Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review.

BACKGROUND: Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care. OBJECTIVE: We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group. METHODS: We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach. RESULTS: One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting. CONCLUSIONS: Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.

Diversity, Equity, and Inclusion in the United States Emergency Medical Services Workforce: A Scoping Review.

OBJECTIVE: Emergency medical services (EMS) workforce demographics in the United States do not reflect the diversity of the population served. Despite some efforts by professional organizations to create a more representative workforce, little has changed in the last decade. This scoping review aims to summarize existing literature on the demographic composition, recruitment, retention, and workplace experience of underrepresented groups within EMS. METHODS: Peer-reviewed studies were obtained from a search of PubMed, CINAHL, Web of Science, ProQuest Thesis and Dissertations, and non-peer-reviewed ("gray") literature from 1960 to present. Abstracts and included full-text articles were screened by two independent reviewers trained on inclusion/exclusion criteria. Studies were included if they pertained to the demographics, training, hiring, retention, promotion, compensation, or workplace experience of underrepresented groups in United States EMS by race, ethnicity, sexual orientation, or gender. Studies of non-EMS fire department activities were excluded. Disputes were resolved by two authors. A single reviewer screened the gray literature. Data extraction was performed using a standardized electronic form. Results were summarized qualitatively. RESULTS: We identified 87 relevant full-text articles from the peer-reviewed literature and 250 items of gray literature. Primary themes emerging from peer-reviewed literature included workplace experience (n = 48), demographics (n = 12), workforce entry and exit (n = 8), education and testing (n = 7), compensation and benefits (n = 5), and leadership, mentorship, and promotion (n = 4). Most articles focused on sex/gender comparisons (65/87, 75%), followed by race/ethnicity comparisons (42/87, 48%). Few articles examined sexual orientation (3/87, 3%). One study focused on telecommunicators and three included EMS physicians. Most studies (n = 60, 69%) were published in the last decade. In the gray literature, media articles (216/250, 86%) demonstrated significant industry discourse surrounding these primary themes. CONCLUSIONS: Existing EMS workforce research demonstrates continued underrepresentation of women and nonwhite personnel. Additionally, these studies raise concerns for pervasive negative workplace experiences including sexual harassment and factors that negatively affect recruitment and retention, including bias in candidate testing, a gender pay gap, and unequal promotion opportunities. Additional research is needed to elucidate recruitment and retention program efficacy, the demographic composition of EMS leadership, and the prevalence of racial harassment and discrimination in this workforce.

Effect of gold addition by the recharge method on silver supported catalysts in the catalytic wet air oxidation (CWAO) of phenol.

Catalysts Ag/ZrO2-CeO2 and Au/ZrO2-CeO2 were synthesized by a deposition-precipitation method and Ag-Au/ZrO2-CeO2 was prepared using a recharge method for the second metal (Au). The materials were characterized by physisorption of N2, XRD, ICP, UV-vis RDS, H2-TPR, XPS and TEM. The results obtained show that the specific areas for monometallic materials were 29-37 m2 g-1 and 27-74 m2 g-1 for bimetallics. The tetragonal crystal phase of ZrO2 stabilizes when CeO2 quantity increases. Using XPS an increment in Ce3+ species abundance was determined for bimetallic catalysts in contrast to the monometallic ones; according to the Ag 3d region, this metal oxidation was observed when augmenting the content of CeO2 in the materials, and with Au the opposite effect was produced. It was determined by TEM, that the average size of the metallic particles was smaller at bimetallic catalysts due the preparation method. Catalytic activity was evaluated by CWAO of phenol, the Ag-Au/ZrO2-CeO2 catalyst with 20% wt of cerium reached a degradation of 100% within an hour, being the most active catalyst. Maleic, formic and oxalic acid were identified as reaction intermediates; and at the end of the reaction acetic acid was identified as the main by-product, because it is the most refractory and the conditions for oxidation must be more severe.

Effect of the CuAl2O4 and CuAlO2 Phases in Catalytic Wet Air Oxidation of ETBE and TAME using CuO/γ-Al2O3 catalysts.

This paper studies Cu/Al2O3 catalysts, synthesized in two ways: copper deposit in the synthesis of alumina (sol gel) and incipient impregnation stabilized at 400 °C. The materials were characterized by X-ray diffraction studies, nitrogen physisorption, temperature programmed reduction of H2, dehydration of isopropanol, scanning electronic microscopy, transmission electronic microscopy, which were evaluated in the liquid phase oxidation reaction of ethyl tert-butyl ether and tert-amyl methyl ether. The formation of CuAl2O4 and CuAlO2 in the samples synthesized by sol gel, led to a modification of the texture, thus resulting in an expansion of the specific area of the materials. CuAl2O4 and CuAlO2 have been identified by DRX from a content of 10 % Copper, the first showed the highest intensity with this technique. In the same way, these species favor the presence of Lewis acid sites; this is reflected in the materials with (Di-isopropyl Ether) DIPE of 96.7 % and 91.1 % for the samples SAlCu5 and SAlCu15 respectively. The catalytic activity of the materials prepared by sol gel is in the function of the number of surface acid sites, the smaller particle size of the Cu and the surface of the contact, in the case of the ETBE meanwhile for TAME the activity was based mainly on the strength of the present acid sites. With impregnated materials, the activity is attributed to the smaller particle size of the Cu and the greater strength of the surface acid sites in the solid. The formation of spinel species inhibits the leaching phenomenon in the reaction milieu.

Comment on: Chocolate Consumption and Risk of Coronary Heart Disease, Stroke, and Diabetes: A Meta-analysis of prospective Studies, Nutrients 2017, 9, 688.

Shen Yuan et al. [1] highlight the protective cardiometabolic effects of chocolate intake. Without doubt, their work contributes to support evidence about the salutary and wide protective effects of chocolate compounds, particularly flavanols and its derivatives.[...].

Aluminum Contamination in Parenteral Nutrition Admixtures for Low-Birth-Weight Preterm Infants in Mexico.

BACKGROUND: Aluminum contamination from intravenous solutions still represents an unsolved clinical and biochemical problem. Increased aluminum intake constitutes a risk factor for the development to metabolic bone disease, anemia, cholestasis, and neurocognitive alterations. Low-birth-weight preterm infants (LBWPIs) are one of the most exposed populations for aluminum toxicity. METHODS: To determine the presence of aluminum in components employed in the preparation of parenteral nutrition (PN) admixtures in Mexico and compare with the maximal aluminum recommended intake from the Food and Drug Administration. RESULTS: Cysteine, trace elements, levocarnitine, phosphate, and calcium salts tested positive for aluminum contamination. All components analyzed were contained in glass vials. Total aluminum intake for 2 sample PN admixtures were calculated in basis to cover nutrition requirements of 2 hypothetical LBWPIs. Aluminum contents, stratified in micrograms per kilogram of weight, exceeded maximal aluminum recommendations, particularly for the very LBWPIs. Substituting sodium phosphate for potassium phosphate salts reduced aluminum intake by 52.7%. Calcium gluconate was the leading aluminum contamination source and confers the greatest risk for aluminum overdose, even with the salt substitution of potassium phosphate by sodium phosphate salts. Adding cysteine and trace elements might increase aluminum content in PN admixtures. CONCLUSION: Cysteine, trace elements, phosphate, and gluconate salts are the main sources of aluminum in PN prepared in Mexico. Substituting sodium phosphate for potassium phosphate salts reduces aluminum intake but does not resolve aluminum contamination risk. Mineral salts contained in plastic vials should be explored as an additional measure to reduce aluminum contamination.

Comportamiento de la mortalidad en el adulto mayor según grupos de enfermedades / Behavior of mortality in the elderly according to disease groups

RESUMEN Fundamento: las defunciones por enfermedades representan más de un tercio del total de la mortalidad del mundo, con mayor incidencia en el adulto mayor. Objetivo: determinar el comportamiento de la mortalidad en el adulto mayor según grupos de enfermedades. Métodos: se realizó un estudio de tipo descriptivo transversal con el objetivo de determinar el comportamiento de la mortalidad en el adulto mayor según grupos de enfermedades en el Hospital Militar Clínico Quirúrgico Docente Dr. Octavio de la Concepción de la Pedraja de la provincia Camagüey, desde enero de 2018 hasta enero de 2019. El universo estuvo compuesto por 97 adultos mayores fallecidos. La muestra estuvo constituida por el total del universo, por lo que no fue necesario aplicar métodos de muestreo. Resultados: en el estudio hubo un predominio de la mortalidad en el grupo de las enfermedades circulatorias con casi la mitad de los casos, el grupo de edad más afectado, fue el 75 a 89 años con más de un tercio y predominó el sexo masculino. La bronconeumonía fue la causa de muerte más frecuente, seguido del síndrome coronario agudo y asociado a estas causas más de la mitad de los pacientes tenían una descompensación de sus enfermedades crónicas no trasmisibles. Las proteínas totales y fraccionadas y el leucograma con diferencial fueron los estudios analíticos más alterados en casi la mitad de los casos. Conclusiones: la mortalidad es mayor en el grupo de las enfermedades circulatorias y respiratorias con franco predominio del síndrome coronario agudo y de la bronconeumonía. El sexo masculino y edades comprendidas entre 75 a 89 años se asocian con mayor frecuencia a la mortalidad. La descompensación de enfermedades crónicas y los valores disminuidos de proteínas fraccionadas son frecuentes en los adultos mayores que fallecen.

ABSTRACT Background: deaths from diseases represent more than a third of the total mortality in the world, with the highest incidence in the elderly. Objective: to determine the behavior of mortality in the elderly according to groups of diseases. Methods: a cross-sectional descriptive study was carried out with the objective of determining the behavior of mortality in the elderly according to groups of diseases in the Octavio de la Concepción y de la Pedraja Teaching Clinical Surgical Military Hospital, Camagüey province, from January 2018 to January 2019. The universe was made up of 97 deceased older adults. The sample consisted of the entire universe, so it was not necessary to apply sampling methods. Results: in the study there was a predominance of mortality in the group of circulatory diseases with almost half of the cases, the most affected age group was 75 to 89 years with more than a third and male sex predominated. Bronchopneumonia was the most frequent cause of death; followed by acute coronary syndrome and associated with these causes more than half of the patients had a decompensation of their chronic non-transmissible diseases. Total and fractionated proteins and the differential leukogram were the most altered analytical studies in almost half of the cases. Conclusions: mortality is higher in the group of circulatory and respiratory diseases with a clear predominance of acute coronary syndrome and bronchopneumonia. Male sex and ages between 75 and 89 years are more frequently associated with mortality. Decompensation of chronic diseases and decreased levels of fractionated proteins are common in older adults who die.

Functional analysis of SAND mutations in AIRE supports dominant inheritance of the G228W mutation.

Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED) is a rare disorder caused by mutations in the autoimmune regulator gene (AIRE) and characterized by a variable combination of organ-specific autoimmune diseases. Studies on AIRE-deficient mice suggest that AIRE is an important factor in the establishment and maintenance of self-tolerance. The AIRE protein contains several structural domains often found in transcriptional regulators and functions as a transcriptional transactivator in vitro. To date, more than 50 patient mutations have been identified in the coding region of the AIRE gene. So far, APECED has been reported to be inherited in an autosomal recessive manner. However, in contrast to all other AIRE mutations, a novel mutation c.682T>G (p.G228W) in the DNA-binding and/or multimerization domain SAND was recently described to be inherited in a dominant fashion. We analyzed the effects of mutant AIRE proteins containing the patient mutations c.682T>G (p.G228W) and c.755C>T (p.P252L) located in the SAND domain on the properties of the wild-type AIRE in a heterozygous situation in vitro. In addition to the patient mutations, we analyzed the effects of a double mutation [c.727A>G;c.728A>C;c.739C>G;c740G>C] (p.K243A;R247A) of positively charged amino acids in the SAND domain. Of the mutants studied, only c.682T>G (p.G228W) mutant changed the subcellular localization and in addition severely disrupted the transactivating capacity of the wild-type AIRE. Our results indicate that the c.682T>G (p.G228W) mutant AIRE protein acts with a dominant negative effect by binding to the wild-type AIRE, thus preventing the protein from forming the complexes needed for transactivation.

Rheumatoid cachexia and other nutritional alterations in rheumatologic diseases.

The prevalence of nutritional alterations in rheumatologic diseases ranges from 4 to 95%, depending on the detection method used. Formerly described as the single term rheumatoid cachexia, nutritional alterations can currently be grouped and subdivided based on the physiopathological mechanisms involved: chronic disease-related inflammatory conditions (cachexia), malnutrition associated to acute malnutrition inflammatory conditions (protein-caloric malnutrition) and starvation-related malnutrition. Clinical manifestations of malnutrition associated to rheumatic diseases vary from the patient with low weight or overweight and obesity; with lean body mass depletion as well as functional repercussions, and impact of quality of life as a common denominator. Additionally, the associated increase in body fat mass increases the risk for cardiovascular morbidity. A multidisciplinary approach towards rheumatic diseases should include aspects oriented towards prevention, early identification, diagnosis and correction of nutritional alterations.

Alteration of prolyl oligopeptidase and activated α-2-macroglobulin in multiple sclerosis subtypes and in the clinically isolated syndrome.

Prolyl oligopeptidase (PREP) has been considered as a drug target for the treatment of neurodegenerative diseases. In plasma, PREP has been found altered in several disorders of the central nervous system including multiple sclerosis (MS). Oxidative stress and the levels of an endogenous plasma PREP inhibitor have been proposed to decrease PREP activity in MS. In this work, we measured the circulating levels of PREP in patients suffering of relapsing remitting (RR), secondary progressive (SP), primary progressive (PP) MS, and in subjects with clinically isolated syndrome (CIS). We found a significantly lower PREP activity in plasma of RRMS as well as in PPMS patients and a trend to reduced activity in subjects diagnosed with CIS, compared to controls. No signs of oxidative inactivation of PREP, and no correlation with the endogenous PREP inhibitor, identified as activated α-2-macroglobulin (α2M*), were observed in any of the patients studied. However, a significant decrease of α2M* was recorded in MS. In cell cultures, we found that PREP specifically stimulates immune active cells possibly by modifying the levels of fibrinogen ß, thymosin ß4, and collagen. Our results open new lines of research on the role of PREP and α2M* in MS, aiming to relate them to the diagnosis and prognosis of this devastating disease.