Caring for Infectious Disease in the Prehospital Setting: A Qualitative Analysis of EMS Providers Experiences and Suggestions for Improvement.

Objective: The purpose of this study was to examine the attitudes and behaviors of emergency medical technicians (EMTs) and Paramedics when faced with the decision to care for patients with suspected Ebola Virus Disease (EVD) and to illicit suggestions for improvement of infectious disease (ID) preparedness. Methods: A convenience sample of 22 EMT/Paramedics were recruited from an emergency department at one of the designated Ebola centers. Each provider participated in one of three on-site focus groups. Participants answered questions about how they gained their knowledge, felt about caring for EVD patients, made decisions about caring for EVD patients, and suggestions for improvement of ID preparedness. Focus groups were recorded, transcribed, and coded using inductive content analysis. Results: Analysis revealed five prominent themes: reactions to scare, education/training, danger, decision making, and suggestions for future responses. Overall, first responders were excited to be a part of the response to EVD. They were more comfortable caring for EVD patients if they received adequate education and transparency from the administration. This resulted in a decreased perceived danger of the disease and decreased hesitancy when caring for EVD patients. However, those that expressed the most hesitancy also expressed the most emotional distress. Suggestions for improvement of ID preparedness included continuing education, tiered training models, peer training models, collaboration between emergency medical services (EMS) systems, better communication between departments, and the development of an infectious disease response team. Conclusions: Although first responders were excited to be a part of the response to EVD, this did not come without hesitation and emotional distress. Some of these concerns may be mitigated by first providing a clear definition of "duty to care," followed by interventions such as the development of clear and consistent ID preparedness training and interventions that address the emotional distress experienced by these providers.

Disaster Preparedness Training for Emergency Medicine Residents Using a Tabletop Exercise.

Introduction: Emergency medicine (EM) physicians serve at the frontline of disasters in our communities. The 2016 Model of Clinical Practice according to the American Board of EM identifies disaster management as an integral task of EM physicians. We described a low-cost and feasible tabletop exercise to implement such training for EM residents. Methods: The exercise took place during 2 hours of resident didactic time. A lecture introduced the incident command system (ICS) and triage concepts, followed by a tabletop scenario with a map of a disaster scene or emergency department. Facilitators presented situational prompts of tasks for residents to address during the exercise. These exposed residents to challenges in disaster scenarios, such as surge and limited resources. The exercise concluded with a debrief and short lecture reviewing scenario-specific topics and challenges. Residents completed an online pre- and postexercise assessment, evaluating knowledge and perceptions of disaster scenario management. Results: Eighteen residents participated in this exercise. The response rates to the pre- and postsurvey were 76% and 72% respectively. Using a Mann Whitney U test, no statistically significant difference was demonstrated on the medical knowledge component of the survey. There was, however, a statistically significant increase in perceived confidence of the residents' ability to manage disaster incidents. Discussion: We developed a simple exercise that is an easily adaptable and practical option for introduction to disaster preparedness training. These concepts are difficult to teach and assess among learners, however it remains an important component of education for EM physicians-in-training.

Cancer mortality in the U.S. flour industry.

The mortality experience among 22,938 white males who were enrolled in the life insurance program of the American Federation of Grain Millers was assessed for the period 1955 through 1985 in a cohort mortality analysis and in a nested case-control analysis. Significantly fewer deaths were observed among this group than expected for all causes of death combined [standardized mortality ratio (SMR) = 89] compared with the number of deaths observed among the general population of U.S. white males of the same age. Excess risks for developing non-Hodgkin's lymphoma (NHL) (SMR = 149), leukemia (SMR = 136), and pancreatic cancer (SMR = 133) were restricted to workers employed in flour mills, where pesticides are used more frequently than in other segments of the industry. In the nested case-control analysis, excess risks for developing these cancers were also observed in these workers, but the relative risk for developing NHL [odds ratio (OR) = 4.2] was approximately twice that for developing pancreatic cancer (OR = 2.2) and that for developing leukemia (OR = 1.8). Within the flour mills, the workers who had ever worked in the maintenance department (OR = 8.1) or in the elevator department (OR = 2.8) were at particularly elevated risk of developing NHL, suggesting that exposures in these departments should receive further attention.

Intra-articular treatment of knee osteoarthritis: from anti-inflammatories to products of regenerative medicine.

OBJECTIVES: Knee osteoarthritis (OA) is a debilitating condition that may ultimately require total knee arthroplasty (TKA). Non-operative treatments are bracing, oral analgesics, physical therapy, and intra-articular knee injection (IAKI). The objective of this paper is to provide a systematic literature review regarding intra-articular treatment of knee OA and insight into promising new products of regenerative medicine that may eventually have a substantial effect on treatment. METHODS: A literature search was executed using Medline, Cochrane, and Embase with keywords "knee osteoarthritis" and "injection." Specifically, 45 articles that discussed intra-articular knee injection using corticosteroids, hyaluronic acid, analgesics, local anesthetics, and newer products of regenerative medicine, such as platelet-rich plasma (PRP) and mesenchymal stem cells (MSC), were analyzed. Of these, eleven were level 1, three were level 2, twelve were level 3, two were level 4, and seventeen were level 5 evidence. Papers included animal models. RESULTS: Local anesthetics have potential side effects and may only be effective for a few hours. Morphine and ketorolac may provide significant pain relief for 24 hours. Corticosteroids may give patients weeks to months of effective analgesia, but complications may occur, such as systemic hyperglycemia, septic arthritis, and joint degradation . Hyaluronic acid is a natural component of synovial fluid, but efficacy with respect to analgesia is controversial. Platelet-rich plasma formulations, autologous conditioned serum, autologous protein solution, and mesenchymal stem cell injections contain anti-inflammatory molecules and have been proposed to attenuate joint destruction or potentially remodel the joint. CONCLUSIONS: Currently, knee OA treatment does not address the progressively inflammatory environment of the joint. More investigation is needed regarding products of regenerative medicine, but they may ultimately have profound implications in the way knee OA is managed.

Identification of problems and strengths of the hospice client by clients, caregivers, and nurses. Implications for nursing.

This exploratory study included instrument development as well as testing. The purpose of the study was to ascertain whether primary caregivers and hospice nurses identified the same problems and strengths of individual clients as did clients themselves. The instrument, a 27-item modified Q-sort, was based on review of literature on the concept Quality of Life. Dembo's Insider versus Outsider Perspective was the theoretical framework. Using the instrument, participants identified the problems and strengths of the client in the current time frame. Twenty consenting hospice clients, their primary caregiver, and their assigned hospice nurse were studied. No significant differences were found between clients, nurses, and caregivers when Total instrument means were compared (F = 1.38, p = 0.26). Three of the 27 items showed significant differences in the means of the three groups. Reliability coefficients showed high internal consistency on the Total instrument (0.87). Nurses and caregivers were found to identify problems and strengths of the client as perceived by the client. Findings corroborated Dembo's theory. Support of the hospice concept as the appropriate method of care for terminally ill clients was suggested.

Risk-taking propensity of nurses: ADN and BSN.

Nursing literature indicates that skills in decision making are inherently important to the modern nurse. The literature also reports a controversy between the associate degree nurse (ADN) and the bachelor degree nurse (BSN). This conflict relates to educational level and experience in terms of leadership and decision-making skills. All decisions involve risk. Therefore decisions in nursing should be influenced by the risk-taking propensity of the individual nurse. The literature shows a linkage between risk-taking propensity and both training and experience. The major purpose of the study was to attempt to correlate risk-taking propensity of nurses by level of education and experience. The study investigated whether differences exist between risk-taking propensity of recently graduated ADNs and BSNs without experience. In addition, the study attempted to determine any differences in risk-taking propensity of ADNs and BSNs with practical experience. The results were analyzed in terms of decision-making competency.

Building TQM into nursing management.

Total quality management (TQM) is a management philosophy that addresses problems currently faced by health care, specifically reducing costs while improving quality of services. As hospital administrators embrace this new management style, nurse executives and managers will be challenged to implement TQM. Building TQM into nursing management will improve quality and reduce costs while meeting the needs of health care customers.

Successful treatment of stent knot in the proximal ureter using ureteroscopy and holmium laser.

Knotted ureteral stent is rare yet tedious complication that might represent a treatment challenge to the endourologist. Only twelve cases of knotted stent have been reported. Different management options have been reported, including simple traction, ureteroscopy, percutaneous removal, and open surgery. In this paper, we present the successful untying of the knot using ureteroscopy with holmium laser.

Perinatal factors, growth and development, and osteosarcoma risk.

Osteosarcoma incidence patterns suggest an aetiologic role for perinatal factors, and growth and development. Osteosarcoma patients (n = 158) and controls with benign orthopaedic conditions (n = 141) under age 40 were recruited from US orthopaedic surgery departments. Exposures were ascertained by interview, birth, and growth records. Age- and sex-adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated. Current height and age- and sex-specific height percentiles were not associated with osteosarcoma risk. Male cases, however, appeared to have an earlier adolescent growth period, and earlier attainment of final height (OR = 7.1; 95% CI = 1.6-50 for <19 vs 19+ years), whereas earlier puberty appeared protective with ORs of 0.41 (95% CI 0.18-0.89) and 0.68 (95% CI 0.31-1.5) for developing facial and pubic hair, respectively. High birth weight was associated with an elevated osteosarcoma risk (OR = 3.9; CI = 1.7-10 for 4000 g vs 3000-3500 g), although there was no trend in risk with increasing weight. These data provide some evidence that osteosarcoma is related to size at birth and in early adolescence, while earlier puberty in male subjects may be protective.

Origin and direction of replication of the chromosome of E. coli B-r.

The origin and direction of replication of the E. coli B/r chromosome has been determined by comparing gene frequencies in P1-transducing lysates prepared on cultures growing at different rates. The gene frequencies found are consistent with the idea that replication of the chromosome is dichotomous in rapidly growing B/r. The origin was found to be between 40 and 55 min on the E. coli genetic map with replication proceeding in a clockwise direction. Markers near the origin behaved anomalously.

Strains of Escherichia coli diploid for the chromosomal origin of DNA replication.

F' strains of E. coli have been isolated which are merodiploid for various chromosomal segments between 66 and 78 minutes. Strains diploid for the chromosomal DNA between the genes bgl and mtl grow slowly, have a reduced DNA/mass and an increased cell size. These properties could result if the chromosomal replication origin and a second, extrachromosomal, copy of the origin (located in this case on the F') were to compete for a substance required to initiate replication. We therefore suggest that these strains are diploid for the chromosomal origin of replication and that, therefore, the origin is located between bgl and mtl, that is between 71 and 73 minutes on the E. coli chromosome.

The frequency of P1 transduction of the genes of Escherichia coli as a function of chromosomal position: preferential transduction of the origin of replication.

The frequencies with which the generalized transducing phage P1 transduced 26 selected markers on the E. coli. chromosome were measured. The frequencies were found to vary relative to argH+ = 1 from a maximum of 6.8 near the origin of replication to a minimum of 0.23 for a marker not far from the terminus. The low frequencies obtained for some markers were shown not to result from poor expression under the selective conditions employed. When plotted as a function of marker position on the chromosome the frequencies were found to exhibit a series of peaks and troughs which correspond to those in gene density noted by Bachmann et al. (1976). The possible relationship of these results to the structure of the E. coli chromosome and to the mechanism of generalized transduction are discussed.

The gender difference on the Mental Rotations test is not due to performance factors.

Men score higher than women on the Mental Rotations test (MRT), and the magnitude of this gender difference is the largest of that on any spatial test. Goldstein, Haldane, and Mitchell (1990) reported finding that the gender difference on the MRT disappears when "performance factors" are controlled--specifically, when subjects are allowed sufficient time to attempt all items on the test or when a scoring procedure that controls for the number of items attempted is used. The present experiment also explored whether eliminating these performance factors results in a disappearance of the gender difference on the test. Male and female college students were allowed a short time period or unlimited time on the MRT. The tests were scored according to three different procedures. The results showed no evidence that the gender difference on the MRT was affected by the scoring method or the time limit. Regardless of the scoring procedure, men scored higher than women, and the magnitude of the gender difference persisted undiminished when subjects completed all items on the test. Thus there was no evidence that performance factors produced the gender difference on the MRT. These results are consistent with the results of other investigators who have attempted to replicate Goldstein et al.'s findings.

Evidence that F' lac replicates asynchronously during the cell cycle of Escherichia coli B/r.

The replication of F' lac was studied in exponentially growing cultures of E. coli B/r. The cells were pulse induced for the synthesis of beta-galactosidase and their DNA pulse labelled with 3H thymidine. The cells were then separated into age classes by centrifugation through a sucrose gradient in a zonal rotor. Plasmide replication was measured in each age fraction by three methods: the rate at which beta-galactosidase could be induced, the amount of label incorporated into CCC plasmid DNA which had been separated from chromosomal DNA on agarose gels, and the amount of label incorporated into plasmid DNA which had been separated from chromosomal DNA by ultracentrifugation through CsCl-EtBr gradients. All these methods gave the same result, that replication of F' lac occurs in cells of all ages and is not confined to a part of the cell cycle.