Paediatric airway management and concerns: a survey of advanced paramedics in Ireland.

BACKGROUND: Paediatric airway management is of fundamental importance in the critically unwell child. Pre-hospital paediatric airway management especially endotracheal intubation is however controversial. AIM: To explore Irish Advanced Paramedics (APs) training, experience and clinical practice in paediatric airway management as well as to examine clinician attitudes toward this topic. METHODS: An anonymous online survey of all graduates of the University College Dublin AP training program (N = 453). RESULTS: With duplicates and failed email deliveries excluded a valid sample of 382 individuals was obtained from whom a response rate of 185/382 (48.4%) was achieved. Three quarters of responding APs worked in urban or mixed practice with the remaining minority operating primarily in rural areas. One quarter of responding APs reported formal training in paediatric intubation. Almost 70% of APs had encountered a child requiring significant airway management in the preceding year. However, this was a rare exposure in terms of overall workload. Basic airway adjuncts were used frequently in such circumstances, with endotracheal intubation having been attempted by only a small minority of APs. Lack of practice was identified by many responding APs as a key issue causing concern in terms of paediatric intubation. CONCLUSION: Paediatric airway management has key relevance for pre-hospital care in Ireland. The overall frequency of exposure to children who may benefit from definitive airway management is however likely to represent a significant barrier to the acquisition and maintenance of competency. The ongoing practice of pre-hospital paediatric intubation by APs may not justify its risks.

Mutation Signatures Depend on Epigenomic Contexts.

Mutation signatures - the patterns of acquired genetic changes in somatic genomes - provide critical insights into DNA repair defects and exposure to mutagenic processes during development, aging, and cancer progression. Efforts to decipher the etiology of the emerging computationally predicted mutation signatures in cancer genomes are currently underway. Since chromatin and epigenomic contexts influence DNA damage and repair pathway choices, taking both epigenomic and sequence contexts of the mutations into consideration is likely to benefit interpretation of mutation signatures.

Dam-Breach hydrology of the Johnstown flood of 1889-challenging the findings of the 1891 investigation report.

In 1891 a report was published by an ASCE committee to investigate the cause of the Johnstown flood of 1889. They concluded that changes made to the dam by the South Fork Fishing and Hunting Club did not cause the disaster because the embankment would have been overflowed and breached if the changes were not made. We dispute that conclusion based on hydraulic analyses of the dam as originally built, estimates of the time of concentration and time to peak for the South Fork drainage basin, and reported conditions at the dam and in the watershed. We present a LiDAR-based volume of Lake Conemaugh at the time of dam failure (1.455 × 10(7) m(3)) and hydrographs of flood discharge and lake stage decline. Our analytical approach incorporates the complex shape of this dam breach. More than 65 min would have been needed to drain most of the lake, not the 45 min cited by most sources. Peak flood discharges were likely in the range 7200 to 8970 m(3) s(-1). The original dam design, with a crest ∼0.9 m higher and the added capacity of an auxiliary spillway and five discharge pipes, had a discharge capacity at overtopping more than twice that of the reconstructed dam. A properly rebuilt dam would not have overtopped and would likely have survived the runoff event, thereby saving thousands of lives. We believe the ASCE report represented state-of-the-art for 1891. However, the report contains discrepancies and lapses in key observations, and relied on excessive reservoir inflow estimates. The confidence they expressed that dam failure was inevitable was inconsistent with information available to the committee. Hydrodynamic erosion was a likely culprit in the 1862 dam failure that seriously damaged the embankment. The Club's substandard repair of this earlier breach sowed the seeds of its eventual destruction.

Development and process evaluation of an educational intervention for overdose prevention and naloxone distribution by general practice trainees.

BACKGROUND: Overdose is the most common cause of fatalities among opioid users. Naloxone is a life-saving medication for reversing opioid overdose. In Ireland, it is currently available to ambulance and emergency care services, but General Practitioners (GP) are in regular contact with opioid users and their families. This positions them to provide naloxone themselves or to instruct patients how to use it. The new Clinical Practice Guidelines of the Pre-hospital Emergency Care Council of Ireland allows trained bystanders to administer intranasal naloxone. We describe the development and process evaluation of an educational intervention, designed to help GP trainees identify and manage opioid overdose with intranasal naloxone. METHODS: Participants (N = 23) from one postgraduate training scheme in Ireland participated in a one-hour training session. The repeated-measures design, using the validated Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales, examined changes immediately after training. Acceptability and satisfaction with training were measured with a self-administered questionnaire. RESULTS: Knowledge of the risks of overdose and appropriate actions to be taken increased significantly post-training [OOKS mean difference, 3.52 (standard deviation 4.45); P < 0.001]; attitudes improved too [OOAS mean difference, 11.13 (SD 6.38); P < 0.001]. The most and least useful delivery methods were simulation and video, respectively. CONCLUSION: Appropriate training is a key requirement for the distribution of naloxone through general practice. In future studies, the knowledge from this pilot will be used to inform a train-the-trainer model, whereby healthcare professionals and other front-line service providers will be trained to instruct opioid users and their families in overdose prevention and naloxone use.

The effect of isolated core training on selected measures of golf swing performance.

PURPOSE: This study aimed to quantify the effect of an 8-wk isolated core training program on selected ball and club parameters during the golf swing and also the variability of these measures. METHODS: Thirty-six club-level golfers were randomly assigned to an exercise (n = 18) or control (n =18) group. The exercise group participated in an 8-wk core training program, which included eight basic exercises. Both groups continued with their normal activity levels including golf. Baseline and postintervention measurements included club-head speed, backspin, sidespin, and timed core endurance. RESULTS: Baseline measures for club-head speed, backspin, sidespin, and core endurance test were 79.9 ± 8.4 mph, 3930 ± 780 rpm, 1410 ± 610 rpm, and 91 ± 56 s for the intervention group and 77.6 ± 8.8 mph, 3740 ± 910 rpm, 1290 ± 730 rpm, and 69 ± 55 s for the control group (mean ± SD). The effect of our core training, when compared with control, was a likely small improvement in club-head speed (3.6%; 90% confidence limits = ±2.7%) and a very likely small improvement in muscular endurance (61%; ±33%). The effect on backspin (5%; ±10%) and sidespin (-6%; ±20%) was unclear. Baseline variability for club-head speed, backspin, and sidespin (based on 10 swings per golfer) was 5.7% ± 5.3%, 43% ± 19%, and 140% ± 180% for the intervention group and 6.5% ± 5.3%, 53% ± 53%, and 170% ± 130% for control group. The effect of the intervention on within-subject variability was a moderate decrease for club-head speed, a small decrease for backspin, and a small increase for sidespin when compared with control. CONCLUSION: The benefits achieved from our isolated core training program are comparable with those from other studies.

Estimated lag time in global carbon emissions and CO2 concentrations produced by commercial nuclear power through 2009 with projections through 2030.

This study examines the past and future impact of nuclear reactors on anthropogenic carbon emissions to the atmosphere. If nuclear power had never been commercially developed, what additional global carbon emissions would have occurred? More than 44 y of global nuclear power have caused a lag time of at least 1.2 y in carbon emissions and CO2 concentrations through the end of 2009. This lag time incorporates the contribution of life cycle carbon emissions due to the construction and operation of nuclear plants. Cumulative global carbon emissions would have been about 13 Gt greater through 2009, and the mean annual CO2 concentration at Mauna Loa would have been ~2.7 ppm greater than without nuclear power. This study finds that an additional 14­17 Gt of atmospheric carbon emissions could be averted by the global use of nuclear power through 2030, for a cumulative total of 27­30 Gt averted during the period 1965­2030. This result is based on International Atomic Energy Agency projections of future growth in nuclear power from 2009­2030, modified by the recent loss or permanent shutdown of 14 reactors in Japan and Germany

COL1A1:PDGFB chimeric transcripts are not present in indeterminate fibrohistiocytic lesions of the skin.

Indeterminate fibrohistiocytic lesions of the skin share histological and immunohistochemical features of both benign fibrous histiocytoma/dermatofibroma and dermatofibrosarcoma protuberans (DFSP). Unlike dermatofibroma, DFSP harbors recurrent genetic aberrations resulting in the fusion of COL1A1 on chromosome 17 and PDGFB on chromosome 22. Because indeterminate fibrohistiocytic lesions share some features with DFSP, they were evaluated for the possible presence of COL1A1-PDGFB chimeric transcripts. Twelve formalin-fixed paraffin-embedded cases were examined for COL1A1-PDGFB chimeric transcripts using a previously validated sensitive multiplex reverse transcriptase-polymerase chain reaction assay. The median patient age was 52.5 years (33-70 years) with 9 females and 3 males. The most common site was the extremities (n = 8) followed by the trunk (n = 2) and the head and neck region (n = 2). All demonstrated the expected reactivity for both CD34 and factor XIIIa, and the majority focally infiltrated into subcutaneous fat. Of the 6 patients with follow-up, 2 had residual tumor excised, but no patient developed a recurrence. None of the tumors harbored COL1A1-PDGFB fusion transcripts identified by reverse transcriptase-polymerase chain reaction. Although indeterminate fibrohistiocytic lesions share some features with DFSP, the lack of COL1A1-PDGFB chimeric transcripts suggests that they are distinct entities.

Balloon tamponade of hemorrhage after uterine curettage for gestational trophoblastic disease.

BACKGROUND: Uterine bleeding frequently complicates gestational trophoblastic disease, particularly after uterine evacuation. Hysterectomy and other procedures used to control this bleeding incur significant risk and can limit fertility. CASE: We present a case of massive hemorrhage complicating uterine curettage performed for metastatic gestational trophoblastic disease. The patient's bleeding was controlled successfully by intrauterine tamponade performed using a balloon catheter. After catheter removal, she achieved complete disease remission. CONCLUSION: Intrauterine balloon catheterization appears to be a promising alternative to control uterine hemorrhage and preserve fertility for young women undergoing treatment for gestational trophoblastic disease. Its use may help avoid invasive interventions, such as hysterectomy and embolization, currently used to control hemorrhage after uterine evacuation.

Actinomycetoma with negative culture: a therapeutic challenge.

Nocardia, Actinomyces, and Streptomyces species comprise the three broad classes of organisms that are causative for bacterial mycetoma. Although culture and molecular laboratory studies can usually identify the precise etiologic agent in bacterial mycetoma, occasionally these methods fail to clarify this situation. We report a classic clinical case of this infectious disease where usual diagnostic methods failed to identify the responsible organism, and discuss the empiric approach to such cases.

Tinea corporis masquerading as subacute cutaneous lupus erythematosus.

Few papers discuss the potential challenge of differentiating dermatophytosis from subacute cutaneous lupus erythematosus. This masquerade, most often manifest on the face, is of both clinical and therapeutic importance. We report a patient whose extensive tinea corporis very closely mimicked SCLE. The threshold for biopsy should be low in cases that exhibit atypical features for either of these entities.

Axillary syringomas.

Syringomas are common benign neoplasms encountered mostly around the eyes. However, as described herein, these tumors can occur in atypical locations such as the axilla. The differential diagnosis revolves around those entities more likely seen in this anatomical location (such as Fox-Fordyce, Hailey-Hailey and Darier diseases). Various ablative modalities are curative.

Differential cellular expression of LIGHT and its receptors in early gestation human placentas.

LIGHT (homologous to lymphotoxins, exhibits inducible expression, competes with herpes simplex virus glycoprotein D for HVEM, a receptor expressed by T lymphocytes) is an apoptosis-inducing member of the tumor necrosis factor family of ligands. Messenger RNAs encoding LIGHT and its receptors, lymphotoxin-beta receptor (LTbetaR), decoy receptor-3 (DcR3) and herpes virus entry mediator (HVEM), are present in first trimester and term placentas. Proteins have been localized to specific cells in term but not earlier gestation placentas. Here, we have studied LIGHT and its receptors in early (6-7 weeks) and early-to-middle (8-13 weeks) gestation using immunohistology. Notable cell-specific, gestation-related features were identified. LIGHT and two of its receptors, a membrane-bound receptor that mediates apoptosis (LTbetaR) and a soluble receptor that interferes with LIGHT signaling (DcR3), were present in syncytiotrophoblast and cytotrophoblast cells in all samples but were detected in placental stromal cells only at week 8 and thereafter. HVEM, a membrane-bound receptor that protects against apoptosis, was expressed only on syncytiotrophoblast. These observations suggest that the LIGHT system may regulate early to middle stages of placental development via cell-specific, temporally programmed expression of the ligand and its receptors, and may also assist in preserving placental immune privilege.

Primary neuroendocrine carcinoma of the vagina with Merkel cell carcinoma phenotype.

We describe a case of primary neuroendocrine carcinoma arising from the anterior vaginal wall of a 67-year-old woman. Primary neuroendocrine carcinoma of the vagina is a rare entity with only 25 previously reported cases in the literature. In previous reports, these tumors have not been distinguished from primary neuroendocrine carcinoma of the skin (Merkel cell carcinoma). The tumor was composed of cells that showed neuroendocrine-type nuclear features with hyperchromasia, nuclear molding, occasional small nucleoli, and a chromatin pattern that was finely granular. The tumor cells were positive for cytokeratin 20 (CK20), neuron specific enolase, pancytokeratin, epithelial membrane antigen, and chromogranin A expression. Ki-67, a marker of proliferation, was also positive in>90% of cells. The tumor cells showed intense expression of Bcl-2 oncoprotein and mild to moderate expression of c-KIT. Synaptophysin, neurofilament, CD45, CD56, CD10, S-100, HMB-45, cytokeratin 7, and thyroid transcription factor 1 were negative. This pattern of staining is consistent with a Merkel cell carcinoma. This is the first report of a primary neuroendocrine carcinoma of the vagina with a Merkel cell phenotype. Previous studies have not distinguished primary neuroendocrine carcinoma of the vagina from Merkel cell carcinoma of the skin. Positive expression of CK20 in primary small cell carcinoma of the vagina might represent a Merkel cell carcinoma subtype of this tumor.