Medevac Utilization and Patient Characteristics in Rural Alaska 2010 to 2018.

OBJECTIVE: Little is known about medevac utilization in remote, rural Alaska where there is no road access and communities are reliant on medevacs for emergency care. With high financial costs and risks to flight crews, there is an urgent need to understand medevac utilization in rural Alaska. This article aimed to describe medevac utilization and patient characteristics over 9 years in the remote, air transport dependent in Alaska. METHODS: Deidentified data (2010-2018) were obtained for all medevacs originating within the Yukon-Kuskokwim Delta. Descriptive statistics were calculated, and chi-square tests of independence were conducted to identify differences. RESULTS: Four thousand nine hundred ninety-one medevacs were performed, averaging 555 (standard deviation = 67.7) per year. Medevacs for respiratory complaints were predominant for children, whereas trauma predominated for adults 18 to 40 years old. Traumatic injury was more common in males than females aged < 65 years but was more common in females than males aged ≥ 65 years. Significant variability occurred in medevacs based on the community and the hour of the day. CONCLUSION: Medevacs are a critical part of health care in rural, remote Alaska but appear subject to clinical and nonclinical determinants. These baseline data provide a foundation for future studies aiming to increase medevac safety and provide decision-making support.

Evidence for synergistic effects of PRNP and ATP7B mutations in severe neuropsychiatric deterioration.

BACKGROUND: Wilson's disease (WD), a rare cause of neuropsychiatric deterioration, is associated with mutations in the ATP7B gene. Prion diseases are also rare causes of neuropsychiatric deterioration that can occur sporadically without an identifiable cause, or can be attributed to mutations in the PRNP gene. CASE PRESENTATION: Here we describe a biological "experiment of nature" in which a patient presented with severe neuropsychiatric decline and strong biochemical evidence of WD. Genetic analysis revealed that he was a compound heterozygote for two ATP7B sequence variants (c.2165dupT, p.Arg723Glufs*32; and c.4039G > A, p.Gly1347Ser), the first having been reported once previously, and the second being novel. In addition, the patient was heterozygous for a PRNP variant, c.160G > A, p.Gly54Ser, that has been reported in a neuropsychiatric patient only once previously in association with a similarly severe clinical course of neuropsychiatric disease and early age of onset, but no accompanying information on ATP7B genotype. Of particular interest was the observation that the patient's older sister, who carried the same ATP7B genotype and laboratory evidence for biochemical WD but was clinically asymptomatic, lacked the PRNP variant allele. CONCLUSIONS: We propose that synergism may occur between at least some allelic variants of ATP7B and PRNP, possibly exerted through effects on cellular copper metabolism.

Excellence and evidence in staffing: a data-driven model for excellence in staffing (2nd edition).

The Patient Protection and Affordable Care Act (PPACA, 2010) and the Institute of Medicine's (IOM, 2011) Future of Nursing report have prompted changes in the U.S. health care system. This has also stimulated a new direction of thinking for the profession of nursing. New payment and priority structures, where value is placed ahead of volume in care, will start to define our health system in new and unknown ways for years. One thing we all know for sure: we cannot afford the same inefficient models and systems of care of yesterday any longer. The Data-Driven Model for Excellence in Staffing was created as the organizing framework to lead the development of best practices for nurse staffing across the continuum through research and innovation. Regardless of the setting, nurses must integrate multiple concepts with the value of professional nursing to create new care and staffing models. Traditional models demonstrate that nurses are a commodity. If the profession is to make any significant changes in nurse staffing, it is through the articulation of the value of our professional practice within the overall health care environment. This position paper is organized around the concepts from the Data-Driven Model for Excellence in Staffing. The main concepts are: Core Concept 1: Users and Patients of Health Care, Core Concept 2: Providers of Health Care, Core Concept 3: Environment of Care, Core Concept 4: Delivery of Care, Core Concept 5: Quality, Safety, and Outcomes of Care. This position paper provides a comprehensive view of those concepts and components, why those concepts and components are important in this new era of nurse staffing, and a 3-year challenge that will push the nursing profession forward in all settings across the care continuum. There are decades of research supporting various changes to nurse staffing. Yet little has been done to move that research into practice and operations. While the primary goal of this position paper is to generate research and innovative thinking about nurse staffing across all health care settings, a second goal is to stimulate additional publications. This includes a goal of at least 20 articles in Nursing Economic$ on best practices in staffing and care models from across the continuum over the next 3 years.

The safety and efficacy of Pain Checker socks in the treatment of mild-to-moderate foot pain: a clinical trial.

BACKGROUND: Heel pain, bunion pain, and other forms of foot pain syndromes are one of the more common reasons a patient visits a podiatrist. Numerous methods are currently available to attempt to achieve pain relief, including pharmaceuticals, magnets, heat, and electrical stimulation. A textile company developed Pain Checker socks (Pain Checker Health Wear, Cresskill, New Jersey), which contains a material that may counter the circuit of pain and oppose the effect, thereby stopping the conduction of pain. METHODS: The purpose of this placebo-controlled, double-blind clinical trial was to evaluate the safety and efficacy of Pain Checker socks in the treatment of mild-to-moderate foot pain. Fifty patients were enrolled, half on active and half on placebo socks. The subjects were evaluated at baseline, 2, 4, and 6 weeks of treatment. RESULTS: There was no statistically significant difference in disability, pain, or activity scales between treatment groups, although only 5% of the treatment group received no pain relief on visual analog scale during the trial, while 38% of the placebo group received no pain relief. CONCLUSION: Although there was no difference in pain relief, the Pain Checker socks were found to be safe and scored high in patient satisfaction. The unique fiber content and construction of the socks may have contributed to the placebo analgesia.

Alcohol Misuse Link to POEMS Syndrome in a Patient.

Previously called Crow-Fukase syndrome, POEMS syndrome is characterized by poly-neuropathy, osteo-sclerotic myeloma, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes. Extremely elevated levels of serum vascular endothelial growth factor (VEGF) are characteristic of the syndrome. Chronic hepatitis B (HBV) and C (HCV) infections can also be present in POEMS. The pathogenesis of the syndrome is not well understood. The link between chronic alcohol consumption and this malignant condition has not been reported until now. In addition, no previous study has evaluated the influence of cytokine and chemokines or viruses in the severity and evolution of POEMS. OBJECTIVES: (1) to describe a heavy-alcohol user, who was diagnosed with POEMS; (2) to demonstrate the utility of quantitative measurement of serum levels of VEGF in the diagnosis of POEMS and the monitoring of therapeutic interventions; (3) to demonstrate that overproduction of pro-inflammatory cytokines is a characteristic of POEMS. METHODS: We describe a case of a POEMS patient presenting HCV and who is a heavy drinker; we compare the serum levels of cytokines and chemokines between the POEMS patient with 80 patients with HCV, 12 healthy controls, and 80 individuals with alcoholic liver disease (ALD). We quantified (ELISA pg/mL) the levels of VEGF, Interferon gamma (IFN-γ), Tumor Necrosis Factor alpha (TNF-α), Regulated-upon-Activation Normal-T-cell-Expressed and presumably-Secreted (RANTES), and Nuclear Factor kappa-B (NFκB). RESULTS: In POEMS patients, VEGF levels were elevated versus control or other diseases, TNFα levels were higher versus control, but lower when compared with HCV or ALD patients. VEGF levels in POEMS patients decreased with therapeutic intervention. CONCLUSIONS: Chronic alcohol misuse can be a strong risk factor to rare malignancies such as POEMS syndrome. Extreme elevation of VEGF levels is diagnostic for POEMS syndrome, and should be followed to assess response to therapy. In addition, other comorbidities should be considered individually to ensure personalized therapeutic intervention.

Breast cancer screening in Rockland County, New York: a survey of attitudes and behaviors.

OBJECTIVES: Higher-than-average breast cancer incidence and mortality rates in Rockland County (NY) may be explained by higher screening rates, but screening frequency has not been measured at the county level. This study was conducted to determine adherence to breast cancer screening guidelines in Rockland, and whether adherence differs by ethnicity, age, educational level, insurance status, and race. METHODS: A telephone survey of screening behaviors and attitudes was administered to a random sample of Rockland County women age > or = 40 years. Prevalence estimates of mammography, clinical breast exam (CBE), and breast self-examination (BSE) were derived by using exact confidence intervals (CIs) for proportions. Differences in demographic groups were assessed with chi-square tests and 95% CIs. Logistic regression was used to determine independent contributions of demographic characteristics after adjustment. RESULTS: Overall, 76.4% of respondents received a mammogram and CBE in the past year, compared with 60.3% in New York State and 55.5% in the United States. Significant predictors of a mammogram in the past year were age, education, marital status, and health insurance; of CBE in the past year were age, education, and marital status; of BSE at least monthly was marital status. Being Jewish was associated with a mammogram and CBE in the past year but did not attain significance (P = .06 and .08, respectively). CONCLUSIONS: Mammography and CBE usage in Rockland County appear to exceed that of New York State and the United States. The county health department can target relevant demographic subgroups for health education programs.

Treatment for simple plantar verrucae: monochloroacetic acid and 10% formaldehyde versus 10% formaldehyde alone.

Verrucae are small, benign, highly vascular epithelial neoplasms that occur singly or in a multiple presentation. Plantar verrucae are usually caused by infection with human papillomavirus types 1, 2, and 4. A clinical trial was conducted to assess the safety and efficacy of monochloroacetic acid and 10% formaldehyde versus 10% formaldehyde alone in the treatment of simple plantar verrucae. Of 57 patients enrolled in the study, 26 were in the monochloroacetic acid and 10% formaldehyde group and 31 were in the 10% formaldehyde alone group. The overall cure rate for this population was 61.4%. There was no statistically significant difference in the cure rate between treatment groups.

Characterization of a novel prostate-specific antigen-activated peptide-doxorubicin conjugate in patients with prostate cancer.

PURPOSE: To evaluate safety and pharmacokinetics (PK), and determine the recommended dose for efficacy studies, of L-377202, a novel peptide conjugate of doxorubicin (Dox) that releases the active metabolites leucine-doxorubicin (Leu-Dox) and Dox on cleavage by membrane-bound prostate-specific antigen (PSA). PATIENTS AND METHODS: Nineteen patients with advanced hormone-refractory prostate cancer were treated intravenously with 71 cycles of L-377202 at escalating dose levels of 20 (n = 1), 40 (n = 3), 80 (n = 4), 160 (n = 3), 225 (n = 6), and 315 mg/m(2) (n = 2) once every 3 weeks. Toxicity, response, and PK of L-377202 were assessed. RESULTS: L-377202 was well tolerated. Dose-limiting grade 4 neutropenia was noted in two of two patients administered 315 mg/m(2) (both patients were able to resume therapy at 225 mg/m(2)). The recommended dose for efficacy studies was 225 mg/m(2), which induced grade 4 neutropenia in one of six patients. PK studies demonstrated that L-377202 was metabolized to Leu-Dox and Dox. PK were linear; after administration of single doses of 225 mg/m(2), the mean area under the concentration-time profiles of L-377202, Leu-Dox, and Dox were 6 micromol x L/h, 4 micromol x L/h, and 1 micromol x L/h, and peak concentrations were 14 micromol/L, 5 micromol/L, and 120 nmol/L, respectively. At 225 and 315 mg/m(2), five patients completed at least three cycles of therapy; two patients had a greater than 75% decrease in PSA, and one patient had a stabilized PSA. No response was noted at dose levels less than 225 mg/m(2). CONCLUSION: This is the first study of selective drug delivery in humans using a novel PSA-activated agent. L-377202 was cleaved to produce detectable levels of the active metabolites Leu-Dox and Dox. L-377202 was well tolerated and established a safe dose level for further study.

A double-blind clinical trial comparing the efficacy and safety of pure lanolin versus ammonium lactate 12% cream for the treatment of moderate to severe foot xerosis.

Xerotic skin is a pattern of reaction to a variety of disorders (eg, winter xerosis, hereditary ichthyosis) with abnormalities of desquamation in common. The trial described in this article was a double-blind randomized-comparison clinical trial investigating the effect of pure lanolin versus ammonium lactate 12% cream in treating moderate to severe foot xerosis. Xerosis was clinically assessed at baseline visit, and designated sites were reevaluated after 1, 2, and 4 weeks of therapy. Ninety-two patients were enrolled; 41 of these were excluded from analysis (25 were lost to follow-up, 8 were noncompliant, 1 was discharged from study because of an adverse event after visit 1, and 7 were noncompliant after visit 2). Although there was significant improvement in xerosis scores for both treatment groups after 2 and 4 weeks of treatment, no differences were statistically significant. Used twice daily for 4 weeks, pure lanolin and ammonium lactate cream were both effective in treating moderate to severe xerosis.

A comparative study of lactic acid 10% and ammonium lactate 12% lotion in the treatment of foot xerosis.

Xerotic skin is a pattern of reaction to a variety of disorders that have abnormalities of desquamation in common. This double-blind, randomized clinical trial investigated the effect of Lactinol (Pedinol Pharmaceuticals, Farmingdale, New York) versus Lac-Hydrin 12% (Bristol-Myers Squibb, Princeton, New Jersey) lotion in mild to moderate foot xerosis. Clinical assessment of xerosis was performed at baseline visit, and the designated sites were evaluated at 2 and 4 weeks after treatment began. Of the 53 patients enrolled, 18 were excluded from analysis. Although both treatment groups had significantly improved xerosis scores after 2 and 4 weeks of treatment, no statistically significant difference was observed. Of the 44% of patients who did express a preference, 72% preferred Lactinol, which may account for the 20% increase in its overall use in the study.

Comparison of Body Temperatures of Goats, Horses, and Sheep Measured With a Tympanic Infrared Thermometer, an Implantable Microchip Transponder, and a Rectal Thermometer.

Body temperature of goats, horses, and sheep was measured, using 3 methods. Tympanic temperature was measured with a tympanic infrared thermometer, subcutaneous temperature was measured with an implantable microchip transponder, and rectal temperature was measured with a digital thermometer. For goats, rectal and subcutaneous temperatures were significantly higher than tympanic temperatures, but rectal and subcutaneous temperatures did not differ significantly. For horses and sheep, rectal temperatures were significantly higher than tympanic and subcutaneous temperatures, and tympanic temperatures were significantly higher than subcutaneous temperatures. Tympanic infrared thermometry correlated well with traditional rectal thermometry in goats and sheep and should be considered as a viable alternative in those species. Additionally, implantable microchip transponders in goats could be used, because those temperatures also correlated well with temperatures derived by rectal thermometry. Due to the poor correlation with rectal thermometry and reaction of some animals to insertion of the tympanic probe, neither of the alternative methods appear to be useful in horses at this time. Tympanic infrared thermometers and implantable microchip transponders were convenient to use and allowed temperature measurements to be obtained more rapidly than when rectal thermometers were used.

Cytoskeletal myotoxicity from simvastatin and colchicine.

We report the case of a 79-year-old man with mild chronic renal failure who developed severe rhabdomyolysis after combined exposure to simvastatin and colchicine. Colchicine induces myopathy through disruption of microtubular function with subsequent vacuolization and pseudomyelinic body accumulation. Statin therapy is associated with myonecrosis, membranous myeloid bodies, and vacuolization, presumably as a function of impaired isoprenoid metabolism. Vesicle trafficking requires small G-protein prenylation and statins can disrupt cytoskeletal integrity. We propose that synergistic cytoskeletal myotoxicity may account for the extreme elevation of serum creatine kinase not previously reported in pure colchicine myopathy.

Previously undetected silicosis in New Jersey decedents.

BACKGROUND: Despite a reported decline in mortality and hospitalizations associated with silicosis [U.S. Department of Health and Human Services, 1999], this decline may be artifactual, stemming in part from underdiagnosis by physicians. METHODS: This study estimates, through radiological confirmation, the prevalence of unrecognized silicosis in a group of silica-exposed New Jersey decedents whose cause of death was chronic obstructive pulmonary disease (COPD), tuberculosis, or cor pulmonale. Two expert readers re-evaluated the chest X-rays of this group to determine the presence or absence of silicosis. The study population was considered to be presumptively exposed to silica dust by virtue of their usual industry of employment as listed on the death certificate. RESULTS: Radiographic evidence of silicosis was found in 8.5% of this population, and evidence of asbestosis was found in another 10.7%, for a total of 19.2%. CONCLUSIONS: The existence of previously unrecognized silicosis and asbestosis in 19.2% of this study group suggests that occupational lung disease is under-recognized and, hence, undercounted.