Examining the quality of work-life of paramedics in northern Ontario, Canada: A cross-sectional study.

BACKGROUND: Paramedics are exposed to multiple stressors in the workplace. They are more likely to develop occupational-related stress conditions compared to other occupations. This study focused on understanding the factors affecting QoWL of paramedics in northern Ontario, Canada; a particular focus was on understanding the personal and organizational factors, such as practicing community paramedicine (CP), which may be associated with Quality of Work Life (QoWL). METHODS: Paramedic QoWL was assessed using an online survey that was distributed to approximately 879 paramedics across northern Ontario. The survey included the 23-Item Work- Related Quality of Work Life Scale. Data analysis involved linear regressions with nine predictor variables deemed to be related to QoWL for paramedics with QoWL and its six subscales as dependent variables. Multiple linear regressions were used to assess the personal and organizational factors, such as practicing of CP, which predicted QoWL. RESULTS: One hundred and ninety-seven paramedics completed the questionnaire. Overall, the mean QoWL score of all paramedic participants was 73.99, and this average compared to relevant published norms for other occupations. Factors that were most associated with higher QoWL were, experience practicing CP (p < 0.05), number of sick days/year (p < 0.01), and higher self- rated mental health (p < 0.001). CONCLUSIONS: Higher paramedic QoWL appears to be associated with many factors such as number of sick days per year, self-rated mental health, and participation in CP. EMS organizations should consider establishing necessary workplace health promotion strategies that are targeted at improving QoWL for paramedics.

Ethical foundations of client-centered care in family planning.

Biomedical ethics provides the foundation for a model of client-centered care that can assure the good quality of family planning and other reproductive health services in developed and developing countries. Client concerns mirror the four ethical principles of autonomy, justice, beneficence, and nonmaleficence. Autonomy reflects clients' desire for full information and respect from providers so that they can exercise their right to make their own informed decisions. Justice, for clients, means fair treatment and ready access to services, regardless of one's socioeconomic status, education, ethnic group, or residence. Beneficence means that providers possess the technical competence and understanding needed to act in the best interest of their clients, as clients expect. Nonmaleficence translates into client concerns about safety--that no harm will come to them as a result of seeking services. Putting these ethical principles into practice requires changing providers' attitudes from paternalistic to client centered. Assessments of client satisfaction can help family planning programs identify and respond to client values and even raise client expectations about the care they should receive. Managers also can contribute to good quality care by meeting providers' professional needs for training, supervision, supplies, record keeping, and so on. Family planning programs around the world are focusing on these ethical concerns to emphasize respect for client values, appropriate decision making, broader access to services, and basic safety issues. Although they use a variety of techniques, all these quality assurance and improvement initiatives share an ethically based, client-centered philosophy.

Family planning programs: improving quality.

PIP: Family planning programs are increasingly making quality of care the highest priority. With improvement in quality of care, contraceptive use is safer and more effective, information and services are more accessible, clients make informed choices and are more satisfied. In addition, family planning providers find their work more rewarding and the general public has a positive view of health care and its providers. Applying the lessons of the quality movement of health care and family planning, programs and providers are finding more creative approaches that suit reproductive health care in developing countries. In addition to adopting a client-centered approach, these efforts suggest that the three sides of the quality triangle are equally essential: quality design, quality control, and quality improvement.^ieng

Breast cancer after breast augmentation with silicone implants.

BACKGROUND: Although epidemiological studies have failed to demonstrate an increased incidence of breast cancer in women who had undergone prior prosthetic augmentation mammoplasty (PAM), it has been reported that when breast cancer arises in this group it presents mostly in a palpable form and at a more advanced stage. This is thought to be secondary to suboptimal mammographic evaluation caused by the masking effect of the implant. This study was undertaken to determine, in our experience, whether breast cancer arising in women who had undergone PAM could be detected in a prepalpable form by mammography and whether it presented at a more advanced stage as compared with nonaugmented women with breast cancer. METHODS: The charts of 22 patients, treated by at least one of the authors, in whom 23 breast cancers developed after PAM (group A) were retrospectively reviewed. The comparison groups consisted of 611 nonaugmented patients who underwent 636 procedures for the treatment of primary breast cancer at our institution (group B) and the surveillance, epidemiology, and end results (SEER) data (group C). Parameters studied were mode of detection, tumor size, axillary lymph node involvement, and histopathology. RESULTS: No significant differences between the groups were found in mean tumor size (group A vs. group B), the incidence of preinvasive cancer (group A vs. group B) or axillary lymph node involvement (group A vs. group B and group A vs. group C). Breast-preserving surgery was performed significantly less in augmented patients (group A vs. group B). CONCLUSION: We conclude that prepalpable and preinvasive breast cancer can be detected in the PAM patient by mammography and that the stage of presentation in this group is not significantly different than in nonaugmented patients. Total mastectomy is preferred over breast-preserving procedures for the treatment of breast cancer in the PAM patient.

Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: results of a large multicenter survey.

Neurologic deficits were compared to somatosensory evoked potential (SEP) spinal cord monitoring in a survey of spinal orthopedic surgeons. Experienced SEP spinal cord monitoring teams had fewer than one-half as many neurologic deficits per 100 cases compared to teams with relatively little monitoring experience. Experienced SEP monitoring teams also had fewer neurologic deficits than were seen in previous surveys of this group. Definite neurologic deficits, despite stable SEPs (false negative monitoring), occurred during surgery in only 0.063% of patients. Factors independently associated with fewer neurologic deficits also included the surgeon's years of experience in orthopedic surgery and the use of the wake-up test. Other technical survey results are also presented here. These results confirm the clinical efficacy of experienced SEP spinal cord monitoring for prevention of neurologic deficits during spinal surgery such as for scoliosis.

Lumbar spinal stenosis secondary to calcium pyrophosphate crystal deposition (pseudogout).

A 62-year-old man demonstrated symptoms, signs, and radiographic evidence of lumbar spinal stenosis and intraoperative pathologic findings of tophaceous deposition in the ligamentum flavum. Although there have been reports of cervical calcium pyrophosphate dihydrate crystal deposition (CPPD) with neurologic compression, this report appears to be the first case of lumbar spinal stenosis secondary to CPPD. Cervical calcium pyrophosphate dihydrate crystal deposition should be added to the differential diagnosis of spinal stenosis.

Relation between self-reported affect and drug urges and cravings in continuing and withdrawing smokers.

In 2 experiments we investigated the effects of withdrawal and stress on the affective correlates of urges to smoke. In both, habitual cigarette smokers were divided into continuing and withdrawing smoker groups. In the 1st study, 44 adults reported current mood, urge, and expectations over a 24-hr period. In the 2nd, a controlled laboratory study, urge, affect, and physiological data were obtained from continuing and withdrawing groups (N = 64) exposed to high- or low-stress conditions. Urges among withdrawing smokers were positively associated with negative affect and negatively associated with positive affect; continuing smokers reported urges that were directly associated with positive affect and unrelated to negative affect. Stress and withdrawal produced urge self-reports that were related to negative affect. Moreover, subjects who smoked after exposure to withdrawal and stress reported greater pleasure and arousal than did other subjects.

1991 Volvo Award in experimental studies. Cauda equina syndrome: neurologic recovery following immediate, early, or late decompression.

An animal model of cauda equina syndrome was developed. Neurologic recovery was analyzed following immediate, early, and delayed decompression. Five experimental groups, each containing six dogs, were studied. Compression of the cauda equina was performed in all 30 dogs following an L6-7 laminectomy. The cauda equina was constricted by 75% in each group. The first group was constricted and immediately decompressed. The remaining groups were constricted for 1 hour, 6 hours, 24 hours, and 1 week, respectively, before being decompressed. Somatosensory evoked potentials were performed before and after surgery, before and immediately after decompression, and 6 weeks following decompression. Daily neurologic exams using the Tarlov grading scale were performed. At 6 weeks postdecompression, all dogs were killed, and the neural elements analyzed histologically. Following compression, all 30 dogs had significant lower extremity weakness, tail paralysis, and urinary incontinence. All dogs recovered significant motor function 6 weeks following decompression. The dogs with immediate decompression generally recovered neurologic function within 2-5 days. The dogs receiving 1-hour and 6-hour compression recovered within 5-7 days. The dogs receiving 24-hour compression remained paraparetic 5-7 days, with bladder dysfunction for 7-10 days and tail dysfunction persisting for 4 weeks. The dogs with compression for 1 week were paraparetic (Tarlov Grade 2 or 3) and incontinent during the duration of cauda equina compression. They recovered to walking by 1 week and Tarlov Grade 5 with bladder and tail control at the time of euthanasia. Immediately after compression, all five groups demonstrated at least 50% deterioration of the posterior tibial nerve evoked potential amplitudes.(ABSTRACT TRUNCATED AT 250 WORDS)

Spinal cord monitoring. Results of the Scoliosis Research Society and the European Spinal Deformity Society survey.

The Scoliosis Research Society (SRS) and the European Spinal Deformity Society (ESDS) membership was surveyed regarding the use of intraoperative monitoring of somatosensory evoked potentials in spinal surgery. A total of 242 people responded, with 188 using intraoperative monitoring. A second survey was distributed detailing the technical aspects of monitoring, of which 71 were returned. A total of 342 neurologic deficits were reported to have occurred with monitoring in place. Two hundred forty-six (72%) were accurately detected, and 96 (28%) were not detected by sensory cord evoked potentials (SCEP). There were 1,003 false-positive cases reported. The incidence of false-negative cases was related to those not monitoring both latency and amplitude, to using fewer recording electrodes, and with those surgeons doing more kyphosis corrections.

Aversion instead of preference learning indicated by nicotine place conditioning in rats.

Although nicotine is a drug of abuse for millions of smokers, it has been difficult to demonstrate clearly the motivational properties of nicotine with rats using the conditioned place preference (CPP) paradigm. The first experiment attempted to replicate CPPs reported by other researchers using nicotine doses of 0.4, 0.8, and 1.2 mg/kg. There was a trend for all three doses to produce aversions, but it was significant only for the 0.8 mg/kg dose. Exposures to the CS alone extinguished aversions, but a "priming" dose (0.2 mg/kg) of nicotine given after extinction produced aversions only in animals exposed to 1.2 mg/kg. Experiment 2 tested whether preexposure to morphine or nicotine would sensitize animals to nicotine's reinforcing effects. In this experiment, rats were exposed to either six nicotine (0.6 mg/kg) or morphine (1.0 mg/kg) dosings prior to preference conditioning. Neither preferences nor aversions were observed in any group following subsequent conditioning with 0.6 mg/kg nicotine. The results suggest that previous observations of preference effects may have been due to specific procedural factors or may have depended on negative reinforcement due to stress reduction.

Corticotropin-releasing factor modulates defensive-withdrawal and exploratory behavior in rats.

The role of corticotropin-releasing factor (CRF), an endogenous neuropeptide, in modulating species-typical responses was examined in an unfamiliar open field containing a small chamber. Rats placed in this small chamber spent most of their time withdrawn in it. However, rats given an intracerebroventricular injection (20 micrograms) of alpha-helical CRF(9-41), a CRF receptor antagonist, emerged from the chamber and explored the unfamiliar open field. Additional studies showed that after 1 exposure to the test environment, vehicle-treated rats increased their time spent in the open field and returned intermittently to the chamber. This result suggests that reexposure reduces the threatening impact of an unfamiliar open field. Importantly, CRF (300 ng) injected centrally, but not peripherally, before reexposure to the test environment significantly reduced exploration in the open field and increased a pattern of defensive-withdrawal into the chamber. Data suggest that whether defensive-withdrawal or exploratory behavior is exhibited may depend on CRF actions in brain systems that mediate the perception of threat in the environment.

Subjective dimensions of heroin urges: influence of heroin-related and affectively negative stimuli.

Thirty-five male drug-free heroin addicts rated their affect, craving, and withdrawal in response to boring, anxiety-eliciting, and heroin stimuli. Results revealed that: (a) heroin cues were more effective than boring or anxiety-eliciting cues in prompting self-reports of craving or withdrawal; (b) heroin cues produced an affective state characterized by self-reported low-pleasure and high anxiety/tension; (c) craving was not correlated with any particular affective state, but rather was associated with a variety of negative affects--anxiety, depression, fatigue, anger; (d) the coherence (intercorrelations) of affective, craving, and withdrawal measures was greatest when addicts made their self-ratings immediately after exposure to drug stimuli; and (e) while addicts routinely reported craving without withdrawal sickness, they virtually never reported withdrawal sickness without reporting craving. These results suggested that the potential for negative reinforcement subserved stimulus elicited craving and that craving involved cognitive appraisal processes (attributions, expectations).

Chest wall stabilization using plate fixation.

Large defects of the chest wall require stabilization of the remaining thorax to prevent paradoxical movement. A technique of fixation using rib grafts and compression plates is presented.

Antagonism of endogenous CRH systems attenuates stress-induced freezing behavior in rats.

Three experiments were conducted to test the hypothesis that brain corticotropin-releasing hormone (CRH) systems mediate stress-induced freezing behavior, an index of a rat's level of fear. We administered i.c.v. 0-50 micrograms of alpha-helical CRH9-41 (a specific CRH antagonist) before foot shock and showed that this peptide had little effect on baseline preshock behavior but significantly attenuated the occurrence of shock-induced freezing. We concluded that this attenuation of freezing behavior was not related to the effects of alpha-helical CRH9-41 on the animals' sensitivity to pain, because no significant effects on latency to respond on a hot-plate test of pain sensitivity were found. We also showed that alpha-helical CRH9-41 has a relatively rapid time course of action when administered i.c.v., since it blocked shock-induced freezing when given 20 min but not 40 min before foot shock. Our findings suggest that endogenous CRH systems mediate stress-induced, fear-related behavior through mechanisms other than alteration of nociceptive systems.

ICV-CRH alters stress-induced freezing behavior without affecting pain sensitivity.

Freezing is an adaptive response often induced by stressful, fear-eliciting stimuli. Three experiments with rats investigated the effects of intracerebroventricular (ICV) administration of corticotropin-releasing hormone (CRH) on freezing behavior and pain sensitivity. Experiments 1 and 3 demonstrated that ICV-CRH (300 ng) enhanced shock-elicited freezing. In Experiment 1, ICV-CRH also enhanced recovery from shock-elicited freezing, suggesting that the peptide has a biphasic effect. Experiments 2 and 3 established that CRH-induced freezing was not caused by heightened pain sensitivity. Interestingly, in Experiment 2, hot-plate exposure produced increased freezing that was attenuated by ICV-CRH. Thus, the direction of the ICV-CRH effect on freezing was found to depend on the nature of the stressor. These results suggest that endogenous CRH systems modulate stress-induced freezing.

The effects of ICV-CRH on novelty-induced behavior.

To assess whether centrally administered corticotropin-releasing hormone (CRH) modulates behavioral and antinociceptive effects of exposure to a novel environment, vehicle or 0.03, 0.3, or 3.0 micrograms of CRH was administered intracerebroventricularly (ICV) to rats, which were then tested under novel or familiar conditions. Novelty decreased sleeping and grooming and increased rearing, walking, and latency to respond on the hot-plate test of analgesia. CRH increased grooming and walking, decreased rearing and sleeping, and had no effect in the hot-plate test. The lowest dose was without effect on any measure; otherwise, CRH effects generally were dose-dependent. There was no evidence that CRH selectively enhanced or interfered with novelty-induced behavioral changes; it influenced behavior to the same degree in both test conditions. However, test condition selectively modulated the degree of peptide-induced self-gnawing and burrowing.

Human bites of the eyelid.

Five patients with traumatic colobomas of the eyelid secondary to human bites were surgically repaired with retrieved autogenous tissue. All patients were treated with prophylactic intravenous antibiotics. Surgical repair consisted of debridement of the autograft, meticulous layered closure of the autograft to the wound, and placement of a lid margin suture. In two of the patients, mild upper eyelid retraction was noted, and two patients had loss of cilia.

ICV-CRH potently affects behavior without altering antinociceptive responding.

To explore the hypothesized integrative function of corticotropin releasing hormone (CRH) in the stress response, stress-related behaviors including antinociception were studied in rats after either intracerebroventricular (ICV) or peripheral administration of CRH. The effects of low-dose (0.3 microgram) and high-dose (3.0 micrograms) ICV-CRH were compared to those of vehicle, employing a within-S design. The two doses yielded comparable behavioral changes suggestive of increased arousal and stress. These changes were characterized by significant increases in grooming, walking, burrowing, self-gnawing, and pica, and decreases in rearing and sleeping. None of these effects of ICV-CRH were obtained with peripheral administration of the same doses. The hot-plate test of analgesia failed to show a significant effect of ICV-CRH or peripherally administered CRH. A between-S experiment incorporating both the tail-flick and the hot-plate tests of analgesia compared ICV-CRH (3.0 micrograms) with vehicle. ICV-CRH did not affect antinociceptive responding in either of these tests. In contrast, ICV morphine (10 micrograms) yielded potent analgesia in both tests. Thus, with doses of ICV-CRH yielding clear evidence of stress-related behavior, no evidence of analgesia was obtained. These findings question the possible role of central CRH systems in antinociceptive processes.