Medical Oversight,Educational Core Content,and Proposed Scopes of Practice of Wilderness EMS Providers: A Joint Project Developed by Wilderness EMS Educators,Medical Directors,and Regulators Using a Delphi Approach

Introduction: A disparity exists between the skills needed to manage patients in wilderness EMS environments and the scopes of practice that are traditionally approved by state EMS regulators. In response, the National Association of EMS Physicians Wilderness EMS Committee led a project to define the educational core content supporting scopes of practice of wilderness EMS providers and the conditions when wilderness EMS providers should be required to have medical oversight. Methods: Using a Delphi process, a group of experts in wilderness EMS, representing educators, medical directors, and regulators, developed model educational core content. This core content is a foundation for wilderness EMS provider scopes of practice and builds on both the National EMS Education Standards and the National EMS Scope of Practice Model. These experts also identified the conditions when oversight is needed for wilderness EMS providers. Results: By consensus, this group of experts identified the educational core content for four unique levels of wilderness EMS providers: Wilderness Emergency Medical Responder (WEMR), Wilderness Emergency Medical Technician (WEMT), Wilderness Advanced Emergency Medical Technician (WAEMT), and Wilderness Paramedic (WParamedic). These levels include specialized skills and techniques pertinent to the operational environment. The skills and techniques increase in complexity with more advanced certification levels, and address the unique circumstances of providing care to patients in the wilderness environment. Furthermore, this group identified that providers having a defined duty to act should be functioning with medical oversight. Conclusion: This group of experts defined the educational core content supporting the specific scopes of practice that each certification level of wilderness EMS provider should have when providing patient care in the wilderness setting. Wilderness EMS providers are, indeed, providing health care and should thus function within defined scopes of practice and with physician medical director oversight.     

两种体温计测量结果的比较

目的：了解液晶体温计与玻璃体温计体温测量结果有无差异。方法：用液晶体温计与玻璃体温计同时测量20位健康成年女性的口腔温度，对结果进行统计学处理。结果：两组测量数值无统计学意义(P＞0．05)。结论：液晶体温计在测量体温中与体温计同样有效，并且使用更安全、简便。     

Comparative study of automated plateletpheresis using five different apheresis systems in a tertiary care hospital

Different types of cell separators are available nowadays based on either continuous or intermittent flow technology to meet the growing demands for single donor apheresis platelets. This prospective study compares the five machines used in our center with regard to procedure parameters, product quality and adverse effects on the donor.A total of 477 plateletpheresis on various machines were performed on eligible donors over a period of 28 months after taking informed consent. All procedures were performed following the departmental standard operating procedure (SOP) and manufacturer’s instructions. All donor and procedure related details were obtained from the procedure register. Statistical analysis was done using the SPSS statistical package (version 12, USA).The median age, BSA and BMI of our plateletpheresis donors were calculated to be 29 years, 1.69 m² and 23.1 kg/m², respectively. Analyzing the parameters related to donor comfort such as donation time (DT), needle time (NT) and processing time (PT), the MCS machines were not “donor friendly” compared to Amicus and Fresenius. Platelet yield by Amicus was significantly higher as compared to other cell separators (p < 0.05). Plateletpheresis associated citrate toxicity was higher with the Amicus and MCS 3p and vasovagal side-effects was observed least with the CS 3000 machine. Though, quality of apheresis product in terms of yield is comparable with all the machines, there are differences in the systems with regard to donor safety, procedure time and donor retention.     

Victimization in individuals suffering from psychosis: a Swedish cross-sectional study

The aims of the study were to investigate: (1) self-reported adulthood and last-year victimization in male and female outpatients suffering from psychosis; (2) relationships to perpetrators; (3) whether drugs or alcohol were involved in victimization situations; (4) places where victimization occurred. Patients were randomly selected from five outpatient units geared to patients with psychosis; 174 patients participated in a structured face-to-face interview. Experiences of victimization in adulthood were reported by 67%, 33% in the previous year. During adulthood 51% had been physically and 32% sexually victimized and 39% threatened. In the previous year 21% reported threats, 20% physical and 15% sexual victimization. Women reported greater exposure to physical and sexual victimization than men during adulthood and in the previous year. Strangers and acquaintances were mainly reported as perpetrators and half (55%) of those victimized in the previous year stated no involvement of alcohol or drugs. Victimization mainly occurred in the patients' own home (59%), outside downtown (34%), or in others homes (38%). The results of this study give reason to highlight the importance for research and clinical practices to adopt a broad frame of interpretation concerning victimization in patients, covering both individual and environmental factors.     

两套不同检测系统甲状腺激素测定结果的可比性分析

目的对Abbott Architect ci16200全自动生化免疫分析仪(雅培系统)和Roche Cobas e601全自动免疫分析仪(罗氏系统)检测甲状腺激素的结果进行对比分析。方法分别采用雅培系统[化学发光微粒子免疫分析(CMIA)]和罗氏系统[电化学发光免疫分析(ECLIA)]对93例血清标本进行甲状腺激素[甲状腺素(T4)、游离甲状腺素(FT4)、三碘甲腺原氨酸(T3)、游离三碘甲腺原氨酸(FT3)、促甲状腺激素(TSH)]的检测,并对结果进行分析。结果两套检测系统检测T4、FT4、T3、FT3、TSH的结果具有良好相关性,相关系数分别为0.960、0.962、0.976、0.900、0.999(P<0.01),但两套检测系统测定结果的差异有统计学意义(P<0.05)。结论两套检测系统测定甲状腺激素的结果不可比。     

Apheresis registry in Sweden: scope, techniques and indications for treatment. A report from the Swedish apheresis study group.

Registries of therapeutic apheresis can be used to evaluate changes in technology, clinical indications and applications over the years. This study reports data collected prospectively and voluntarily in Sweden during 1993-1999. A total number of 40 apheresis units have been performing therapeutic apheresis procedures: 16 blood centers, 20 dialysis units, two intensive care units, one hematology ward and one hemotherapy unit. The registry includes a median of 92%) of the centers for therapeutic apheresis in Sweden during the years and in 1999 there were 31 active units in 26 hospitals. The total numbers of procedures per year have remained fairly stable corresponding to a median of 46 treatments/ 100,000 inhabitants, and in 1999 4084 procedures were performed. The number of plasma exchanges has decreased, but LDL-apheresis and immunoadsorption procedures have increased over the years. 70% of the patients have been referred for 12 indications. A significant decline was found for patients with SLE and Guillain Barres syndrome. The use of extracorporeal photo-chemotherapy has increased over the years, and 3 indications include >75$ of the patients. There has been an adaptation to the experience learned by different studies. The number of collections of hematopoietic progenitor cells is about 9/100,000 inhabitants, and in 1999 821 collections were performed. The use of allogeneic donors is increasing. The extent of therapeutic apheresis in Sweden was compared to other countries on the basis of published data. In Sweden, the extent of therapy is two- to three-fold to that for Canada and France.     

血清心肌酶谱三项指标在两生化分析系统间检测的偏倚评估

目的通过对两生化分析系统进行方法对比分析和预期偏倚评估，探讨天冬氨酸氨基转移酶（AST）、肌酸激酶（CK）、乳酸脱氢酶（LDH）在两生化分析系统间是否具有一致性或检测结果的偏倚是否在允许范围内，以确保能得到具有一致临床意义的检测结果。方法按照美国临床实验室标准化委员会批准的EP9-A文件要求，以Beckman Coulter CX7全自动生化分析仪为对比方法，日立7600全自动生化分析仪为实验方法，对患者血清AST、CK、LDH进行检测，以美国临床实验室改进修正法案（CLIA’88）对室间质评允许误差（Ea）的1／2为判断依据，判断各项目在给定的医学决定水平（Xc）处的相对系统误差（SE％）是否可接受。结果AST、LDH在3个Xc处的SE％均可被接受，而CK在3个Xc处的SE％均不可被接受。结论基体效应导致检测系统间偏倚的存在，有必要对苴讲行对№仆析和偏倚评估，并对偏倚不可接受部分采取整改措施。     

Clinical usefulness of different lipid measures for prediction of coronary heart disease in type 2 diabetes: a report from the Swedish National Diabetes Register

OBJECTIVE

We assessed the association between different blood lipid measures and risk of fatal/nonfatal coronary heart disease (CHD).

RESEARCH DESIGN AND METHODS

We conducted an observational study of patients with type 2 diabetes from the Swedish National Diabetes Register. Baseline LDL cholesterol, non-HDL cholesterol, ratio of non-HDL to HDL cholesterol (non-HDL:HDL), and ratio of triacylglycerol to HDL cholesterol (TG:HDL) was measured in 18,673 patients aged 30–70 years, followed for a mean of 4.8 years from 2003 to 2007.

RESULTS

Hazard ratios (HRs) for CHD per 1-SD increment in lipid measures were 1.23 with non-HDL:HDL, 1.20 with non-HDL cholesterol, 1.17 with LDL cholesterol, and 1.15 with TG:HDL (all P < 0.001 when adjusted for clinical characteristics and nonlipid risk factors). The best global model fit was found with non-HDL:HDL. When patients within the lowest tertile of a lipid measure were compared with those with all lipid measures within the highest tertile, the adjusted HR for CHD was 0.62 with non-HDL:HDL <3.5 mmol/L, 0.65 with non-HDL cholesterol <3.3 mmol/L, and 0.70 with LDL cholesterol <2.5 mmol/L (all P < 0.001). The lowest tertile of LDL and non-HDL cholesterol corresponded with treatment targets according to U.S. and European guidelines. HRs for CHD were 0.52, 0.62, and 0.66 with the lowest deciles of non-HDL:HDL, non-HDL cholesterol, and LDL cholesterol ≤1.8 mmol/L (all P < 0.001). Mean TG:HDL was considerably lower in patients within the lowest tertile of non-HDL:HDL, 0.82 ± 0.47, than in those within the lowest tertile of LDL cholesterol (<2.5 mmol/L), 1.49 ± 1.03.

CONCLUSIONS

Non-HDL:HDL had a stronger effect on CHD risk than LDL cholesterol, and low TG:HDL values were more often seen within the lowest non-HDL:HDL tertile than within the lowest LDL cholesterol tertile. LDL cholesterol was not the best predictor of CHD risk in type 2 diabetes.Randomized controlled clinical trials have established the clinical benefits of lowering LDL cholesterol levels for risk reduction of coronary heart disease (CHD) (1). The National Cholesterol Education Program Adult Treatment Panel (ATP) III (2) and the American Diabetes Association (3) have recommended LDL cholesterol <2.5 mmol/L as the primary treatment goal in patients with diabetes and hyperlipidemia.ATP III has also identified non-HDL cholesterol (the sum of LDL and VLDL) <3.3 mmol/L as a secondary treatment target in patients with triacylglycerol >2.3 mmol/L or HDL cholesterol <1.0 mmol/L (2). European guidelines recommend the same targets for LDL and non-HDL cholesterol (4,5), and these as well as those of the U.S. National Cholesterol Education Program (1) and the American Diabetes Association (3) have also recently underlined LDL cholesterol ≤1.8 mmol/L as an optional goal for patients with diabetes and overt cardiovascular disease (CVD).Against this background, we assessed the clinical usefulness of several lipid measures with regard to the risk of CHD in an observational study of 18,673 patients with type 2 diabetes in the Swedish National Diabetes Register (NDR). The main aim was to evaluate LDL cholesterol as a risk factor in comparison with the ratio of non-HDL cholesterol to HDL cholesterol (non-HDL:HDL).     

Gross errors made by routine blood sampling from two sites using a tourniquet applied at different positions.

Tourniquet application in routine blood sampling procedures may induce considerable haemoconcentration and thereby augment the concentration of serum protein and protein-bound substances. To evaluate this effect serum protein, calcium and magnesium were measured in 31 healthy persons before and after 3-min venous stasis induced by a standardized tourniquet. Four sites of tourniquet and two sampling sites on the arm were compared. The concentration of measured serum constituents rose after the stasis period (5--13% rise in serum protein), the changes being similar at all tourniquet positions. However, blood sampled from a cubital arm vein showed significantly larger haemoconcentration than samples obtained simultaneously more distally on the arm. Taking three samples in a series, the serum concentration of protein, calcium and magnesium rose from tube to tube (5--10% change). The study demonstrates that neither use of a standardized tourniquet nor release of the tourniquet before blood sampling eliminates the errors inherent in routine venepuncture. Adjustment to a constant serum protein level minimizes these errors.     

CT-guided percutaneous skull biopsy using a drill-assisted system: Technical report of two cases

The OnControl coaxial biopsy system (Vidacare Corporation, Shavano Park, TX) includes an inner diamond-tipped access needle and hollow biopsy needle that engage with a battery-powered hand drill. Herein, we report the use of this novel device to perform two CT-guided percutaneous skull biopsies. Both procedures were performed without complication and facilitated a pathologic diagnosis.     

Outcome of foot examinations in Tanzanian and Swedish diabetic patients,a comparative study

Aims and objectives. The aim of the current study was to present the outcome of clinical nurse performed foot examinations in a group of Tanzanian diabetic patients and make comparisons with matched Swedish patients. Background. Nurses working with diabetic patients in any country need to be familiar with foot problems in diabetic patients to educate patients about foot care. Design. A comparative study examining diabetic patients in Tanzania and Sweden with a quantitative approach. Method. One hundred and forty‐five diabetic patients in each country were examined. They were matched in gender and age. All patients responded verbally to questions about individual foot‐care and underwent clinical foot examination concerning existing foot lesions, sensitivity testing using Semmes–Weinstein monofilament (5·07) and, vibratory perception using a tuning fork (128 Hz). Results. The Tanzanians had more reported foot problems than the Swedes. The latter reported problems due to poorly fitting footwear whilst the Tanzanians reported pain issues of the feet irrespective of footwear. In the Tanzanian group 37 patients presented with peripheral neuropathy (PN), 13 with peripheral vascular disease (PVD) and six had both PN and PVD. In the Swedish group of patients four had PN, three PVD, but none had both PN and PVD. Only 20 Tanzanians reported carrying out self‐inspections of their feet, while 103 Swedes reported doing so. Conclusions. Nurse performed foot examinations showed that the Tanzanian diabetic patients in this study had poorer foot status than the Swedish study sample. Relevance to clinical practice. Knowledge about foot problems in diabetic patients worldwide will hopefully improve education about self foot‐care and therefore decrease incidence of foot lesions and other foot problems in this cohort.     

血尿素氮、肌酐及尿酸在两种生化分析系统的比对和偏倚评估

目的 探讨不同的生化检测系统间血尿素氮(BUN)、肌酐(Cr)、尿酸(UA)三项指标测定结果的可比性,为本实验室不同检测系统检验结果的一致性提供依据.方法 取中值和高值质控品分别在Beckman LX-20和日立7600两种生化分析系统进行批内以及日间精密度检测,并以厂商声明和本实验室规定的精密度要求为评价标准.然后依据美国临床实验室标准化协会(CLSI)的EP9-A2文件,以Beckman LX-20型生化分析仪为比较方法,以日立7600为实验方法,分别测定40例患者血清BUN、Cr、UA的含量,计算实验方法与比较方法之间的相对偏倚(SE％),并以各专业室间质量评价检验项目及可接受性能准则的规定为判断标准,判断不同生化分析系统的一致性.结果 两种生化分析系统肾功能项目的批内CV和日间CV均低于厂商声明和本实验室规定的精密度要求,符合临床要求,比对实验数据可靠.日立7600的BUN在低中高三个医学决定水平的SE％分别为9.4％、2.0％、0.8％,Cr的SE％则为7.3％、3.8％、2.8％,UA的SE％为7.9％、1.7％、1.2％.而除BUN在低医学决定水平处的SE％超过了规定范围9％,两种生化分析系统不具可比性外,其余项目均低于可接受限,两种生化分析系统均一致.结论 在一个实验室当同一检测项目存在两种或两种以上的检测系统时,应进行比对及偏倚评估,判断其一致性,以保证检验结果的可比性.     

Comparisons of the in vitro susceptibility testing results for garenoxacin using six different national methods: report from the garenoxacin international bridging study

BACKGROUND: Laboratories worldwide carry out MIC/disc diffusion (DD) tests using various national methods, often published by local organizations. Potentially different results may complicate drug development or registration between the US methods and those used in the European Union (EU). This study uses a new des-F(6)quinolone, garenoxacin, to compare in vitro results among the most utilized antimicrobial susceptibility testing methods. METHODS: Investigators in France, Germany, Spain, Sweden and the UK tested two bacterial collections designated, challenge (CC; n = 330) containing quinolone-resistant strains and national (NC; n = 540) that were recent clinical isolates (2000-2001). Results were compared with values derived from the National Committee for Clinical Laboratory Standards (NCCLS) methods, carried out by the US coordinating site. Discords (greater than four-fold) between MIC method results were repeated. Results were analysed for variation from the NCCLS results (+/-1-2 dilutions or greater than 3-6 mm) and by regression statistics. Ciprofloxacin was used as the control quinolone agent. RESULTS: CC and NC testing compliance averaged 98.4% and 86.4% among participating centres, respectively, and correlation (r) of the national method to the NCCLS MIC was: France (0.98), Germany (0.95), Spain (0.98), Sweden (0.96) and UK (0.95). CC produced MIC results that were identical to the NCCLS (Spain) to 0.6 x log(2) greater (Germany), but the percentage of strains +/-2 dilutions versus NCCLS MIC results was 98% (Germany)-100% (Sweden, UK). Similar patterns were observed for the NC (r = 0.93-0.98), and all nations had >99% of results within +/-2 dilutions (+/-6 mm for disc tests) of NCCLS values. MIC results from four national methods were slightly elevated compared to the NCCLS result (average 0.2 x log(2)). Control ciprofloxacin MIC and DD test results showed similar patterns. CONCLUSIONS: Inter-method garenoxacin susceptibility test results indicate that MIC and zone diameter endpoints derived from five EU methods compare favourably to the NCCLS method results, and generally were identical or a fraction of a log(2) dilution step higher. In contrast, zone diameters for garenoxacin and ciprofloxacin were routinely larger for the EU methods. This unique inter-method 'bridging' experiment allows regulatory agencies to better correlate in vitro testing results derived from procedures that use different national methodologies.