New vision for the role of emergency medical services

Genital human papillomavirus (HPV) infection is the major causal factor of cervical intraepithelial neoplasia (CIN). The potential role of nutrition as an additional, independent risk factor for CIN has not been appropriately addressed in the context of HPV. This case-control study evaluated the etiologic role of HPV in terms of viral type and load and examined the association between CIN and plasma levels of micronutrients adjusting for HPV. Cases (n = 378) with histo-pathologically confirmed CIN and controls (n = 366) with no history of abnormal Pap smears were recruited from colposcopy and gynecology clinics, respectively. Risk of CIN was significantly increased among women who were infected with multiple HPV types (odds ratio [OR] = 21.06), a high viral load (OR = 13.08) and HPV 16 (OR = 62.49). After adjusting for HPV positivity and demographic factors, there was an inverse correlation between plasma alpha-tocopherol and risk of CIN (OR = 0.15). Plasma ascorbic acid was protective at a high level of > or = 0.803 mg/dl (OR = 0.46). CIN was not associated with plasma retinol and beta-carotene levels. The effect of genital HPV infection on CIN development is highly influenced by oncogenic viral type and high viral load. Vitamins C and E may play an independent protective role in development of CIN that needs to be confirmed in prospective studies.     

Organizational problems in emergency medical care and reorganization of emergency services in hospitals

Entropic properties of the neural signal space, the neurodynamic basis of Weber's and Steven's law. Acta Physiol. Pol., 1977, 28 (2): 113--116. Taking into account the number of neural units, number of their efferent synapses and the average impulse frequency as well as the notion of neural momentum the dependence of neural entropy on neural tonus was examined. Based on the above model the neurodynamic basis of the Weber's and Steven's law was considered.     

The role of protocols and professional judgement in emergency medical dispatching

The task of evaluating incoming calls to Emergency Medical Services (EMS) systems in order to determine the most appropriate response is performed in many different ways in current EMS systems. At one end of the spectrum, the process is entirely dependent on the judgement of professionals, while at the other end protocols specify the exact questions to be asked and corresponding decisions. This case study describes the experience of the Montreal EMS system, Urgences santé, where professional telephone evaluation performed by nurses since 1981 was replaced by a protocolized system in 1992. During the professional era, there were many attempts to formalize the nurses' decision-making process. These first revealed that professional judgement tended to override decision-support tools that did not allow a flexible processing of the information spontaneously provided by callers. Second, the choice of a single protocol for each call was unnatural for professionals who could spontaneously integrate multiple aspects of a problem in parallel. Third, when protocols were used by professionals, it was a posteriori in order to document their decisions rather than actually support them. Fourth, the use of Artificial Intelligence (AI) methods in order to formalize professional judgement revealed its great complexity, which was confirmed by cognitive analyses of the nurses' decision-making processes. In particular, decisions of not sending EMS resources seemed to be the most difficult. These unsuccessful attempts at formalizing professional judgement led to an evaluation of its performance in terms of results, i.e. to which extent actual decisions minimized errors (both false positives and false negatives) and decision times. A random sample of 1006 calls was collected and the ideal decision was determined by concensus of experts for each call based on the patient's clinical condition. This theoretical decision was considered as a goal standard to which actual decisions were compared. Data analysis revealed that sensitivity of telephone triage (i.e. decision to send EMS resources or not) was almost perfect and specificity was 0.55. The necessary compromise between sensitivity and specificity varied with the types of decisions. Decision times were related to the urgency of the situations, more urgent calls being processed more rapidly. These results were interpreted as representing sophisticated optimization processes in professional judgement. The professional system was replaced by a non-professional protocolized system in 1992. This new system has not yet been formally evaluated in terms of results, but many sources of evidence suggest that it was accompanied by a deterioration of performance. Many contextual factors influence the organization of telephone assessment in EMS systems. This case study suggests that professional judgement may be most useful in contexts where the demand for EMS services often exceeds the availability of resources. On the other hand, protocolized systems may be more appropriate in the absence of such constraints, and where the litigation context prohibits the occurrence of any false negative.     

Impact of first-responder defibrillation in an urban emergency medical services system

OBJECTIVE: To evaluate the impact of adding first-responder defibrillation by fire-fighters to an existing advanced life-support emergency medical services system. DESIGN: Nonrandomized, controlled clinical trial with periodic crossover. SETTING: Memphis, Tenn, a city of 610,337 people, which is served by a fire department-based emergency medical services system. All city ambulances provide advanced life support. PATIENTS: Adult victims of out-of-hospital cardiac arrest due to heart disease. INTERVENTION: Twenty of 40 participating engine companies were equipped with an automated external defibrillator and ordered to apply it immediately in all cases of cardiac arrest. The other 20 companies were ordered to start cardiopulmonary resuscitation (CPR) immediately and wait for paramedics to arrive. Every 75 days, group roles were reversed. Care otherwise proceeded according to 1986 American Heart Association guidelines. MAIN OUTCOME MEASURES: Return of spontaneous circulation in the field, survival to hospital admission, survival to hospital discharge, and neurological status at discharge. RESULTS: During the 39-month study interval, 879 patients were treated by a project engine company. Four hundred thirty-one (49%) of these were found in ventricular fibrillation. Bystander CPR was started in only 12% of cases. Overall, firefighters reached the scene a mean of 2.5 minutes faster than simultaneously dispatched paramedics. Although our automated external defibrillators proved to be reliable and efficacious for terminating ventricular fibrillation and pulseless ventricular tachycardia, patients treated by an automated external defibrillator-equipped engine company were no more likely than CPR-treated controls to be resuscitated (32% vs 34%, respectively), to survive to hospital admission (31% vs 29%), or to survive to hospital discharge (14% vs 10%). Neurological outcomes were also similar in the two treatment groups. CONCLUSIONS: In a fast-response, urban emergency medical services system served by paramedics, the impact of adding first-responder defibrillation appears to be small. Early defibrillation alone cannot overcome low community rates of bystander CPR. Careful attention to every link in the "chain of survival" is needed to achieve optimal rates of survival after cardiac arrest.     

Psychology training in emergency services.

Describes the training of psychology interns and postdoctoral fellows in the Emergency Department of the University of Rochester Medical Center. The psychiatric service receives almost 4,000 patient visits a year. The primary focus of the emergency service is psychological first aid. There is also a follow-up clinic for hard-to-reach patients. The clinic requires students to learn short-term crisis intervention therapy and uses the services of a wide range of mental health professionals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of the Federal government in financing health and medical services

A detailed examination on a group of oxen naturally infested with Parafilaria bovicola suggested a prepatent period varying from 238 to 250 days. In these animals 54% of all lesions bled only once, 22% a second time and 24% more than twice. Of all active lesions 42% occurred in the shoulder region and decreased from this area both cranially and caudally. The same tendency was noticeable on carcasses after slaughter. During the observation period May 1974 to February 1975 the number of positive animals increased, reaching peak values during September - October 1974, after which a decline was noticed. The filaricidal effects of nine compounds were tested. These were suramin (used in combination with diethylcarbamazine citrate), thiacetarsamide sodium, fenchlorphos, phosmet, mebendazole, fenbendazole, levamisole hydrochloride and trichlorphon.     

The Canadian Agricultural Injury Surveillance Program: a new injury control initiative

Acropustulosis, or chronic palmar plantar pustulosis (PPP), is a phenomenon of recurrent sterile pustules, erythema, and scaling affecting the palms and soles. Its pathogenesis is unclear, and it is difficult to treat. The purpose of this study was to elucidate further the factors involved in causing PPP, thereby enhancing the ability to manage this disease. All cases of PPP seen at Mayo Clinic Scottsdale from 1987 to 1993 were reviewed. 21 patients with PPP were identified, 15 of whom had been patch tested. 9 of the 15 patients (60%) showed positive patch test results. Fragrance was the most common sensitivity, but nickel, formaldehyde, para-phenylenediamine, thiuram, neomycin, mercury, balsam of Peru, and cinnamic aldehyde sensitivities were demonstrated. Less important factors included atopy, fungal and bacterial infections, and irritation. Although the mechanism of this sterile pustulosis response does not depend solely on delayed hypersensitivity mechanisms, we believe that we have demonstrated such a large number of positive patch tests in this chronic pustular dermatosis that patch testing should be considered in the routine work-up of these patients.     

Management of primary headache in emergency services of Santos and surrounding towns

OBJECTIVES: Primary headaches are often seen by Clinicians on duty at Emergency Services. We have investigated the treatment of such patients by 43 medical doctors who have been working at Emergency Services in the city of Santos and surrounding towns for many years. RESULTS: We confirmed the high prevalence of primary headaches in Emergency Services. There seem to be diagnosis difficulties concerning differentiating attacks of migraine and tension type headache. We also observed that IV dipirone was the most frequently prescribed treatment for patients with primary headaches in this study. There is no protocol in the literature which recommends IV dipirone for the treatment of migraine attacks or other primary headaches. CONCLUSION: It would be advisable to perform controlled double blind studies in order to verify the advantages of IV dipirone in the treatment of intense attacks primary headaches. We concluded that headache management recycling programs could be of interest for doctors who regularly work at Emergency Services.     

The potential benefit of a home fire safety intervention during emergency medical services calls

The clinical significance of silent myocardial ischemia (SMI) in the elderly was assessed in 91 patients with Q wave infarction who showed ischemic ST depression during treadmill stress testing, as well as reversible defect (RD) during dipyridamole thallium imaging. They were divided into two groups (47 patients with silent ST depression and 44 patients with painful ST depression) and compared for scintigraphic and coronary arteriographic features, and prognosis. There was no significant difference in age, gender and site of infarction between the two groups. The prevalence of single and double vessel coronary stenosis was higher in patients with SMI (66%) than in those with painful ischemia (p < 0.05). The results of treadmill stress testing showed a longer exercise duration (4.7 +/- 1.7 vs. 4.1 +/- 1.8 min) and higher maximal heart rate (138 +/- 15/vs. 126 +/- 20/min) in patients with SMI than in those with painful ischemia (p < 0.01). Dipyridamole thallium imaging revealed a larger infact (18.8 +/- 9.1 vs. 14.6 +/- 10.2 segments) in patients with SMI than in those with painful ischemia (p < 0.05). The prevalence of RD in the area of infarction was also higher in patients with SMI (74%) than in those with painful ischemia (45%) (p < 0.05). Although a higher proportion of the patients with painful ischemia (42%) underwent CABG or PTCA as their initial therapy, compared with those with SMI (25%) (ns), there was no difference in the cardiac event rate between the two groups who were initially treated medically. Dipyridamole thallium imaging is useful in the assessment of SMI in elderly patients with Q wave myocardial infarction. Those with SMI may have a larger infarct and a higher prevalence of ischemia localized within the infarction than those with painful ischemia.     

Implementation of legislative requirements for emergency medical services in prepaid group practice organizations

This study was based on the concept that intracellular accumulation of calcium plays a role in mediating ischemic myocardial injury and that inhibition of entry of calcium into cells may have a salutary effect on the ischemic heart. Nifedipine, a potent vasodilator and inhibitor of transmembrane calcium flux, was infused into the aortic root of 6 dogs (5 microgram/kg/hr) during 2 hours of myocardial ischemia while on cardiopulmonary bypass. Seven control animals received normal saline at the same flow rate and temperature (20 degrees C). The results showed that none of the 7 control animals were able to maintain adequate aortic pressure or cardiac output after 30 to 60 minutes of normothermic reperfusion. All had marked left ventricular failure and were unresponsive to large doses of inotropic agents. In contrast, the 6 dogs treated with nifedipine were weaned from bypass either without difficulty or requiring small doses of calcium chloride and norepinephrine. Light microscopy demonstrated more marked ischemic damage in the control group than in the group of drug-treated dogs. We conclude that the concept of inhibition of transmembrane calcium flux offers a new and potent method for myocardial preservation during ischemia.     

Prevention services in primary care: taking time, setting priorities

Standard family history and family study methods were used with 650 first- and 1174 second-degree biological relatives of 133 adolescents who were studied initially 6 to 8 years ago. They included 69 prepubertal children considered at risk for suicidal behavior and 64 prepubertal children selected from the community. This study aimed to identify relationships between family psychopathology and adolescents' lifetime history of suicidal states. Family discord, suicide attempts of mother, and substance abuse of mothers and fathers were significantly more prevalent among adolescents with lifetime history of a suicide attempt. Mothers' and fathers' substance abuse was associated with adolescents' lifetime history of suicidal ideation. Results highlight importance of evaluating and treating family psychopathology to reduce risk for youth suicidal states.     

Predicting symptomatic distress in emergency services personnel.

This study identified predictors of symptomatic distress in emergency services (EMS) personnel exposed to traumatic critical incidents. A replication was performed in 2 groups: 154 EMS workers involved in the 1989 Interstate 880 freeway collapse during the San Francisco Bay area earthquake, and 213 counterparts from the Bay area and from San Diego. Evaluated predictors included exposure, social support, and psychological traits. Replicated analyses showed that levels of symptomatic distress were positively related to the degree of exposure to the critical incident. Level of adjustment was also related to symptomatic distress. After exposure, adjustment, social support, years of experience on the job, and locus of control were controlled, 2 dissociative variables remained strongly predictive of symptomatic response. The study strengthens the literature linking dissociative tendencies and experiences to distress from exposure to traumatic stressors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The federal role in injury control.

Early federal injury control programs in the 1960s and 1970s were centered first in the Division of Accident Prevention (Public Health Service) and subsequently in the National Highway Traffic Safety Administration (Department of Transportation) and the Consumer Product Safety Commission. The Centers for Disease Control (CDC) in the early 1970s also began to investigate injuries, particularly in the home and recreational environment. The field expanded in the 1970s and 1980s to include injuries that occur in many settings and both intentional injuries (violence) and unintentional injuries. After a 1985 report, Injury in America, CDC was chosen to be the national coordinating agency because of its mission of prevention. The current program also includes acute care, rehabilitation, and biomechanics. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A GP looks abroad: emergency medical services in the Federal Republic of Germany

1. The methylester derivative of DNP-amino acid was examined by gas-chromatography and amino acid shown in fig. 1 was detected. 2. The gaschromatography was more sensitive than the ion-exchange chromatography, but detectable peaks were few, and it must be further studied. 3. The measurements of five amino acids in food were almost coincident with those obtained by the ion-exchange method in literatures.     

The school psychologist's role in suicide prevention.

Suggests that the school psychologist's involvement in the issue of youth suicide spans primary, secondary, and tertiary prevention and working with the aftermath of a suicide or suicide attempt. Primary prevention activities involve supporting and delivering curricula educating youth about suicide, promoting social problem solving in the school milieu, screening all students for suicidal ideation, creating networks of peer helpers, working to reduce the availability of suicidal means, training school personnel to identify and refer potentially suicidal youth, and establishing interdisciplinary crisis response teams. Secondary prevention involves working with individuals and groups at risk (i.e., alternative education students, gay and lesbian youth, and minority youth) for engaging in suicidal behavior. Tertiary prevention requires swift treatment and referral, including services delivered following a suicide. (PsycINFO Database Record (c) 2010 APA, all rights reserved)