A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment.

Pre-oxygenation before tracheal intubation aims to increase safe apnoea duration by denitrogenation of the functional residual capacity of the lungs, and increasing oxygen stores at the onset of apnoea. Pre-oxygenation options in the pre-hospital environment are limited due to oxygen availability and equipment portability. The aim of this study was to evaluate the effectiveness of strategies available in this setting. This was a prospective, randomised, crossover study of 30 healthy volunteers who underwent 3-min periods of pre-oxygenation by tidal volume breathing with a non-rebreather mask, a bag-valve-mask and a portable ventilator. The primary outcome measure was fractional expired oxygen concentration of the first exhaled breath after each technique. The secondary outcome measure was ease of breathing, assessed using a visual analogue scale. The mean (95%CI) fractional expired oxygen concentrations achieved with the non-rebreather mask were 64 (60-68)%, bag-valve-mask 89 (86-92)% and portable ventilator 95 (94-96)%. Pre-oxygenation efficacy with the non-rebreather mask was significantly worse than with either the bag-valve-mask (p < 0.001) or ventilator (p < 0.001). No significant difference in ease of breathing was identified between the bag-valve-mask and ventilator, but both were perceived as being significantly more difficult to breathe through than the non-rebreather mask. We conclude that, in healthy volunteers, the effectiveness of pre-oxygenation by bag-valve-mask and portable ventilator was superior to pre-oxygenation with a non-rebreather mask, although the non-rebreather mask was easier to breathe through than the other pre-oxygenation devices.

Failure to rescue the elderly: a superior quality metric for trauma centers.

BACKGROUND: Trauma centers require reliable metrics to better compare the quality of care delivered. We compared mortality after a reported complication, termed failure to rescue (FTR), and FTR in the elderly (age >65 years) (FTRE) to determine which is a superior metric to assess quality of care delivered by trauma centers. METHODS: This was a retrospective review of the National Trauma Databank (NTDB) research data sets 2010 and 2011. Patients ≥16 years admitted to centers reporting ≥80% of AIS and/or ≥ 20% of comorbidities with > 200 subjects in the NTDB were selected. Centers were classified based on the rate of FTR and FTRE (<5 vs. 5-14 vs. ≥15%). The primary outcome was adjusted mortality for each group of trauma centers based on FTR and FTRE classifications. RESULTS: The overall mean ± SD FTR rate was 7.2 ± 5.2% and FTRE was 10.4 ± 7.9%. The adjusted odds ratio (AOR) for mortality was not different when centers with FTR <5% were compared to those with FTR of 5-14 or ≥15%. In contrast, a stepwise increase in FTRE predicted a significantly higher mortality when centers with FTRE 5% were compared to those with 5-14% (AOR: 1.05, p = 0.031) and ≥15% (AOR: 1.13, p < 0.001). Similarly, stepwise increase in FTRE predicted higher adjusted mortality for severely and critically injured patients, whereas FTR did not. CONCLUSIONS AND RELEVANCE: Higher FTRE predicts increased adjusted mortality better than FTR after trauma and should, therefore, be considered an important metric when comparing quality care delivered by trauma centers.

Blunt Pharyngoesophageal Injuries: Current Management Strategies.

BACKGROUND:: Blunt pharyngoesophageal injuries pose a management challenge to the trauma surgeon. The purpose of this study was to explore whether these injuries can be managed expectantly without neck exploration. METHODS:: The National Trauma Databank datasets 2007-2011 were reviewed for blunt trauma patients who sustained a pharyngeal injury, including an injury to the cervical esophagus. Patients who survived over 24 h and were not transferred from other institutions were divided into two groups based on whether a neck exploration was performed. Outcomes included mortality and hospital stay. RESULTS:: A total of 545 (0.02%) patients were identified. The median age was 18 years and 69% were male. Facial fractures were found in 16%, while 13% had an associated traumatic brain injury. Of the 284 patients who survived over 24 h and were not transferred from another institution, 65 (23%) underwent a neck exploration. The injury burden was significantly higher in this group as indicated by the higher median Injury Severity Score (17 vs 10, p < 0.01) and need for intensive care unit admission (75% vs 31%, p < 0.01). The overall mortality was 2%: 3.1% for neck explorations versus 1.6% for conservative management (adjusted p = 0.54). Neck exploration patients were more likely to remain longer in the hospital (median 13 vs 10 days, adjusted p = 0.03). CONCLUSION:: Pharyngoesophageal injuries are rare following blunt trauma. Only a quarter require a neck exploration and this decision appears to be dictated by the injury burden. Selective non-operative management based on clinical status seems to be feasible and is not associated with increased mortality.

Overview and quality assurance for the National Health and Nutrition Examination Survey (NHANES) oral health component, 1999-2002.

The Oral Health Component of the 1999-2002 National Health and Nutrition Examination Survey (NHANES) is a collaborative effort between the National Institute of Dental and Craniofacial Research (NIDCR), the National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health (NCCDPHP/DOH), and the National Center for Health Statistics (NCHS). The current NHANES is designed as a continuous survey with data released on a 2-year cycle to represent the civilian, non-institutionalized population of the US. Oral health data are currently available for 8082 and 9010 persons aged > or =2 years who participated in the 1999-2000 and 2001-2002 NHANES, respectively. This article provides background information on previous national examination surveys with oral health content. It also provides general analytical considerations, oral health content information, and evaluations of data quality in terms of examiner reliability statistics (percent agreements, kappa, and correlation coefficients) for the 1999-2002 NHANES Oral Health Component.

Insulin-dependent diabetes and serious trauma.

PURPOSE: Trauma patients with diabetes mellitus (DM) represent a unique population as the acute injury and the underlying disease may both cause hyperglycemia that leads to poor outcomes. We investigated how insulin-dependent DM (IDDM) and noninsulin-dependent DM (NIDDM) impact mortality after serious trauma without brain injury. METHODS: The National Trauma Data Bank (NTDB) version 7.0 was queried for all patients with moderate to severe traumatic injury [injury severity score (ISS) >9]. Patients were excluded if missing data, age <10 years, severe brain injury [head abbreviated injury scale (AIS) >3], dead on arrival or any AIS = 6. Logistic regression modeled the association between DM and mortality as well as IDDM, NIDDM and mortality. RESULTS: Overall 166,103 trauma patients without brain injury were analyzed. Mortality was 7.6 and 4.4 % in patients with and without DM, respectively (p < 0.01). Mortality was 9.9 % for patients with IDDM and 6.7 % for NIDDM (p < 0.01). The increased mortality associated with DM was only significantly higher for DM patients in their forties (5.6 vs. 3.3 %, p < 0.01). Regression analyses demonstrated that DM (AOR 1.14, p = 0.04) and IDDM (AOR 1.46, p < 0.01) were predictors of mortality compared to no DM, but NIDDM was not (AOR 1.02, p = 0.83). CONCLUSIONS: While DM was a predictor for higher mortality after serious trauma, this increase was only observed in IDDM and not NIDDM. Our findings suggest IDDM patients who present after serious trauma are unique and attention to their hyperglycemia and related insulin therapy may play a critical role in recovery.

Inter- and intralaboratory variation of in vitro diffusion cell measurements: an international multicenter study using quasi-standardized methods and materials.

In vitro measurements of skin absorption are an increasingly important aspect of regulatory studies, product support claims, and formulation screening. However, such measurements are significantly affected by skin variability. The purpose of this study was to determine inter- and intralaboratory variation in diffusion cell measurements caused by factors other than skin. This was attained through the use of an artificial (silicone rubber) rate-limiting membrane and the provision of materials including a standard penetrant, methyl paraben (MP), and a minimally prescriptive protocol to each of the 18 participating laboratories. "Standardized" calculations of MP flux were determined from the data submitted by each laboratory by applying a predefined mathematical model. This was deemed necessary to eliminate any interlaboratory variation caused by different methods of flux calculations. Average fluxes of MP calculated and reported by each laboratory (60 +/- 27 microg cm(-2) h(-1), n = 25, range 27-101) were in agreement with the standardized calculations of MP flux (60 +/- 21 microg cm(-2) h(-1), range 19-120). The coefficient of variation between laboratories was approximately 35% and was manifest as a fourfold difference between the lowest and highest average flux values and a sixfold difference between the lowest and highest individual flux values. Intralaboratory variation was lower, averaging 10% for five individuals using the same equipment within a single laboratory. Further studies should be performed to clarify the exact components responsible for nonskin-related variability in diffusion cell measurements. It is clear that further developments of in vitro methodologies for measuring skin absorption are required.

Electrocardiographic changes induced by insertion of an intrauterine device and other uterine manipulations.

A prospective study was carried out in normal women in order to investigate the effects of the following procedures on the electrocardiogram and blood pressure: (1) insertion of an intrauterine device (IUD)--the Lippes loop, Tcu-200, uterine progesterone system or Cu-7; (2) endometrial biopsy; and (3) uterine flushing. In groups in which a large IUD like the Lippes loop and/or a stiff IUD like the Cu-7 was inserted, the frequency of bradycardia was significantly higher than in any other groups. The severity of the bradycardia was similar in all of the groups and the frequency of this alteration was also similar among the nulliparous women or in those who complained of pain during the instrumentation, irrespective of the type of IUD inserted or the procedure carried out. No alarming modifications of blood pressure were observed and maintaining the patients in the recumbent position was sufficient to alleviate symptoms. In severe cases use of the Trendelenburg position should be enough to correct any alterations.

PIP: The effects of the insertion of an intrauterine device (IUD), endometrial biopsy, and uterine flushing on electrocardiograph patterns were evaluated in a prospective study of 260 women. The frequency of bradycardia was significantly higher during insertion of a Lippes loop IUD (p less than .001) or Cu-7 IUD (p less than .02) than with other procedures. The frequency of tachycardia was greater than that of bradycardia during the insertion of an uterine progesteronr system and TCu-200 IUD. However, the severity of bradycardia was similar in all groups. The frequency of bradycardia was similar among nulliparous women, and was correlated with reports of pain during any of the procedures. Changes in blood pressure were not severe, and symptoms were relieved by maintaining patients in a recumbent position. The Trendelenburg position is recommended in severe cases.

Traumatic aneurysm of the internal carotid artery: a late finding presenting as a mass in the sphenoid sinus.

We describe a case of a traumatic aneurysm of the cavernous portion of the internal carotid artery in a patient who had had craniofacial trauma 12 years before. MR and CT revealed a mass in the sphenoid sinus thought to be unrelated to the patient's symptoms. Carotid angiography gave the correct diagnosis.

Shedding and colonization of Campylobacter jejuni in broilers from day-of-hatch to slaughter age.

Poultry are considered to be the primary reservoirs of Campylobacter jejuni for humans. Campylobacter jejuni can colonize the poultry intestinal tract and its subsequent shedding can result in environmental contamination, resulting in an increased risk of infection for the rest of the flock. At present, there is no information on the daily shedding pattern of C. jejuni in broiler chickens. Thus, the purpose of this study was to determine the daily shedding pattern of C. jejuni in broiler chickens and to correlate intestinal colonization with fecal shedding, which would aid in the development of intervention strategies such as the use of competitive exclusion products at 1 day of age. Twenty-four broiler chicks were orally inoculated with 1.6 x 10(7) colony-forming units of C. jejuni, and the reisolation rate of the organism was determined daily from day 1 to day 43. Fifty percent and 70% of the chicks were shedding C. jejuni within 24 and 48 hr postinoculation, respectively. The group collectively reached a peak excretion on days 13-19 postinoculation. There was a steady decline in fecal shedding after the third week. By market age, on day 43, only 37.5% (9/24) of the birds were shedding C. jejuni in their feces. Throughout the sampling period from days 1 to 43, a cyclic pattern of shedding was observed in individual birds. Individual birds excreted C. jejuni on an average of 25 out of 43 days. The C. jejuni isolate failed to colonize 16.6% (4/24) of the birds. A small percentage of the birds, 12.5% (3/24), were observed to be chronic shedders. Enumeration of C. jejuni in the crop, jejunum, and cecum on day 43 revealed that the cecum was the major colonization site, and 15 out of the 24 birds carried C. jejuni in their intestinal tract.

Prevalence of Salmonella, Campylobacter, and Escherichia coli on ostrich carcasses and the susceptibility of ostrich-origin E. coli isolates to various antibiotics.

There has been limited research on the prevalence of foodborne pathogens such as Escherichia coli O157:H7, Salmonella, and Campylobacter on ostrich carcasses. Likewise, few studies have been done in ostriches to determine the antimicrobial susceptibilities of common bacteria, like E. coli. In this study, ostrich carcasses were sampled from eight slaughterhouses in Ohio and one in Indiana. Although results demonstrated no E. coli O157:H7 from the carcasses sampled, 91% (116/128) of the dressed carcasses sampled had E. coli present. One carcass sample (1/152) was positive for Salmonella. Campylobacter were detected in 10% (19/191) of the carcasses. Antimicrobial susceptibility testing on 93 carcass E. coli isolates showed resistance to erythromycin (99%), neomycin (65%), netilmicin (2%), oxytetracycline (22%), streptomycin (2%), and trimethoprim (3%). All isolates were resistant to bacitracin, lincomycin, penicillin, and vancomycin. For the large intestinal sampling, 149 of the 217 (69%) samples had E. coli present. Fifty of these 149 samples had E. coli levels ranging from 10(2) to 10(5) colony-forming units/g feces. Campylobacter were isolated from 6 of 201 (3%) samples. No Salmonella colony was detected. Antimicrobial susceptibility testing on 131 intestinal E. coli isolates showed resistance to erythromycin (98%), neomycin (66%), netilmicin (34%), oxytetracycline (34%), streptomycin (40%), and trimethoprim (13%). All isolates were resistant to bacitracin, lincomycin, penicillin, and vancomycin.

Serologic survey of slaughter-age ostriches (Struthio camelus) for antibodies to selected avian pathogens.

Serum samples from 163 slaughter-age ostriches (Struthio camelus) in Ohio and Indiana were tested for antibodies to avian influenza virus (AIV), Newcastle disease virus (NDV), paramyxovirus (PMV) 2, PMV3, PMV7, infectious bursal disease virus (IBDV), Bordetella avium, Mycoplasma synoviae, Mycoplasma gallisepticum, Ornithobacterium rhinotracheale, Salmonella pullorum, Salmonella gallinarum, and Salmonella typhimurium. One ostrich had antibodies to AIV H5N9, 57% of the ostriches had antibodies to NDV, four ostriches had antibodies to both NDV and PMV2, and one ostrich had antibodies to NDV, PMV2, PMV3, and PMV7. None of the ostriches had antibodies to IBDV, B. avium, M. synoviae, M. gallisepticum, O. rhinotracheale, S. pullorum, S. gallinarum, and S. typhimurium. This is the first report of antibodies to avian influenza and PMV7 in ostriches in the United States.

Survey of pathogens and blood parasites in free-living passerines.

To determine the disease prevalence of free-living passerines, 1709 passerines were sampled from 38 different field sites in Ohio. Choanal and cloacal swabs were collected from each bird and cultured for the presence of Pasteurella multocida, Salmonella spp., and Escherichia coli by standard microbiologic techniques. In addition, the serum from each bird was analyzed for the presence of antibodies to Mycoplasma gallisepticum, Mycoplasma synoviae, Newcastle disease virus, and avian influenza virus. A blood smear was also made to examine for the presence of blood parasites. Results indicated that the isolation of E. coli varied with bird species, with the European starling having a higher (21.4%) isolation of E. coli. Salmonella spp. were also isolated from these free-living passerines. Pasteurella multocida was not isolated from any of the sampled passerines. These birds did not have antibodies to M. gallisepticum, M. synoviae, Newcastle disease virus, or avian influenza virus. Blood parasites were not detected in any of the birds sampled.

Female sterilization using the tubal ring.

The surgical and early postoperative complications were evaluated in a study of 221 laparoscopies and 29 minilaparotomies in which tubal occlusions were performed with the application of tubal rings. For either procedure, complications were infrequent. None of the procedures had to be completed by another technique of tubal occlusion, and none of the patients required an extended hospitalization for the treatment of a complication. Among the 79 patients who have been followed up for more than 6 months, no pregnancies have been reported. The tubal ring technique appears to be safe and effective when used with either laparoscopy of minilaparotomy.

Faculty retention in dental hygiene programs.

This study assesses the extent to which faculty turnover in dental hygiene programs is related to the type of educational institution. A questionnaire was mailed to 201 dental hygiene program directors; 17 5 responded (87 percent). Nearly 47 per-cent of the directors associated with programs in state colleges and universities indicated they had experienced some degree of difficulty retaining faculty in the past five years; less than 18 percent of those in community colleges and technical schools experienced similar problems. Faculty attrition due to personal reasons and job and salary dissatisfaction occurred to a slightly greater extent in state educational institutions than in community colleges and technical schools. Achieving tenure was perceived as a problem primarily by directors of programs in state colleges and universities. Although inadequate salary was a direct cause of attrition in some cases, the degree to which it influenced personal reasons for leaving was not determined.

Maintenance of an adequate dental hygiene education system.

Decreases in faculty size and declining enrollments in dental hygiene programs are, in part, reflections of the economic difficulties faced by educational institutions with which the programs are affiliated. Administrative decisions about the future of dental hygiene programs are often based on inadequate information about employment trends and about the importance of the dental hygienist in dental practices. Although the relationship between demand for dental care and the availability of personnel to meet that demand is now unclear, studies indicate that demand for dental hygiene services will remain high in the 1980s. The impact of dental hygienists on dental health care delivery in any given region must be studied carefully when decisions are made about dental hygiene programs, because it is very expensive to replace discontinued programs or those disabled by large budget cuts.

Increasing intent to donate in Hispanic American high school students: results of a prospective observational study.

BACKGROUND: High school students are an important target audience for organ donation education. A novel educational intervention focused on Hispanic American (HA) high school students might improve organ donation rates. METHODS: A prospective observational study was conducted in five Los Angeles High Schools with a high percentage of HA students. A "culturally sensitive" educational program was administered to students in grades 9 to 12. Preintervention surveys that assessed awareness, knowledge, perception, and beliefs regarding donation as well as the intent to become an organ donor were compared to postintervention surveys. RESULTS: A total of 10,146 high school students participated in the study. After exclusions, 4876 preintervention and 3182 postintervention surveys were analyzed. A significant increase in the overall knowledge, awareness, and beliefs regarding donation was observed after the intervention, as evidenced by a significant increase in the percentage of correct answers on the survey (41% pre- versus 44% postintervention, P < .0001). When specifically examining HA students, there was a significant increase in the intent to donate organs (adjusted odds ratio 1.21, 95% confidence interval: 1.09, 1.34, P = .0003). CONCLUSION: This is the first study to demonstrate a significant increase in the intent to donate among HA high school students following an educational intervention.