Paramedic Student Clinical Performance During High-Fidelity Simulation After a Physically Demanding Occupational Task: A Pilot Randomized Crossover Trial.

INTRODUCTION: Paramedic duties include assessing, treating, and maneuvering patients in physically challenging environments. Whether clinical skills and patient care are affected by these occupational demands is unknown. High-fidelity simulation affords the opportunity to study this in a controlled setting. METHODS: Using a randomized crossover design, 11 regional paramedicine students and graduates (mean ± SD age = 23 ± 2 years) completed two, 20-minute high-fidelity simulations that included cardiopulmonary resuscitation (CPR) immediately after either an acute bout of occupational physical activity (OPA) or a rest period (REST). Heart rate, respiratory rate, and mean arterial pressure were measured throughout. Clinical performance was scored using the Global Rating Score and a patient care record. Measures of CPR efficacy were recorded in the manikin. RESULTS: There were no significant differences in Global Rating Score ( P = 0.07, ES = 0.03) or CPR efficacy between conditions. Patient care record accuracy was higher after the OPA versus REST simulations (mean ± SD = 61.8 ± 12.6% vs. 55.5 ± 12.0%, P = 0.03, ES = 0.5). Mean heart rate was higher during OPA simulations versus REST simulations (121 ± 14 vs. 84 ± 9 beats per minute, P < 0.01, ES = 3.1), as was mean respiratory rate (19 ± 3 vs. 16 ± 3 breaths per minute, P < 0.01, ES = 1.0). Mean arterial pressure was higher for OPA versus REST at simulation start (105 ± 11.3 vs. 95.8 ± 11.8 mm Hg, P = 0.01, Effect Size = 0.8), although not different after simulation. CONCLUSIONS: Paramedicine students including recent graduates performed as well, or better, in a simulated clinical scenario immediately after occupation-specific acute physical exertion compared with a REST, despite higher physiological exertion. Whether this is the case for more experienced but potentially less physically fit paramedics in the workforce warrants investigation.

Impurities in Oligonucleotide Drug Substances and Drug Products.

This white paper, which is the 10th in a series intended to address issues associated with the development of therapeutic oligonucleotides, examines the subject of product-related impurities. The authors consider chemistry and safety aspects and advance arguments in favor of platform approaches to impurity identification and qualification. Reporting, identification, and qualification thresholds suitable for product-related impurities of therapeutic oligonucleotides are proposed.

Exchange characteristics of calcium ions bound to anthrax protective antigen.

Protective antigen (PA), the receptor-binding moiety of anthrax toxin, contains two calcium atoms buried within domain 1(') (amino acid residues 168-258). We showed that these ions are stably bound and exchange with free 45Ca(2+) only slowly (t(1/2) approximately 4.0 h). Dissociation is the rate-limiting step. PA(63), the heptameric prepore form of PA, showed a slightly higher exchange rate than the monomeric intact protein. Exchange by this form was retarded by binding of the enzymatic moieties of the toxin, but was unaffected by reducing the pH to 5.0, a condition known to trigger conversion of the prepore to the pore form. These results are consistent with the hypothesis that bound Ca(2+) within PA plays primarily a structural role, maintaining domain 1(') in a conformation that allows PA(63) to oligomerize and bind the enzymatic moieties of the toxin.

Limitations of and Barriers to Using Performance Measurement: Purchasers' Perspectives.

Although health plan performance data are becoming increasingly more available, many purchasers are still not using these data to make their purchasing decisions. In this article, we review barriers that private purchasers face to using performance data. In addition, we consider the effects of the larger health care purchasing environment and employers' quality improvement activities on their use of the data. We conclude that a variety of factors, including trends, the health care purchasing environment, characteristics of firms, and problems with performance data and their presentation to users create barriers to incorporating this information into health care decisionmaking.