Effects of COVID-19 on EMS Refresher Course Completion and Delivery

Introduction: The COVID pandemic has significantly impacted educational development and delivery, yet there is little quantitative research on this topic. The primary objective of this study was to compare the total number of Emergency Medical Service (EMS) Refresher (ER) course completions during 2020 versus prior years. Secondary outcomes examined in person versus on-line/distributive learning during the study period. Methods: The Commission on Accreditation for Prehospital Continuing Education (CAPCE) is the only national organization that accredits continuing education (CE) for paramedics and EMTs and currently has a database with over 14 million CE records. The total number of ER course completions each month in 2020 were compared to 2019 and 2018. We also compared the different educational format types: live in-person (LIP), asynchronous on-line distributive learning (DL), and virtual instructor lead training (VILT) synchronous DL courses. Data was analyzed using descriptive and two-way ANOVA statistics. Results: There were 1,922,783 ER course completions in 2020 versus 1,166,335 in 2019 and 1,074,636 in 2018, representing a 179% increase during the study period. Asynchronous DL course completions in 2020 were 1,830,513 EMS versus 1,078,580 in 2019 and 987,749 in 2018 a 185% increase over the three-year study period. Asynchronous DL monthly means by year was statistically significant, F(2, 99) = 95.632, p < .001. Mean monthly LIP and VLIT educational deliveries by year were not significantly different, p = .802, p = .754, respectively. Total LIP course completions in 2020 were 20,045 versus 51,552 in 2019 and 63,058 in 2018. In 2020 LIP courses made up only 1.0% (20,045/1,922,783) of all ER completions. This study was limited to only EMS professionals taking ER course completions in the CAPCE database. However EMS is not unique, since previous research has suggested that DL has flourished in other health care disciplines while LIP courses have continued to decrease. Conclusion: This large nationwide study of EMS profession has shown the trend toward DL education and a trend away from LIP courses. Future studies should examine the advantages and disadvantages of DL education.

Peroxiredoxin V in multiple sclerosis lesions: predominant expression by astrocytes

Oxidative stress is implicated in the pathogenesis of multiple sclerosis (MS). Defence against oxidative damage is mediated by antioxidants. Peroxiredoxin V (PRDX V) is an intracellular anti-oxidant enzyme with peroxynitrite reductase activity. It is increased during inflammation, when free radical production intensifies, and is protective in an animal model of brain injury. However, little is known about PRDX V expression in the human brain. We investigated PRDX V expression in white matter from normal human brain (n = 5) and MS patients (n = 18), using immunohistochemistry and immunoblotting. A global increase in PRDX V was evident in MS normal-appearing white matter (NAWM) but the most striking increase was in astrocytes in MS lesions. PRDX V- positive hypertrophic reactive astrocytes were seen in acute lesions where inflammation was present. Yet surprisingly, in chronic lesions (CL), where inflammation has abated and a glial scar formed, there was strong PRDX V staining of post-reactive, scar astrocytes. Furthermore, immunoblotting analysis of tissue from two MS cases confirmed a substantial increase in PRDX V expression in CL compared with NAWM from the same individual. This might indicate ongoing oxidative stress despite the absence of histologically defined inflammation. Further investigations of this phenomenon will be of interest for therapeutic targeting.

Pulmonary antioxidant concentrations and oxidative damage in ventilated premature babies

OBJECTIVE

To determine the relation between lipid peroxidation and the antioxidants ascorbate, urate, and glutathione in epithelial lining fluid in ventilated premature babies, and to relate the biochemical findings to clinical outcome.

DESIGN

A cohort study conducted between January 1999 and June 2001.

SETTING

A NHS neonatal intensive care unit.

PATIENTS

An opportunity sample of 43 ventilated babies of less than 32 weeks gestation.

MAIN OUTCOME MEASURES

The duration of supplementary oxygen according to the definition of bronchopulmonary dysplasia (BPD; oxygen dependency at 36 weeks gestational age).

METHODS

Epithelial lining fluid was sampled by bronchoalveolar lavage. Ascorbate, urate, glutathione, and malondialdehyde (a marker of lipid peroxidation) were measured.

RESULTS

Babies who developed BPD had significantly lower initial glutathione concentrations (mean (SEM) 1.89 (0.62) v 10.76 (2.79) microM; p = 0.043) and higher malondialdehyde concentrations (mean (SEM) 1.3 (0.31) v 0.345 (0.09) microM; p < 0.05) in the epithelial lining fluid than those who were not oxygen dependent. These variables were poor predictors of the development of BPD. Gestational age, endotracheal infection, and septicaemia had good predictive power. The level of oxidative damage was associated with the presence of endotracheal infection/septicaemia rather than inspired oxygen concentration.

CONCLUSIONS

Endotracheal infection, septicaemia, and gestational age, rather than antioxidant concentrations, are the most powerful predictors of the development of BPD.

Astrocyte characterization in the multiple sclerosis glial scar

Dense astrocytic scarring in chronic multiple sclerosis (MS) plaques produces an inhibitory environment which can impede tissue repair. Animal studies have shown that the antigenic phenotype of the most abundant cell type in the brain, the astrocyte, varies depending on astrocyte type and location. To identify the phenotype of scar astrocytes (SAs) in chronic lesions, markers of reactive astrocytes characterized in animal studies were investigated. To date these are the only established markers. Cerebral subventricular deep white matter from normal control, MS normal appearing white matter and lesions (acute, subacute and chronic) were examined by immunohistochemistry and immunoblotting. The antigenic profile of SAs revealed significant modification of astrocyte protein expression in chronic MS lesions. SAs express nestin, embryonic neural cell adhesion molecule, fibroblast growth factor receptor 4, epidermal growth factor receptor, nerve growth factor and a subpopulation of SAs also express basic fibroblast growth factor. These are in addition to the expected markers glial fibrillary acidic protein, vimentin, and the tenascins C and R. Therefore, an SA antigenic phenotype has now been defined. This knowledge may allow the development of therapeutic strategies that prevent scar formation and promote tissue repair.

Carbon monoxide poisoning in racing car drivers

BACKGROUND

To determine if carbon monoxide (CO) exposure during competition racing is significant enough to cause post-racing symptoms among professional racing drivers.

METHODS

Closed vehicle professional racing drivers were questioned after competition regarding symptoms consistent with heat exposure, dehydration, and carbon monoxide poisoning. All drivers, regardless of symptoms, underwent expired CO monitoring using a breath analyzer both before and after competition events. CO measurements were performed prior to any post-race interviews. Driver smoking history, laps at low speed (under caution), cockpit fire or damage to the exhaust system were also noted. An association between driver symptoms, track and vehicle condition, and increases in expired CO levels during racing was sought.

RESULTS

Twenty-eight drivers completed the study. Each driver was tested both before and after each competition event, and some drivers were tested at different tracks. All of the tested drivers experienced an increase in carboxyhemoglobin concentrations during the competition event. Drivers who smoked had higher baseline levels than non-smokers, but were no more likely to have symptoms. The driver with the highest post-race CO level was exposed to a fire which completely destroyed the vehicle, but he complained of no symptoms after the race. Most drivers complained of post-race symptoms or appeared symptomatic, but no correlation could be shown between post-race CO levels and symptoms.

CONCLUSIONS

There is a mild increase in driver CO levels during professional road racing competition, however, no correlation with CO level and driver symptomatology can be demonstrated. Carbon monoxide does not appear to be a significant cause of post-race driver symptoms such as fatigue, nausea, headache, and weakness.

Serum iron concentrations and symptoms of acute iron poisoning in children

STUDY OBJECTIVE

To determine whether serum iron concentrations correlate with the development of symptoms of iron poisoning in children.

DESIGN

A retrospective study of medical records from January 1976 through June 1992.

SETTING

A tertiary care children's medical center.

PATIENTS

Criteria for patient selection included an acute ingestion of iron-containing drugs, measurement of serum iron prior to deferoxamine administration, and a serum iron concentration (obtained within 2-9 hours of exposure) that was greater than 150 micrograms/dl (27 mumol/L). Of the 128 children who were hospitalized for acute iron poisoning, 92 patients (mean age 2.3 +/- 2.2 years) met the selection criteria.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The mean (+/-SD) serum iron concentrations (microgram/dl) of patients who exhibited cardiovascular instability (725 +/- 555, n = 6; p < 0.001) differed from those categorized with central nervous system changes (373 +/- 77, n = 30), gastrointestinal symptoms (334 +/- 83, n = 44), and no symptoms (368 +/- 102, n = 12). Serum iron concentrations in patients with cardiovascular instability ranged from 205-500 micrograms/dl (37-269 mumol/L), whereas those with no symptoms ranged from 170-513 micrograms/dl (30 to 92 mumol/L) demonstrating considerable overlap of ranges.

CONCLUSIONS

Serum iron concentrations do not necessarily relate to acute toxicity, and further study is needed to demonstrate the value of serum iron concentrations and to identify alternative strategies in the emergency assessment of the acutely poisoned child.

Relationship of serum iron and nonprotein-bound iron concentrations following administration of ferrous sulfate in pigs

A prospective analytical study was conducted to determine the relationship between nonprotein-bound iron and serum iron concentrations following gastric instillation of ferrous sulfate. Four female pigs (20-22 kg) with indwelling central venous lines and gastrostomy tubes were studied. A 5% solution of ferrous sulfate (20 mg elemental iron/kg bwt) was administered through the gastrostomy tube over 1 to 2 min. Six hourly blood samples were collected, and serum samples were subjected to ultrafiltration with the filtrate representing nonprotein-bound iron. Iron concentrations were determined by atomic absorption spectrophotometry. Baseline (mean +/- SD) iron concentrations were 73 +/- 25 micrograms/dL as the serum total and 21 +/- 4 micrograms/dL as nonprotein-bound iron. The serum iron and nonprotein-bound iron concentrations achieved a peak of 191 +/- 66 and 23 +/- 10, respectively, at 2 h and declined to near baseline values at 6 h. The mean ratio of filtrate to serum iron concentration was 0.16 +/- 0.08 and ranged from 0.08 to 0.29. Nonprotein-bound iron did not increase as the serum iron concentration increased (r = 0.18) within the ranges achieved in the study. The absence of protein, particularly transferrin and albumin, was verified by electrophoresis. A form of apparent nonprotein-bound iron was isolated from serum by ultrafiltration and its concentration was relatively constant despite the rise and fall of total serum iron concentrations during the 6 h. These observations warrant further investigation to understand the development of toxicity in acute iron poisoning.

Correlation of drug pharmacokinetics and effectiveness of multiple-dose activated charcoal therapy

STUDY OBJECTIVE

To evaluate an animal model of multiple-dose activated charcoal (MDAC) therapy and correlate the pharmacokinetic properties of four drugs with the efficacy of MDAC.

DESIGN

Prospective, randomized, controlled, crossover design.

SETTING

A university animal research facility.

PARTICIPANTS

Seven female pigs (15 to 22 kg) with an indwelling central venous line and gastrostomy tube.

INTERVENTIONS

Acetaminophen (30 mg/kg), digoxin (30 micrograms/kg), theophylline (8.9 mg/kg), and valproic acid (18 mg/kg) were simultaneously administered intravenously over 12 minutes. In the experimental arm, 25 g activated charcoal was administered at 0, 2, 4, 6, 12, 18, 24, and 30 hours through the gastric tube. In the control arm, an equal volume of water was given at the same times. Blood specimens were obtained over 36 hours to measure serum drug concentrations.

RESULTS

Each drug exhibited enhanced elimination (P < .01) in the MDAC group except valproic acid. Lower intrinsic clearance was correlated (P < .05) with increased systemic elimination during the charcoal arm. Volume of distribution, half-life, and protein binding were not significantly correlated with charcoal-enhanced systemic drug elimination.

CONCLUSION

The response of a drug to MDAC may be affected by its intrinsic clearance. The restrictive nature of the protein binding of valproic acid may be responsible for its lack of response. Results with the porcine model are consistent with the effects observed in human beings.

Pharmacists' use of safety caps on refilled prescriptions

Investigations have shown that pharmacists' use of child-resistant containers for dispensing prescriptions has been inconsistent. Use of new child-resistant containers when refilling prescription orders, however, has not been studied. For this study, an investigator presented a prescription order for 30 amitriptyline 50-mg tablets to 50 randomly selected pharmacies in Memphis. Approximately three weeks later, the investigator returned the empty prescription vials to the pharmacies for refills. Of the 44 pharmacies that completed the study, 39 (89%) dispensed the original drug in child-resistant containers, and 38 (86%) dispensed the refill in child-resistant containers. Only 29 (66%) refilled prescriptions were placed in new prescription vials, as specified by federal regulation. Chain pharmacies were twice as likely (p < 0.005) to dispense the refills in new containers as were independent pharmacies.

Physician staffing in the emergency departments of public teaching hospitals: a national survey

STUDY HYPOTHESIS

To evaluate factors influencing emergency physician staffing patterns in an important subset of US hospitals.

DESIGN

Survey of emergency department directors and hospital administrators.

PARTICIPANTS

Member institutions of the National Association of Public Hospitals and the Council of Teaching Hospitals.

MEASUREMENTS

Of 498 hospitals enrolled, two mailings and telephone follow-up yielded 277 replies (56% response rate). To adjust for differences in ED size and volume, levels of staffing were converted to full-time equivalents (FTEs) per 10,000 annual ED visits.

RESULTS

Responding institutions included 160 private and 115 public hospitals, 74 of which were Veterans Administration hospitals. Formal medical school affiliation was noted by 86% of responding institutions, and 82 (30%) supported emergency medicine residency programs. Full-time attending emergency physician staffing varied widely, from less than one to more than three FTEs per 10,000 visits; however, mean levels of staffing at public hospitals did not differ significantly from private institutions (2.7 +/- 1.6 vs 2.5 +/- 3.1, respectively; P = .50). Three of four hospitals reported using part-time emergency physician attending but only 33% used nurse practitioners or physicians' assistants. Two thirds of responding hospitals used rotating house officers-in-training. Of note, hospitals that supported emergency medicine residency programs reported significantly higher levels of staffing by housestaff (2.2 +/- 1.8 vs 1.0 +/- 1.2 FTEs/10,000 visits; P less than .0004), but levels of total staffing by full- and part-time attending physicians were virtually identical (2.69 +/- 1.6 vs 2.67 +/- 2.6 FTEs/10,000 visits; respectively; P = .95). Marked variability in levels and patterns of ED staffing at public and teaching hospitals currently exists, but the differences are not explained by hospital ownership. The reasons for such variations and their implications for patient care must be explored.