Improving the introduction of telemedicine in pre-hospital emergency medicine: understanding users and how acceptability, usability and effectiveness influence this process.

INTRODUCTION: Increasing numbers of ambulance calls, vacant positions and growing workloads in Emergency Medicine (EM) are increasing the pressure to find adequate solutions. With telemedicine providing health-care services by bridging large distances, connecting remote providers and even patients while using modern communication technologies, such a technology seems beneficial. As the process of developing an optimal solution is challenging, a need to quantify involved processes could improve implementation. Existing models are based on qualitative studies although standardised questionnaires for factors such as Usability, Acceptability and Effectiveness exist. METHODS: A survey was provided to participants within a German county. It was based on telemedical surveys, the System Usabilty Scale (SUS) and earlier works describing Usability, Acceptability and Effectiveness. Meanwhile a telemedical system was introduced in the investigated county. A comparison between user-groups aswell as an exploratory factor analysis (EFA) was performed. RESULTS: Of n = 91 included participants n = 73 (80,2%) were qualified as emergency medical staff (including paramedics n = 36 (39,56%), EMTs n = 28 (30,77%), call handlers n = 9 (9,89%)) and n = 18 (19,8%) as emergency physicians. Most participants approved that telemedicine positively impacts EM and improved treatment options with an overall Usabilty Score of 68,68. EFA provided a 3-factor solution involving Usability, Acceptability and Effectiveness. DISCUSSION: With our results being comparable to earlier studies but telemedicine only having being sparsely introduced, a positive attitude could still be attested. While our model describes 51,28% of the underlying factors, more research is needed to identify further influences. We showed that Usability is correlated with Acceptability (strong effect), Usability and Effectiveness with a medium effect, likewise Acceptability and Effectiveness. Therefore available systems need to improve. Our approach can be a guide for decision makers and developers, that a focus during implementation must be on improving usability and on a valid data driven implementation process.

[Dr. Valentin Grandis and Dr. Virgilio Ducceschi, two italian masters who initiated Experimental Physiology at the Faculty of Medical Sciences - Universidad Nacional De Cordoba (Argentina)] / Dr. Valentin Grandis y Dr. Virgilio Ducceschi, Dos maestros italianos iniciadores de la Fisiología experimental en la Facultad de Ciencias Médicas - UNC.

This paper examines the significant contribution of Dr. Valentín Grandis and Dr. Virgilio Ducceschi to the founding and development of experimental physiology at the Faculty of Medical Sciences of the National University of Córdoba (UNC), Argentina. Although the most notable contribution to the field of experimental physiology in Argentina is attributed to Bernardo Alberto Houssay, this study highlights the importance of the previous and fundamental efforts of Grandis and Ducceschi, two Italian professors whose work in Buenos Aires and Córdoba laid the foundations for research and teaching in this discipline. The paper details how, in 1904, the arrival of Valentin Grandis at the UNC marked the formal beginning of the teaching and practice of experimental physiology at the institution, followed by the incorporation of Virgilio Ducceschi, who continued and expanded Grandis' legacy. The work of these two Italian masters involved not only the installation of a state-of-the-art laboratory but also the establishment of a solid academic and scientific foundation that would influence future generations of Argentine physicians and researchers. Through a detailed analysis of their biographies, scientific contributions, and the impact of their work, this paper illustrates how Grandis and Ducceschi were key figures in the development of medical science in Argentina, particularly in the field of experimental physiology. Furthermore, the study highlights the importance of their educational approach and their ability to train disciples who would continue their research, thus ensuring the permanence of their legacy at the National University of Córdoba and in Argentine science in general. In conclusion, this paper vindicates and celebrates the contributions of Valentín Grandis and Virgilio Ducceschi to the initiation of research and experimentation in physiology and biological chemistry at the UNC, highlighting their importance in the advancement of medicine and science in Argentina.

Este trabajo examina el significativo aporte de los doctores Valentín Grandis y Virgilio Ducceschi a la fundación y desarrollo de la fisiología experimental en la Facultad de Ciencias Médicas de la Universidad Nacional de Córdoba (UNC), Argentina. A pesar de que la contribución más notable en el campo de la fisiología experimental en Argentina se atribuye a Bernardo Alberto Houssay, este estudio destaca la importancia de los esfuerzos previos y fundamentales de Grandis y Ducceschi, dos profesores italianos cuyo trabajo en Buenos Aires y Córdoba sentó las bases para la investigación y la enseñanza de esta disciplina.   El trabajo detalla cómo, en 1904, la llegada de Valentín Grandis a la UNC marcó el inicio formal de la enseñanza y práctica de la fisiología experimental en la institución, seguida por la incorporación de Virgilio Ducceschi, quien continuó y expandió el legado de Grandis. La labor de estos dos maestros italianos no solo involucró la instalación de un laboratorio de vanguardia sino también el establecimiento de una sólida base académica y científica que influiría en generaciones futuras de médicos e investigadores argentinos.   A través de un análisis detallado de sus biografías, contribuciones científicas, y el impacto de su trabajo, este documento ilustra cómo Grandis y Ducceschi fueron figuras clave en el desarrollo de la ciencia médica en Argentina, particularmente en el ámbito de la fisiología experimental. Además, el estudio resalta la importancia de su enfoque educativo y su capacidad para formar discípulos que continuarían sus investigaciones, asegurando así la permanencia de su legado en la Universidad Nacional de Córdoba y en la ciencia argentina en general.   En conclusión, el presente trabajo reivindica y celebra las contribuciones de Valentín Grandis y Virgilio Ducceschi al inicio de la investigación y experimentación en fisiología y química biológica en la UNC, subrayando su importancia en el avance de la medicina y la ciencia en Argentina.

Addressing therapeutic inertia for asthma biologics: Lessons from the KOFU study.

Despite evidence-based guidelines and the availability of five biologics in Japan to treat severe asthma, approximately one-third of patients with severe asthma continue to have uncontrolled disease. This lack of appropriate evidence-based treatment is a complex issue resulting from therapeutic inertia, a lack of treatment intensification according to evidence-based guidelines for patients who are considered eligible but not receiving therapy, and is often driven by complex factors involving patients, physicians, and healthcare systems. The KOFU study, the largest cross-sectional Internet Survey for severe asthma in Japan, addressed potential barriers to starting biologic treatment and sought a solution for therapeutic inertia regarding asthma biologics. Although the burden of high medical costs is the largest barrier to initiating biologic treatment for patients, other important barriers were also revealed, including an incorrect perception of asthma severity or a poor recognition of the need for treatment intensification, a lack of proper communication with patients or a lack of confidence in the physicians, initiating biologics together with the complicated process of the insurance systems to ease the burden of high medical costs or strict criteria for the approval of biologics for health care insurance systems. Increased awareness and understanding of these barriers to biologic treatment may facilitate an optimal recommendation process to individualize treatment in patients with severe asthma.

A retrospective review of the utility of chest X-rays in diving and submarine medical examinations.

Introduction: Performance of routine Chest X-rays (CXRs) in asymptomatic individuals to assess hyperbaric exposure risk is controversial. The radiation risk may overshadow the low yield in many settings. However, the yield may be higher in certain settings, such as tuberculosis-endemic countries. We evaluated the utility of routine CXR in diving and submarine medical examinations in South Africa. Methods: Records of 2,777 CXRs during 3,568 fitness examinations of 894 divers and submariners spanning 31 years were reviewed to determine the incidence of CXR abnormality. Associated factors were evaluated using odds ratios and a binomial logistic regression model, with a Kaplan-Meier plot to describe the duration of service until first abnormal CXR. Results: An abnormal CXR was reported in 1.1% per person year of service, yielding a cumulative incidence of 6.5% (58/894) of the study participants. Only four individuals had a clinical indication for the CXR in their medical history. A range of potential pathologies were seen, of which 15.5% were declared disqualifying and the rest (84.5%) were treated, or further investigation showed that the person could be declared fit. Conclusions: In South Africa, a routine CXR has a role to play in detecting abnormalities that are incompatible with pressure exposures. The highest number of abnormalities were found during the initial examinations and in individuals with long service records. Only four individuals had a clinical indication for their CXR during the 31-year span of our study. Similar studies should be performed to make recommendations in other countries and settings.

Handheld echocardiographic screening for rheumatic heart disease by non-experts in rural South Kordofan, Sudan: Supporting task shifting for control of a serious disease.

BACKGROUND: Rheumatic heart disease (RHD) is a major and preventable cause of cardiac morbidity in Sudan. It can be detected early with a handheld echocardiography (HHE) machine. Our study aimed to screen for RHD in rural South Kordofan and to investigate the ability of non-experts to obtain good quality HHE records. METHODS: A cross-sectional study was conducted in South Kordofan, Sudan. A team of non-experts was trained for two weeks on handheld echocardiographic screening for RHD using a simplified protocol. Cases were recorded and reviewed by a pediatric cardiologist. Demographic and clinical features of screened subjects were studied. Descriptive statistics were presented as "number (%)" or "mean ± SD". RHD frequency was expressed as cases per 1000, and the Chi-Square test/Fisher's Exact test was used to compare RHD findings between different groups. RESULTS: A total of 467 subjects were screened. Echocardiographic quality was acceptable in 93% of recorded studies, hence 452 cases were included in the analysis. The disease frequency was found to be 50 per 1000. Out of 452 screened subjects (age 10-25 years), 23 were found to have RHD. The disease was mild in 70% and moderate or involving two valves in 30% of patients. Risk factors for the disease included the father's occupation and the village of residence. CONCLUSION: Shortly trained non-expert medicals can assist in RHD surveillance in remote areas using HHE for early detection and management. South Kordofan state is highly endemic to RHD and a control program needs to be implemented.

The usefulness of the RSTC medical questionnaire in pre-participation health risk assessment of recreational scuba divers in Hong Kong.

INTRODUCTION: The current practice in Hong Kong is to have potential recreational divers complete a Recreational Scuba Training Council self-declared medical statement (RSTC form) prior to participation in diving. There are no reports in the literature on the usefulness of the Chinese version of the form. METHODS: The Professional Association of Diving Instructors (PADI) RSTC form (Chinese version) was completed by 117 research participants who were then individually interviewed (without examination) to establish whether relevant information was not captured by the form. Any discrepancies or problems identified were recorded for further analysis. RESULTS: Among participants, 15.4% expressed difficulty in completing the RSTC form. Less than one-third (28.2%) replied 'all negative' to the questions. Some health conditions that could impose diving risks were not elicited by the questionnaire alone. Nevertheless, there was good sensitivity, specificity, positive predictive value and negative predictive value with the exception of a few questions. However, significant discrepancies were identified when comparing the English and Chinese versions. There was also uncertainty with aspects of implementation, including attitudes of the user and provider, reliability of self-declaration answers and the handling of completed questionnaires. CONCLUSIONS: Health screening with a questionnaire for recreational divers remains practical and acceptable. Full revision of the RSTC form in Chinese is recommended in view of problems with the construct validity and translation. People should be informed about the non-prescriptive approach of health assessment for recreational divers. Further research on the implementation of the form may help to improve the screening strategy in the future.

El funcionamiento del equipo de autoevaluación como garantía de la calidad en la carrera de Medicina / The functioning of the self-assessment team as a guarantee of quality in the Medicine career

RESUMEN La mejora continua de la calidad en la carrera de Medicina constituye no solo un reto, sino un compromiso para las actuales y futuras generaciones. En este sentido, la autoevaluación resulta trascendental. Para ello, es preciso contar con un equipo que lidere el proceso de forma efectiva. El presente artículo tiene como propósito reflexionar acerca de la estructura, funcionamiento, roles y responsabilidades del equipo de autoevaluación. Las valoraciones realizadas permiten precisar elementos en cuanto a su composición, y cualidades que deben distinguir a sus integrantes y al coordinador. Se presentan y ejemplifican funciones a desarrollar en el orden de la planificación y organización, de la ejecución y del control del proceso. Por otra parte, se señalan condiciones o requisitos que deben ser atendidos para el cumplimiento exitoso de las funciones enunciadas. Se enfatiza en la necesidad de la observancia de los aspectos señalados, para contribuir a la mejora continua de la calidad en la carrera de Medicina.

ABSTRACT The continuous improvement of quality in the Medicine career constitutes not only a challenge, but also a commitment for current and future generations. In this sense, self-evaluation is crucial. For this, it is necessary to have a team that leads the process effectively. The purpose of this article is to reflect on the structure, operation, roles and responsibilities of the self-assessment team. The evaluations made allow to specify elements regarding its composition, and qualities that should distinguish its members and the coordinator. Functions to be developed are presented and exemplified in the order of planning and organization, execution and control of the process. On the other hand, conditions or requirements are indicated that must be met for the successful fulfillment of the stated functions. Emphasis is placed on the need to observe the aforementioned aspects, to contribute to the continuous improvement of quality in the Medicine career.

South Pacific Underwater Medicine Society guidelines for cardiovascular risk assessment of divers.

The South Pacific Underwater Medicine Society (SPUMS) diving medical for recreational scuba divers was last reviewed in 2011. From 2011 to 2019, considerable advancements have occurred in cardiovascular risk assessment relevant to divers. The SPUMS 48th (2019) Annual Scientific Meeting theme was cardiovascular risk assessment in diving. The meeting had multiple presentations updating scientific information about assessing cardiovascular risk. These were distilled into a new set of guidelines at the final conference workshop. SPUMS guidelines for medical risk assessment in recreational diving have subsequently been updated and modified including a new Appendix C: Suggested evaluation of the cardiovascular system for divers. The revised evaluation of the cardiovascular system for divers covers the following topics: 1. Background information on the relevance of cardiovascular risk and diving; 2. Defining which divers with cardiovascular problems should not dive, or whom require treatment interventions before further review; 3. Recommended screening procedures (flowchart) for divers aged 45 and over; 4. Assessment of divers with known or symptomatic cardiovascular disease, including guidance on assessing divers with specific diagnoses such as hypertension, atrial fibrillation, cardiac pacemaker, immersion pulmonary oedema, takotsubo cardiomyopathy, hypertrophic cardiomyopathy and persistent (patent) foramen ovale; 5. Additional cardiovascular health questions included in the SPUMS guidelines for medical risk assessment in recreational diving; 6. Updated general cardiovascular medical risk assessment advice; 7. Referencing of relevant literature. The essential elements of this guideline are presented in this paper.

Diving after SARS-CoV-2 (COVID-19) infection: Fitness to dive assessment and medical guidance.

Scuba diving is a critical activity for commercial industry, military activities, research, and public safety, as well as a passion for many recreational divers. Physicians are expected to provide return-to-diving recommendations after SARS-CoV-2 (COVID-19) infection based upon the best available evidence, often drawn from experience with other, similar diseases. Scuba diving presents unique physiologic challenges to the body secondary to immersion, increased pressure and increased work of breathing. The long-term sequelae of COVID-19 are still unknown, but if they are proven to be similar to other coronaviruses (such as Middle East respiratory syndrome or SARS-CoV-1) they may result in long-term pulmonary and cardiac sequelae that impact divers' ability to safely return to scuba diving. This review considers available literature and the pathophysiology of COVID-19 as it relates to diving fitness, including current recommendations for similar illnesses, and proposes guidelines for evaluation of divers after COVID-19. The guidelines are based upon best available evidence about COVID-19, as well as past experience with determination of diving fitness. It is likely that all divers who have contracted COVID-19 will require a medical evaluation prior to return to diving with emphasis upon pulmonary and cardiac function as well as exercise capacity.

Professional diver routine health surveillance and certification: an internet-based satisfaction survey of New Zealand divers.

INTRODUCTION: Professional divers, like many other specialised occupational groups, are subject to regulatory constraints that include mandatory initial medical certification and routine recertification. The New Zealand system of diver certification and health surveillance has undergone modifications in recent years, but its acceptance among end-users has never been formally assessed. Because of the wide variety of tasks, circumstances and personalities encountered in the diving industry, unanimous satisfaction is an unrealistic expectation, but establishing the current mood of divers in this regard and canvassing opinions on possible improvements is an important step towards optimising the certification process. METHOD: A multi-choice satisfaction questionnaire was added, as a quality assurance measure, to the on-line health questionnaire completed annually by all New Zealand professional divers. A complete 12-month dataset was analysed to determine levels of satisfaction, areas of dissatisfaction and suggestions for improvement. Comparison of the opinions of various diver groups was achieved by stratification into employment-type sub-groups and those working locally, overseas or both. RESULTS: The responses of 914 divers who completed the survey established an 85% satisfaction rate with the existing diver certification system. Dissatisfaction was independent of diving locality. Compliance cost was the most common area of dissatisfaction, particularly among recreational diving instructors. CONCLUSIONS: Most New Zealand professional divers consider the current certification system satisfactory. Effective communication between the regulating authority and divers was identified as an important area for further development.

Diving with hypertension and antihypertensive drugs.

Hypertension is a common condition, which is highly prevalent amongst scuba divers. As a consequence, a substantial proportion of divers are hypertensive and/or on antihypertensive drugs when diving. In this article, we review available literature on the possible risks of diving in the presence of hypertension and antihypertensive drugs. Guidelines are presented for the diving physician for the selection of divers with hypertension suitable for diving, along with advice on antihypertensive treatment best compatible with scuba diving.

The impact of health on professional diver attrition.

INTRODUCTION: Approximately 77% of professional divers leave the industry within five years of entry, for reasons that are uncertain. One possibility is that attrition is due to ill-health. The health of New Zealand occupational divers is surveyed by a comprehensive medical examination every five years and by a health questionnaire in the intervening years. Divers are thereby confirmed 'fit' annually. The aim of this study was to determine if divers quit the industry due to a health problem not identified by this health surveillance system. METHOD: 601 divers who had left the industry within five years of entry medical examination ('quitters') were identified from a computerised database. One hundred and thirty-six who could be contacted were questioned about their principal reason for quitting. Comparison was made between the health data of all those defined as 'quitters' and a group of 436 'stayers' who have remained active in the industry for over 10 years. RESULTS: Health was the principal reason for abandoning a diving career for only 2.9% of quitters. The overwhelming majority (97.1%) quit because of dissatisfaction with aspects of the work, such as remuneration and reliability of employment. Besides gender, the only significant difference between the health data of quitters and stayers was that smoking was four times more prevalent among quitters. CONCLUSIONS: The key determinant of early attrition from the New Zealand professional diver workforce is industry-related rather than health-related. The current New Zealand diver health surveillance system detects the medical problems that cause divers to quit the industry.

The impact of diving on hearing: a 10-25 year audit of New Zealand professional divers.

INTRODUCTION: Surveillance of professional divers' hearing is routinely undertaken on an annual basis despite lack of evidence of benefit to the diver. The aim of this study was to determine the magnitude and significance of changes in auditory function over a 10-25 year period of occupational diving with the intention of informing future health surveillance policy for professional divers. METHODS: All divers with adequate audiological records spanning at least 10 years were identified from the New Zealand occupational diver database. Changes in auditory function over time were compared with internationally accepted normative values. Any significant changes were tested for correlation with diving exposure, smoking history and body mass index. RESULTS: The audiological records of 227 professional divers were analysed for periods ranging from 10 to 25 years. Initial hearing was poorer than population norms, and deterioration over the observation period was less than that predicted by normative data. Changes in hearing were not related to diving exposure, or smoking history. CONCLUSION: Audiological changes over 10 to 25 years of occupational diving were not found to be significantly different from age-related changes. Routine annual audiological testing of professional divers does not appear to be justifiable.

Eurasian Tunnel Project: the first saturation dives during compressed-air work in Turkey.

The Eurasian Tunnel is a 5.64-km crossroad tunnel that connects Europe and Asia. Located under the seabed for the first time, 3.34 km of the tunnel that crosses the Bosphorus was built by advanced tunneling techniques. An exclusively designed tunnel boring machine (TBM), which has an operating pressure of 11 bars and a diameter of 13.7 meters was used for boring the seabed tunnel. The deepest point was 106 meters below sea level. One bounce diving period and seven saturation diving periods were needed for the repair and maintenance of the TBM during the project. Total time spent under pressure was 5,763 hours. A saturation decompression chamber for four divers was used for the saturation interventions, and divers breathed trimix at storage and excursion depths. The longest saturation run was the second, with storage at 10 bars and excursions to 10.4 bars. Twenty-three professional divers who were all experienced in compressed-air work were assigned to work on the project. Four dive physicians provided medical support, which included screening of divers before and during the hyperbaric interventions as well as on-site supervision. There were no diving-related accidents. A minor hand trauma, an external otitis and occasional insomnia were non-diving-related health issues that occurred during saturation and bounce diving. To our knowledge, the Eurasian Tunnel was the first project to perform TBM repair operations at such depths under the seabed and the first saturation diving in Turkey. In this report, we aimed to share our experiences of hyperbaric medical consulting in support of this type of tunneling project.

Long-term changes in spirometry in occupational divers: a 10-25 year audit.

AIM: To determine whether long-term engagement in occupational diving causes significant changes in spirometric measurements. METHOD: All divers with adequate spirometric records spanning at least 10 years were identified from the New Zealand occupational diver database. Changes in lung function over time were compared with normative values derived using published prediction equations. Any significant changes were tested for correlation with age, duration of occupational diving, gender, smoking history and body mass index (BMI). RESULTS: Spirometry data spanning periods of 10 to 25 years were analysed for 232 divers. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) declined with increasing duration of diving, but slightly less than predicted with increasing age, while peak expiratory flow (PEF) declined more than expected for age in longer-term divers. The changes in PEF were statistically significant, and correlated with duration of diving exposure, initial age and final BMI. Nevertheless, the changes were small and probably clinically insignificant. CONCLUSION: We compared changes in spirometric parameters over long periods of occupational diving with normative data and found no clinically significant differences that could be attributed to diving. We found no justification for routine spirometry in asymptomatic divers.

A Study on Strategic Planning and Procurement of Medicals in Uganda's Regional Referral Hospitals.

This study was an analysis of the effect of strategic planning on procurement of medicals in Uganda's regional referral hospitals (RRH's). Medicals were defined as essential medicines, medical devices and medical equipment. The Ministry of Health (MOH) has been carrying out strategic planning for the last 15 years via the Health Sector Strategic Plans. Their assumption was that strategic planning would translate to strategic procurement and consequently, availability of medicals in the RRH's. However, despite the existence of these plans, there have been many complaints about expired drugs and shortages in RRH's. For this purpose, a third variable was important because it served the role of mediation. A questionnaire was used to obtain information on perceptions of 206 respondents who were selected using simple random sampling. 8 key informant interviews were held, 2 in each RRH. 4 Focus Group Discussions were held, 1 for each RRH, and between 5 and 8 staff took part as discussants for approximately three hours. The findings suggested that strategic planning was affected by funding to approximately 34% while the relationship between funding and procurement was 35%. The direct relationship between strategic planning and procurement was 18%. However when the total causal effect was computed it turned out that strategic planning and the related variable of funding contributed 77% to procurement of medicals under the current hierarchical model where MOH is charged with development of strategic plans for the entire health sector. Since even with this contribution there were complaints, the study proposed a new model called CALF which according to a simulation, if adopted by MOH, strategic planning would contribute 87% to effectiveness in procurement of medicals.

Does self-certification reflect the cardiac health of UK sport divers?

BACKGROUND: Since 2009, the United Kingdom diving incident data show an increasing number of fatalities in the over-50s age group. Previous studies also suggest some divers take cardiac medications. Since 2001, diving medicals have not been mandatory for UK sport divers. Instead, an annual medical self-certification form, submitted to their club/school or training establishment, is required. We documented in a survey of UK sport divers the prevalence of cardiac events and medications and the frequency of medical certifications. METHODS: An anonymous on-line questionnaire was publicised. Measures included diver and diving demographics, prescribed medications, diagnosed hypertension, cardiac issues, events and procedures, other health issues, year of last diving medical, diagnosed persistent foramen ovale (PFO), smoking and alcohol habits, exercise and body mass index. RESULTS: Of 672 completed surveys, hypertension was reported by 119 (18%) with 25 of these (21%) having not had a diving medical. Myocardial infarction 6 (1%), coronary artery bypass grafting 3 (< 1%), atrial fibrillation 19 (3%) and angina 12 (2%) were also reported. PFOs were reported by 28 (4%), with 20 of these opting for a closure procedure. From 83 treated incidences of decompression illness (DCI), 19 divers reported that a PFO was diagnosed. CONCLUSIONS: Divers inevitably develop health problems. Some continue to dive with cardiac issues, failing to seek specialised diving advice or fully understand the role of the diving medical. Physicians without appropriate training in diving medicine may inform a diver they are safe to continue diving with their condition without appreciating the potential risks. The current procedure for medical screening for fitness to dive may not be adequate for all divers.