Sharps injury recordkeeping activities and safety product use in California health care facilities: pilot study results from the sharps injury control program

BACKGROUND: In 1999, licensed health care facilities in California (N = 2532) were invited to participate in a survey about occupational bloodborne pathogens exposure surveillance activities, recordkeeping methods, and use of safety-enhanced sharps devices. RESULTS: A total of 1274 facilities responded to the survey from January 1999 through August 1999 (response rate = 50%). Sharps-related injuries were recorded for multiple departments on various forms in diverse manners. Only 66% of hospitals, 37% of home health agencies, and 33% of skilled nursing facilities reported sharps injuries on a mandated sharps injury log. More than 70% of facilities stated that they used some type of safety device or needleless system, but this figure varied by type of device and facility type. Eighty-four percent of general acute care hospitals, 28% of home health agencies and skilled nursing facilities each had evaluated at least 1 safety-enhanced device. Almost 90% of all facilities expressed a need for educational materials on topics such as device selection and evaluation. CONCLUSIONS: Standardization of surveillance and recordkeeping activities does not exist across facility types. Standards and regulations demand complex recordkeeping activities. Increased funding for distribution of educational materials and on-site training should accompany changes in mandated reporting activities when appropriate. Increased testing and evaluation of devices across facility types are necessary to ensure that safety-enhanced devices are protective of health care workers and patients.     

Time of initiation of antiretroviral therapy: impact on HIV-1 viraemia. The Swiss HIV Cohort Study

OBJECTIVE: The current recommendation that patients infected with HIV-1 be treated early is based on little evidence. We examined whether the early initiation of antiretroviral treatment affects residual HIV-1 viraemia. METHODS: Viraemia was measured using an assay with a detection limit of 3 HIV-1 RNA copies/ml in drug-naive patients who started antiretroviral therapy at the time of primary HIV-1 infection (PHI) (n = 10), during chronic infection without immune suppression (CD4 cell counts > or = 500/mm3; median 577) (n = 10), or after immune suppression developed (CD4 cell counts < 500/mm3; median 113) (n = 21). RESULTS: In 249 samples collected 24 to 120 weeks after treatment initiation, the mean proportion of samples with HIV-1 RNA levels of less than 3 copies/ml was 75% for PHI patients compared with 32 and 8% for immunocompetent and immunosuppressed chronically infected patients, respectively. Fifty per cent of PHI patients, but none of the chronically infected patients, had persistently fewer than 3 HIV-1 RNA copies/mL. PHI patients had lower residual HIV-1 RNA levels than chronically infected patients, and immunocompetent patients had lower residual HIV-1 RNA levels than immunosuppressed patients (all pairwise, P< 0.001). The mean residual HIV-1 RNA level was independently associated with the initiation of therapy during PHI and baseline CD4 cell counts (P < 0.001 for both associations). CONCLUSION: Viraemia levels are associated with clinical progression and predict virological treatment failure. The initiation of antiretroviral therapy at the time of PHI and while CD4 cell counts are high results in lower residual viraemia. These results support early antiretroviral therapy in HIV-1-infected patients.     

A descending dopamine pathway conserved from basal vertebrates to mammals

Dopamine neurons are classically known to modulate locomotion indirectly through ascending projections to the basal ganglia that project down to brainstem locomotor networks. Their loss in Parkinson’s disease is devastating. In lampreys, we recently showed that brainstem networks also receive direct descending dopaminergic inputs that potentiate locomotor output. Here, we provide evidence that this descending dopaminergic pathway is conserved to higher vertebrates, including mammals. In salamanders, dopamine neurons projecting to the striatum or brainstem locomotor networks were partly intermingled. Stimulation of the dopaminergic region evoked dopamine release in brainstem locomotor networks and concurrent reticulospinal activity. In rats, some dopamine neurons projecting to the striatum also innervated the pedunculopontine nucleus, a known locomotor center, and stimulation of the dopaminergic region evoked pedunculopontine dopamine release in vivo. Finally, we found dopaminergic fibers in the human pedunculopontine nucleus. The conservation of a descending dopaminergic pathway across vertebrates warrants re-evaluating dopamine’s role in locomotion.Dopaminergic neurons represent a vital neuromodulatory component essential for vertebrate motor control, and their loss in neurodegenerative disease is devastating. The meso-diencephalic dopamine (DA) neurons are known to provide ascending projections to the basal ganglia, which, in turn, provide input to cortical structure in mammals but also project caudally to the mesencephalic locomotor region (MLR), a highly conserved structure that controls locomotion in all vertebrates investigated to date (1–7; for review, see ref. 8). A growing body of evidence supports the view that basal ganglia connectivity is highly conserved among vertebrates, from lampreys to mammals (9–11; for review, see ref. 12), with some interspecies differences recently highlighted (13). As such, the homology between DA cell populations remains to be resolved in vertebrates. As a general rule, DA neurons from the meso-diencephalon send projections to the striatum in all vertebrates. In lampreys and teleosts, those neurons are located only in the diencephalon (posterior tuberculum), but in tetrapods and cartilaginous fishes (14) they are located in both the diencephalon and the mesencephalon. An increasing number of authors seem to agree with the hypothesis that at least some of the meso-diencephalic DA neurons located in the diencephalon are homologous in all vertebrates, and thus, homologous to at least a portion of the mammalian substantia nigra pars compacta (SNc)/ventral tegmental area (VTA) (13, 15–19; for review, see ref. 20). Alternatively, it was suggested that the posterior tuberculum DA neurons projecting to the striatum in zebrafish are homologs of the mammalian DA neurons of the A11 group (21). This will be discussed below in light of the results of the present study.In lampreys, only a few meso-diencephalic DA neurons send ascending projections to the striatum (9, 22); the majority of DA neurons send a direct descending projection to the MLR (22, 23), where DA is released and increases locomotor output through D1 receptors (22). These results demonstrate that the descending dopaminergic pathway to the MLR is an important modulator of locomotor output, but it remains to be determined whether this pathway is conserved in higher vertebrates.The existence of a descending dopaminergic pathway that powerfully increases locomotor output has important implications for Parkinson’s disease, which involves the meso-diencephalic DA neurons. A loss of descending dopaminergic projections could play a role in the locomotor deficits systematically observed in that disease. Because of the highly conserved nature of both the dopaminergic system and brainstem locomotor circuitry in vertebrates, we hypothesized that a direct descending dopaminergic pathway to the MLR also exists in higher vertebrates. Previous anatomical (24, 25) and electrophysiological (26) studies in rats support the idea of a descending connection from the SNc to the pedunculopontine nucleus [PPN, considered part of the MLR (2)]. Moreover, dopaminergic terminals were found in the PPN of monkeys (27), but the origin of this projection is still unknown in mammals.Here, we investigated whether the direct descending projection from meso-diencephalic DA neurons to the MLR is present in two tetrapods, the salamander and the rat. Moreover, we supplement our analyses with anatomical data from human brain tissue. Using traditional and virogenetic axonal tracing, immunofluorescence, in vivo voltammetry, and calcium imaging of reticulospinal neurons, we provide anatomical and functional evidence strongly supporting a conserved role for the descending projections of meso-diencephalic DA neurons in the regulation of brainstem locomotor networks across the vertebrate subphylum.     

Threats to Life in Residential Structure Fires

Introduction. Firefighters are taught that heat, oxygen deprivation, andcarbon monoxide (CO) are the primary threats to life in residential structure fires, andthey are taught to search for victims on the fire floor first, andthen floors above. The objective of this study was to gather data regarding oxygen, CO, andheat conditions inside a realistic house fire, to examine the validity of these teachings. Methods. During six live-burn training evolutions in a two-story wood-frame house, metering for oxygen levels, CO levels, andtemperature was conducted. Except where noted, all readings were taken 24 inches off the floor, to simulate the location of a crawling victim or firefighter. Readings were hand-recorded on a convenience basis by firefighters stationed outside the building, near the meters. Results. Of the 35 oxygen levels recorded, the lowest was 18.2%, with only 12 readings below 20%. Three of 16 first-floor readings were below 20%, whereas nine of 19 second-floor readings were below 20% (p = 0.07). First- andsecond-floor readings were comparable (mean 20.3% vs. 19.9%, p = 0.11). Except for one reading of 1,870 ppm, all CO readings at the ceiling exceeded the 2,000-ppm limit of the meters. Of the 34 CO levels recorded 24 inches off the floor, 29 (76%) exceeded the permissible exposure limit of 50 ppm, with the highest reading being 1,424 ppm, well above the “immediately dangerous to life andhealth” level of 1,200 ppm. None of the 20 CO levels recorded on the first floor exceeded the 30-minute exposure limit of 800 ppm, whereas seven of 14 second-floor readings exceeded this limit (p < 0.001). While ceiling temperatures frequently exceeded the 1,000°F limit of the meters, none of 16 readings taken 24 inches off the floor exceeded 137°F. First- andsecond-floor temperatures were comparable (mean 88.5°F vs. 90.1°F, p = 0.9). Conclusions. In residential structure fires, CO poses a greater threat to victims andfirefighters than does oxygen deprivation or heat. Emergency medical services personnel should consider CO toxicity in all fire victims. Conditions on the floor above a fire are at least as adverse as those on the fire floor.     

Twelve Years,Five Thousand Pages

Abstract

Medical oversight is a fundamental component of every emergency medical services (EMS) system. The quality of physician medical direction has a significant impact upon the system and patient outcome. The lead agency for the state EMS system is a principal facet of our emergency care system, and the state EMS medical director is a vital component within this comprehensive network. The selection of an experienced, qualified physician for the provision of state EMS medical direction is a critical decision. This resource document provides a snapshot of the status of state EMS medical direction in our nation in 2007 and a projection of the achievable benchmarks for the role of the state EMS medical director in the future. As an informational resource, this tool will assist state EMS officials, legislators, laypersons, and partners within the emergency care system to comprehend, create or improve, and support the state EMS medical director position within their jurisdictions.     

Injuries to emergency medicine residents on ems rotations

Objectives. To study the incidence and nature of injuries sustained by emergency medicine (EM) residents during EMS rotations, and steps taken at EM residency programs to increase resident safety during field activities. Methods. An eight-question survey form was mailed to all 114 U.S. EM residency directors, with a second mailing to nonresponders eight weeks after the initial mailing. Results. A total of 105 surveys were returned (92%). Six surveys were from new programs whose residents have not yet rotated on EMS. These were excluded from further analysis, leaving 99 programs. Of these, 91 (92%) reported no injuries. One EM resident died in a helicopter crash in 1985. Seven other injury events were reported: 1) facial lacerations, rib fractures, and a shoulder injury in an ambulance accident; 2) an open finger fracture (crushed by a backboard); 3) contusions and a concussion when an ambulance was struck by a fire engine; 4) a groin pull sustained while entering a helicopter; 5) bilateral metatarsal fractures in a fall; 6) rib fractures, a pneumothorax, and a concussion in an ambulance accident; and 7) “minor injuries” sustained in a crash while responding to a scene in a program-owned response vehicle. Actions taken at residency programs to reduce the risk of injury include the use of ballistic vests (four programs), requiring helmets on flights (five programs), and changing flight experience from mandatory to optional (two programs). Ten programs (10%) reported using ground scene safety lectures, and nine programs (15% of those offering flights) reported various types of flight safety instruction. Sixty-nine programs (70%) reported no formal field safety training or other active steps to increase resident safety on EMS rotations. Conclusions. Injuries sustained by EM residents during EMS rotations are uncommon but nontrivial, with several serious injuries and one fatality reported. The majority of EM residency programs have no formal safety training programs for EMS rotations.     

Medical Student Career Advice Related to Emergency Medicine

Objective: To describe the advisors and the advice given to residency candidate interviewees interested in specializing in emergency medicine (EM).
Methods: All interviewees at a university-based EM residency program were surveyed. Data were collected anonymously and included demographic information, characteristics of each applicant's medical school, career advice by non-EM faculty, and access to advisors who are residency-trained in and practicing EM.
Results: Of 114 interviewees, 104 (91%) completed the survey. Only 45% of the respondents reported they were assigned an emergency physician (EP) advisor by their school, and 38% sought advice informally from an EP. Of those students receiving advice from an EP, 70% reported their advisor was residency-trained in EM. Most (57%) respondents reported receiving negative advice concerning a career in EM from non-EM medical school faculty. Of the 59 students reporting negative advice, 18 (31%) received negative comments from non-EM residency program directors, 23 (39%) from non-EM department chairs, and 4 (7%) from medical school deans. The presence of a residency training program increased the chances of a student's being assigned an EP advisor, but neither an EP advisor nor the departmental status of EM within the students' institutions was associated with receipt of negative advice.
Conclusions: Students considering specializing in EM often receive negative advice or have no assigned EP advisor. These factors may adversely affect entry into the field of EM.     

Relationship of plasma buprenorphine and norbuprenorphine to withdrawal symptoms during dose induction, maintenance and withdrawal from sublingual buprenorphine

Aims. Examine the relationship between buprenorphine and norbuprenorphine plasma concentrations with subject-reported withdrawalsymptomatology during buprenorphine dose induction, maintenance treatment (daily and alternate-day dosing) and withdrawal . Design. Two groups of randomly assigned subjects inducted onto buprenorphine and maintained on 8 mg daily by the sublingual route for 18 days. Group 1 continued to receive daily buprenorphine to day 36. Group 2 subjects received alternate-day dosing of buprenorphine and placebo on days 19 to 36. Both groups received placebo on days 37 to 52 . Setting. Inpatient facilities at the Addiction Research Center, Intramural Research Center, NIDA, Baltimore, MD . Participants. Eleven male, heroin-dependent volunteers participating in a research study . Intervention. Medications for treatment of withdrawal symptoms were prescribed as needed after day 39 (72 hours after the last dose of buprenorphine) . Measurements. Plasma concentrations of buprenorphine and norbuprenorphine, withdrawal symptomatology and pupil diameter . Findings. The mean steady-state buprenorphine plasma concentration (24 hours) after daily administration of sublingual buprenorphine for study days 21-35 was 0.80 ng/ml, and the mean alternate day steady-state buprenorphine plasma concentration (24 hours) was 0.77 ng/ml. Daily and alternate day steady-state norbuprenorphine plasma concentrations were 1.10 and 0.90 ng/ml, respectively. Predicted alternate day steady-state buprenorphine and norbuprenorphine plasma concentrations at 48 hours were 0.49 ng/ml and 0.57 ng/ml, respectively. Withdrawal scores varied inversely with plasma concentration. There were no significant differences between Groups 1 and 2 during steady-state (days 21-35) with regard to withdrawal scale scores or pupillary diameter. The overall, mean terminal elimination half-lives for buprenorphine and norbuprenorphine were 42 and 57 hours, respectively . Conclusions. During daily buprenorphine maintenance, plasma concentrations greater than 0.7 ng/ml of buprenorphine and norbuprenorphine were associated with minimal withdrawal symptoms. The long elimination half-life of buprenorphine suggested that increasing the buprenorphine dose with alternate-day administration may provide an effective, flexible therapy regimen for the treatment of opioid dependence.     

Detection and viability of tumor cells in peripheral blood stem cell collections from breast cancer patients using immunocytochemical and clonogenic assay techniques [see comments]

Although peripheral blood stem cell collections (PBSC) are thought to have less tumor involvement than bone marrow (BM), the incidence of circulating tumor cells in patients with breast cancer has not been widely investigated. We prospectively investigated the incidence and viability of tumor cell involvement in PBSC and BM collections from breast cancer patients undergoing high-dose chemotherapy/hematopoietic stem cell transplantation. Paired samples of PBSC and BM from 48 patients were analyzed using an immunocytochemical technique that detects one epithelial-derived tumor cell per 5 x 10(5) mononuclear cells. Immunostained tumor cells were detected in 9.8% (13/133) PBSC specimens from 9/48 (18.7%) patients and in 62.3% (38/61) BM specimens from 32/48 (66.7%) patients, a significantly higher rate than in PBSC (P < .005). The geometric mean concentration of tumor cells in contaminated PBSC specimens was 0.8/10(5) mononuclear cells (range 0.33 to 2.0/10(5)) compared with 22.9/10(5) mononuclear cells in BM (range 1 to 3,000/10(5), P < .0001). In culture experiments, clonogenic tumor colonies grew in 21/26 immunocytochemically positive specimens. No tumor colony growth was detected in 30/32 immunocytochemically negative specimens. Immunocytochemical detection of tumor involvement in BM and PBSC correlated significantly with in vitro clonogenic growth (P < .0001). We conclude that PBSC contain fewer tumor cells than paired BM specimens from patients with advanced breast cancer and that these tumor cells appear to be capable of clonogenic growth in vitro.