Simulating Early Clinical Experiences With Surgical Procedures in the Anatomy Laboratory.

Background There is evidence to suggest that early exposure to clinical experiences could bolster a medical student's education and prepare them to tackle the problem-based learning encountered during clinical rotations. We hypothesized that incorporating common surgical procedures into the gross anatomy laboratory during preclinical years would enhance the anatomical learning experience for students. The incorporation of these procedures would not be disruptive to the normal conduct of the anatomy laboratory, nor result in exorbitant costs. Objectives The goal of a more integrated curriculum is to better enable medical students by providing them a unique learning experience, so that they may more readily recall the knowledge needed to deal with the complex problems of clinical work. Recognizing the importance of this concept, we have incorporated multiple common clinical procedures into our anatomy curriculum as a pilot program. Methods Seven common surgical procedures, including intraosseous needle insertion, venous cut-down, chest tube insertion, surgical cricothyroidotomy, core needle liver biopsy, appendectomy, and hysterectomy, were taught as a part of this study. Video instructions on each of the surgical procedures were provided before each corresponding laboratory. Surveys were distributed to study participants to measure their satisfaction with the procedures and whether or not it was disruptive to the allotted laboratory time. Results Both students and faculty who were sampled in the study reported that they were satisfied with the procedures (96.5% and 100%, respectively), that the procedures did not interfere with laboratory times (96% and 100%), and that the procedures facilitated clinical learning (98% and 100%). Conclusion This study demonstrated that providing a novel surgical teaching program to medical students was beneficial to their education and non-disruptive to the conventional anatomy curriculum. This exercise further facilitates osteopathic education by demonstrating how structure and function organize surgical practice. The integration of Edward Via College of Osteopathic Medicine, Auburn Campus's (VCOM-AC's) surgical procedures into other medical school anatomy courses can yield more prepared and confident students as they venture into their clinical rotations.

The aeromedical physician assistant.

The US Army aeromedical physician assistant (PA) serves aviation units in regards to crewmember medical readiness. All PAs are graduates of a 6-week flight surgeon course. They are responsible for conducting nearly 40% of the annual US Army flight physicals. This unique training and deployment illustrates the growing adaptability of PAs to assume a greater role in military medicine.

Compliance with antimalaria chemoprophylaxis in a combat zone.

Compliance with malaria chemoprophylaxis by military service members (MSMs) is notoriously low, ranging from 30% to 56%. Our objective was to determine the rate of compliance and reasons for non-compliance with malaria chemoprophylaxis among healthy US MSMs in Afghanistan. An eight-question, anonymous online survey was used to collect data regarding the compliance of healthy MSMs with malaria chemoprophylaxis. E-mail surveys were sent to 1,200 MSMs; 528 (44%) MSMs completed the survey. One-time daily doxycycline was the most commonly prescribed chemoprophylaxis (90%); 60% (N = 318) responded that they were compliant with their chemoprophylaxis as prescribed, whereas 40% (N = 221) indicated that they were not compliant. Compliance with daily dosing was 61% and weekly dosing was 38%. The most common reasons for non-compliance were gastrointestinal effects (39%), forgetfulness (31%), and low perception of risk (24%). Malaria chemoprophylaxis compliance by healthy MSMs in Afghanistan is poor. Side effects, forgetfulness, and lack of education are contributing factors. Commanders bear the primary responsibility for the health of their soldiers, and the individual MSM bears personal responsibility; however, additional public health interventions could possibly have a positive impact on prevention.

Improving compliance with malaria chemoprophylaxis in Afghanistan.

OBJECTIVE: Historically, compliance with malaria chemoprophylaxis by military service members (MSM) has been notoriously low, ranging from 30 to 56%. Since 2002, 28 to 85 cases per year of malaria have occurred in MSM deployed to Afghanistan. During their deployment to Afghanistan, the authors identified a low compliance rate with malaria chemoprophylaxis. A performance improvement project was developed to improve compliance. METHODS: In July 2011, a performance improvement plan was developed to improve malaria chemoprophylaxis compliance in MSM arriving on a remote base in western Afghanistan. The plan included a 15-minute briefing and a medical consultation for MSM who had discontinued their chemoprophylaxis because of side effects. At the conclusion of their deployment, the MSM were surveyed on their compliance. RESULTS: Ninety-four MSM attended the briefings. Eighty (85%) MSM completed the survey in October 2011. Ninety-eight percent were taking doxycycline (n = 78). Ninety percent (n = 72) reported that they were compliant with their chemoprophylaxis. One entire unit (n = 29) was identified to be critically short of doxycycline, which initiated an emergency order for medication. Two noncompliant soldiers requested a consultation concerning side effects and were able to continue their chemoprophylaxis. CONCLUSION: Personalized in-theater briefings and consultations by knowledgeable providers may improve compliance with malaria chemoprophylaxis in MSM in Afghanistan.

Interlaboratory evaluation of trace element determination in workplace air filter samples by inductively coupled plasma mass spectrometry.

Inductively coupled plasma mass spectrometry (ICP-MS) is becoming more widely used for trace elemental analysis in the occupational hygiene field, and consequently new ICP-MS international standard procedures have been promulgated by ASTM International and ISO. However, there is a dearth of interlaboratory performance data for this analytical methodology. In an effort to fill this data void, an interlaboratory evaluation of ICP-MS for determining trace elements in workplace air samples was conducted, towards fulfillment of method validation requirements for international voluntary consensus standard test methods. The study was performed in accordance with applicable statistical procedures for investigating interlaboratory precision. The evaluation was carried out using certified 37-mm diameter mixed-cellulose ester (MCE) filters that were fortified with 21 elements of concern in occupational hygiene. Elements were spiked at levels ranging from 0.025 to 10 µg filter(-1), with three different filter loadings denoted "Low", "Medium" and "High". Participating laboratories were recruited from a pool of over fifty invitees; ultimately twenty laboratories from Europe, North America and Asia submitted results. Triplicates of each certified filter with elemental contents at three different levels, plus media blanks spiked with reagent, were conveyed to each volunteer laboratory. Each participant was also provided a copy of the test method which each participant was asked to follow; spiking levels were unknown to the participants. The laboratories were requested to prepare the filters by one of three sample preparation procedures, i.e., hotplate digestion, microwave digestion or hot block extraction, which were described in the test method. Participants were then asked to analyze aliquots of the prepared samples by ICP-MS, and to report their data in units of µg filter(-1). Most interlaboratory precision estimates were acceptable for medium- and high-level spikes (RSD <25%), but generally yielded greater uncertainties than were anticipated at the outset of the study.

Preparation, certification and interlaboratory analysis of workplace air filters spiked with high-fired beryllium oxide.

Occupational sampling and analysis for multiple elements is generally approached using various approved methods from authoritative government sources such as the National Institute for Occupational Safety and Health (NIOSH), the Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA), as well as consensus standards bodies such as ASTM International. The constituents of a sample can exist as unidentified compounds requiring sample preparation to be chosen appropriately, as in the case of beryllium in the form of beryllium oxide (BeO). An interlaboratory study was performed to collect analytical data from volunteer laboratories to examine the effectiveness of methods currently in use for preparation and analysis of samples containing calcined BeO powder. NIST SRM(®) 1877 high-fired BeO powder (1100 to 1200 °C calcining temperature; count median primary particle diameter 0.12 µm) was used to spike air filter media as a representative form of beryllium particulate matter present in workplace sampling that is known to be resistant to dissolution. The BeO powder standard reference material was gravimetrically prepared in a suspension and deposited onto 37 mm mixed cellulose ester air filters at five different levels between 0.5 µg and 25 µg of Be (as BeO). Sample sets consisting of five BeO-spiked filters (in duplicate) and two blank filters, for a total of twelve unique air filter samples per set, were submitted as blind samples to each of 27 participating laboratories. Participants were instructed to follow their current process for sample preparation and utilize their normal analytical methods for processing samples containing substances of this nature. Laboratories using more than one sample preparation and analysis method were provided with more than one sample set. Results from 34 data sets ultimately received from the 27 volunteer laboratories were subjected to applicable statistical analyses. The observed performance data show that sample preparations using nitric acid alone, or combinations of nitric and hydrochloric acids, are not effective for complete extraction of Be from the SRM 1877 refractory BeO particulate matter spiked on air filters; but that effective recovery can be achieved by using sample preparation procedures utilizing either sulfuric or hydrofluoric acid, or by using methodologies involving ammonium bifluoride with heating. Laboratories responsible for quantitative determination of Be in workplace samples that may contain high-fired BeO should use quality assurance schemes that include BeO-spiked sampling media, rather than solely media spiked with soluble Be compounds, and should ensure that methods capable of quantitative digestion of Be from the actual material present are used.

Variable application and misapplication of cricoid pressure.

BACKGROUND: In 1961, Sellick described a three-finger technique of cricoid pressure used to prevent gastric regurgitation during induction of anesthesia. The "Sellick maneuver" is now used worldwide. The authors have observed great variability in the application of cricoid pressure by health care providers and have suspected that misapplication occurs. The objectives of this observational study were to determine how many different techniques of cricoid pressure were being used and to identify the reasons for such variability of technique. METHODS: During a 30-month period, the authors observed 32 health care providers applying cricoid pressure at five hospitals. The technique and the professional degree of the person performing the maneuver were recorded. We also reviewed five national courses that provide airway management training to determine which technique of cricoid pressure was being taught. RESULTS: Ten different techniques of cricoid pressure were identified in 32 observations. We identified cases in which pressure was mistakenly applied to the thyroid cartilage and sternocleidomastoid muscles. The original three-finger Sellick technique was rarely used (3 of 32). A review of five national training courses revealed that none provide specific cricoid pressure training. CONCLUSION: This observational study demonstrates that there is great variability in the application of cricoid pressure, identifying 10 different techniques in 32 observations. Misapplication does occur with possible patient harm. We suggest four possible reasons for this variability of technique. The authors use the three-finger cricoid pressure technique as originally described by Sellick and thought that this technique is effective, easy to teach, and safely keeps the fingers in the midline of the cricoid cartilage.

Interlaboratory evaluation of a standardized inductively coupled plasma mass spectrometry method for the determination of trace beryllium in air filter samples.

A collaborative interlaboratory evaluation of a newly standardized inductively coupled plasma mass spectrometry (ICP-MS) method for determining trace beryllium in workplace air samples was carried out toward fulfillment of method validation requirements for ASTM International voluntary consensus standard test methods. The interlaboratory study (ILS) was performed in accordance with an applicable ASTM International standard practice, ASTM E691, which describes statistical procedures for investigating interlaboratory precision. Uncertainty was also estimated in accordance with ASTM D7440, which applies the International Organization for Standardization Guide to the Expression of Uncertainty in Measurement to air quality measurements. Performance evaluation materials (PEMs) used consisted of 37 mm diameter mixed cellulose ester filters that were spiked with beryllium at levels of 0.025 (low loading), 0.5 (medium loading), and 10 (high loading) microg Be/filter; these spiked filters were prepared by a contract laboratory. Participating laboratories were recruited from a pool of over 50 invitees; ultimately, 20 laboratories from Europe, North America, and Asia submitted ILS results. Triplicates of each PEM (blanks plus the three different loading levels) were conveyed to each volunteer laboratory, along with a copy of the draft standard test method that each participant was asked to follow; spiking levels were unknown to the participants. The laboratories were requested to prepare the PEMs by one of three sample preparation procedures (hotplate or microwave digestion or hotblock extraction) that were described in the draft standard. Participants were then asked to analyze aliquots of the prepared samples by ICP-MS and to report their data in units of mu g Be/filter sample. Interlaboratory precision estimates from participating laboratories, computed in accordance with ASTM E691, were 0.165, 0.108, and 0.151 (relative standard deviation) for the PEMs spiked at 0.025, 0.5, and 10 microg Be/filter, respectively. Overall recoveries were 93.2%, 102%, and 80.6% for the low, medium, and high beryllium loadings, respectively. Expanded uncertainty estimates for interlaboratory analysis of low, medium, and high beryllium loadings, calculated in accordance with ASTM D7440, were 18.8%, 19.8%, and 24.4%, respectively. These figures of merit support promulgation of the analytical procedure as an ASTM International standard test method, ASTM D7439.

The real issue with wall deposits in closed filter cassettes--what's the sample?

The measurement of aerosol dusts has long been utilized to assess the exposure of workers to metals. Tools used to sample and measure aerosol dusts have gone through many transitions over the past century. In particular, there have been several different techniques used to sample for beryllium, not all of which might be expected to produce the same result. Today, beryllium samples are generally collected using filters housed in holders of several different designs, some of which are expected to produce a sample that mimics the human capacity for dust inhalation. The presence of dust on the interior walls of cassettes used to hold filters during metals sampling has been discussed in the literature for a number of metals, including beryllium, with widely varying data. It appears that even in the best designs, particulates can enter the sampling cassette and deposit on the interior walls rather than on the sampling medium. The causes are not well understood but are believed to include particle bounce, electrostatic forces, particle size, particle density, and airflow turbulence. Historically, the filter catch has been considered to be the sample, but the presence of wall deposits, and the potential that the filter catch is not representative of the exposure to the worker, puts that historical position into question. This leads to a fundamental question: What is the sample? This article reviews the background behind the issue, poses the above-mentioned question, and discusses options and a possible path forward for addressing that question.

Interlaboratory evaluation of an extraction and fluorescence method for the determination of trace beryllium in soils.

Analytical methods for the determination of trace beryllium in soils are needed so that anthropogenic sources of this element can be distinguished from native (background) levels of beryllium. In this work, a collaborative interlaboratory evaluation of a new extraction and fluorescence-based procedure for determining beryllium in soil samples was carried out to fulfil method validation requirements for ASTM International voluntary consensus standard test methods. A Canadian reference material, CCRMP Till-1 soil, with a background beryllium concentration of 2.4 microg g(-1), was selected for study. This certified reference material (CRM) was spiked and homogenized with varying levels of beryllium oxide in order to give batches of material with beryllium concentrations of 4.36 +/- 0.69, 11.5 +/- 0.7, 124 +/- 7 and 246 +/- 16 microg g(-1) (+/- values are standard deviations). In the interlaboratory study (ILS), which was carried out in accordance with an applicable ASTM International standard practice (ASTM E691), samples of these spiked soils were subjected to extraction in dilute ammonium bifluoride at approximately 90 degrees C for 40 h. Fluorescence measurement of the extracted beryllium was carried out via detection using the high quantum yield fluorophore, hydroxybenzoquinoline sulfonate (HBQS). Interlaboratory precision estimates from six participating laboratories ranged from 0.048 to 0.103 (relative standard deviations) for the five different beryllium concentrations. Pooled bias estimates resulting from this ILS were between -0.049 and 0.177 for the various beryllium levels. These figures of merit support promulgation of the analytical procedure as an ASTM International standard test method.

Extraction and optical fluorescence method for the measurement of trace beryllium in soils.

Beryllium metal and beryllium oxide are important industrial materials used in a variety of applications in the electronics, nuclear energy, and aerospace industries. These materials are highly toxic, they must be disposed of with care, and exposed workers need to be protected. Recently, a new analytical method was developed that uses dilute ammonium bifluoride for extraction of beryllium and a high quantum yield optical fluorescence reagent to determine trace amounts of beryllium in airborne and surface samples. The sample preparation and analysis procedure was published by both ASTM International and the National Institute for Occupational Safety and Health (NIOSH). The main advantages of this method are its sensitivity, simplicity, use of lower toxicity materials, and low capital costs. Use of the technique for analyzing soils has been initiated to help meet a need at several of the U.S. Department of Energy legacy sites. So far this work has mainly concentrated on developing a dissolution protocol for effectively extracting beryllium from a variety of soils and sediments so that these can be analyzed by optical fluorescence. Certified reference materials (CRM) of crushed rock and soils were analyzed for beryllium content using fluorescence, and results agree quantitatively with reference values.

A theoretical framework for evaluating analytical digestion methods for poorly soluble particulate beryllium.

Complete digestion of all chemical forms and sizes of particulate analytes in environmental samples is usually necessary to obtain accurate results with atomic spectroscopy. In the current study, we investigate the physicochemical properties of beryllium particles likely to be encountered in samples collected from different occupational environments and present a hypothesis that a dissolution theory can be used as a conceptual framework to guide development of strategies for digestion procedures. For monodisperse single-chemical constituent primary particles, such as those encountered when handling some types of beryllium oxide (BeO) powder, theory predicts that a digestion procedure is sufficient when it completely dissolves all primary particles, independent of cluster size. For polydisperse single-chemical constituent particles, such as those encountered during the handling of some types of beryllium metal powder, theory predicts that a digestion procedure is sufficient only when it completely dissolves the largest particle in the sample. For samples with unknown or multi-chemical constituent particles and with particles having undefined sizes, e.g., fume emissions from a copper-beryllium alloy furnace operation or dust from a beryl ore crushing operation, a surface area-limited and single-constituent-dependent dissolution theory may not predict complete dissolution, thereby requiring non-routine robust treatment procedures with post-digestion filtration, followed by examination of residual particulate material. Additionally, for beryllium, and likely other poorly soluble materials, particulate reference materials of various chemical forms and size distributions are needed to better evaluate and harmonize analytical digestion procedures. Figure Generation of aerosol particles during machining of beryllium oxide.

Trace-level beryllium analysis in the laboratory and in the field: state of the art, challenges and opportunities.

Control of workplace exposure to beryllium is a growing issue in the United States and other nations. As the health risks associated with low-level exposure to beryllium are better understood, the need increases for improved analytical techniques both in the laboratory and in the field. These techniques also require a greater degree of standardization to permit reliable comparison of data obtained from different locations and at different times. Analysis of low-level beryllium samples, in the form of air filters or surface wipes, is frequently required for workplace monitoring or to provide data to support decision-making on implementation of exposure controls. In the United States and the United Kingdom, the current permissible exposure level is 2 microg m(-3) (air) and the United States Department of Energy has implemented an action level of 0.2 microg m(-3) (air) and 0.2 microg/100 cm(2) (surface). These low-level samples present a number of analytical challenges, including (1) a lack of suitable standard reference materials, (2) unknown robustness of sample preparation techniques, (3) interferences during analysis, (4) sensitivity (sufficiently low detection limits), (5) specificity (beryllium speciation) and (6) data comparability among laboratories. Additionally, there is a need for portable, real-time (or near real-time) equipment for beryllium air monitoring and surface wipe analysis that is both laboratory-validated and field-validated in a manner that would be accepted by national and/or international standards organizations. This paper provides a review of the current analytical requirements for trace-level beryllium analysis for worker protection and also addresses issues that may change those requirements. The current analytical state of the art and relevant challenges facing the analytical community will be presented, followed by suggested criteria for real-time monitoring equipment. Recognizing and addressing these challenges will present opportunities for laboratories, research and development organizations, instrument manufacturers and others.