 11 min (institution bylaws require 20 min before scheduled start time), yet OR teams required 22 min on average to bring a patient into the room after surgeon identification.

Conclusion

The SmartOR automatically and reliably captures data on OR room state and, in real time, identifies outlier cases that may be examined closer to improve efficiency. As no manual entry is required, the data are indisputable and allow OR teams to maintain a patient-centric focus.



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Optimal timing for a second ERCP after failure of initial biliary cannulation following precut sphincterotomy: an analysis of experience at two tertiary centers

Abstract

Background and study aims

Precut sphincterotomy increases the success of deep biliary cannulation, but the method fails at the initial ERCP in 5–12% of cases. Although other invasive strategies are often used to access the bile duct, a second ERCP may be effective and safe. We evaluated the efficacy, safety, and factors related to a second ERCP after failed cannulation using a precut sphincterotomy.

Patients and methods

We reviewed all patients that underwent an ERCP with native papilla from 2006 to 2014 at two tertiary institutions. Efficacy was based on the cannulation rate of the second ERCP, and safety was assessed in terms of adverse events.

Results

We identified 112 patients with failed cannulation after precut, and a second ERCP was performed in 72 (64.3%). Median time between procedures was 7 days (IQR 5–11). Deep cannulation was achieved in 54 cases (75%). The only factor associated with cannulation failure was an ERCP within 4 days after the initial precut (cannulation success 44.4 vs. 79.4% after 4 days, p = 0.026). Adverse events were recorded after the first ERCP in 13 of 112 patients (11.8%): delayed bleeding in four, pancreatitis in five, and perforation in four. After the second ERCP, three of 72 patients (4.2%) presented adverse events: two delayed bleeding and one pancreatitis.

Conclusions

A second ERCP after failure of initial biliary cannulation following precut appears to be safe and effective. A second ERCP should be delayed at least 4 days if feasible.



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Increased identification of parathyroid glands using near infrared light during thyroid and parathyroid surgery

Abstract

Background

Parathyroid gland (PG) identification during thyroid and parathyroid surgery is challenging. Accidental parathyroidectomy increases the rate of postoperative hypocalcaemia. Recently, autofluorescence with near infrared light (NIRL) has been described for PG visualization. The aim of this study is to analyze the increased rate of visualization of PGs with the use of NIRL compared to white light (WL).

Materials and methods

All patients undergoing thyroid and parathyroid surgery were included in this study. PGs were identified with both NIRL and WL by experienced head and neck surgeons. The number of PGs identified with NIRL and WL were compared. The identification of PGs was correlated to age, sex, and histopathological diagnosis.

Results

Seventy-four patients were included in the study. The mean age was 48.4 (SD ±13.5) years old. Mean PG fluorescence intensity (47.60) was significantly higher compared to the thyroid gland (22.32) and background (9.27) (p < 0.0001). The mean number of PGs identified with NIRL and WL were 3.7 and 2.5 PG, respectively (p < 0.001). The difference in the number of PGs identified with NIRL and WL and fluorescence intensity was not related to age, sex, or histopathological diagnosis, with the exception of the diagnosis of thyroiditis, in which there was a significant increase in the number of PGs visualized with NIRL (p = 0.026).

Conclusion

The use of NIRL for PG visualization significantly increased the number of PGs identified during thyroid and parathyroid surgery, and the differences in fluorescent intensity among PGs, thyroid glands, and background were not affected by age, sex, and histopathological diagnosis.



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EMS Artwork: London Ambulance Service Incident Response Unit personnel

See all of Daniel Sundahl's photos.

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Oral appliances for managing sleep bruxism in adults: a systematic review from 2007 to 2017

Summary

The review focuses on the last decade of research regarding the use of various oral appliances (OA) in the management of sleep bruxism (SB) in adults. Sixteen (N = 16) papers out of 641 identified citations involving 398 participants were included in the review. Of them, 7 were randomised controlled trials (RCTs), 7 were uncontrolled before–after studies and 2 were crossover trials. Analysis of the included articles revealed a high variability of study designs and findings. Generally, the risk of bias was low-to-unclear for RCTs and high for crossover studies, whilst the before–after studies exhibited several structural limitations. Nine studies used polysomnography/polygraphy/electromyography for SB diagnosis, whilst others were based on history taking and clinical examination. Most of them featured small samples and were short-term. Of the studies using objective SB evaluations, eight showed positive results for almost every type of OA in reducing SB activity, with a higher decrease for devices that are designed to provide a certain extent of mandibular advancement. Among the studies using a subjective SB evaluation, one demonstrated a significant reduction in SB activity, and additional two showed a myorelaxant effect of OA in SB patients. Although many positive studies support the efficiency of OA treatment for SB, accepted evidence is insufficient to support its role in the long-term reduction of SB activity. Further studies with larger samples and sufficient treatment periods are needed to obtain more acknowledgements for clinical application.

This article is protected by copyright. All rights reserved.



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Paramedic - Superior Ambulance

Superior Air-Ground Ambulance Service, Inc. is the largest independent, locally owned and operated Emergency Medical Service provider in Michigan, Northern Illinois, Northwest Indiana and Ohio. We provide wheelchair transportation, Basic Life Support, Advanced Life Support and Critical Care Ground Transportation; as well as Critical Care Rotary Air Transportation. Much of our proven success is attributable ...

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Paramedic Firefighter - Metro Paramedic Services, Inc.

Metro Paramedic Services, Inc., a subsidiary of Superior Air-Ground Ambulance, Inc., contracts with municipalities to provide emergency medical services and/or fire services. We are currently seeking a Part-time Firefighter II/Medic at our Roselle IL location. Qualifications include: IL Paramedic license in good standing, in the CDH EMS System or able to test in before beginning work OSFM Firefighter ...

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Inside EMS Podcast: Why did you become a caregiver?

<!--cke_bookmark_116S--><!--cke_bookmark_116E--> Download this podcast on iTunes, SoundCloud or via RSS feed ​​In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson discuss their funniest calls they have encountered, as well as the one call that caused them to be better caregivers. Learn more about the EMS1 Academy and schedule a free demo.

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