Paramedic Endotracheal Intubation Success Rates Before and After an Intensive Airway Management Education Session.

Introduction Advanced airway management by paramedics is potentially life-saving, but carries a significant risk to patient safety and can be associated with poor clinical outcome if performed incorrectly. Previously, our team had found that an intensive education intervention demonstrated an improvement in paramedic performance on a written exam and increased confidence in airway skills. This study measured intubation success and the number of attempts per patient before and after intensive paramedic airway management education intervention. Methods A 10-hour mandatory course was taken by all advanced life support (ALS) paramedics in a provincial system (2009/04-07, n=~395). The course was done during semi-annual continuing education Emergency Health Services (EHS) in-services. These day-long courses were held in person over four months. The electronic charting database was queried for intubation attempts and successful placements 12 months before the training, during the four months of training, and 12 months post-training. The primary outcome is the difference in success rates between the before (pre-intervention) and after (post-intervention) periods. The secondary outcome is the number of attempts per patient. Stationarity of success in pre- and post-periods was tested. The model was fit tested using Maximum Likelihood regression, and variables were tested using the Wald test. Results A sample size of 476 intubation attempts in each of the pre- and post-periods was required to detect a 10% improvement with the pre-intervention success of 60%. A total of 1421 intubation attempts occurred; 674 pre-intervention, 604 post-intervention, and 143 during teaching. Seven attempts were excluded (success unknown). Intubation success rates improved, from 0.68 (95% CI 0.64-0.71) to 0.75 (95% CI 0.72-0.78); a difference of 0.076 (95% CI 0.03-0.12) (p = 0.001). Intubation success rates in the pre-intervention and post-intervention periods were found to be static. A significant decrease was found in the number of attempts per patient in the post-period (p = 0.005). Conclusion Intubation success increased from 68% to 75% and was maintained over the 12-month post-period. There is a potential that judgment may also have improved, based on the decreased number of attempts per patient. Limitations include missing values, paramedics' self-reported number of attempts, and the definition of what is considered to be an attempt. In addition to previously demonstrated improvements in paramedic exam and scenario performance, this airway education intervention appears to have made a significant improvement to patient outcomes. These findings support the value of such education interventions to improve performance.

Pediatric Secondary Transfer Percentages: A Retrospective Observational Study.

INTRODUCTION: Certain adult conditions treated by paramedics, such as myocardial infarction or stroke, have better outcomes if transported to a specialty centre, bypassing local generalist facilities when necessary. Little evidence exists to inform guidelines to identify pediatric patients who would benefit from direct transport to a pediatric centre. This study describes the characteristics of children brought to community emergency departments (ED) who subsequently required transfer to pediatric specialty care. METHODS: A retrospective observational cohort study was performed in a metropolitan area with one tertiary pediatric specialty centre and four community EDs. The patient care record database was queried for patients under 16 years old transported by paramedics to a community ED during a five-year period. Secondary transfer to the pediatric specialty centre within 24 hours was identified. The primary outcome was percentage of transfers to specialty care. Descriptive statistics were used to characterize the whole group as well as stratified by age category, chief complaint and Canadian Triage Acuity Scale (CTAS). RESULTS: A total of 872 pediatric patients were transported to community EDs with 95 (10.9%) requiring secondary transfer to the pediatric specialty centre. CTAS 1 and 2 were associated with increased secondary transfer (p<0.001). There were also differences in transfer proportion by chief complaint. There was no association between age or gender and transfer to pediatric specialty care. CONCLUSIONS: This retrospective study shows an association between acuity and certain chief complaints and percentage of secondary transfer to pediatric specialty care.

Chest compression fraction in simulated cardiac arrest management by primary care paramedics: King laryngeal tube airway versus basic airway management.

OBJECTIVE: The objective of this randomized simulation study was to determine whether use of the King laryngeal tube (KLT) airway resulted in differences in chest compression fraction (CCF) during simulated cardiac arrest managed by primary care paramedics (PCPs), as compared with basic airway management (bag-mask ventilation [BMV]). METHODS: The KLT was introduced to all providers in our system at the time of study initiation. All participants received the same training, and were not aware that the primary outcome of the study was CCF. Standard airway management by PCPs prior to this was BMV. Pairs of PCPs were randomized to use KLT or BMV during a scripted 6-minute cardiac arrest scenario. The scenarios were videotaped, and data were abstracted by a single investigator. The CCF was calculated (fraction of time chest compressions were done/total scenario time). The CCF, number of seconds to first ventilation, and number of seconds to first compression were compared using the Mann-Whitney U test. RESULTS: Sixty-seven pairs of PCPs participated: 30 in the KLT arm and 37 in the BMV arm. Demographics were similar in each group: KLT 68.3% males, BMV 55.4% males; KLT mean age 33.52 years (standard deviation [SD]: 11.95), BMV mean age 32.07 years (SD: 8.78); and KLT mean years of experience 9.03 (SD: 9.86), BMV mean years of experience 6.59 (SD: 6.58). The CCF was higher in the KLT group: median 0.82 (interquartile range [IQR] 0.71-0.88) compared with the BMV group: median 0.70 (IQR 0.66-0.73), p < 0.001. Time to first ventilation was longer in the KLT group: median 83.00 sec (IQR 43.75-139.25 sec) than in the BMV group: median 48.00 sec (IQR 37.00-71.00 sec), p = 0.004. Times to first compression were similar: KLT median 13.00 sec (IQR 8.00-17.00 sec), BMV median 14.00 sec (IQR 11.00-18.50 sec), p = 0.331. CONCLUSION: In this randomized simulation study, KLT use by PCPs during simulated standard cardiac arrest scenarios was found to significantly increase CCF compared with basic airway management with BMV.

The impact of intense airway management training on paramedic knowledge and confidence measured before, immediately after and at 6 and 12 months after training.

INTRODUCTION: Airway management is a core component in the practice of advanced life support (ALS) paramedics. OBJECTIVE: To determine if an intense airway management course would improve ALS paramedic knowledge and confidence and if knowledge was retained over time. METHODS: An identical written survey (measuring demographics and confidence) and multiple-choice examination (measuring knowledge) was administered at the start and end of a 10 h airway course. At 6 and 12 months after the course, paramedics took the knowledge examination. Paired confidence and written knowledge examination scores before and immediately after the course were compared. Differences between knowledge examination scores at all four time points (before, immediately after and at 6 and 12 months) were tested using analysis of variance and Tukey's test. RESULTS: 299 ALS paramedics were enrolled in the study. 209 (69%) reported 6 or more years of ALS experience. The mean pre-course confidence score was 2.74/4 and the mean post-course confidence score was 3.39/4; a difference of 0.7 points (95% CI 0.61 to 0.71). Post-course examination scores improved by 4.9 points (95% CI 4.58 to 5.20), from 7.7 to 12.6/20. At 6 months the mean score was 10.3/20, and at 12 months 10.2/20. Post-course scores were significantly better than pre-course scores. Scores at 6 and 12 months did not differ significantly and remained significantly improved from pre-course scores. CONCLUSION: Significant improvement in confidence and knowledge was found after paramedics completed an intense airway management course. Knowledge at 6 and 12 months remained significantly better compared with pre-course.

A novel non-containing-nitrogen bisphosphonate inhibits both in vitro and in vivo angiogenesis.

Bisphosphonates (BP) are powerful inhibitors of bone resorption and are widely used in the treatment of patients with metastasis-induced osteolysis. In the present study, we show that a novel non-nitrogen-containing BP (BP7033) that exhibits antitumor activity is a potent inhibitor of both in vivo and in vitro angiogenesis. When administered to mice, BP7033 inhibited tumoral angiogenesis (65% at 0.06mg/injection) as well as tumor growth (65% at 0.006mg/injection) in a tumor model of A431 cells xenografted in nude mice, with no sign of toxicity. Additionally, in vivo angiogenesis induced by vascular endothelial growth factor-containing Matrigel implants was reduced by 90% in the presence of BP7033 (0.6mg/plug). In vitro, BP7033 inhibited proliferation of human umbilical vein endothelial cells (HUVEC) (IC(50) value 3x10(-4) M) and completely prevented the formation of capillary-like tubules by HUVEC in Matrigel. Moreover, treatment of A431 cells by BP7033 induced an inhibition of Ras processing and a decrease in the secretion of both vascular endothelial growth factor and matrix metalloproteinase-2, two well-known stimulators of the proliferation and migration of endothelial cells. These findings indicate that this new BP compound has marked antiangiogenic properties and thus represents a promising candidate for treatment of malignant diseases with an angiogenic component.

Aminoglycoside and glycopeptide renal toxicity in intensive care patients studied by proton magnetic resonance spectroscopy of urine.

OBJECTIVE: Aminoglycoside and glycopeptide antibiotics are responsible for renal toxicity. In most cases, the nephrotoxicity is limited to a reversible tubular injury, but an acute and sustained renal failure may occur. The aim of our study was to explore the renal function of patients given these antimicrobial agents with proton magnetic resonance spectroscopy of urine. This technique is able to detect, in urine samples, a wide range of metabolites reflecting renal tubular function. The variables assessed by magnetic resonance spectroscopy were compared with the routine markers of renal function: creatinine, urea, and 24-hr urine volume. DESIGN: Prospective clinical study. SETTING: Intensive care unit. PATIENTS: All patients in an intensive care unit receiving an aminoglycoside and/or a glycopeptide were included in the study if they presented with signs of renal dysfunction. All experiments were performed on urine samples collected for the routine follow-up of these patients. INTERVENTION: Proton spectra were acquired with water suppression, and the peak intensity of each metabolite was reported in relationship to the intensity of the creatinine peak. MEASUREMENTS AND MAIN RESULTS: The ratio values obtained by magnetic resonance spectroscopy were compared with the values of creatininemia and blood urea obtained routinely by biochemistry and with the value of the 24-hr urine volume by logistic regression and general linear models. This statistical analysis showed that the ratio of dimethylamine to creatinine was highly correlated with creatininemia. CONCLUSIONS: Dimethylamine is an osmolyte released from the medullar region of the kidney. Thus, our study demonstrated that nephrotoxicity from aminoglycosides and glycopeptides is not limited to proximal tubular toxicity but also may involve the medullar region (Henle loop and collecting duct) of the nephron.

Bisphosphonate chelating agents. Coordination ability of 1-phenyl-1-hydroxymethylene bisphosphonate towards Cu(2+) ions.

Potentiometric and EPR data allow for evaluation of the coordination equilibria in the Cu(2+)-bisphosphonate system. The bisphosphonic ligand was found very efficient in Cu(2+) chelation with formation of monomeric and dimeric species. Two phosphonate groups are basic binding sites for metal ion. The involvement of hydroxyl in metal ion coordination is also likely, especially when one phosphonate is protected by dimethyl ester. As the metal bound phosphonate groups are relatively bulky (six oxygens) and their negative charge above pH 4 is high (four per ligand) the equimolar species is a dominant complex at physiological pH.

A new phenylacetate-bisphosphonate inhibits breast cancer cell growth by proapoptotic and antiangiogenic effects.

Sodium phenylacetate (NaPa) and some bisphosphonates demonstrated antiproliferative and proapoptotic properties against cancer. We have previously shown that NaPa inhibited cell proliferation of MCF7-ras tumor breast cells both in vitro and in vivo. On the other hand, bisphosphonate activities have only been demonstrated in vitro. Here we evaluated the antitumor effects of a new bisphosphonate, the phenylacetate-bisphosphonate (PaBp), on human breast cancer MCF7 and MCF7-ras cell lines, both in vitro and in vivo. To our knowledge, this is the first report indicating the use of a bisphosphonate derivative as a powerful cytostatic and cytotoxic agent, with proapoptotic and antiangiogenic properties on human breast cancer cells lines, with no animal toxicity.