The US Government Principles for the use of animals in research are a landmark statement of ethical values and guidance for the biomedical research community. However, when The Principles were introduced, a context was not provided for their source or foundation. The US Government Principles were formulated with input from the Council of Europe, World Health Organization, and US Interagency Research Animal Committee. The Principles continue to provide an ethical foundation for the biomedical research community.

ObjectiveWhile emphasized in clinical practice, the association between advanced airway insertion first-pass success (FPS) and patient outcomes is incompletely understood. We sought to determine the association of airway insertion FPS with adult out-of-hospital cardiac arrest (OHCA) outcomes in the Pragmatic Airway Resuscitation Trial (PART). MethodsWe performed a secondary analysis of PART, a multicenter clinical trial comparing LT and ETI upon adult OHCA outcomes. We defined FPS as successful LT insertion or ETI on the first attempt as reported by EMS personnel. We examined the outcomes return of spontaneous circulation (ROSC), 72-h survival, hospital survival, and hospital survival with favorable neurologic status (Modified Rankin Scale ≤3). Using multivariable GEE (generalized estimating equations), we determined the association between FPS and OHCA outcomes, adjusting for age, sex, witnessed arrest, bystander CPR, initial rhythm, and initial airway type. ResultsOf 3004 patients enrolled in the trial, 1423 received LT, 1227 received ETI, 354 received bag-valve-mask ventilation only. FPS was: LT 86.2% and ETI 46.7%. FPS was associated with increased ROSC (aOR 1.23; 95%CI: 1.07–1.41)), but not 72-h survival (1.22; 0.94–1.58), hospital survival (0.90; 0.68–1.19) or hospital survival with favorable neurologic status (0.66; 0.37–1.19). ConclusionIn adult OHCA, airway insertion FPS was associated with increased ROSC but not other OHCA outcomes. The influence of airway insertion FPS upon OHCA outcomes is unclear.

Anaphylaxis is a life-threatening hypersensitivity reaction where rapid, early administration of epinephrine (adrenaline) can be lifesaving in the first aid setting. There are instances where a single dose of epinephrine does not relieve symptoms and a second dose may be required to further mitigate symptoms and preserve life.We performed a scoping review as part of an update to a previously conducted International Liaison Committee on Resuscitation First Aid Task Force (ILCOR) review. PubMed and Embase were searched using the strategy from the 2015 ILCOR review (dates January 1, 2015 to October 22, 2019) and a review of the grey literature (all dates up to November 18, 2019) was performed to identify data on the requirement, use, and effectiveness of a second dose of epinephrine. Each search was rerun on June 26, 2020. We included all human studies of adults and children with an English abstract. Critical outcomes included resolution of symptoms, adverse effects, and complications of second dosing of epinephrine in the treatment of acute anaphylaxis. Included studies are presented descriptively.Our updated search identified 909 potential sources, 890 from the published literature and 19 from the grey literature. After full text review, two studies met our eligibility criteria (Campbell et al. and Akari et al.). For the outcome of resolution of symptoms, both studies found that two or more doses of epinephrine were required in 8% of 582 patients and 28% of 18 patients, respectively, with anaphylaxis requiring treatment with epinephrine. The other a priori outcomes were not reported.This scoping review identified limited evidence regarding the use of a second dose of epinephrine for anaphylaxis in the first aid setting, however, due to the potential benefit, it is reasonable to administer a second dose when symptoms of severe anaphylaxis fail to resolve following an initial dose. Given the potential mortality associated with anaphylaxis, further research is needed to better identify individuals who may benefit from a second dose of epinephrine.

Background: Survival following out-of-hospital cardiac arrest (OHCA) decreases as the interval from collapse to CPR and defibrillation increases. Most OHCA events occur in private locations. Innovative approaches are needed to reduce response interval, especially into private locations. Methods: We undertook the Verified Responder Program in 5 United States communities during calendar year 2018, whereby off-duty EMS professionals volunteered and were equipped with Philips automated external defibrillators (AEDs). Volunteers were alerted using a geospatial smartphone application (PulsePoint) integrated with 9-1-1 dispatch to respond to nearby private and public suspected OHCA. The prospective study evaluated the frequency of verified responder alert, response, scene arrival, and initial care for OHCA occurring prior to EMS arrival. The investigation surveyed responder experience using a 5 point Likert scale. OHCA surveillance was assessed using the CARES registry. Results: The Verified Responder Program involved 593 volunteers equipped with 550 AEDs drawn from 5 EMS agencies covering a population of 1.3 million persons (Table 1). Of the 660 eligible OHCA events (483 private, 177 public), verified responders were alerted in 9.4% (n=62) of events. Among the 483 in a private location, responders were alerted in 10.4% (n=50), responded in 2.1% (n=10), arrived on scene in 1.7% (n=8), and provided initial care in 1.5% (n=7). Among the 177 in a public location, responders were alerted in 6.8% (n=12), responded in 3.4% (n=6), arrived on scene in 2.8% (n=5), and provided initial care in 1.1% (n=2). Overall, responders reported a highly favorable experience (4.5/5). None reported an adverse event. Conclusions: In this initial US-based experience of smartphone alert program for suspected OHCA in private or public locations, volunteer experiences were uniformly favorable. Volunteers were alerted, responded, and involved in a small fraction of OHCA.

School nurses are proportionally older in age as compared to the overall U.S. nursing workforce. In anticipation of a school nurse workforce shortage in the next few years, we must focus our attention on developing and implementing orientation and transition programs for new school nurses, many of whom represent the millennial generation. Formative experiences are thought to create specific characteristics and difference between generations; yet, stereotypes are sometimes present in defining generations. The NASN School Nurse Editorial Advisory Board interviewed four millennial school nurses to highlight the need to embrace this new generation as they enter the specialty practice of school nursing.

An electrical accident victim's recollection is often distorted by Bayesian inference in multisensory integration. For example, hearing the sound and seeing the bright flash of an electrical arc can create the false impression that someone had experienced an electrical shock. These subjects will often present to an emergency department seeking either treatment or reassurance. We present seven cases in which the subjects were startled by an electrical shock (real or perceived) and injury was reported. Calculations of the current and path were used to allocate causality between the shock and a history of chronic disease or previous trauma. In all seven cases, our analysis suggests that no current was passed through the body. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Symptomology seen as corroborating may actually be confounding. Witness and survivor descriptions of electrical shocks are fraught with subjectivity and misunderstanding. Available current is usually irrelevant and overemphasized, such as stress on a 100-ampere welding source, which is orders of magnitude beyond lethal limits. History can also be biased for a number of reasons. Bayesian inference in multisensory perception can lead to a subject sincerely believing they had experienced an electrical shock. Determination of the current pathway and calculations of the amplitude and duration of the shock can be critical for understanding the limits and potential causation of electrical injury.

Trauma registries are used to evaluate and improve trauma care, yet potentially miss certain trauma deaths and high-risk patients. We estimated the number of missed deaths and high-risk trauma patients using commonly available sources of trauma data and resulting bias in quality metrics for field trauma triage. This was a preplanned secondary analysis of a population-based prospective cohort of injured patients transported by 44 emergency medical services agencies to 28 hospitals in seven Northwest counties from January 1, 2011 to December 31, 2011 and followed through hospitalization. We used a stratified probability sampling design for 17,633 patients, weighted to represent all 53,487 injured patients transported by emergency medical services. We compared patients meeting National Trauma Data Bank (NTDB) criteria (weighted n = 5,883), all injured patients presenting to major trauma centers (weighted n = 16,859), and all admitted patients (weighted n = 18,433), to the full sample. Outcomes included in-hospital mortality, Injury Severity Score (ISS) of 16 or higher, and critical resource use within 24 hours. Among 53,487 injured patients, there were 520 emergency department and in-hospital deaths, 1,745 with ISS of 16 or higher, and 923 requiring early critical resources. Compared to the full cohort, the NTDB cohort missed 62.1% of deaths, 39.2% of patients with ISS of 16 or higher, and 23.8% requiring early critical resources, especially older adults injured by falls and admitted to nontrauma hospitals. The admission cohort missed the fewest patients-23.3% of deaths, 10.5% with an ISS of 16 or higher, and 13.1% requiring early resources. Compared to triage sensitivity in the full cohort (66.2%), sensitivity estimates ranged from 63.6% (all admissions) to 93.4% (NTDB). Compared to triage specificity in the full cohort (87.8%), estimates ranged from 36.4% (NTDB) to 77.3% (all admissions). Common sources of trauma data miss substantial numbers of trauma deaths and high-risk trauma patients and can generate biased estimates for trauma system quality metrics. Epidemiologic, level III.

Core instruction is an important part of an effective response to intervention (RTI) model. To implement RTI effectively, school teams should regularly examine the effectiveness of their core instruction to determine if at least 80% of students meet the proficiency standard with core support alone. However, some educators may not have the skills necessary to hold a meeting that focuses exclusively on core instruction. To provide educators with a format to lead such a meeting, the authors describe a grade-level team meeting in which the purpose is to use data to analyze the effectiveness of core instruction in reading. A sample agenda and detailed case example are provided.

A large water supply pipeline has been designed to carry water from the Willamette River in Gladstone, OR to the cities of Lake Oswego and Tigard, Oregon. The pipeline ranges in diameter from 24 to 48 inches and traverses more than 10 miles. The pipeline was part of an overall water supply project that included a raw water intake, a raw water pipeline, a water treatment plant, a finished water pipeline, and a reservoir. Finding a route for the pipeline was challenging as it traversed through many cities, and required a number of interagency agreements. Along with the routing challenges, there were many technical challenges such as crossing beneath the Willamette River. This crossing is 36-inches in diameter through basalt that varies in unconfined compressive strength, which exceeds 40,000 psi. An extensive trenchless evaluation was performed to determine the method that offered the highest chance of success with the lowest overall risk profile. Horizontal directional drilling (HDD) was chosen as the preferred trenchless installation technique. The length of the river crossing is 3,800 feet, making the 36inch diameter rock drill very challenging. In addition to the challenges of the drill, site and pipe layout was very restricted, further complicating and increasing the risk of the project.. Many aspects of the drill had to be thoroughly laid out during design, leaving little flexibility to the contractor.