Wilderness Paramedic-A Practice Analysis.

Emergency medical services (EMS) has existed in its modern form for over 50 years. EMS has become a critical public safety net and access point to the larger health care system. Mature EMS systems are in place in most urban areas. However, EMS systems are not as developed in wilderness areas. A barrier to further development of these systems is the lack of an agreed-upon standard of minimum competence and validation of specialized practice. A practice analysis was completed to create such standards. The practice analysis was completed using a multi-step process. A group of subject matter experts constructed a survey of tasks and knowledge needed for wilderness EMS (WEMS) specialty practice. The tasks and knowledge were validated through an industry survey. A total of 947 surveys were submitted for analysis. Of these, 196 were at least 55% complete and used for analysis. North America was heavily represented as a primary practice location with 177 (90.3%) responses out of the 196 total. Of these 177 responses, 164 (92.7%) were from the United States and 12 (6.8%) were from Canada. One hundred seven of the 116 tasks identified by the subject matter expert group were passed by the survey group, and 164 of the 175 knowledge statements were passed by the survey group. An index of agreement (IOA) was calculated and found to be greater than 0.9 for each task and knowledge statement across all subgroups. A content coverage rating was also calculated and the results indicate survey participants felt the content was "adequate" to "well" covered. The survey results were used to construct a pilot examination. Beta testing of the pilot examination was performed. The beta test results were analyzed and a cut score was determined using the Angoff method with a Beuk compromise. The final product of this process is a defensible exam that will certify candidates' cognitive knowledge of the specialty of WEMS. Completion of this practice analysis solidifies WEMS as distinct subspecialty of out-of-hospital medicine. Additionally, it establishes a consensus definition of wilderness paramedicine and standards that may be used by WEMS systems and regulatory entities.

Cell-free human papillomavirus DNA kinetics after surgery for human papillomavirus-associated oropharyngeal cancer.

BACKGROUND: New ultrasensitive methods for detecting residual disease after surgery are needed in human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+OPSCC). METHODS: To determine whether the clearance kinetics of circulating tumor human papillomavirus DNA (ctHPVDNA) is associated with postoperative disease status, a prospective observational study was conducted in 33 patients with HPV+OPSCC undergoing surgery. Blood was collected before surgery, postoperative days 1 (POD 1), 7, and 30 and with follow-up. A subcohort of 12 patients underwent frequent blood collections in the first 24 hours after surgery to define early clearance kinetics. Plasma was run on custom droplet digital polymerase chain reaction (ddPCR) assays for HPV genotypes 16, 18, 33, 35, and 45. RESULTS: In patients without pathologic risk factors for recurrence who were observed after surgery, ctHPVDNA rapidly decreased to <1 copy/mL by POD 1 (n = 8/8). In patients with risk factors for macroscopic residual disease, ctHPVDNA was markedly elevated on POD 1 (>350 copies/mL) and remained elevated until adjuvant treatment (n = 3/3). Patients with intermediate POD 1 ctHPVDNA levels (1.2-58.4 copies/mL) all possessed pathologic risk factors for microscopic residual disease (n = 9/9). POD 1 ctHPVDNA levels were higher in patients with known adverse pathologic risk factors such as extranodal extension >1 mm (P = .0481) and with increasing lymph nodes involved (P = .0453) and were further associated with adjuvant treatment received (P = .0076). One of 33 patients had a recurrence that was detected by ctHPVDNA 2 months earlier than clinical detection. CONCLUSIONS: POD 1 ctHPVDNA levels are associated with the risk of residual disease in patients with HPV+OPSCC undergoing curative intent surgery and thus could be used as a personalized biomarker for selecting adjuvant treatment in the future. LAY SUMMARY: Human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+OPSCC) is increasing at epidemic proportions and is commonly treated with surgery. This report describes results from a study examining the clearance kinetics of circulating tumor HPV DNA (circulating tumor human papillomavirus DNA [ctHPVDNA]) following surgical treatment of HPV+OPSCC. We found that ctHPVDNA levels 1 day after surgery are associated with the risk of residual disease in patients with HPV+OPSCC and thus could be used as a personalized biomarker for selecting adjuvant treatment in the future. These findings are the first to demonstrate the potential utility of ctHPVDNA in patients with HPV+OPSCC undergoing surgery.

Paramedic Board Certification: The International Board of Specialty Certification Turns 20.

The International Board of Specialty Certification (IBSC) has been offering specialty certification for 20 years. Originally formed as the Board for Critical Care Transport Paramedic Certification (BCCTPC), the first official examination at the Air Medical Transport Conference (AMTC) in October of 2000. Paramedic specialty certification flourished because of the vision and tireless commitment of a small group of paramedic champions. Some of that group from 20 years ago included David O. Bump, John R. Clark, Dr. John Cole, Dr. Robert Donovan, Chris Giller, Lisa Gilmore, Jonathan Gryniuk; Bob Hesse, TJ Kennedy, Brian Schaeffer, and Jackie Stocking. Without their tenacity, paramedic specialty certification would not be celebrating this milestone. The IBSC is a functional specialty board with a mission to support paramedicine specialties anywhere in the world. The Certified Flight Paramedic (FP-C®), Certified Critical Care Paramedic (CCP-C®) Certified Tactical Paramedic (TP-C®), Certified Tactical Responder (TR-C®) and Certified Community Paramedic (CP-C®) examinations are well established and have become a recognized standard for clinical competency by medical providers in the United States, Europe, South Africa and the Middle East. Founded in 2000, the IBSC is a not-for-profit professional certification organization responsible for the administration and development of specialty certification exams for critical care professionals. The mission of the IBSC is to improve quality of care in all aspects of specialty EMS care across a wide variety of settings by providing a portfolio of certification exams that are an objective, fair, and honest validation of specialty knowledge to paramedics and other allied health providers are called upon to perform critical care transport. Exams are developed that are responsive to the needs of the paramedic community. Currently, there are nearly 10,000 board certified providers in one of the five specialty designations.

High-density linkage maps and loci for berry color and flower sex in muscadine grape (Vitis rotundifolia).

KEY MESSAGE: Linkage maps of muscadine grape generated using genotyping-by-sequencing (GBS) provide insight into genome collinearity between Muscadinia and Euvitis subgenera and genetic control of flower sex and berry color. The muscadine grape, Vitis rotundifolia, is a specialty crop native to the southeastern USA. Muscadine vines can be male, female, or perfect-flowered, and berry color ranges from bronze to black. Genetic linkage maps were constructed using genotyping-by-sequencing in two F1 populations segregating for flower sex and berry color. The linkage maps consisted of 1244 and 2069 markers assigned to 20 linkage groups (LG) for the 'Black Beauty' × 'Nesbitt' and 'Supreme' × 'Nesbitt' populations, respectively. Data from both populations were used to generate a consensus map with 2346 markers across 20 LGs. A high degree of collinearity was observed between the genetic maps and the Vitis vinifera physical map. The higher chromosome number in muscadine (2n = 40) compared to V. vinifera (2n = 38) was accounted for by the behavior of V. vinifera chromosome 7 as two independently segregating LGs in muscadine. The muscadine sex locus mapped to an interval that aligned to 4.64-5.09 Mb on V. vinifera chromosome 2, a region which includes the previously described V. vinifera subsp. sylvestris sex locus. While the MYB transcription factor genes controlling fruit color in V. vinifera are located on chromosome 2, the muscadine berry color locus mapped to an interval aligning to 11.09-11.88 Mb on V. vinifera chromosome 4, suggesting that a mutation in a different gene in the anthocyanin biosynthesis pathway determines berry color in muscadine. These linkage maps lay the groundwork for marker-assisted breeding in muscadine and provide insight into the evolution of Vitis species.

A molecular phylogeny of the Pacific clade of Cyrtandra (Gesneriaceae) reveals a Fijian origin, recent diversification, and the importance of founder events.

Cyrtandra (Gesneriaceae) is among the largest genera of flowering plants in the remote oceanic islands of the Pacific, with an estimated 175 species distributed across an area that extends from the Solomon Islands, east to the Marquesas Islands, and north to the Hawaiian Islands. The vast majority of species are single-island endemics that inhabit upland rainforests. Although previous molecular phylogenetic studies greatly advanced our understanding of the diversification of Pacific Cyrtandra, a number of uncertainties remain regarding phylogenetic relationships, divergence times, and biogeographic patterns within this large and widely dispersed group. In the present study, five loci (ITS, ETS, Cyrt1, psbA-trnH, and rpl32-trnL) were amplified and sequenced for phylogenetic reconstruction of 121 Cyrtandra taxa. Maximum likelihood and Bayesian inference confirmed that C. taviunensis from Fiji is sister to the remaining members of the Pacific clade. Dating analyses and ancestral area estimation indicates that the Pacific clade of Cyrtandra originated in Fiji during the Miocene ca. 9mya. All major crown lineages within the Pacific clade appeared < 5mya, coincident with the emergence of numerous Pacific islands and a subsequent increase in available habitat. The biogeographic history of Cyrtandra in the Pacific has been shaped by extinction, dispersal distance, and founder events. Biogeographic stochastic mapping analyses suggest that cladogenesis within Pacific Cyrtandra involved a combination of narrow (within-area) sympatry and founder events. A mean of 24 founder events was recovered between Pacific archipelagos, while a mean of 10 founder events was recovered within the Hawaiian archipelago.

Paramedic specialization: a strategy for better out-of-hospital care.

Demographic, economic, and political forces are driving significant change in the US health care system. Paramedics are a health profession currently providing advanced emergency care and medical transportation throughout the United States. As the health care system demands more team-based care in nonacute, community, interfacility, and tactical response settings, specialized paramedic practitioners could be a valuable and well-positioned resource to meet these needs. Currently, there is limited support for specialty certifications that demand appropriate education, training, or experience standards before specialized practice by paramedics. A fragmented approach to specialty paramedic practice currently exists across our country in which states, regulators, nonprofit organizations, and other health care professions influence and regulate the practice of paramedicine. Multiple other medical professions, however, have already developed effective systems over the last century that can be easily adapted to the practice of paramedicine. Paramedicine practitioners need to organize a profession-based specialty board to organize and standardize a specialty certification system that can be used on a national level.

ShinyFruit: interactive fruit phenotyping software and its application in blackberry.

Introduction: Horticultural plant breeding programs often demand large volumes of phenotypic data to capture visual variation in quality of harvested products. Increasing the throughput potential of phenomic pipelines enables breeders to consider data-hungry molecular breeding strategies such as genome-wide association studies and genomic selection. Methods: We present an R-based web application called ShinyFruit for image-based phenotyping of size, shape, and color-related qualities in fruits and vegetables. Here, we have demonstrated one potential application for ShinyFruit by comparing its estimates of fruit length, width, and red drupelet reversion (RDR) with ImageJ and analogous manual phenotyping techniques in a population of blackberry cultivars and breeding selections from the University of Arkansas System Division of Agriculture Fruit Breeding Program. Results: ShinyFruit results shared a strong positive correlation with manual measurements for blackberry length (r = 0.96) and ImageJ estimates of RDR (r = 0.96) and significant, albeit weaker, correlations with manual RDR estimation methods (r = 0.62 - 0.70). Neither phenotyping method detected genotypic differences in blackberry fruit width, suggesting that this trait is unlikely to be heritable in the population observed. Discussion: It is likely that implementing a treatment to promote RDR expression in future studies might strengthen the documented correlation between phenotyping methods by maximizing genotypic variance. Even so, our analysis has suggested that ShinyFruit provides a viable, open-source solution to efficient phenotyping of size and color in blackberry fruit. The ability for users to adjust analysis settings should also extend its utility to a wide range of fruits and vegetables.