Analysis of Structure and Function of Ladybird Leg and Subsequent Design and Fabrication of a Simplified Leg Structure for Robotic Applications.

Many insects are able to walk vertically or upside down on both hard and soft surfaces. In beetles such as the ladybird (Coccinella septempunctata), intermolecular forces between tarsal setae on the footpads of the insects make this movement possible. In prior work, adhesion structures made from polydimethylsiloxane (PDMS) that mimic the action of the tarsal setae have been developed. It is proposed that these adhesion structures could be attached to a simplified version of the leg of a ladybird and used in practical applications. For example, the leg structures could potentially be employed in small surveillance drones to enable attachment to surfaces during flights, in order to preserve battery power. Alternatively, the structures could be used in small robotic devices to enable walking on steeply inclined surfaces. In this program of work, the morphology and movement of the leg of a ladybird were closely studied using a 3D X-ray microscope and a high-speed microscope. The positions of the tendons that facilitated movement were identified. From this knowledge, a simplified leg structure using pin-joints was designed and then fabricated using 3-D printing. The PDMS adhesion structures were then attached to the leg structure. The tendons in the actual insect leg were replicated using thread. Typical detachment forces of about 4 N indicated that the simplified leg structure was, in principle, more than capable of supporting the weight of a small device and then detach successfully. Attachment/detachment movement operations were performed using a linear actuator and controlled remotely. Therefore, proof of concept has been demonstrated for the use of such a simplified ladybird leg structure for the attachment/detachment of small robotic devices to horizontal, inclined, or vertical surfaces.

Permanent junctional reciprocating tachycardia due to an atypical retrograde slow conducting decremental left posterolateral accessory pathway and tachycardia-induced cardiomyopathy in a pregnant adolescent.

Permanent junctional reciprocating tachycardia (PJRT) is a rare form of supraventricular tachycardia (SVT) due to a retrograde slow conducting decremental accessory pathway (AP) which is often incessant and can lead to tachycardia-induced cardiomyopathy (TIC). We report the challenging clinical course of a pregnant adolescent with PJRT due to an atypical retrograde slow conducting decremental left posterolateral AP. Pregnancy is known to exacerbate supraventricular arrhythmias and can lead to adverse maternal and fetal outcomes. To the best of our knowledge, there are no prior reports on the clinical course of rare incessant and difficult-to-treat arrhythmias such as PJRT in a pregnant adolescent patient.

Comparison of the Scope of Practice of the Army Combat Medic Specialist and Civilian National EMS Certification Levels.

INTRODUCTION: The transition of Army Combat Medic Specialists (Military Occupational Specialty Code: 68W) from military to civilian emergency medical services (EMS) is challenging, and the pathway is not clearly defined. Our objective was to evaluate the current military requirements for 68W and how they compare to the 2019 EMS National Scope of Practice Model (SoPM) for the civilian emergency medical technician (EMT) and advanced emergency medical technician (AEMT). METHODS: This was a cross-sectional evaluation of the 68W skill floor as defined by the Soldier's Manual and Trainer's Guide Healthcare Specialist and Medical Education and Demonstration of Individual Competence in comparison to the 2019 SoPM, which categorizes EMS tasks into seven skill categories. Military training documents were reviewed and extracted for specific information on military scope of practice and task-specific training requirements. Descriptive statistics were calculated. RESULTS: Army 68Ws were noted to perform all (59/59) tasks that coincide with the EMT SoPM. Further, Army 68W practiced above scope in the following skill categories: airway/ventilation (3 tasks); medication administration route (7 tasks); medical director approved medication (6 tasks); intravenous initiation maintenance fluids (4 tasks); and miscellaneous (1 task). Army 68W perform 96% (74/77) of tasks aligned with the AEMT SoPM, excluding tracheobronchial suctioning of an intubated patient, end-tidal CO2 monitoring or waveform capnography, and inhaled nitrous oxide monitoring. Additionally, the 68W scope included six tasks that were above the SoPM for AEMT; airway/ventilation (2 tasks); medication administration route (2 tasks); and medical director approved medication (2 tasks). CONCLUSIONS: The scope of practice of U.S. Army 68W Combat Medics aligns well with the civilian 2019 Scope of Practice Model for EMTs and AEMTs. Based on the comparative scope of practice analysis, transitioning from Army 68W Combat Medic to civilian AEMT would require minimal additional training. This represents a promising potential workforce to assist with EMS workforce challenges. Although aligning the scope of practice is a promising first step, future research is needed to assess the relationship of Army 68Ws training with state licensure and certification equivalency to facilitate this transition.

National examination of occupational hazards in emergency medical services.

OBJECTIVE: Emergency medical services (EMS) clinicians operate in environments that predispose them to occupational hazards. Our objective was to evaluate the frequency of occupational hazards and associations with mitigation strategies in a national dataset. METHODS: We performed a cross-sectional analysis of currently working, nationally certified civilian EMS clinicians aged 18-85 in the USA. After recertifying their National EMS Certification, respondents were invited to complete a survey with questions regarding demographics, work experience and occupational hazards. Three multivariable logistic regression models (OR, 95% CI) were used to describe associations between these hazards and demographics, work characteristics and mitigation strategies. Models were adjusted for age, sex, minority status, years of experience, EMS agency type, service type and EMS role. RESULTS: A total of 13 218 respondents met inclusion criteria (response rate=12%). A high percentage of EMS clinicians reported occupational injuries (27%), exposures (38%) and violence (64%) in the past 12 months. Odds of injury were lower with the presence of a lifting policy (0.73, 0.67-0.80), lift training (0.74, 0.67-0.81) and always using a powered stretcher (0.87, 0.78-0.97). Odds of exposure decreased with chemical, biological and nuclear exposure protection training (0.75, 0.69-0.80). Training in de-escalation techniques was associated with lower odds of experiencing violence (0.87, 0.79-0.96). CONCLUSIONS: Occupational hazards are commonly experienced among EMS clinicians. Common mitigation efforts are associated with lower odds of reporting these hazards. Mitigation strategies were not widespread and associated with lower odds of occupational hazards. These findings may present actionable items to reduce occupational hazards for EMS clinicians.

Defensive medicine: A symptom of uncertainty?

Defensive medicine is a well-documented phenomenon and refers to the practice of over-cautious management of patients, leading to excessive clinical activity such as over-investigation, unnecessary appointments and additional interventions. Adopting this approach is not in the best interest of patients and can lead to clinical reasoning being replaced by lists, guidelines and algorithms which do not consider the complexity of a patients presentation or the reasoning inherent in good clinical judgement. The drivers of defensive medicine are varied and include a high level of uncertainty alongside other factors including clinical experience with past cases, system pressures and patient expectations. This paper explores these drivers and considers strategies on how best to avoid a defensive medicine approach. It reinforces the need to adopt a patient centred focus and use sound clinical reasoning to support the management of patients.

Paramedic and EMT Program Performance on Certification Examinations Varies by Program Size and Geographic Location.

Introduction: The quality of an Emergency Medical Technician (EMT) or paramedic training program is likely one factor that contributes to a candidate's success on the National Registry Cognitive Examination. However, program pass rates and their associated geographic location have not previously been evaluated. Our objective was to evaluate the performance of EMT and paramedic programs in the United States, pass rates on the National Registry Cognitive Examinations, and relationship to geography.Methods: We conducted a cross-sectional evaluation of EMT and paramedic programs' first and cumulative third attempt pass rates on the National Registry Cognitive Examination in 2015. Included were civilian EMT and paramedic programs with >5 graduates testing for certification. Descriptive statistics were calculated for program pass rates, total graduates testing, and pass rates by National Association of State EMS Officials (NASEMSO) regions.Results: We included 1,939 EMT programs (6-1,892 graduates testing/program) and 602 paramedic programs (6-689 graduates testing/program). We excluded 262 (11.9%) EMT and 51 (7.8%) paramedic programs with ≤5 graduates testing annually due to unstable estimates of program pass rates. EMT programs in the highest quartile for total number of graduates testing outperformed the lowest quartile in both first attempt (65.7% vs. 61.9%, p < 0.001) and cumulative third attempt pass rates (79.1% vs 72.7%, p < 0.001). This difference was also seen for paramedic programs on first attempt (77.3% vs. 62.5%, p < 0.001) and cumulative third attempt (91.9% vs. 76.9%, p < 0.001). EMT program pass rates for first and cumulative third attempts also varied by NASEMSO region (first: 62-68%; third: 74-78%) with the Great Lakes and West regions outperforming the other regions. Paramedic program pass rates differed by NASEMSO regions as well (first: 65-83%; third: 81-95%) with highest pass rates in the West region.Conclusions Program performance for both EMT and paramedic programs varies by total number of graduates testing and geographic location. Graduates from larger EMT and paramedic programs have higher first and cumulative third attempt pass rates compared to graduates from smaller programs. Additionally, there is variability in program pass rates across NASEMSO regions for both certification levels. Further evaluation is necessary to better understand the variability in program performance in the United States.

Myopericarditis after messenger RNA Coronavirus Disease 2019 Vaccination in Adolescents 12 to 18 Years of Age.

OBJECTIVES: To characterize the clinical course and outcomes of children 12-18 years of age who developed probable myopericarditis after vaccination with the Pfizer-BioNTech (BNT162b2) coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) vaccine. STUDY DESIGN: A cross-sectional study of 25 children, aged 12-18 years, diagnosed with probable myopericarditis after COVID-19 mRNA vaccination as per the Centers for Disease Control and Prevention criteria for myopericarditis at 8 US centers between May 10, 2021, and June 20, 2021. We retrospectively collected the following data: demographics, severe acute respiratory syndrome coronavirus 2 virus detection or serologic testing, clinical manifestations, laboratory test results, imaging study results, treatment, and time to resolutions of symptoms. RESULTS: Most (88%) cases followed the second dose of vaccine, and chest pain (100%) was the most common presenting symptom. Patients came to medical attention a median of 2 days (range, <1-20 days) after receipt of Pfizer mRNA COVID-19 vaccination. All adolescents had an elevated plasma troponin concentration. Echocardiographic abnormalities were infrequent, and 92% showed normal cardiac function at presentation. However, cardiac magnetic resonance imaging, obtained in 16 patients (64%), revealed that 15 (94%) had late gadolinium enhancement consistent with myopericarditis. Most were treated with ibuprofen or an equivalent nonsteroidal anti-inflammatory drug for symptomatic relief. One patient was given a corticosteroid orally after the initial administration of ibuprofen or an nonsteroidal anti-inflammatory drug; 2 patients also received intravenous immune globulin. Symptom resolution was observed within 7 days in all patients. CONCLUSIONS: Our data suggest that symptoms owing to myopericarditis after the mRNA COVID-19 vaccination tend to be mild and transient. Approximately two-thirds of patients underwent cardiac magnetic resonance imaging, which revealed evidence of myocardial inflammation despite a lack of echocardiographic abnormalities.

Demography of the National Emergency Medical Services Workforce: A Description of Those Providing Patient Care in the Prehospital Setting.

BACKGROUND: The emergency medical services (EMS) workforce is a key component of healthcare in the U.S. Characteristics of active EMS professionals who are treating patients in the prehospital setting is unclear. The purpose of this study was to describe the roles and settings in which nationally certified EMS professionals are providing patient care and to evaluate similarities and differences of the demographics and practice settings of the three major certification levels. METHODS: We conducted a cross-sectional evaluation of all nationally certified EMS professionals in the U.S. that recertified between October 1, 2017 and March 31, 2018 and October 1, 2018 and March 31, 2019. Within the recertification application, EMS professionals completed an optional demographic profile. Those who were nationally certified, functioning as a patient care provider for at least one nonmilitary EMS organization, aged 18 to 85 years, and recertified at the EMT level or higher were included. Demographic, agency and job characteristics were assessed and descriptive statistics were calculated. RESULTS: In 2017-2018, 101,363 EMS professionals recertified and 87,471 (86%) completed the profile; in 2018-2019, 106,893 EMS professionals recertified and 92,640 (87%) completed the profile. Of the 142,751 EMS professionals who met inclusion criteria, the population was primarily male (76%) and age increased by certification level. By race/ethnicity, 85% were white, 5% were Hispanic/Latino, 5% were Black/African American, 2% were American Indian/Alaskan Native, 2% were Asian and 1% were Native Hawaiian/Pacific Islander.Paramedics had the highest proportion of associate degrees (EMT:16.0%; AEMT:16.6%; paramedic:28.5%); some college experience was common for all certification levels (EMT:34.7%; AEMT:37.2%; paramedic:31.6%). Most EMS professionals reported 3-7 years of experience, were working full-time (78%) and 28% were working for 2 or more agencies. Most were working for a fire department (48%) or private agency (21%) and providing 9-1-1 service (72%). No substantial differences were observed between the two recertification cycles. CONCLUSION: This is the most comprehensive study evaluating the demographics of the national EMS workforce of active patient care providers. Understanding the characteristics of EMS professionals and the settings they practice in is important for educational and training initiatives, as well as protocols and policies.

Comparison of Volunteer and Paid EMS Professionals in the United States.

BACKGROUND: Emergency medical response is provided by volunteer emergency medical services (EMS) professionals in many parts of the United States. However, little is known about those who serve as volunteer EMS professionals, especially as their main EMS job. Our objective was to compare the characteristics of nationally-certified volunteer versus paid EMS professionals in the U.S. Methods: We conducted a cross-sectional evaluation of EMS professionals who recertified their National EMS Certification between October 1, 2017-March 31, 2018 or October 1, 2018-March 31, 2019. Data were obtained from 2 cycles of the biennial National EMS Certification recertification application. We included currently working, nonmilitary EMS professionals aged 18-85 years at the emergency medical technician (EMT) or higher certification level. Volunteer was defined as receiving nominal or no compensation for the provision of EMS services at an agency as the main EMS job. Comparisons were made, accounting for the large sample size, to determine notable differences between volunteer and paid EMS professionals. Results: Of the 154,229 EMS professionals that met inclusion criteria (response rate = 86%), 13% volunteered at their main EMS job. More volunteer than paid EMS professionals were female (38% vs. 22%). There was also a significant difference in certification level between volunteer and paid (EMT: 82% vs. 46%). Three-quarters (74%) of volunteer EMS professionals reported working in rural communities compared to 30% of paid. The states with the largest proportion of volunteers to any currently working EMS professionals who recertified were Vermont (47%) and North Dakota (45%). Conclusion: Approximately 13% of the EMS workforce held a primary job in EMS as a volunteer, and these volunteer EMS professionals differed from their paid counterparts - e.g., volunteers were more likely to be women, have EMT certification, and work in rural areas. We encourage further research to understand motivations for volunteering in EMS.

Comparison of Air Force, Army, and Navy Emergency Medical Technician Candidates' Performance on the National Registry Cognitive Examination.

INTRODUCTION: Military medics function similarly to civilian emergency medical technicians (EMTs); however, they perform their emergency medical care in combat zones and military treatment facilities. Both civilian and military EMTs must take and pass the National Registry of EMT's cognitive examination to be certified as a Nationally Registered EMT; however, there is a discrepancy in requirements for obtaining and maintaining National EMT Certification between the military branches of the DoD. In our study, we aimed to compare the performance of the U.S. Air Force (USAF), U.S. Army (USA), and U.S. Navy (USN) EMT candidates on the National EMT Certification cognitive examination from 2015 to 2017. MATERIALS AND METHODS: We performed a cross-sectional analysis of the National Registry of EMT's database for the examination results of all military EMT candidates who attempted the National EMT Certification cognitive examination between January 1, 2015, and December 31, 2017. First and cumulative third attempt pass rates and cognitive performance from mean ability estimates (MAEs) on the examination were assessed. Descriptive statistics were calculated and comparisons between branches with regard to passing rates and MAEs were made using chi-square tests and ANOVA, respectively, at the alpha level of 0.05. RESULTS: During the 3-year study period, a total of 3,642 USAF, 14,050 USA, and 1,187 USN candidates attempted the cognitive examination one or more times. The USA candidates demonstrated the highest first attempt pass rates (2015: 78%; 2016: 78%; and 2017: 81%) followed by the USAF candidates (2015: 58%; 2016: 62%; and 2017: 64%) and the USN candidates (2015: 41%; 2016: 56%; and 2017: 62%). The cumulative third attempt pass rates followed a similar trend (e.g., USA: 2015: 94%; 2016: 95%; and 2017: 96%). These differences by branch were statistically significant for each year (P < .001). The overall test MAE scores also differed by branch, but only the USN candidates' MAE scores differed by year. The USA candidates demonstrated the highest MAE from 2015 to 2017 (523) followed by the USAF (489) and the USN (464) candidates. The overall test MAE scores for the USN candidates improved over the study period (2015: 449; 2016: 475; and 2017: 479, P < .001). CONCLUSION: Military EMT candidates had different performances on the EMT cognitive examination between branches. The USA candidates demonstrated higher pass rates and cognitive performance on the examination compared to their counterparts from the USAF and USN from 2015 to 2017. Further work should be directed at defining the cause of the differences in military EMT candidate performance and determining the characteristics that impact these differences.

Ultrasound Use in the Prehospital Setting for Trauma: A Systematic Review.

BACKGROUND: Trauma is a leading cause of death in the United States. Ultrasound use in the prehospital environment has the potential to change trauma management. Although ultrasound use for prehospital trauma is increasing, the role of this modality is not clearly defined. OBJECTIVES: We examined the use of prehospital ultrasound (PHUS) for trauma patients and the use by different provider types. Specific factors of interest were if prehospital ultrasound has been shown to improve providers' ability to recognize conditions that can be managed in the prehospital setting, treat these conditions, change transport destination, or improve overall mortality rates for trauma patients. METHODS: We searched MEDLINE/PubMed, EBSCOhost, Cochrane Library, and Embase medical literature databases for articles that addressed our outcomes. Abstracts and articles were examined and studies that did not specifically evaluate ultrasound in the prehospital setting for trauma and duplicates were eliminated. Studies included in this comprehensive review were assessed for the use of ultrasound in the prehospital setting to aid in the diagnosis, treatment, and transport of trauma patients. We also conducted an analysis of bias in the included articles. Due to the large heterogeneity in the included studies, no meta-analysis could be performed. RESULTS: Sixteen studies were identified comprising 3,317 patients. One study evaluated Emergency Medical Services (EMS) professionals as the ultrasound operator while five studies involved mixed practitioners and ten studies involved only physicians. Diagnostic accuracy was similar amongst physicians and mixed practitioners with no studies reporting PHUS accuracy for EMS providers alone. Seven studies evaluated treatment and transport impact of PHUS though the variables measured were inconsistent and results varied by protocol and outcomes measured. There were no studies that evaluated PHUS and its impact on patient mortality. CONCLUSION: Ultrasound use in the prehospital setting for trauma is feasible and demonstrates potential. However, the evidence in the medical literature mainly consists of prospective observational studies of physicians utilizing ultrasound for trauma in a HEMS setting. Further scientific research must be undertaken to firmly establish the role of prehospital ultrasound in trauma management by all types of EMS providers.

Safety netting; best practice in the face of uncertainty.

Safety netting is a recognised General Practitioner (GP) diagnostic strategy often used in the face of uncertainty to help ensure that a patient with unresolved or worsening symptoms knows when and how to access further advice. It is an important way of reducing clinical risk. In the context of the COVID-19 pandemic and the rapid move to mainly remote consultations within the musculoskeletal field, safety netting is an important strategy to embed within all consultations. Only those presenting with potentially serious conditions are offered face to face consultations. Screening for Red Flags and any indication of a serious cause of symptoms is always first line in any consultation, however, clinical presentations are not always black and white with patients falling into a clear diagnostic category. With patients minds more focussed on COVID-19 symptoms this can be problematic. With the additional ramifications of public health social restrictions, onward management can be a conundrum. Many people with risk factors of serious pathology are also as a consequence, vulnerable to contracting COVID-19. In situations of uncertain clinical presentations, to avoid unnecessary social contact, safety netting can help to monitor symptoms over time until the clinical context becomes more certain. Embedding safety netting within physiotherapy best practice could be a silver lining in this pandemic black cloud.

International Framework for Red Flags for Potential Serious Spinal Pathologies.

SYNOPSIS: The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) led the development of a framework to help clinicians assess and manage people who may have serious spinal pathology. While rare, serious spinal pathology can have devastating and life-changing or life-limiting consequences, and must be identified early and managed appropriately. Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. This framework is intended to provide a clinical-reasoning pathway to clarify the role of red flags. J Orthop Sports Phys Ther 2020;50(7):350-372. Epub 21 May 2020. doi:10.2519/jospt.2020.9971.

The Brighton musculoskeletal Patient-Reported Outcome Measure (BmPROM): An assessment of validity, reliability, and responsiveness.

BACKGROUND: In response for the need of a freely available, stand-alone, validated outcome measure for use within musculoskeletal (MSK) physiotherapy practice, sensitive enough to measure clinical effectiveness, we developed an MSK patient reported outcome measure. OBJECTIVES: This study examined the validity and reliability of the newly developed Brighton musculoskeletal Patient-Reported Outcome Measure (BmPROM) within physiotherapy outpatient settings. METHODS: Two hundred twenty-four patients attending physiotherapy outpatient departments in South East England with an MSK condition participated in this study. The BmPROM was assessed for user friendliness (rated feedback, N = 224), reliability (internal consistency and test-retest reliability, n = 42), validity (internal and external construct validity, N = 224), and responsiveness (internal, n = 25). RESULTS: Exploratory factor analysis indicated that a two-factor model provides a good fit to the data. Factors were representative of "Functionality" and "Wellbeing". Correlations observed between the BmPROM and SF-36 domains provided evidence of convergent validity. Reliability results indicated that both subscales were internally consistent with alphas above the acceptable limits for both "Functionality" (α = .85, 95% CI [.81, .88]) and 'Wellbeing' (α = .80, 95% CI [.75, .84]). Test-retest analyses (n = 42) demonstrated a high degree of reliability between "Functionality" (ICC = .84; 95% CI [.72, .91]) and "Wellbeing" scores (ICC = .84; 95% CI [.72, .91]). Further examination of test-retest reliability through the Bland-Altman analysis demonstrated that the difference between "Functionality" and "Wellbeing" test scores did not vary as a function of absolute test score. Large treatment effect sizes were found for both subscales (Functionality d = 1.10; Wellbeing 1.03). CONCLUSION: The BmPROM is a reliable and valid outcome measure for use in evaluating physiotherapy treatment of MSK conditions.

Polytetrafluoroethylene conduits versus homografts for right ventricular outflow tract reconstruction in infants and young children: An institutional experience.

OBJECTIVE: Our institution uses a valved polytetrafluoroethylene conduit as an alternative to homografts. The objective of this study was to investigate the performance of bicuspid valved polytetrafluoroethylene conduits used for right ventricular outflow tract reconstruction in children aged less than 2 years and to evaluate risk factors for earlier conduit explant. METHODS: We performed an Institutional Review Board-approved retrospective chart review of all patients aged less than 2 years who underwent surgical right ventricular outflow tract reconstruction with a bicuspid valved polytetrafluoroethylene conduit or homograft conduit from July 2004 to December 2014. The end points of the study were defined as conduit explant, conduit explant or reintervention, conduit stenosis, and conduit insufficiency. RESULTS: Fifty-four patients underwent 65 right ventricular outflow tract reconstructions with a bicuspid valved polytetrafluoroethylene conduit (n = 39) or a homograft conduit (n = 26, 23 pulmonary, 3 aortic). The majority of diagnoses were truncus arteriosus (n = 28) and tetralogy of Fallot with pulmonary atresia (n = 19). Median age of patients at surgery was 134 (8-323) days and 128 (7-384) days in the PTFE and homograft groups, respectively. There was no difference in demographic data between the 2 groups. Time-to-event analysis demonstrated no difference in time to explant (P = .474) or time to explant or reintervention (P = .206) between the 2 conduit types. Younger age at surgery was the only independent risk factor for conduit explant (subdistribution hazard ratio 1.104 per 30 days younger, P < .001). There was no significant influence of conduit type on the development of moderate conduit stenosis (P = .931) or severe conduit insufficiency (P = .880). Larger conduit z score was protective for the development of moderate conduit stenosis (subdistribution hazard ratio, 0.46; P = .001). CONCLUSIONS: Bicuspid valved polytetrafluoroethylene conduits are a satisfactory choice for right ventricular outflow tract reconstruction in patients aged less than 2 years. Their availability, low cost, and lack of potential sensitization make them an appealing alternative to homograft conduits.

An exploration of factors influencing physical activity levels amongst a cohort of people living in the community after stroke in the south of England.

PURPOSE: To explore factors influencing physical activity (PA) reported by people living in rural/semi-rural communities in the south of England post-stroke, and to understand relationships between personal, interpersonal and environmental barriers and self-reported levels of PA. METHOD: A survey was mailed to patients of NHS Trusts who were identified as potential participants. Self-reported PA levels, type, and frequency of reported barriers were tabulated. Spearman's rank correlation coefficient was used to explore associations between self-reported PA level and: age, gender, level of physical function, fear of falling, beliefs regarding PA, available supports, and socioeconomic status. RESULTS: Seventy-six of 322 questionnaires distributed were returned (24%). Only 55.2% of respondents reported undertaking PA of sufficient intensity to meet current guidelines. Personal barriers included fear of falling, stroke-related disability, pain, and fatigue. Interpersonal and environmental barriers included lack of social support, transport, and inclement weather. Significant relationships existed between self-reported PA and fear of falling, functional mobility, and beliefs relating to PA. CONCLUSIONS: Almost half of the survey cohort reported PA levels insufficient to meet current guidelines. Similar to barriers reported in previous studies in USA and other parts of the UK, numerous interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA were identified. Implications for Rehabilitation This study found that although more than 60% of the survey population were able to ambulate >200 m, only 55.2% reported undertaking sufficient PA to meet current guidelines, putting them at increased risk of further stroke and other co-morbidities. Participants reported a number of interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA, which may explain this discrepancy between mobility status and self reported activity levels. Rehabilitation professionals and primary care providers are well positioned to address the barriers identified in this survey, such as providing interventions to reduce fear of falling, pain, and fatigue, providing support and education about safely increasing physical activity and addressing unhelpful beliefs about PA. Behaviour change strategies, such as increasing self-efficacy, and partnering with the person with stroke to problem solve strategies to address the barriers identified by this, and related research, are likely to be more successful in increasing PA than providing information alone.

The stiff shoulder; A case study.

Clinicians working in outpatient departments and advanced practitioner clinics frequently encounter patients presenting with multidirectional stiffness of the glenohumeral joint. This case report describes the assessment and treatment of a patient presenting with glenohumeral joint stiffness and describes the possible differential diagnoses. The evidence base used to inform the decision-making process is presented and the use of radiology that helped to ultimately establish the diagnosis is discussed. The clinical reasoning process of applying knowledge and experience to identify patient problems and to make appropriate decisions that result in positive patient outcomes is discussed. The case report highlights the importance of early diagnosis.

Automated external defibrillators in West Virginia schools.

INTRODUCTION: Sudden death, particularly when occurring in children and adolescents, is a traumatic event not only for the victim's family, but for the entire community. It has been shown that school-based automated external defibrillator (AED) programs provide a high survival rate for both students and nonstudents who suffer sudden cardiac arrest (SCA) on school grounds. The use of AEDs is becoming increasingly more common in schools in the United States. In West Virginia middle and high schools, we analyzed the prevalence and use of AEDs, barriers to obtaining a device, and cases of sudden death on school grounds. METHODS: A mailed survey distributed to West Virginia high schools and middle schools collected general demographic data, AED data, and occurrences of sudden death on school grounds. Schools reporting a death were contacted to obtain details regarding the event. For schools with a device, the number of AEDs, length of possession, reasons for and means of obtaining the AED, personnel trained to operate the AED and the number of device uses were determined. For schools without an AED, barriers to and interest in obtaining a device were determined. RESULTS: Two hundred and twenty-five of 312 surveys (72%) were returned. One hundred and fifty-two schools (68%) currently have at least one AED and 73 schools (32%) do not have an AED. Public high schools had the highest prevalence of AEDs (76%) compared to public middle schools (62%) and private schools (67%). Sixty-nine percent of schools obtained their devices by donations or grants and 32% obtained them using school funds. Barriers to obtaining a device included cost (82%), lack of trained personnel (45%), unfamiliarity with AED (22%), and liability issues (19%). There were a total of 23 deaths on school premises reported by 20 schools. There was one reported occurrence of an AED being used to save a life. CONCLUSION: Over two thirds of West Virginia middle schools and high schools currently have at least one AED on their premises. An AED is an effective way of preventing death following sudden cardiac arrest, and has saved at least one life in a West Virginia school. While most schools without AEDs cite cost as the main deterrent, the majority of schools with a device received them via donation or grant. We submit that a number of sudden deaths on West Virginia school grounds could possibly have been averted by use of an AED.