Nation-Wide Variation in Presence of Legislation or Protocols for EMS Care of Operational Canines.

BACKGROUND & AIMS: Deployment of law enforcement operational canines (OpK9s) risks injuries to the animals. This study's aim was to assess the current status of states' OpK9 (veterinary Emergency Medical Services [VEMS]) laws and care protocols within the United States. METHODS: Cross-sectional standardized review of state laws/regulations and OpK9 VEMS treatment protocols was undertaken. For each state and for the District of Columbia (DC), the presence of OpK9 legislation and/or care protocols was ascertained. Information was obtained through governmental records and from stakeholders (eg, state EMS medical directors and state veterinary boards).The main endpoints were proportions of states with OpK9 laws and/or treatment protocols. Proportions are reported with 95% confidence intervals (CIs). Fisher's exact test (P <.05) assessed whether presence of an OpK9 law in a given jurisdiction was associated with presence of an OpK9 care protocol, and whether there was geographic variation (based on United States Census Bureau regions) in presence of OpK9 laws or protocols. RESULTS: Of 51 jurisdictions, 20 (39.2%) had OpK9 legislation and 23 (45.1%) had state-wide protocols for EMS treatment of OpK9s. There was no association (P = .991) between presence of legislation and presence of protocols. There was no association (P = .144) between presence of legislation and region: Northeast 66.7% (95% CI, 29.9-92.5%), Midwest 50.0% (95% CI, 21.1-78.9%), South 29.4% (95% CI, 10.3-56.0%), and West 23.1% (95% CI, 5.0-53.8%). There was significant (P = .001) regional variation in presence of state-wide OpK9 treatment protocols: Northeast 100.0% (95% CI, 66.4-100.0%), Midwest 16.7% (95% CI, 2.1-48.4%), South 47.1% (95% CI, 23.0-72.2%), and West 30.8% (95% CI, 9.1-61.4%). CONCLUSION: There is substantial disparity with regard to presence of OpK9 legal and/or clinical guidance. National collaborative guidelines development is advisable to optimize and standardize care of OpK9s. Additional attention should be paid to educational and training programs to best utilize the limited available training budgets.

Building a functional national One Health platform: the case of Tanzania.

BACKGROUND: The USAID Preparedness and Response (P&R) project's publication on Multisectoral Coordination that Works identified five dimensions most critical to creating effective and sustainable One Health platforms: political commitment, institutional structure, management and coordination capacity, technical and financial resources, and joint planning and implementation. This case study describes Tanzania experience in using these dimensions to establish a functional One Health platform. The main objective of this case study was to document the process of institutionalizing the One Health approach in Tanzania. METHODS: An analysis of the process used to establish and institutionalize the MCM in Tanzania through addressing the five dimensions mentioned above was conducted between August 2018 and January 2019. Progress activity reports, annual reports and minutes of meetings and consultations regarding the establishment of the Tanzania national One Health platform were examined. Relevant One Health publications were studied as reference material. RESULTS: This case study illustrates the time and level of effort required of multiple partners to build a functional multi-sectoral coordinating mechanism (MCM). Key facilitating factors were identified and the importance of involving policy and decision makers at all stages of the process to facilitate policy decisions and the institutionalization process was underscored. The need for molding the implementation process using lessons learnt along the way -- "sailing the ship as it was being built" -- is demonstrated. CONCLUSIONS: Tanzania now has a functioning and institutionalized MCM with a sound institutional structure and capacity to prevent, detect early and respond to health events. The path to its establishment required the patient commitment of a core group of One Health champions and stakeholders along the way to examine carefully and iteratively how best to structure productive multisectoral coordination in the country. The five dimensions identified by the Preparedness and Response project may provide useful guidance to other countries working to establish functional MCM.

Perceived Barriers to Exercise in the First Trimester of Pregnancy.

Regular physical activity has been shown to improve pregnancy outcomes. We sought to identify barriers to exercise during the first trimester of pregnancy. Five hundred forty-nine pregnant women in their first trimester rated barriers to exercise on a scale of 1 (not a barrier) to 5 (a huge barrier) and recorded physical activity (minutes/week). Women were placed into one of three classifications, nonexercisers (zero exercise), infrequent exercisers (<150 minutes/week), or exercisers (≥150 minutes/week). The greatest barriers (mean) were nausea/fatigue (3.0) and lack of time (2.6). Exercisers reported significantly lower barrier levels. Nausea/fatigue was a greater barrier for nonexercisers compared to exercisers (3.6 vs 2.8, p < .001). Focusing education and interventions on these barriers may help pregnant women achieve healthy exercise levels.

Congratulations, You're Pregnant! Now About Your Shifts . . . : The State of Maternity Leave Attitudes and Culture in EM.

INTRODUCTION: Increasing attention has been focused on parental leave, but little is known about early leave and parental experiences for male and female attending physicians. Our goal was to describe and quantify the parental leave experiences of a nationally representative sample of emergency physicians (EP). METHODS: We conducted a web-based survey, distributed via emergency medicine professional organizations, discussion boards, and listservs, to address study objectives. RESULTS: We analyzed data from 464 respondents; 56% were women. Most experienced childbirth while employed as an EP. Fifty-three percent of women and 60% of men reported working in a setting with a formal maternity leave policy; however, 36% of women and 18% of men reported dissatisfaction with these policies. Most reported that other group members cover maternity-related shift vacancies; a minority reported that pregnant partners work extra shifts prior to leave. Leave duration and compensation varied widely, ranging from no compensated leave (18%) to 12 or more weeks at 100% salary (7%). Supportive attitudes were reported during pregnancy (53%) and, to a lesser degree (43%), during leave. Policy improvement suggestions included the development of clear, formal policies; improving leave duration and compensation; adding paternity and adoption leave; providing support for physicians working extra to cover colleagues' leave; and addressing breastfeeding issues. CONCLUSION: In this national sample of EPs, maternity leave policies varied widely. The duration and compensation during leave also had significant variation. Participants suggested formalizing policies, increasing leave duration and compensation, adding paternity leave, and changing the coverage for vacancies to relieve burden on physician colleagues.

New predictors of complications in carotid body tumor resection.

OBJECTIVE: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. METHODS: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. RESULTS: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92). CONCLUSIONS: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

Improving mortality trends for hospitalization of aortic dissection in the National Inpatient Sample.

OBJECTIVE: Population-based assessment of aortic dissection (AD) hospitalizations in the general United States population is limited. We assessed the current trends in AD admissions and in-hospital mortality for surgical and medical AD treatment. METHODS: Patients admitted for primary diagnosis of AD were identified from the National Inpatient Sample database (2003-2012). Patients were identified by International Classification of Diseases-Ninth Revision diagnosis codes and categorized by treatment type: type A open surgical repair (TASR), type B open surgical repair (TBSR), thoracic endovascular aortic repair (TEVAR), and medical management (MM). Our primary outcomes were to evaluate admission trends and in-hospital mortality of AD. Secondary outcomes included postoperative complications. We used weighted national estimates of admissions to assess trends over time using linear regression. We also identified factors associated with mortality via a hierarchical multivariable logistic regression model. RESULTS: We identified 15,641 patients (60.7% male; mean age, 63.5 years) admitted with a primary diagnosis of AD between 2003 and 2012. Intervention types included TASR in 3253 (20.8%), TBSR in 3007 (19.2%), TEVAR in 1417 (9.1%), and MM in 7964 (50.9%). Overall weighted admissions for AD increased significantly, from 6980 in 2003 to 8875 in 2012 (P < .01, test of trend), with increases in admission for TASR, from 1143 in 2003 to 2130 in 2012 (P < .01, test of trend), and TEVAR from 96 in 2005 to 1130 in 2012 (P < .01, test of trend). TBSR and MM admissions were stable, with TBSR admissions at 1519 in 2003 and 1540 in 2012 (P = .9, test of trend) and MM admissions at 4319 in 2003 and 4075 in 2012 (P = .8, test of trend). During the same interval, overall in-hospital mortality rates for AD decreased from 18.1% to 13.0% (P < .01, test of trend). When stratified by intervention type, mortality rates decreased for TASR, from 20.5% to 14.8% (P < .01, test of trend), for TBSR, from 18.0% to 14.3% (P = .03, test of trend), and for MM, from 17.5% to 13.9% (P < .01, test of trend). Mortality rates for TEVAR were stable, with an average mortality of 7.9% (P = .8, test of trend) during the study period. Factors associated with increased mortality included older age, Caucasian race, nonelective admission, pre-existing peripheral vascular disease, and acute postoperative complication of myocardial infarction, stroke, or kidney failure. Admissions at a center with high surgical volume were associated with a decreased mortality for TBSR admissions only (odds ratio, 0.55; 95% confidence interval, 0.4-0.7). CONCLUSIONS: Overall and surgical admission rates for AD appear to be increasing, and in-hospital mortality rates are decreasing. TEVAR mortality remains mostly unchanged, however, suggesting targets for further improvement in mortality for AD treatment. Decreased mortality for TBSR at centers with a high surgical volume may suggest a need for regionalization of AD care.

The effect of medical students and residents on measures of efficiency and timeliness in an academic medical center emergency department.

PURPOSE: Research regarding the effect of trainees on emergency department (ED) operations has demonstrated mixed results. In this study, the authors evaluated the effect of trainees on ED length of stay (LOS), door to medical provider (DTMP) time, and door to disposition decision (DTDD) time while accounting for covariates known to influence ED efficiency and timeliness. METHOD: The authors used retrospective cohort data for ED visits to Maine Medical Center's mixed adult and pediatric ED for the calendar years 2005 through 2009. Each visit was coded indicating the type of provider conducting the visit (student-attending, resident-attending, midlevel provider, or attending group). Ordinary least squares regression analyses were performed to examine the relationships between provider groups and ED LOS, DTMP time, and DTDD time. Hierarchical regression models were constructed to control for the confounding effects of triage acuity, time of year, laboratory testing, radiographic testing, and patient characteristics. RESULTS: The analysis of 246,142 visits found significant intergroup differences across provider groups for each outcome (P < .001). Multiple regression modeling revealed that treatment by trainees was a significant predictor of longer LOS (medical students and residents), shorter DTMP time (residents), and longer DTDD time (medical students and residents), after controlling for covariates. CONCLUSIONS: Laboratory and radiographic testing accounted for a much larger proportion of variation in outcomes than did trainees. The small increases in LOS and DTDD time are balanced by the decrease in DTMP time and the intangible benefits of educating trainees.

The success and safety of endovenous ablation in patients with previous superficial venous thrombosis: a retrospective case-control study.

OBJECTIVES: Retrospective case-control study to determine the failure and endovenous heat-induced thrombosis (EHIT) rates of endovenous ablation (EVA) in patients with a history of superficial venous thrombosis (SVT). METHODS: Study and control groups each consisted of 73 patients with or without the history of SVT, who underwent EVA between June 2010 and July 2012. All patients were followed with venous duplex ultrasound. Procedural failure and EHIT rates were considered primary outcomes. RESULTS: There was no difference in EHIT or failure rates between study and control groups (P = 1.00). There was no difference in EHIT or failure rates between patients with and without the history of venous thromboembolism (VTE), with and without the history of VTE and/or SVT, with and without the history of thrombophilia, and on and off anticoagulation for either group or the combined study population. For the combined study population, failure rate was higher in patients with a history of VTE. CONCLUSIONS: Although EVA seems to be safe and effective in patients with a history of SVT, vein access in this patient group might require multiple attempts.

Chronic venous ulcer: minimally invasive treatment of superficial axial and perforator vein reflux speeds healing and reduces recurrence.

BACKGROUND: Chronic venous ulcer (CVU) is common and is responsible for significant health care expenditures worldwide. Compression is the mainstay of treatment, but long-term compliance with this therapy is often inconsistent, particularly in the elderly and infirm. Surgical ablation of axial and perforator reflux has been used as an adjunct to compression to reduce recurrence rates and assist healing. These surgical techniques are being replaced by minimally invasive procedures, such as thermal ablation and foam sclerotherapy, in the treatment of uncomplicated venous disease. The role for these techniques in the treatment of CVU is just beginning to be defined. METHODS: Eighty-six patients with CVU with 95 active ulcers (Clinical, Etiology, Anatomy, Physiology-CEAP clinical class 6) presenting to a multispecialty wound clinic were retrospectively reviewed and analyzed by leg. All patients underwent duplex scanning for venous insufficiency. Ulcer dimensions at each visit were recorded and used to calculate healing rates. Presence or absence of ulcer recurrence at 1-year follow-up was recorded. Ulcers treated with compression alone ("compression group") were compared with those treated with compression and minimally invasive interventions, such as thermal ablation of superficial axial reflux and ultrasound-guided foam sclerotherapy (UGFS) of incompetent perforating veins and varicosities ("intervention group"). RESULTS: The average age in the intervention and compression groups was 67 and 71 years, respectively (P = not significant [NS]). Body mass index was 32.4 ± 9.5 and 33.6 ± 11.8 kg/m(2), in the compression and intervention groups, respectively (P = not significant [NS]). Ulcers were recurrent in 42% of the intervention group and 26% of the compression group (P = NS). In the intervention group, 33% had radiofrequency ablation of axial reflux, 31% had UGFS of perforators, and 29% had both treatments. The only complication of intervention was a single case of cellulitis requiring hospitalization. Compared with the compression group, the ulcers in the intervention group healed faster (9.7% vs. 4.2% per week; P = 0.001) and showed fewer recurrences at 1-year follow-up (27.1% vs. 48.9 %; P < 0.015). Multivariate analysis showed use of intervention was the strongest determinant of healing with a coefficient of variation of 7.432, SE 2.406, P = 0.003. Analysis of just the intervention group before and after intervention using matched pairs showed acceleration of healing after intervention from ranging from a median of 1.2% (interquartile range [IQR], 14.3) to 9.7% (IQR, 11.3) per week (P ≤ 0.001). CONCLUSIONS: Minimally invasive ablation of superficial axial and perforator vein reflux in patients with active CVU is safe and leads to faster healing and decreased ulcer recurrence when combined with compression alone in the treatment of CVU.