RESUMO
OBJECTIVE: Handoffs by emergency medical services (EMS) personnel suffer from poor structure, inattention, and interruptions. The relationship between the quality of EMS communication and the non-technical performance of trauma teams remains unknown. METHODS: We analyzed 3 months of trauma resuscitation videos (highest acuity activations or patients with an Injury Severity Score [ISS] of ≥15). Handoffs were scored using the mechanism-injury-signs-treatment (MIST) framework for completeness (0-20), efficiency (category jumps), interruptions, and timeliness. Trauma team non-technical performance was scored using the Trauma Non-Technical Skills (T-NOTECHS) scale (5-15). RESULTS: We analyzed 99 videos. Handoffs lasted a median of 62 seconds [IQR: 43-74], scored 11 [10-13] for completeness, and had 2 [1-3] interruptions. Most interruptions were verbal (85.2%) and caused by the trauma team (64.9%). Most handoffs (92%) were efficient with 2 or fewer jumps. Patient transfer during handoff occurred in 53.5% of the videos; EMS providers giving handoff helped transfer in 69.8% of the Primary surveys began during handoff in 42.4% of the videos. Resuscitation teams who scored in the top-quartile on the T-NOTECHS (>11) had higher MIST scores than teams in lower quartiles (13 [11.25-14.75] vs. 11 [10-13]; p < .01). There were no significant differences in ISS, efficiency, timeliness, or interruptions between top- and lower-quartile groups. CONCLUSIONS: There is a relationship between EMS MIST completeness and high performance of non-technical skill by trauma teams. Trauma video review (TVR) can help identify modifiable behaviors to improve EMS handoff and resuscitation efforts and therefore trauma team performance.
Assuntos
Serviços Médicos de Emergência , Transferência da Responsabilidade pelo Paciente , Humanos , Comunicação , Ressuscitação , Grupo SocialAssuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Socorristas/estatística & dados numéricos , Pneumonia Viral/complicações , COVID-19 , Causas de Morte/tendências , Infecções por Coronavirus/epidemiologia , Feminino , Saúde Global , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/epidemiologia , SARS-CoV-2 , Taxa de Sobrevida/tendênciasRESUMO
On August 25, 2017, Hurricane Harvey made landfall near Corpus Christi, Texas. The ensuing unprecedented flooding throughout the Texas coastal region affected millions of individuals.1 The statewide response in Texas included the sheltering of thousands of individuals at considerable distances from their homes. The Dallas area established large-scale general population sheltering as the number of evacuees to the area began to amass. Historically, the Dallas area is one familiar with "mega-sheltering," beginning with the response to Hurricane Katrina in 2005.2 Through continued efforts and development, the Dallas area had been readying a plan for the largest general population shelter in Texas. (Disaster Med Public Health Preparedness. 2019;13:33-37).
Assuntos
Defesa Civil/métodos , Tempestades Ciclônicas/estatística & dados numéricos , Serviços Médicos de Emergência/métodos , Abrigo de Emergência/estatística & dados numéricos , Defesa Civil/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Abrigo de Emergência/métodos , Abrigo de Emergência/organização & administração , Humanos , Texas/epidemiologiaRESUMO
Lactation studies are necessary evaluations of medications for reproductive-age women. We evaluated pharmacokinetics (PK), pharmacodynamics, safety, and adherence profiles associated with 7 days of 1% tenofovir (TFV) vaginal gel use during lactation. Tenofovir levels (maternal/infant serum, milk) and anti-HIV activity (milk), adverse events (AEs), and adherence were measured for 17 HIV-1-seronegative breast-feeding mother-infant pairs. Tenofovir use was well-tolerated and detected at low levels in maternal serum, milk, and infant serum but demonstrated no anti-HIV activity in milk.
Assuntos
Fármacos Anti-HIV/sangue , Leite Humano/metabolismo , Tenofovir/sangue , Tenofovir/farmacocinética , Adulto , Aleitamento Materno , Feminino , Infecções por HIV/sangue , Infecções por HIV/tratamento farmacológico , Infecções por HIV/metabolismo , HIV-1/efeitos dos fármacos , Humanos , Lactente , Lactação/metabolismo , Mães , Tenofovir/uso terapêutico , Cremes, Espumas e Géis Vaginais/farmacocinética , Cremes, Espumas e Géis Vaginais/uso terapêutico , Adulto JovemRESUMO
There is a global need for the implementation of more cost-effective green technologies for the treatment of effluent from wineries. However, systems reliant on microbial biodegradation may be adversely affected by the highly seasonal character of cellar waste. In this study, the biodegradation of two different formulations of winery effluent in sand bioreactors was compared. The degradation of organic substrates and formation of metabolites was monitored by physicochemical analyses of pore water and final effluent samples. Changes in the bacterial community structures were detected using molecular fingerprinting. In wastewater with an overall COD of 2027 mg/L, a formulation with a high concentration of acetate (800 mg COD/L) was more recalcitrant to degradation than a formulation with a high concentration of glucose (800 mg COD/L). Ethanol, glucose and phenolics were degraded preferentially in the deeper layers of the sand bioreactors (average Eh 25 mV) than in the superficial layers (average Eh 102 mV). The redox status also played a pivotal role on the bacterial community composition. The study yielded valuable insight that can be utilized in the design (configuration and operation) of full scale sand bioreactors.
Assuntos
Resíduos Industriais/análise , Consórcios Microbianos , Dióxido de Silício/química , Eliminação de Resíduos Líquidos/métodos , Águas Residuárias/análise , Vinho , Biodegradação Ambiental , Reatores BiológicosRESUMO
Ecosystem approaches recognize the complexity of many contemporary public health challenges and offer an alternative for dealing with problems that have proven intractable and unresponsive to conventional public health strategies. Infectious disease outbreaks are among the most dramatic aspects of systems failure, and the Canadian cases of SARS (Severe Acute Respiratory Syndrome) in Toronto, and the E. coli outbreak in Walkerton, serve as useful illustrative examples. This paper examines some of the limitations of current public health approaches, the fundamental tenets of an alternative, transdisciplinary ecosystem approach, and changes necessary for implementation, including those in philosophical approach, communications and education, and, finally, institutions and governance.
Assuntos
Surtos de Doenças , Infecções por Escherichia coli/epidemiologia , Administração em Saúde Pública/métodos , Síndrome Respiratória Aguda Grave/epidemiologia , Vacinas Bacterianas , Canadá/epidemiologia , Infecções por Escherichia coli/tratamento farmacológico , Humanos , Comunicação Interdisciplinar , Vigilância da População , Síndrome Respiratória Aguda Grave/tratamento farmacológico , Vacinas ViraisRESUMO
Kentucky farmers and University of Kentucky extension agents applied the principles of the Work Crew Performance Model (WCPM), used previously in mining and construction, to identify and prioritize critical action factors (CAFs) for safe handling of cattle. One focus group of farmers helped identify a set of 32 critical action factors in four categories: environmental conditions, animal behavior, facilities and equipment, and handling techniques. A second focus group of farmers used a Q-sort nominal group process to rate each of the factors on the basis of the cost consequences of failure to properly perform the activity. A three-stage binary sort process resulted in a five-point ordinal ranking of tasks within each of the four categories. The Q-sort procedure was performed with assumptions of both routine and emergency animal handling activities. The list and the rankings were validated and modified by extension agriculture agents and by an expert panel of animal scientists and an agricultural engineering educator. The validation process added seven CAFs to the original list. The result of the process was the development of a cattle safety handling checklist that has been used with success in Master Cattleman educational workshops conducted for approximately 1500 Kentucky farmers.
Assuntos
Acidentes de Trabalho/prevenção & controle , Agricultura/normas , Criação de Animais Domésticos/métodos , Criação de Animais Domésticos/normas , Comportamentos Relacionados com a Saúde , Agricultura/instrumentação , Agricultura/métodos , Animais , Animais Domésticos , Bovinos , Grupos Focais , Humanos , Q-Sort , População Rural , SegurançaRESUMO
There are few evidence-based measures of emergency medical services (EMS) system performance. In many jurisdictions, response-time intervals for advanced life support units and resuscitation rates for victims of cardiac arrest are the primary measures of EMS system performance. The association of the former with patient outcomes is not supported explicitly by the medical literature, while the latter focuses on a very small proportion of the EMS patient population and thus does not represent a sufficiently broad selection of patients. While these metrics have their place in performance measurement, a more robust method to measure and benchmark EMS performance is needed. The 2007 U.S. Metropolitan Municipalities' EMS Medical Directors' Consortium has developed the following model that encompasses a broader range of clinical situations, including myocardial infarction, pulmonary edema, bronchospasm, status epilepticus, and trauma. Where possible, the benefit conferred by EMS interventions is presented in the number needed to treat format. It is hoped that utilization of this model will serve to improve EMS system design and deployment strategies while enhancing the benchmarking and sharing of best practices among EMS systems.
Assuntos
Benchmarking , Serviços Médicos de Emergência/normas , Medicina Baseada em Evidências , Serviços Médicos de Emergência/métodos , Humanos , Modelos Organizacionais , Garantia da Qualidade dos Cuidados de Saúde/métodosRESUMO
PURPOSE OF REVIEW: The most current practice guidelines for cardiopulmonary resuscitation published by the American Heart Association and European Resuscitation Council have placed the highest priority on achieving the most optimal circulation possible following sudden cardiac arrest through the delivery of early, consistent, high-quality and infrequently interrupted chest compressions during resuscitative efforts. The purpose of this review is to analyze the most recent trials involving adjunct mechanical devices designed to optimize blood flow to vital organs during cardiopulmonary resuscitation conditions. RECENT FINDINGS: Six devices show substantial promise based on the compelling results of numerous animal and small-scale clinical trials. All of these promising interventions, however, have yet to be validated in definitive clinical trials, particularly those examining long-term survival and neurological function. SUMMARY: Markedly enhanced circulation during cardiopulmonary resuscitation efforts has been found to be a critical element for effecting successful resuscitation. Preliminary studies of adjunct mechanical cardiopulmonary resuscitation devices have revealed significant increases in improved hemodynamics in both animal models and human studies, as well as improvements in short-term human survival in the clinical setting. Several of these devices are currently undergoing definitive clinical trials that hopefully will establish irrefutable efficacy and improved long-term neurological outcomes.
Assuntos
Reanimação Cardiopulmonar/instrumentação , Animais , Reanimação Cardiopulmonar/educação , Equipamentos e Provisões , Parada Cardíaca/terapia , Sociedades MédicasRESUMO
Thousands of critically ill emergency patients are treated in the out-of-hospital setting in the United States every year. In many patients intravenous (IV) therapy cannot be initiated because of inadequate access to peripheral veins. In some cases, this lack of vascular access may limit benefit of medications because of late administration.[1] Both speed and overall success of vascular access are important when evaluating potential methodologies for their use in the out-of-hospital environment. Insertion of an IV cannula has been reported to require substantial time in the prehospital environment, with a recent study reporting an average successful intravenous line placement time of 4.4+/-2.8 minutes.[2] In critically ill pediatric patients, vascular access may present substantial difficulties to the provide.[3] Intraosseous access may provide a significant time saving which may benefit many critically ill patients, both by decreasing the time to achieve access and by decreasing the time to administration of indicated medications.[4] Achieving rapid administration of medications may facilitate the care of critically ill patients.[1] Devices are now available that permit rapid, accurate access to the intraosseous space. Recent changes in the American Heart Association's resuscitation guidelines state that the intraosseous route should be the first alternative to difficult or delayed intravenous access.[5] With these considerations, the role of intraosseous vascular access in the out-of-hospital environment should be reemphasized.
Assuntos
Serviços Médicos de Emergência , Infusões Intraósseas/métodos , Contraindicações , Humanos , Fatores de Tempo , Estados UnidosRESUMO
A case-control study was conducted from 1 January to 31 May 2003 to identify risk factors for S . Heidelberg infection in Canada. Controls were pair-matched by age group and telephone exchange to 95 cases. Exposures in the 7 days before illness/interview were assessed using multivariate conditional logistic regression. Consumption of home-prepared chicken nuggets and/or strips [matched odds ratio (mOR) 4.0, 95% confidence interval (CI) 1.4-13.8], and undercooked eggs (mOR 7.5, 95% CI 1.5-75.5) increased the risk of illness. Exposure to a farm setting lowered the risk (mOR 0.22, 95% CI 0.03-1.00). The population-attributable fraction associated with chicken nuggets/strips was 34% and with undercooked eggs was 16%. One-third of study participants did not perceive, handle or prepare chicken nuggets and strips as high-risk products, although the majority of the products on the Canadian market are raw. These findings have prompted changes in product-labelling policy and consumer education.
Assuntos
Microbiologia de Alimentos , Intoxicação Alimentar por Salmonella/epidemiologia , Salmonella/isolamento & purificação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Canadá/epidemiologia , Estudos de Casos e Controles , Galinhas/microbiologia , Criança , Pré-Escolar , Ovos/microbiologia , Feminino , Manipulação de Alimentos , Humanos , Lactente , Recém-Nascido , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Salmonella/classificação , Intoxicação Alimentar por Salmonella/microbiologia , Intoxicação Alimentar por Salmonella/prevenção & controleRESUMO
The escalating national problem of oversaturated hospital beds and emergency departments (EDs) has resulted in serious operational impediments within patient-receiving facilities. It has also had a growing impact on the 9-1-1 emergency care system. Beyond the long-standing difficulties arising from ambulance diversion practices, many emergency medical services (EMS) crews are now finding themselves detained in EDs for protracted periods, unable to transfer care of their transported patients to ED staff members. Key factors have included a lack of beds or stretcher space, and, in some cases, EMS personnel are used transiently for ED patient care services. In other circumstances, ED staff members no longer prioritize rapid turnaround of EMS-transported patients because of the increasing volume and acuity of patients already in their care. The resulting detention of EMS crews confounds concurrent ambulance availability problems, creates concrete risks for delayed EMS responses to impending critical cases, and incurs regulatory jeopardy for hospitals. Communities should take appropriate steps to ensure that delivery intervals (time elapsing from entry into the hospital to physical transfer of patient care to ED staff) remain extremely brief (less than a few minutes) and that they rarely exceed 10 minutes. While recognizing that the root causes of these issues will require far-reaching national health care policy changes, EMS and local government officials should still maintain ongoing dialogues with hospital chief administrators to mitigate this mutual crisis of escalating service demands. Federal and state health officials should also play an active role in monitoring progress and compliance.
Assuntos
Aglomeração , Eficiência Organizacional , Serviços Médicos de Emergência/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Ocupação de Leitos , Planejamento em Saúde Comunitária , Serviço Hospitalar de Emergência/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Transferência de Pacientes , Fatores de Tempo , Estados UnidosRESUMO
OBJECTIVE: To audit trends in maternal mortality in the Peninsula Maternal and Neonatal Service (PMNS) over a 50-year period, with respect to rates and patterns of causation. DESIGN: Retrospective and prospective audit. SETTING: The PMNS, an integrated perinatal service composed of primary, secondary and tertiary facilities in Cape Town. Population All women giving birth in the area of the Cape Peninsula served by the PMNS over the 50-year period. METHODS: Data on maternal deaths were collected for 1953-2002 inclusive, from annual obstetric and gynaecological reports. Three triennia (1954-1956, 1981-1983 and 1999-2001) were selected for a detailed comparison of trends in rates and causes of death. MAIN OUTCOME MEASURES: Maternal mortality rates (MMRs). Causes of maternal deaths. RESULTS: Total deliveries increased from 7315 in 1953 to 27,575 in 2002. The MMR declined from 301 deaths per 100,000 deliveries in 1953 to 31.2 in the triennium, 1987-1989. From 1999, the MMR increased, reaching 112 in 2002. Comparing 1954-1956 (MMR of 253.9) with 1981-1983 (MMR of 43.8), there was a marked decline in the MMR related to hypertension (80.4 to 11.3), haemorrhage (50.8 to 4.2), abortion (55 to 4.2), suspected pulmonary embolism (25.4 to 2.8), pregnancy-related sepsis (8.5 to 4.2) and cardiac disease (21.2 to 2.8). Comparing 1981-1983 (MMR of 43.8) with 1999-2001 (MMR of 59.4), there was a decline in the MMR associated with abortion (4.2 to 0). The MMR for haemorrhage, suspected pulmonary embolism and cardiac disease remained the same. There was a slight increase in the MMR attributed to hypertension (11.3 to 14.5) and pregnancy-related sepsis (4.2 to 7.3). There was a marked increase in the MMR associated with non-pregnancy-related infections/AIDS (4.2 to 18.2). CONCLUSIONS: The MMR for all causes of maternal death declined significantly from 1953 to 1981 as a result of several interventions. From 1999, there has been a non-significant increase in MMR, predominantly due to the burden of HIV/AIDS-related mortality.
Assuntos
Mortalidade Materna , Complicações na Gravidez/mortalidade , Causas de Morte , Intervalos de Confiança , Feminino , Infecções por HIV/mortalidade , Humanos , Auditoria Médica , Gravidez , Complicações Infecciosas na Gravidez/mortalidade , Estudos Prospectivos , Estudos Retrospectivos , África do Sul/epidemiologiaRESUMO
OBJECTIVE: The San Francisco Fire Department deployed an automated, load-distributing-band chest compression device (AutoPulse, Revivant Corporation) to evaluate its function in a large urban emergency medical services (EMS) service. A retrospective chart review was undertaken to determine whether the AutoPulse had altered short-term patient outcome, specifically, return of spontaneous circulation (ROSC). METHODS: AutoPulse cardiopulmonary resuscitation (A-CPR) was used by paramedic captains responding to adult cardiac arrests with an average +/-SD response time of 15 +/- 5 minutes. The primary endpoint was patient arrival to an emergency department with measurable spontaneous pulses. The manual CPR comparison group was case-matched for age, gender, initial presenting electrocardiogram rhythm, and the number of doses of Advanced Cardiac Life Support medications as a proxy for treatment time. Matching was performed by an investigator blinded to outcome and treatment group. RESULTS: Sixty-nine AutoPulse uses were matched to 93 manual-CPR-only cases. A-CPR showed improvement in the primary outcome when compared with manual CPR with any presenting rhythm (A-CPR 39%, manual 29%, p = 0.003). When patients were classified by first presenting rhythm, shockable rhythms showed no difference in outcome (A-CPR 44%, manual 50%, p = 0.340). Outcome was improved with A-CPR in initial presenting asystole and approached significance with pulseless electrical activity (PEA)(asystole: A-CPR 37%, manual 22%, p = 0.008; PEA: A-CPR 38%, manual 23%, p = 0.079). CONCLUSION: The AutoPulse may improve the overall likelihood of sustained ROSC and may particularly benefit patients with nonshockable rhythms. A prospective randomized trial comparing the AutoPulse with manual CPR in the setting of out-of-hospital sudden cardiac arrest is under way.
Assuntos
Suporte Vital Cardíaco Avançado/instrumentação , Reanimação Cardiopulmonar/instrumentação , Serviços Médicos de Emergência/métodos , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Massagem Cardíaca/métodos , Adulto , Suporte Vital Cardíaco Avançado/métodos , Idoso , Idoso de 80 Anos ou mais , Reanimação Cardiopulmonar/métodos , Estudos de Casos e Controles , Segurança de Equipamentos , Feminino , Parada Cardíaca/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Probabilidade , Estudos Retrospectivos , Medição de Risco , São Francisco , Sensibilidade e Especificidade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
During the winter of 2000 to 2001, an outbreak due to Salmonella Enteritidis (SE) phage type 30 (PT30), a rare strain, was detected in Canada. The ensuing investigation involved Canadian and American public health and food regulatory agencies and an academic research laboratory. Enhanced laboratory surveillance, including phage typing and pulsed-field gel electrophoresis, was used to identify cases. Case questionnaires were administered to collect information about food and environmental exposures. A case-control study with 16 matched case-control pairs was conducted to test the hypothesis of an association between raw whole almond consumption and infection. Almond samples were collected from case homes, retail outlets, and the implicated processor, and environmental samples were collected from processing equipment and associated farms for microbiological testing. One hundred sixty-eight laboratory-confirmed cases of SE PT30 infection (157 in Canada, 11 in the United States) were identified between October 2000 and July 2001. The case-control study identified raw whole almonds as the source of infection (odds ration, 21.1; 95% confidence interval, 3.6 to infinity). SE PT30 was detected in raw whole natural almonds collected from home, retail, distribution, and warehouse sources and from environmental swabs of processing equipment and associated farmers' orchards. The frequent and prolonged recovery of this specific organism from a large agricultural area was an unexpected finding and may indicate significant diffuse contamination on these farms. Identification of almonds as the source of a foodborne outbreak is a previously undocumented finding, leading to a North American recall of this product and a review of current industry practices.
Assuntos
Surtos de Doenças , Prunus/microbiologia , Intoxicação Alimentar por Salmonella/epidemiologia , Fagos de Salmonella/classificação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Tipagem de Bacteriófagos , Canadá/epidemiologia , Estudos de Casos e Controles , Criança , Pré-Escolar , Intervalos de Confiança , Contaminação de Equipamentos , Feminino , Contaminação de Alimentos , Indústria Alimentícia/normas , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores de Risco , Fagos de Salmonella/isolamento & purificação , Salmonella enteritidis/isolamento & purificaçãoAssuntos
Infecção Hospitalar/epidemiologia , Surtos de Doenças/prevenção & controle , Infecções por Escherichia coli/epidemiologia , Escherichia coli O157 , Adulto , Estudos de Casos e Controles , Infecção Hospitalar/etiologia , Infecção Hospitalar/prevenção & controle , Infecções por Escherichia coli/etiologia , Infecções por Escherichia coli/prevenção & controle , Feminino , Microbiologia de Alimentos , Serviço Hospitalar de Nutrição , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Ilha do Príncipe Eduardo/epidemiologiaRESUMO
African American men have the highest incidence of prostate cancer in the world. Despite this statistic, linkage studies designed to localise prostate cancer susceptibility alleles have included primarily men of Caucasian descent. In this report, we performed a linkage analysis using 33 African American prostate cancer families from two independent research groups. In total, 126 individuals (including 89 men with prostate cancer) were genotyped using markers that map to five prostate cancer susceptibility loci, namely HPC1 at 1q24-25, PCAP at 1q42.2-43, CAPB at 1p36, HPC20 on chromosome 20, and HPCX at Xq27-28. Multipoint mode-of-inheritance-free linkage analyses were performed using the GENEHUNTER software. Some evidence of prostate cancer was detected to HPC1 using all families with a maximum NPL Z score of 1.12 near marker D1S413 (P=0.13). Increased evidence of linkage was observed in the 24 families with prostate cancer diagnosis prior to age 65 years and in the 20 families with male-to-male transmission. Some evidence of prostate cancer linkage was also detected at markers mapping to PCAP, HPC20, and HPCX. Continued collection and analysis of African American prostate cancer families will lead to an improved understanding of inherited susceptibility in this high-risk group.