Fixed dose ketamine for prehospital management of hyperactive delirium with severe agitation.

INTRODUCTION: Patients exhibiting signs of hyperactive delirium with severe agitation (HDSA) may require sedating medications for stabilization and safe transport to the hospital. Determining the patient's weight and calculating the correct weight-based dose may be challenging in an emergency. A fixed dose ketamine protocol is an alternative to the traditional weight-based administration, which may also reduce dosing errors. The objective of this study was to evaluate the frequency and characteristics of adverse events following pre-hospital ketamine administration for HDSA. METHODS: Emergency Medical Services (EMS) records from four agencies were searched for prehospital ketamine administration. Cases were included if a 250 mg dose of ketamine was administered on standing order to an adult patient for clinical signs consistent with HDSA. Protocols allowed for a second 250 mg dose of ketamine if the first dose was not effective. Both the 250 mg initial dose and the total prehospital dose were analyzed for weight based dosing and adverse events. RESULTS: Review of 132 cases revealed 60 cases that met inclusion criteria. Patients' median weight was 80 kg (range: 50-176 kg). No patients were intubated by EMS, one only requiring suction, three required respiratory support via bag valve mask (BVM). Six (10%) patients were intubated in the emergency department (ED) including the three (5%) supported by EMS via BVM, three (5%) others who were sedated further in the ED prior to requiring intubation. All six patients who were intubated were discharged from the hospital with a Cerebral Performance Category (CPC) 1 score. The weight-based dosing equivalent for the 250 mg initial dose (OR: 2.62, CI: 0.67-10.22) and the total prehospital dose, inclusive of the 12 patients that were administered a second dose, (OR: 0.74, CI: 0.27, 2.03), were not associated with the need for intubation. CONCLUSION: The 250 mg fixed dose of ketamine was not >5 mg/kg weight-based dose equivalent for all patients in this study. Although a second 250 mg dose of ketamine was permitted under standing orders, only 12 (20%) of the patients were administered a second dose, none experienced an adverse event. This indicates that the 250 mg initial dose was effective for 80% of the patients. Four patients with prehospital adverse events likely related to the administration of ketamine were found. One required suction, three (5%) requiring BVM respiratory support by EMS were subsequently intubated upon arrival in the ED. All 60 patients were discharged from the hospital alive. Further research is needed to determine an optimal single administration dose for ketamine in patients exhibiting signs of HDSA, if employing a standardized fixed dose medication protocol streamlines administration, and if the fixed dose medication reduces the occurrence of dosage errors.

Does Mixing Activated Charcoal With Cola Improve Tolerability Without Affecting Pharmacokinetics? A Randomized Controlled Crossover Trial.

INTRODUCTION: Activated charcoal is the most common form of gastrointestinal decontamination used for the poisoned patient. One limitation to its use is patient tolerability due to palatability. Some recommend mixing activated charcoal with cola to improve palatability. An important question is whether mixing activated charcoal with cola affects the ability of the activated charcoal to adsorb xenobiotic. METHODS: This was a prospective randomized controlled crossover trial. Five healthy adults aged 18 to 40 years were recruited. Participants received 45 mg/kg acetaminophen rounded down to the nearest whole tablet. One hour later, they were randomized to receive 50 g of an activated charcoal-water premixture alone or mixed with cola. Acetaminophen levels were collected. The area under the curve of acetaminophen concentrations over time was measured as a marker for degree of absorption. Participants also completed an appeal questionnaire in which they rated the activated charcoal preparations. Participants would then return after at least 7 days to repeat the study with the other activated charcoal preparation. RESULTS: Four male participants and 1 female participant were recruited. There was no statistical difference in preference score for activated charcoal alone versus the cola-activated charcoal mixture. There was no statistical difference in the area under the curve of acetaminophen concentrations over time between activated charcoal alone and the cola-activated charcoal mixture. Of note, the study is limited by the small sample size, limiting its statistical power. DISCUSSION: The absorption of acetaminophen in an overdose model is no different when participants received activated charcoal alone or a cola-activated charcoal mixture as suggested by area under the curve. In this small study, there was no difference in preference for activated charcoal alone or a cola-activated charcoal mixture across a range of palatability questions. On an individual level, some participants preferred the activated charcoal-cola mixture, and some preferred the activated charcoal alone.

Comparing Hypothermic and Thermal Neutral Conditions to Induce Metabolic Suppression.

Suppressing metabolism in astronauts could decrease CO2 production. It is unknown whether active cooling is required to suppress metabolism in sedated patients. We hypothesized that hypothermia would have an additive effect with dexmedetomidine on suppressing metabolism. This is a randomized crossover trial of healthy subjects receiving sedation with dexmedetomidine and exposure to a cold (20°C) or thermal neutral (31°C) environment for 3 hours. We measured heart rate, blood pressure, core temperature, resting oxygen consumption (VO2), resting carbon dioxide production (VCO2), and resting energy expenditure (REE) at baseline and each hour of exposure to either environment. We also evaluated components of the Defense Automated Neurobehavioral Assessment (DANA) Brief to evaluate the effect of metabolic suppression on cognition. Six subjects completed the study. Heart rate and core temperature were lower during the cold (56 bpm) condition than the thermal neutral condition (67 bpm). VO2, VCO2, and REE decreased between baseline and the 3-hour measurement in the cold condition (Δ = 0.9 mL/min, 56.94 mL/min, 487.9 Kcal/D, respectively). DANA simple response time increased between baseline and start of recovery in both conditions (20°C 136.9 cognitive efficiency [CE] and 31°C 87.83 CE). DANA procedural reaction time increased between baseline and start of recovery in the cold condition (220.6 CE) but not in the thermal neutral condition. DANA Go/No-Go time increased between baseline and start of recovery in both conditions (20°C 222.1 CE and 31°C 122.3 CE). Sedation and cold environments are required for metabolic suppression. Subjects experienced decrements in cognitive performance in both conditions. A significant recovery period may be required after metabolic suppression before completing mission critical tasks.

Social Determinants of Health in EMS Records: A Mixed-methods Analysis Using Natural Language Processing and Qualitative Content Analysis.

Introduction: Social determinants of health (SDoH) are known to impact the health and well-being of patients. However, information regarding them is not always collected in healthcare interactions, and healthcare professionals are not always well-trained or equipped to address them. Emergency medical services (EMS) professionals are uniquely positioned to observe and attend to SDoH because of their presence in patients' environments; however, the transmission of that information may be lost during transitions of care. Documentation of SDoH in EMS records may be helpful in identifying and addressing patients' insecurities and improving their health outcomes. Our objective in this study was to determine the presence of SDoH information in adult EMS records and understand how such information is referenced, appraised, and linked to other determinants by EMS personnel. Methods: Using EMS records for adult patients in the 2019 ESO Data Collaborative public-use research dataset using a natural language processing (NLP) algorithm, we identified free-text narratives containing documentation of at least one SDoH from categories associated with food, housing, employment, insurance, financial, and social support insecurities. From the NLP corpus, we randomly selected 100 records from each of the SDoH categories for qualitative content analysis using grounded theory. Results: Of the 5,665,229 records analyzed by the NLP algorithm, 175,378 (3.1%) were identified as containing at least one reference to SDoH. References to those SDoH were centered around the social topics of accessibility, mental health, physical health, and substance use. There were infrequent explicit references to other SDoH in the EMS records, but some relationships between categories could be inferred from contexts. Appraisals of patients' employment, food, and housing insecurities were mostly negative. Narratives including social support and financial insecurities were less negatively appraised, while those regarding insurance insecurities were mostly neutral and related to EMS operations and procedures. Conclusion: The social determinants of health are infrequently documented in EMS records. When they are included, they are infrequently explicitly linked to other SDoH categories and are often negatively appraised by EMS professionals. Given their unique position to observe and share patients' SDoH information, EMS professionals should be trained to understand, document, and address SDoH in their practice.

Transport Rates and Prehospital Intervals for an EMS Telemedicine Intervention.

INTRODUCTION: Emergency medical services (EMS) facilitated telemedicine encounters have been proposed as a strategy to reduce transports to hospitals for patients who access the 9-1-1 system. It is unclear which patient impressions are most likely able to be treated in place. It is also unknown if the increased time spent facilitating the telemedicine encounter is offset by the time saved from reducing the need for transport. The objective of this study was to determine the association between the impressions of EMS clinicians of the patients' primary problems and transport avoidance, and to describe the effects of telemedicine encounters on prehospital intervals. METHODS: This was a retrospective review of EMS records from two commercial EMS agencies in New York and Tennessee. For each EMS call where a telemedicine encounter occurred, a matched pair was identified. Clinicians' impressions were mapped to the corresponding category in the International Classification of Primary Care, 2nd edition (ICPC-2). Incidence and rates of transport avoidance for each category were determined. Prehospital interval was calculated as the difference between the time of ambulance dispatch and back-in-service time. RESULTS: Of the 463 prehospital telemedicine evaluations performed from March 2021 to April 2022, 312 (67%) avoided transports to the hospital. Respiratory calls were most likely to result in transport avoidance (p = 0.018); no other categories had statistically significant transport rates. Four hundred sixty-one (99.6%) had matched pairs identified and were included in the analysis. When compared to the matched pair, telemedicine without transport was associated with a prehospital interval reduction in 68% of the cases with a median reduction of 16 min; this is significantly higher than telemedicine with transport when compared to the matched pair with a median interval increase in 27 min. Regardless of transport status, the prehospital interval was a median of 4 min shorter for telemedicine encounters than non-telemedicine encounters (p = 0.08). CONCLUSION: In this study, most telemedicine evaluations resulted in ED transport avoidance, particularly for respiratory issues. Telemedicine interventions were associated with a median four-minute decrease in prehospital interval per call. Future research should investigate the long-term effects of telemedicine on patient outcomes.

A Qualitative Analysis of the Experiences of EMS Clinicians in Recognizing and Treating Witnessed Cardiac Arrests.

BACKGROUND: Survival from out of hospital cardiac arrest (OHCA) increases when effective cardiopulmonary resuscitation (CPR) and defibrillation are performed early. Patients who suffer OHCA in front of emergency medical services (EMS) clinicians have greater likelihood of survival, but little is known about how EMS clinicians think about and experience those events. We sought to understand how EMS clinicians assessed patients who devolved to cardiac arrest in their presence and uncover the perceived barriers and facilitators associated with recognizing and treating witnessed OHCAs. METHODS: EMS clinicians who had attended an EMS-witnessed OHCA and consented to participate were interviewed within 72 hours of the index case. Transcripts of the interviews were coded through the consolidated framework for implementation research to understand enabling and constraining factors involved and the predictability and anticipation of OHCA and subsequent management of patient care. Utstein data points, interventions, and associated times were extracted from the medical records. RESULTS: We interviewed 29 EMS clinicians who attended 27 EMS-witnessed OHCAs. Twenty-six (96.3%) of the EMS-witnessed OHCAs were preceded by prodromal symptoms and were classified as predictable. Of the predictable cases, clinicians anticipated 53.8% of them and attributed the prodromes of other cases to serious but not peri-arrest etiologies. Participants described various environmental, crew, and intrapersonal enabling and constraining factors associated with recognizing and treating EMS-witnessed OHCAs. Environmental elements included issues of safety and physical locations, crew elements included familiarity with their partners and working with them in the past, and intrapersonal elements included abilities to collect information and stress associated with responding to and managing the calls. CONCLUSION: Recognition and treatment of EMS-witnessed OHCAs are influenced by numerous environmental, crew, and intrapersonal factors. Future training and education on OHCA should include diverse locations, situations, and crew make-up, along with nontraditional patient complaints to broaden experiences associated with cardiac arrest management.

Eating Patterns among Emergency Medical Service Providers in the United States: A Qualitative Interview Study.

Emergency medical service (EMS) providers experience demanding work conditions in addition to shift work, which increases risk for nutrition related chronic disease such as metabolic syndrome, diabetes, obesity, and cardiovascular disease. The high stress, emergent, and unpredictable nature of EMS may interfere with healthy eating patterns on and off shift, however little is known about how these conditions impact dietary patterns among EMS providers. This study aimed to understand factors impacting dietary patterns through semi-structured interviews with 40 EMS providers throughout the United States. Interviews were conducted virtually via Zoom video conference. Inductive coding was used to identify themes throughout the interviews. Salient factors mentioned in the interviews included hunger, fatigue, stress, coworker influence, ambulance posting, geographical location, agency policy, and culture. Factors were grouped into 4 domains: physiological factors, psychosocial factors, physical environment, and organizational environment, represented by an adapted version of the social ecological model of health behaviors to include factors influencing eating patterns specific to EMS, which may contribute to overall health. Various barriers to healthy eating exist within EMS, and future studies should explore interventions at each level of our proposed model to improve conditions and reduce nutrition related disease risk in this essential population.

Physical symptoms provoked by normobaric hot and humid disabled pressurized rescue module scenarios.

We tested the hypothesis that thermal discomfort will be greater, mood will be worse, and physical symptoms of heat illness will be exacerbated with elevations in dry bulb temperature during exposure to >95% relative humidity disabled pressurized rescue module simulation. On three occasions, 15 healthy males (23 ± 3 years) sat in 32.1 ± 0.1°C, 33.1 ± 0.2°C or 35.0 ± 0.1°C, and 95 ± 2% relative humidity normobaric environments for eight hours. Thermal discomfort (visual analog scale), mood (profile of mood states), and physical symptoms of heat illness, ear-nose-throat, and muscle discomfort (environmental symptoms questionnaire) were assessed before and following each hour of exposure. Thermal discomfort was greater throughout the exposure in 35°C versus both 32°C and 33°C (p ≥ 0.03) and did not differ between the latter conditions (p ≥ 0.07). Mood worsened over time in all trials (p ≺ 0.01) and was worse in 35°C compared to 32°C and 33°C after five hours of exposure (p ≤ 0.05). Heat illness symptoms increased over time in all trials and was greater in 35°C versus 32°C and 33°C throughout the exposure (p ≤ 0.04). Ear-nose-throat and muscle discomfort symptoms increased over time in all trials (p < 0.01) and were higher in 35°C versus 32°C and 33°C after the sixth hour of exposure (p ≤ 0.02). In support of our hypothesis, mood was worse, physical symptoms of heat illness, and ear-nose-throat and muscle discomfort symptoms were exacerbated, and thermal discomfort was greater with elevations in dry bulb temperature during an eight-hour exposure to a >95% relative humidity disabled PRM simulation.

Thermoregulation during a six-hour exposure to warm, humid hyperbaric conditions.

Purpose: In a disabled submarine scenario, a pressurized rescue module (PRM) may be deployed to rescue survivors. If the PRM were to become disabled, conditions could become hot and humid exposing the occupants to heat stress. We tested the hypothesis that the rise in core temperature and fluid loss from sweating would increase with rising dry bulb temperature. Methods: Twelve males (age 22 ± 3 years; height 179 ± 7 cm; mass 77.4 ± 8.3 kg) completed this study. On three occasions, subjects were exposed to high humidity and either 28-, 32-, or 35˚C for six hours in a dry hyperbaric chamber pressurized to 6.1 msw. Changes in core temperature (Tc) and body mass were recorded and linear regression lines fit to estimate the predicted rise in Tc and loss of fluid from sweating. Results: Heart rate was higher in the 35°C condition compared to the 28°C and 32°C conditions. Tc was higher in the 32°C condition compared to 28°C and higher in 35°C compared to the 28˚°C and 32°C conditions. Projected fluid loss in all of the tested conditions could exceed 6% of body mass after 24 hours of exposure endangering the health of sailors in a DISSUB or disabled PRM. A fluid intake of 1.0 to 3.5 L would be required to limit dehydration to 2% or 4% of initial mass depending upon condition. Conclusions: Prolonged exposure to 35°C conditions under pressure results in uncompensable heat stress. 32°C and 35°C exposures were compensable under these conditions but further research is required to elucidate the effect of increased ambient pressure on thermoregulation.

Implementing a Novel Statewide Network to Support Emergency Department-initiated Buprenorphine Treatment.

INTRODUCTION: Medications for opioid use disorder (MOUD), including buprenorphine, represent an evidence-based treatment that supports long-term recovery and reduces risk of overdose death. Patients in crisis from opioid use disorder (OUD) often seek care from emergency departments (ED). The New York Medication for Addiction Treatment and Electronic Referrals (MATTERS) network is designed to support ED-initiated buprenorphine and urgent referrals to long-term care for patients suffering from OUD. METHODS: Using the PRECEDE-PROCEED implementation science framework, we provide an overview of the creation of the MATTERS network in Western New York. We also include an explanation of how the network was designed and launched as a response to the opioid epidemic. Finally, we analyzed the program's outputs and outcomes, thus far, as it continues to grow across the state. RESULTS: The New York MATTERS network was created and implemented in 2019 with a single hospital referring patients with OUD to three local clinics. In the social assessment and situational analysis phase, we describe the opioid epidemic and available resources in the region at the outset of the program. In the epidemiological assessment phase, we quantify the epidemic on the state and regional levels. In the educational and ecological assessment, we review local ED practices and resources. In the administrative and policy assessment and intervention alignment phase, the program's unique framework is reviewed. In the piloting phase, we describe the initial deployment of New York MATTERS. Finally, in the process evaluation phase, we depict the early lessons we learned. By the beginning of 2021, the New York MATTERS network included 35 hospitals that refer to 47 clinics throughout New York State. CONCLUSION: The New York MATTERS network provides a structured approach to reduce barriers to ED-initiated buprenorphine and urgent referral to long-term care. An implementation framework provides a structured means of evaluating this best practice model.

Prehospital Providers' Perspectives about Online Medical Direction in Emergency End-of-Life Decision-Making.

Background: End-of-life treatment decisions present special challenges for prehospital emergency providers. Paramedics regularly make value-laden choices that transcend technical judgment and professional skill, affecting the type of care, how and to whom it is provided. Changes in prehospital emergency care over the last decade have created new moral challenges for prehospital emergency providers; these changes have also accentuated the need for paramedics to make rapid and reasoned ethical judgments. Objective: The purpose of the study was to explore the decision-making process that occurs when prehospital emergency teams respond to an end-of-life call with a focus on how state authorized documents such as a Non-Hospital Do Not Resuscitate (NHDNR) or Medical/Physician's Orders for Life-Sustaining Treatment (MOLST/POLST) or lack thereof inform decision-making. This paper presents the specific circumstances that informed the need for intervention from Online Medical Direction (OLMD) framed in the perspectives and words of the prehospital providers seeking that assistance. Methods: This study involved in-depth in-person interviews with 50 providers to elicit participants' experiences in their own words using a semi-structured interview instrument. Interviews were audio recorded and transcribed with permission. Results: Five themes emerged that illuminated how and when OLMD was involved in emergency end-of-life decisions: Termination of Resuscitation (TOR); Family Revoked DNR; Missing Documents; No Documents and No CPR; and Unusual Situations. Participants illustrated how the decision to terminate efforts was best-supported when it was made by collaboration between the on-scene provider and OLMD. Participants described ethical dilemmas when families asked them to initiate CPR in the presence of DNR orders and cognitive dissonance when CPR has been initiated but a valid DNR/MOLST is subsequently located. Conclusions: The study findings demonstrate the invaluable contribution of OLMD for complex end-of-life care decisions by prehospital providers, especially when there are difficult legal, ethical, and logistical questions. OLMD provides far more than technical support.

Ultrasonographic Inferior Vena Cava Measurement is More Sensitive Than Vital Sign Abnormalities for Identifying Moderate and Severe Hemorrhage.

BACKGROUND: Ultrasound inferior vena cava (IVC) diameter has been shown to decrease in response to hemorrhage. IVC diameter cut points to identify moderate and severe blood loss have not been established. OBJECTIVES: This study sought to find ultrasound IVC diameter cut points to identify moderate and severe hemorrhage and assess the performance of these cut points vs. vital sign abnormalities. METHODS: This is a secondary analysis of data from a study that described changes in vital signs and sonographic measurements of the IVC during a lower body negative pressure model of hemorrhage. Using receiver operator curve analyses, optimal cut points for identifying moderate and severe hemorrhage were identified. The ability of these cut points to identify hemorrhage in patients with no vital sign abnormalities was then assessed. RESULTS: In both long- and short-axis views, maximum and minimum IVC diameters (IVCmax and IVCmin) were significantly lower than baseline in severe blood loss. The optimal cut point for IVCmax in both axes was found to be ≤ 0.8 cm. This cut point is able to distinguish between no blood loss vs. moderate blood loss, and no blood loss vs. severe blood loss. The optimal cut point for IVCmin was variable between axes and blood loss severity. IVC diameter cut points obtained were able to identify hemorrhage in patients with no vital sign abnormalities. CONCLUSION: An ultrasound IVCmax of ≤ 0.8 cm may be useful in identifying moderate and severe hemorrhage before vital sign abnormalities are evident.

The EMS Modified Early Warning Score (EMEWS): A Simple Count of Vital Signs as a Predictor of Out-of-Hospital Cardiac Arrests.

Objective: For patients at risk for out-of-hospital cardiac arrest (OHCA) after Emergency Medical Services (EMS) arrival, outcomes may be mitigated by identifying impending arrests and intervening before they occur. Tools such as the Modified Early Warning Score (MEWS) have been developed to determine the risk of arrest, but involve relatively complicated algorithms that can be impractical to compute in the prehospital environment. A simple count of abnormal vital signs, the "EMS Modified Early Warning Score" (EMEWS), may represent a more practical alternative. We sought to compare to the ability of MEWS and EMEWS to identify patients at risk for EMS-witnessed OHCA.Methods: We conducted a retrospect analysis of the 2018 ESO Data Collaborative database of EMS encounters. Patients without cardiac arrest before EMS arrival were categorized into those who did or did not have an EMS-witnessed arrest. MEWS was evaluated without its temperature component (MEWS-T). The performance of MEWS-T and EMEWS in predicting EMS witnessed arrest was evaluated by comparing receiver-operating characteristic curves.Results: Of 369,064 included encounters, 4,651 were EMS witnessed arrests. MEWS-T demonstrated an area under the curve (AUC) of 0.79 (95% CI: 0.79 - 0.80), with 86.8% sensitivity and 51.0% specificity for MEWS-T ≥ 3. EMEWS demonstrated an AUC of 0.74 (95% CI: 0.73 - 0.75), with 81.3% sensitivity and 53.9% specificity for EMEWS ≥ 2.Conclusions: EMEWS showed a similar ability to predict EMS-witnessed cardiac arrest compared to MEWS-T, despite being significantly simpler to compute. Further study is needed to evaluate whether the implementation of EMEWS can aid EMS clinicians in anticipating and preventing OHCA.

Efficacy of Inhaled Ciclesonide for Outpatient Treatment of Adolescents and Adults With Symptomatic COVID-19: A Randomized Clinical Trial.

Importance: Systemic corticosteroids are commonly used in treating severe COVID-19. However, the role of inhaled corticosteroids in the treatment of patients with mild to moderate disease is less clear. Objective: To determine the efficacy of the inhaled steroid ciclesonide in reducing the time to alleviation of all COVID-19-related symptoms among nonhospitalized participants with symptomatic COVID-19 infection. Design, Setting, and Participants: This phase 3, multicenter, double-blind, randomized clinical trial was conducted at 10 centers throughout the US and assessed the safety and efficacy of a ciclesonide metered-dose inhaler (MDI) for treating nonhospitalized participants with symptomatic COVID-19 infection who were screened from June 11, 2020, to November 3, 2020. Interventions: Participants were randomly assigned to receive ciclesonide MDI, 160 µg per actuation, for a total of 2 actuations twice a day (total daily dose, 640 µg) or placebo for 30 days. Main Outcomes and Measures: The primary end point was time to alleviation of all COVID-19-related symptoms (cough, dyspnea, chills, feeling feverish, repeated shaking with chills, muscle pain, headache, sore throat, and new loss of taste or smell) by day 30. Secondary end points included subsequent emergency department visits or hospital admissions for reasons attributable to COVID-19. Results: A total of 413 participants were screened and 400 (96.9%) were enrolled and randomized (197 [49.3%] in the ciclesonide arm and 203 [50.7%] in the placebo arm; mean [SD] age, 43.3 [16.9] years; 221 [55.3%] female; 2 [0.5%] Asian, 47 [11.8%] Black or African American, 3 [0.8%] Native Hawaiian or other Pacific Islander, 345 [86.3%] White, and 1 multiracial individuals [0.3%]; 172 Hispanic or Latino individuals [43.0%]). The median time to alleviation of all COVID-19-related symptoms was 19.0 days (95% CI, 14.0-21.0) in the ciclesonide arm and 19.0 days (95% CI, 16.0-23.0) in the placebo arm. There was no difference in resolution of all symptoms by day 30 (odds ratio, 1.28; 95% CI, 0.84-1.97). Participants who were treated with ciclesonide had fewer subsequent emergency department visits or hospital admissions for reasons related to COVID-19 (odds ratio, 0.18; 95% CI, 0.04-0.85). No participants died during the study. Conclusions and Relevance: The results of this randomized clinical trial demonstrated that ciclesonide did not achieve the primary efficacy end point of reduced time to alleviation of all COVID-19-related symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT04377711.

Eating and Physical Activity Patterns in Day and Night Shift EMS Clinicians.

Objective: EMS clinicians work in shifts to provide 24-hour care. Shift work is linked with metabolic disease and over 70% of EMS clinicians report having overweight or obesity. Inability to store food in their vehicles combined with limited overnight dining establishments, and unpredictable job demands leads to reliance on convenience and fast foods. The objective of this study was to describe the eating and physical activity patterns among EMS clinicians on days on and off shift.Methods: EMS clinicians throughout the United States participated in a study involving four 24-hour monitoring periods. Participants wore activity monitors to measure physical activity level and remote food photography was used to collect dietary data on two work days and two days off. Repeated measures analysis of variance was conducted to compare energy and macronutrient intake and activity levels in day and night workers on and off shift.Results: We analyzed data from 39 EMS clinicians (29.7 + 8.5yrs old). Controlling for sex, those working night shifts consumed more kilocalories (p=.037) and total fat (p=.043) compared to day shift workers. Night shift workers had fewer steps (p = 0.045), more sedentary time (p = 0.053), and less moderate activity (p = 0.037) during a shift compared to day workers.Conclusion: Among EMS clinicians, night shift is associated with greater energy intake, and decreased physical activity during shifts. This may contribute to positive energy balance and weight gain overtime, increasing risk for metabolic disease.

Variability in venous gas emboli following the same dive at 3,658 meters.

Exposure to a reduction in ambient pressure such as in high-altitude climbing, flying in aircrafts, and decompression from underwater diving results in circulating vascular gas bubbles (i.e., venous gas emboli [VGE]). Incidence and severity of VGE, in part, can objectively quantify decompression stress and risk of decompression sickness (DCS) which is typically mitigated by adherence to decompression schedules. However, dives conducted at altitude challenge recommendations for decompression schedules which are limited to exposures of 10,000 feet in the U.S. Navy Diving Manual (Rev. 7). Therefore, in an ancillary analysis within a larger study, we assessed the evolution of VGE for two hours post-dive using echocardiography following simulated altitude dives at 12,000 feet. Ten divers completed two dives to 66 fsw (equivalent to 110 fsw at sea level by the Cross correction method) for 30 minutes in a hyperbaric chamber. All dives were completed following a 60-minute exposure at 12,000 feet. Following the dive, the chamber was decompressed back to altitude for two hours. Echocardiograph measurements were performed every 20 minutes post-dive. Bubbles were counted and graded using the Germonpré and Eftedal and Brubakk method, respectively. No diver presented with symptoms of DCS following the dive or two hours post-dive at altitude. Despite inter- and intra-diver variability of VGE grade following the dives, the majority (11/20 dives) presented a peak VGE Grade 0, three VGE Grade 1, one VGE Grade 2, four VGE Grade 3, and one VGE Grade 4. Using the Cross correction method for a 66-fsw dive at 12,000 feet of altitude resulted in a relatively low decompression stress and no cases of DCS.

A Change from a Spinal Immobilization to a Spinal Motion Restriction Protocol was Not Associated with an Increase in Disabling Spinal Cord Injuries.

BACKGROUND: Over the past decade, Emergency Medical Service (EMS) systems decreased backboard use as they transition from spinal immobilization (SI) protocols to spinal motion restriction (SMR) protocols. Since this change, no study has examined its effect on the neurologic outcomes of patients with spine injuries. OBJECTIVES: The object of this study is to determine if a state-wide protocol change from an SI to an SMR protocol had an effect on the incidence of disabling spinal cord injuries. METHODS: This was a retrospective review of patients in a single Level I trauma center before and after a change in spinal injury protocols. A two-step review of the record was used to classify spinal cord injuries as disabling or not disabling. A binary logistic regression was used to determine the effects of protocol, gender, age, level of injury, and mechanism of injury (MOI) on the incidence of significant disability from a spinal cord injury. RESULTS: A total of 549 patients in the SI period and 623 patients in the SMR period were included in the analysis. In the logistic regression, the change from an SI protocol to an SMR protocol did not demonstrate a significant effect on the incidence of disabling spinal injuries (OR: 0.78; 95% CI, 0.44 - 1.36). CONCLUSION: This study did not demonstrate an increase in disabling spinal cord injuries after a shift from an SI protocol to an SMR protocol. This finding, in addition to existing literature, supports the introduction of SMR protocols and the decreased use of the backboard.