Test–Retest Reliability of Capability Measurement in the UK General Population

Although philosophically attractive, it may be difficult, in practice, to measure individuals' capabilities (what they are able to do in their lives) as opposed to their functionings (what they actually do). To examine whether capability information could be reliably self‐reported, we administered a measure of self‐reported capability (the Investigating Choice Experiments Capability Measure for Adults, ICECAP‐A) on two occasions, 2 weeks apart, alongside a self‐reported health measure (the EuroQol Five Dimensional Questionnaire with 3 levels, EQ‐5D‐3L). We found that respondents were able to report capabilities with a moderate level of consistency, although somewhat less reliably than their health status. The more socially orientated nature of some of the capability questions may account for the difference. © 2014 The Authors Health Economics Published by John Wiley & Sons Ltd.     

Treatment of acute heart failure in the emergency department

Millions of patients are hospitalized for acute heart failure (AHF) every year throughout the world. Despite tremendous advances in cardiovascular care, morbidity and mortality for AHF remain high, consuming billions of health care dollars. With the aging of the population, the incidence and prevalence of HF is projected to increase. Yet, initial treatment of AHF today is similar to 40 years ago. Multiple studies have yielded new insights regarding initial management, with regards to both treatment and strategies of care. These advances will be reviewed in the context of initial or early AHF management. There remains, however, an unmet need to improve outcomes for AHF patients.     

Pilot Study to Determine the Feasibility of Training Army National Guard Medics to Perform Focused Cardiac Ultrasonography

Abstract

Objective. To assess the ability of Army National Guard combat medics to perform a limited bedside echocardiography (BE) to determine cardiac activity after a brief training module. Methods. Twelve Army National Guard health care specialists trained to the level of emergency medical technician–basic (EMT-B) underwent an educational session consisting of a 5-minute lecture on BE followed by hands-on practical training. After the training session, each medic performed BEs, in either the subxiphoid (SX) or parasternal (PS) location at his or her discretion, on four healthy volunteers. The time required to complete the BE and the anatomic location of the examination (SX vs. PS) was documented. A 3-second video clip representing the best image was recorded for each BE. These clips were subsequently reviewed independently by two of the investigators with experience performing and interpreting BE; each BE was graded on a six-point scale designed for the study, the Cardiac Ultrasound Structural Assessment Scale (CUSAS). A score of 3 or greater was considered to be adequate to assess for the presence of cardiac activity. Where there was disagreement on the CUSAS score, the reviewers viewed the clip together and agreed on a consensus CUSAS score. We calculated the median time to completion and interquartile range (IQR) for each BE, the median CUSAS scores and IQR for examinations performed in the SX and PS locations, and kappa for agreement between the two reviewers on the CUSAS. Results. A total of 48 BEs were recorded and reviewed. Thirty-seven of 48 (77%) were obtained in the SX location, and 11 of 48 (23%) were obtained in the PS location. Forty-four of 48 (92%) were scored as a 3 or higher on the CUSAS. Median time to completion of a BE was 5.5 seconds (IQR: 3.7–10.9 seconds). The median CUSAS score in the SX location was 4 (IQR: 4–5), and the median CUSAS score in the PS location was 4 (IQR: 4–4). Weighted kappa for the CUSAS was 0.6. Conclusion. With minimal training, the vast majority of the medics in our study were able to rapidly perform a focused BE on live models that was adequate to assess for the presence of cardiac activity.     

Clinical response to statins: Mechanism(s) of variable activity and adverse effects

Abstract

Statins represent a major advance in the treatment of hypercholesterolemia, a significant risk factor for atherosclerosis. There is, however, notable interindividual variation in the cholesterolemic response to statins, and the origin of this variability is poorly understood; pharmacogenetics has attempted to determine the role of genetic factors. Myopathy, further, has been reported in a considerable percentage of patients, but the mechanisms underlying muscle injury have yet to be fully characterized. Most statins are the substrates of several cytochrome P450s (CYP). CYP polymorphisms may be responsible for variations in hypolipidemic activity; inhibitors of CYPs, e.g. of CYP3A4, can significantly raise plasma concentrations of several statins, but consequences in terms of clinical efficacy are not uniform. Pravastatin and rosuvastatin are not susceptible to CYP inhibition but are substrates of the organic anion-transporting polypeptide (OATP) 1B1, encoded by the SLCO1B1 gene. Essentially all statins are, in fact, substrates of membrane transporters: SLCO1B1 polymorphisms can decrease the liver uptake, as well as the therapeutic potential of these agents, and may be linked to their muscular side-effects. A better understanding of the mechanisms of statin handling will help to minimize adverse effects and interactions, as well as to improve their lipid-lowering efficiency.     

Establishing biennial paramedic experience benchmarks

Objective. Since stroke symptoms are often vague, and acute therapies for stroke are more recently available, it has been hypothesized that stroke patients may not be treated with the same urgency as myocardial infarction (MI) patients by emergency medical services (EMS). To examine this hypothesis, EMS transport times were examined for both stroke and MI patients who used a paramedic-level, county-based EMS system for transportation to a single hospital during 1999. Methods. Patients were first identified by their hospital discharge diagnosis as stroke (ICD-9 430–436, n = 50) or MI (ICD-9 410, n = 55). Trip sheets with corresponding transport times were retrospectively obtained from the 911 center. A separate analysis was performed on patients identified by dispatchers with a chief complaint of stroke (n = 85) or MI (n = 372). Results. Comparing stroke and MI patients identified by ICD-9 codes, mean EMS transport times in minutes did not meaningfully differ with respect to dispatch to scene arrival time (8.3 vs 8.9, p = 0.61), scene time (19.5 vs 21.4, p = 0.23), and transport time (13.7 vs 16.2, p = 0.10). Mean total call times in minutes from dispatch to hospital arrival were similar between stroke and MI patients (41.5 vs 46.4, p = 0.22). Results were similar when comparing patients identified by dispatchers with a chief complaint indicative of stroke or MI. Conclusion. In this single county, EMS response times were not different between stroke and MI patients. Replication in other EMS settings is needed to confirm these findings.     

EMTs' Attitudes' toward Death before andafter a Death Education Program

Objective. To test the hypothesis that emergency medical technicians' (EMTs') attitudes toward death will change after exposure to a death education program. Methods. A convenience sample of 83 rural EMTs participated in this pretest–posttest study after exposure to an educational program related to death. Intact groups of EMTs were randomly assigned to one of three conditions. The short-intervention group received a two-hour class solely on making death notifications. The long-intervention group received a 16-hour, two-day workshop based on the Emergency Death Education andCrisis Training (EDECT^SM) program. The control group received a program about toxicology. Each participant completed a questionnaire with items structured in a Likert five-point format with “strongly agree” and“strongly disagree” as the anchors. Results. Before the training programs, most (77%) participants reported that an EMT's actions impact the family's grief. Less than half (43%) reported that an EMT's role should include making a death notification. The majority (84%) reported that their training was inadequate to make a death notification or to help the family with their grief. Most (84%) felt uncomfortable making a death notification. Those EMTs in the long-intervention group were significantly more likely (92%) to feel that their training was adequate after the intervention when compared with those EMTs in the short-intervention group (43%) or those in the control group (21%). Conclusion. The data showed that EMTs' attitudes toward death changed after exposure to a training program about death.     

Therapeutic potential of tyrosine kinase 2 in autoimmunity

Introduction: Tyrosine kinase 2 (Tyk2) is a Janus kinase family member that is crucial for signaling transduction in response to a wide variety of cytokines, including type I IFNs, IL-6, IL-10, IL-12 and IL-23. An appropriate expression of Tyk2-mediated signaling might be essential for maintaining normal immune responses.

Areas covered: This review summarizes that Tyk2 is essential for the differentiation and function of a wide variety of immune cells, including natural killer cells, B cells, as well as T helper cells. In addition, Tyk2-mediated signaling promoted the production of autoimmune-associated components, which is implicated in the pathogenesis of autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis. Aberrant expression of Tyk2 was observed in many autoimmune conditions.

Expert opinion: Until recently, no patent filings had claimed selective inhibitors of Tyk2. Both CP-690,500 and CMP6 failed to be used in clinical treatment due to the difficulties of finding suitable selective leads or due to detrimental toxicities. Although the result of Cmpd1 is promising, it remains to be seen how specific the Tyk2 inhibitor is and how they are working. Currently, structure-based drug design (SBDD) technology has provided us with a quite useful window for SBDD of Tyk2 inhibitors.     

I NTRODUCTION TO F IRE P REVENTION,F IFTH E DITION

Objectives: To determine whether members of a ski patrol, most of whom have no off-season medical responsibilities, can successfully complete an automated external defibrillator (AED) training program prior to the ski season, and retain AED skills at the end of the season and at the beginning of the following season. Methods: A prospective educational study was conducted with 61 ski patrol personnel: 51 (84%) had no other medical training, 44 (72%) had no off-season medical duties, and 57 (93%) had no prior exposure to AEDs. Prior to the ski season (December 1, 1998), all members were trained and tested using the standard American Heart Association (AHA) AED training package and a Life-Pak 500 AED and AED Trainer donated by the Medtronic Physio-Control Corporation. Both after the ski season (April 1, 1999) and prior to the following season (October 30, 1999), with no refresher training, participants were retested with the same written and practical exams. Cochrane's linear trend test was used to compare scores on the practical and written tests over time. Results: For the three testing sessions, practical test pass rates were 95%, 92%, and 97%, and written test pass rates were 100%, 98%, and 98%. There was no change in individuals' scores on either the written test (p = 0.914) or the practical test (p = 0.413) over time. Conclusions: A heterogeneous group of ski patrollers can successfully complete an AED training course, with good skill retention both after the ski season and at the beginning of the following season.