Ultrasound-Guided Regional Anesthesia Simulation Training: A Systematic Review.

BACKGROUND AND OBJECTIVES: Ultrasound-guided regional anesthesia (UGRA) has become the criterion standard of regional anesthesia practice. Ultrasound-guided regional anesthesia teaching programs often use simulation, and guidelines have been published to help guide URGA education. This systematic review aimed to examine the effectiveness of simulation-based education for the acquisition and maintenance of competence in UGRA. METHODS: Studies identified in MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and ERIC were included if they assessed simulation-based UGRA teaching with outcomes measured at Kirkpatrick level 2 (knowledge and skills), 3 (transfer of learning to the workplace), or 4 (patient outcomes). Two authors independently reviewed all identified references for eligibility, abstracted data, and appraised quality. RESULTS: After screening 176 citations and 45 full-text articles, 12 studies were included. Simulation-enhanced training improved knowledge acquisition (Kirkpatrick level 2) when compared with nonsimulation training. Seven studies measuring skill acquisition (Kirkpatrick level 2) found that simulation-enhanced UGRA training was significantly more effective than alternative teaching methods or no intervention. One study measuring transfer of learning into the clinical setting (Kirkpatrick level 3) found no difference between simulation-enhanced UGRA training and non-simulation-based training. However, this study was discontinued early because of technical challenges. Two studies examined patient outcomes (Kirkpatrick level 4), and one of these found that simulation-based UGRA training improved patient outcomes compared with didactic teaching. CONCLUSIONS: Ultrasound-guided regional anesthesia knowledge and skills significantly improved with simulation training. The acquired UGRA skills may be transferred to the clinical setting; however, further studies are required to confirm these changes translate to improved patient outcomes.

Coxiella burnetii Infection in a Community Operating a Large-Scale Cow and Goat Dairy, Missouri, 2013.

Coxiella burnetii is a zoonotic pathogen that causes Q fever in humans and is transmitted primarily from infected goats, sheep, or cows. Q fever typically presents as an acute febrile illness; however, individuals with certain predisposing conditions, including cardiac valvulopathy, are at risk for chronic Q fever, a serious manifestation that may present as endocarditis. In response to a cluster of Q fever cases detected by public health surveillance, we evaluated C. burnetii infection in a community that operates a large-scale cow and goat dairy. A case was defined as an individual linked to the community with a C. burnetii phase II IgG titer ≥ 128. Of 135 participants, 47 (35%) cases were identified. Contact with or close proximity to cows, goats, and their excreta was associated with being a case (relative risk 2.7, 95% confidence interval 1.3-5.3). Cases were also identified among individuals without cow or goat contact and could be related to windborne spread or tracking of C. burnetii on fomites within the community. A history of injection drug use was reported by 26/130 (20%) participants; follow-up for the presence of valvulopathy and monitoring for development of chronic Q fever may be especially important among this population.

No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever.

OBJECTIVE: To evaluate whether cosmetically relevant dental effects occurred among children who had received doxycycline for treatment of suspected Rocky Mountain spotted fever (RMSF). STUDY DESIGN: Children who lived on an American Indian reservation with high incidence of RMSF were classified as exposed or unexposed to doxycycline, based on medical and pharmacy record abstraction. Licensed, trained dentists examined each child's teeth and evaluated visible staining patterns and enamel hypoplasia. Objective tooth color was evaluated with a spectrophotometer. RESULTS: Fifty-eight children who received an average of 1.8 courses of doxycycline before 8 years of age and who now had exposed permanent teeth erupted were compared with 213 children who had never received doxycycline. No tetracycline-like staining was observed in any of the exposed children's teeth (0/58, 95% CI 0%-5%), and no significant difference in tooth shade (P=.20) or hypoplasia (P=1.0) was found between the 2 groups. CONCLUSIONS: This study failed to demonstrate dental staining, enamel hypoplasia, or tooth color differences among children who received short-term courses of doxycycline at <8 years of age. Healthcare provider confidence in use of doxycycline for suspected RMSF in children may be improved by modifying the drug's label.

Community-based control of the brown dog tick in a region with high rates of Rocky Mountain spotted fever, 2012-2013.

Rocky Mountain spotted fever (RMSF) transmitted by the brown dog tick (Rhipicephalus sanguineus sensu lato) has emerged as a significant public health risk on American Indian reservations in eastern Arizona. During 2003-2012, more than 250 RMSF cases and 19 deaths were documented among Arizona's American Indian population. The high case fatality rate makes community-level interventions aimed at rapid and sustained reduction of ticks urgent. Beginning in 2012, a two year pilot integrated tick prevention campaign called the RMSF Rodeo was launched in a ∼ 600-home tribal community with high rates of RMSF. During year one, long-acting tick collars were placed on all dogs in the community, environmental acaricides were applied to yards monthly, and animal care practices such as spay and neuter and proper tethering procedures were encouraged. Tick levels, indicated by visible inspection of dogs, tick traps and homeowner reports were used to monitor tick presence and evaluate the efficacy of interventions throughout the project. By the end of year one, <1% of dogs in the RMSF Rodeo community had visible tick infestations five months after the project was started, compared to 64% of dogs in Non-Rodeo communities, and environmental tick levels were reduced below detectable levels. The second year of the project focused on use of the long-acting collar alone and achieved sustained tick control with fewer than 3% of dogs in the RMSF Rodeo community with visible tick infestations by the end of the second year. Homeowner reports of tick activity in the domestic and peridomestic setting showed similar decreases in tick activity compared to the non-project communities. Expansion of this successful project to other areas with Rhipicephalus-transmitted RMSF has the potential to reduce brown dog tick infestations and save human lives.