Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data.

STUDY OBJECTIVE: We compare reported crash rates for US ambulances responding to or transporting patients from a 911 emergency scene with or without lights and sirens. Our null hypothesis is that there will be no difference in the rate of ambulance crashes whether lights and sirens are used. METHODS: For this retrospective cohort study, we used the 2016 National EMS Information System data set to identify 911 scene responses and subsequent patient transports by transport-capable emergency medical services (EMS) units. We used the system's "response mode to scene" and "transport mode from scene" fields to determine lights and sirens use. We used the "type of response delay" and "type of transport delay" fields to identify responses and transports that were delayed because of a crash involving the ambulance. We calculated the rate of crash-related delays per 100,000 responses or transports and used multivariable logistic regression with clustered (by agency) standard errors to calculate adjusted odds ratios (AORs) (with 95% confidence intervals [CIs]) for the association between crash-related delays and lights and sirens use for responses and transports separately. RESULTS: Among 19 million included 911 scene responses, the response phase crash rate was 4.6 of 100,000 without lights and sirens and 5.4 of 100,000 with lights and sirens (AOR 1.5; 95% CI 1.2 to 1.9). For the transport phase, the crash rate was 7.0 of 100,000 without lights and sirens and 17.1 of 100,000 with lights and sirens (AOR 2.9; 95% CI 2.2 to 3.9). Excluding responses and transports with only partial lights and sirens use did not meaningfully alter the results (response AOR 1.5, 95% CI 1.2 to 1.9; transport AOR 2.8, 95% CI 2.1 to 3.8). CONCLUSION: Ambulance use of lights and sirens is associated with increased risk of ambulance crashes. The association is greatest during the transport phase. EMS providers should weigh these risks against any potential time savings associated with lights and sirens use.

Assessing trauma readiness costs in level III and level IV trauma centers.

BACKGROUND: Readiness costs are expenses incurred by trauma centers to maintain essential infrastructure. Although the components for readiness are described in the American College of Surgeons' Resources for Optimal Care of the Injured Patient , the cost associated with each component is not well defined. Previous studies describe readiness costs for levels I and II trauma centers based on these criteria. The purpose of this study was to quantify the cost of levels III and IV trauma center readiness. METHODS: The state trauma commission, along with trauma medical directors, program managers, and trauma center financial staff, standardized definitions for each component of trauma center readiness costs and developed a survey tool for reporting. Readiness costs were grouped into four categories: Administrative/Program Support Staff, Clinical Medical Staff, and Education/Outreach. A financial auditor analyzed all data to verify consistent cost reporting. Trauma center outliers were evaluated to validate variances. All levels III and IV trauma centers (n = 14) completed the survey on 2019 data. RESULTS: Average annual readiness cost is $1,715,025 for a level III trauma center and $81,620 for level IV centers. Among the costliest components were clinical medical staff for level IIIs and administrative costs for level IVs, representing 54% and 97% of costs, respectively. Although education/outreach is mandated, levels III and IV trauma centers only spend approximately $8,000 annually on this category (0.8-3%). CONCLUSION: This study defines the cost associated with each readiness component outlined in the Resources for Optimal Care of the Injured Patient manual. The average readiness cost for a level III trauma center is $1,715,025 and $81,620 for a level IV, underscoring the need for additional trauma center funding to meet the requirements set forth by the American College of Surgeons. LEVEL OF EVIDENCE: Economic and Value-Based Evaluations; Level III.

The Unusual Presentation of a Single Case of Synchronous Metastatic Clear Cell Renal Cell Carcinoma to the Gallbladder: A Case Report and Literature Review.

Clear cell renal cell carcinoma, accounts for approximately 70% of all adult renal tumors. This disease is well known for its high metastatic potential, with estimates of 25-50% of patients reporting metastasis to distant structures. However, there have only been several reported cases in medical literature describing hematogenous spread to the gallbladder, with the majority occurring metachronously, in males, and with multiple metastases. This case report follows an extremely unique presentation in a 60-year-old female. Although the patient did not exhibit the usual signs and symptoms or meet the typical demographics seen with metastatic renal cell carcinoma, it should find a place on the differential diagnosis list when a gallbladder lesion is detected on imaging during the initial staging and/or restaging in patients with renal-cell carcinoma.

Development of a content-validated venous ulcer guideline.

Evidence-based practice for venous ulcers may improve healing and reduce costs of care. The Association for the Advancement of Wound Care Government and Regulatory Task Force developed a content-validated venous ulcer guideline based on best available evidence supporting each aspect of venous ulcer care. After compiling all-inclusive lists of elements in venous ulcer algorithms published before August 2002, the Task Force objectively rated and summarized up to five best references from MEDLINE, CINAHL, and EMBASE literature searches covering each aspect of care. Sixteen multidisciplinary wound care professionals and educators used judgment quantification to content validate all steps. A 2004 email survey of AAWC members (N = 1,514) clarified effects of under-reimbursement on evidence-based venous practice. The Venous Ulcer Guideline containing all elements with A-level evidence plus those with a Content Validity Index >0.75 now resides on the AAWC and the Agency for Healthcare Research and Quality National Guideline Clearinghouse websites. However, a review of US healthcare environment components, including reimbursement policies, and the results of the survey identified many barriers to implementation of A-level evidence supported steps (sustained graduated high compression, autolytic debridement, and moist wound environments) in practice. Sufficient evidence supports improved venous ulcer care in the US but inadequate and/or inconsistent reimbursement policies impede quality evidence-based venous ulcer practice, delaying healing and increasing the burden of venous ulcers on society.

γ knife surgery anterior capsulotomy for severe and refractory obsessive-compulsive disorder.

OBJECT: Obsessive-compulsive disorder (OCD) is a challenging psychiatric condition associated with anxiety and ritualistic behaviors. Although medical management and psychiatric therapy are effective for many patients, severe and extreme cases may prove refractory to these approaches. The authors evaluated their experience with Gamma Knife (GK) capsulotomy in treating patients with severe OCD. METHODS: A retrospective review of an institutional review board-approved prospective clinical GK database was conducted for patients treated for severe OCD. All patients were evaluated preoperatively by at least one psychiatrist, and their condition was deemed refractory to pharmacological and psychiatric therapy. RESULTS: Five patients were identified. Gamma Knife surgery with the GK Perfexion unit was used to target the anterior limb of the internal capsule bilaterally. A single 4-mm isocenter was used; maximum radiation doses of 140-160 Gy were delivered. All 5 patients were preoperatively and postoperatively assessed for clinical response by using both subjective and objective metrics, including the Yale-Brown Obsessive Compulsive Scale (YBOCS); 4 of the 5 patients had postoperative radiological follow-up. The median clinical follow-up was 24 months (range 6-33 months). At the time of radiosurgery, all patients had YBOCS scores in the severe or extreme range (median 32, range 31-34). At the last follow-up, 4 (80%) of the 5 patients showed marked clinical improvement; in the remaining patient (20%), mild improvement was seen. The median YBOCS score was 13 (range 12-31) at the last follow-up. Neuroimaging studies at 6 months after GK treatment demonstrated a small area of enhancement corresponding to the site of the isocenter and some mild T2 signal changes in the internal capsule. No adverse clinical effects were noted from the radiosurgery. CONCLUSIONS: For patients with severe OCD refractory to medications and psychiatric therapy, GK capsulotomy afforded clinical improvement. Further study of this approach seems warranted.

A potent novel anti-HIV protein from the cultured cyanobacterium Scytonema varium.

A new anti-HIV protein, scytovirin, was isolated from aqueous extracts of the cultured cyanobacterium Scytonema varium. The protein displayed potent anticytopathic activity against laboratory strains and primary isolates of HIV-1 with EC50 values ranging from 0.3 to 22 nM. Scytovirin binds to viral coat proteins gp120, gp160, and gp41 but not to cellular receptor CD4 or other tested proteins. This unique protein consists of a single 95-amino acid chain with significant internal sequence duplication and 10 cysteines forming five intrachain disulfide bonds.