Electronic control device exposure: a review of morbidity and mortality.

The use of electronic control devices has expanded worldwide during the last few years, the most widely used model being the Taser. However, the scientific knowledge about electronic control devices remains limited. We reviewed the medical literature to examine the potential implications of electronic devices in terms of morbidity and mortality, and to identify and evaluate all the existing experimental human studies. A single exposure of an electronic control device on healthy individuals can be assumed to be generally safe, according to 23 prospective human experimental studies and numerous volunteer exposures. In case series, however, electronic control devices could have deleterious effects when used in the field, in particular if persons receive multiple exposures, are intoxicated, show signs of "excited delirium," or present with medical comorbidities. As the use of electronic control devices continues to increase, the controversy about its safety, notably in potentially high-risk individuals, is still a matter of debate. The complications of electronic control device exposure are numerous but often recognizable, usually resulting from barbed dart injuries or from falls. Persons exposed to electronic control devices should therefore be fully examined, and traumatic lesions must be ruled out.

Injury pattern of the Flash-Ball, a less-lethal weapon used for law enforcement: report of two cases and review of the literature.

Less-lethal weapons are used in law enforcement to neutralize combative individuals and to disperse riot crowds. Local police recently used such an impact weapon, the Flash-Ball, in two different situations. This gun fires large rubber bullets with kinetic energies around 200 J. Although it is designed to avoid skin penetration, impacts at such energies may still create major trauma with associated severe injuries to internal organs. This is a report of 2 patients shot with the Flash-Ball who required medical attention. One could be discharged quickly, but the other required hospitalization for heart and lung contusion. Both patients required advanced investigations including computed tomography (CT) scan. The medical literature on injuries induced by less-lethal impact weapons is reviewed. Impacts from the Flash-Ball can cause significant injury to internal organs, even without penetration. Investigations as for other high-energy blunt traumas are called for in these cases.

Urgences vitales au cabinet médical: implications pour la formation et l'equipement du médecin de premier recours [Life-threatening emergencies at the office: implications for medical education and equipment of the primary care physician].

Every medical practitioner is confronted on a daily basis with emergencies. Among these, life-threatening emergencies can have disastrous consequences in term of morbidity and mortality; 22 cardiac arrests and 10 deaths were reported among the 1,650 Swiss practices during a 5 year period. The occurrence of life-threatening emergencies at the office necessitates, according to the type and place of the practice, the skills of the practitioner and the organization of his practice, the implementation of procedures, equipments (for example room equipped with a defibrillator, respiratory nebulizer, splints, emergency drugs) and specific continuous education programs that should be encouraged and made available to the whole medical corporation.

Dispatch centres: what is the right population catchment size?

Literature on medical dispatch is growing, focusing mainly on efficiency (under and overtriage) and dispatch-assisted CPR. But the issue of population catchment size, functional costs and rationalization is rarely addressed. If we can observe a trend toward a decreasing number of dispatch centres in many European countries, there is today no evidence on what is the right catchment size to reach the best balance between quality of services and costs.

Acute Lyme Neuroborreliosis With Transient Hemiparesis and Aphasia.

Nervous system involvement in Lyme disease often mimics other conditions and thus represents a diagnostic challenge, especially in an emergency department setting. We report a case of a female teenager presenting with sudden-onset aphasia and transient right-sided faciobrachial hemiplegia, along with headache and agitation. Ischemia, vasculitis, or another structural lesion was excluded by brain imaging. Toxicologic evaluation results were negative. Cerebral perfusion computed tomography and electroencephalography showed left parietotemporal brain dysfunction. Lumbar puncture result, although atypical, suggested bacterial infection and intravenous ceftriaxone was initiated. Finally, microbiological cerebrospinal fluid analysis revealed Lyme neuroborreliosis, showing specific intrathecal antibody production and high level of C-X-C motif chemokine 13. The patient rapidly recovered. To our knowledge, this report for the first time illustrates that acute-onset language and motor symptoms may be directly related to Lyme neuroborreliosis. Neuroborreliosis may mimic other acute neurologic events such as stroke and should be taken into diagnostic consideration even in the absence of classic symptoms and evolution.

Alumnos en las consultas clínicas. Normas de estilo para un mejor aprovechamiento de las rotaciones clínicas de los estudiantes de medicina

Los estudiantes de medicina efectúan una parte de sus rotaciones en entornos como salas de hospitalización, consultas externas y centros de salud, donde comparten las experiencias clínicas con un médico al que llamaremos"tutor". La reforma de los planes docentes abordados por las facultades de medicina pone el acento en este tipo de prácticas [1,2]. El presente trabajo se enmarca en un esfuerzo de la Facultad de Medicina de la Universitat de Barcelona para hacer presente las habilidades de comunicación en la tarea docente [3,4], e indica algunas pautas para la recepción y acomodación de estos estudiantes, así como situaciones delicadas que deben ser resueltas con asertividad...

An evaluation of the Swiss staging model for hypothermia using case reports from the literature.

BACKGROUND: Core body temperature is used to stage and guide the management of hypothermic patients, however obtaining accurate measurements of core temperature is challenging, especially in the pre-hospital context. The Swiss staging model for hypothermia uses clinical indicators to stage hypothermia. The proposed temperature range for clinical stage 1 is <35-32 °C (95-90 °F), for stage 2, <32-28 °C (<90-82 °F) for stage 3, <28-24 °C (<82-75 °F), and for stage 4 below 24 °C (75 °F). However, the evidence relating these temperature ranges to the clinical stages needs to be strengthened. METHODS: Medline was used to retrieve data on as many cases of accidental hypothermia (core body temperature <35 °C (95 °F)) as possible. Cases of therapeutic or neonatal hypothermia and those with confounders or insufficient data were excluded. To evaluate the Swiss staging model for hypothermia, we estimated the percentage of those patients who were correctly classified and compared the theoretical with the observed ranges of temperatures for each clinical stage. The number of rescue collapses was also recorded. RESULTS: We analysed 183 cases; the median temperature for the sample was 25.2 °C (IQR 22-28). 95 of the 183 patients (51.9 %; 95 % CI = 44.7 %-59.2 %) were correctly classified, while the temperature was overestimated in 36 patients (19.7 %; 95 % CI = 13.9 %-25.4 %). We observed important overlaps among the four stage groups with respect to core temperature, the lowest observed temperature being 28.1 °C for Stage 1, 22 °C for Stage 2, 19.3 °C for Stage 3, and 13.7 °C for stage 4. CONCLUSION: Predicting core body temperature using clinical indicators is a difficult task. Despite the inherent limitations of our study, it increases the strength of the evidence linking the clinical hypothermia stage to core temperature. Decreasing the thresholds of temperatures distinguishing the different stages would allow a reduction in the number of cases where body temperature is overestimated, avoiding some potentially negative consequences for the management of hypothermic patients.

An ABC for decision making

The present study was aimed at proposing a systematic evaluation of cranial computed tomography, identifying the main aspects to be analyzed in order to facilitate the decision making process regarding diagnosis and management in emergency settings. The present descriptive study comprised a literature review at the following databases: Access Medicine and Access Emergency Medicine (McGraw- Hill Education); British Medical Journal Evidence Center; UptoDate; Bireme; PubMed; Lilacs; SciELO; ProQuest; Micromedex (Thomson Reuters); Embase. Once the literature review was completed, the authors identified the main diseases with tomographic repercussions and proposed the present system to evaluate cranial computed tomography images. An easy-to-memorize ABC system will facilitate the decision making in emergency settings, as it covers the main diseases encountered by intensivists and emergency physicians, and provides a sequential guidance about anatomical structures to be investigated as well as their respective alterations.

La influencia del lenguaje cotidiano en el desarrollo de la escritura de los inmigrantes en los centros educativos

El objetivo de nuestra investigación es demostrar la importancia deluso de la lengua escolar fuera del entorno educativo y como este uso podría repercutir notablemente en el rendimiento académico del alumnado inmigrante. Según nuestra hipótesis, los alumnos inmigrantes que no practican en su vida cotidiana la lengua que se usa en los centros educativos realizarán más errores en la escritura que aquellos alumnos inmigrantes que sí practican dicho lenguaje fuera del entorno educativo. Las técnicas que emplearíamos para recopilar y clasificar la información serían cuestionarios y un corpus lingüístico. Los resultados que esperamos obtener son un número considerablemente alto de errores en la escritura por parte de los alumnos inmigrantes que no hablan el catalán en su entorno social no escolar, mientras que los alumnos autóctonos y los alumnos inmigrantes que sí practican el catalán fuera del ámbito educativo obtendrían mejores resultados. Estos resultados nos proporcionarían una evidencia más sobre la importancia del uso de las lenguas escolares en entornos no escolares.

Studies on Neuromuscular Blocking Agents and Their Antagonists During Anaesthesia

Neuromuscular blocking agents (NMBAs) are widely used in clinical anaesthesia and emergency medicine. Main objectives are to facilitate endotracheal intubation and to allow surgery by reducing muscle tone and eliminating sudden movements, which may otherwise lead to trauma and complications. The most commonly used NMBAs are non-depolarizing agents with a medium duration of action, such as rocuronium and cisatracurium. They bind to the acetylcholine receptors in the neuromuscular junction, thus inhibiting the depolarization of the postsynaptic (muscular) membrane, which is a prerequisite for muscle contraction to take place. Previously, it has been assumed that nitrous oxide (N2O), which is commonly used in combination with volatile or intravenous anaesthetics during general anaesthesia, has no effect on NMBAs. Several studies have since claimed that N2O in fact does increase the effect of NMBAs when using bolus administration of the relaxant. The effect of N2O on the infusion requirements of two NMBAs (rocuronium and cisatracurium) with completely different molecular structure and pharmacological properties was assessed. A closed-loop feedback controlled infusion of NMBA with duration of at least 90 minutes at a 90% level of neuromuscular block was used. All patients received total intravenous anaesthesia (TIVA) with propofol and remifentanil. In both studies the study group (n=35) received N2O/Oxygen and the control group (n=35) Air/Oxygen. There were no significant differences in the mean steady state infusion requirements of NMBA (rocuronium in Study I; cisatracurium in Study II) between the groups in either study. In Study III the duration of the unsafe period of recovery after reversal of rocuronium-induced neuromuscular block by using neostigmine or sugammadex as a reversal agent was analyzed. The unsafe period of recovery was defined as the time elapsed from the moment of no clinical (visual) fade in the train-of-four (TOF) sequence until an objectively measured TOF-ratio of 0.90 was achieved. The duration of these periods were 10.3 ± 5.5 and 0.3 ± 0.3 min after neostigmine and sugammadex, respectively (P < 0.001). Study IV investigated the possible effect of reversal of a rocuronium NMB by sugammadex on depth of anaesthesia as indicated by the bispectral index and entropy levels in thirty patients. Sugammadex did not affect the level of anaesthesia as determined by EEG-derived indices of anaesthetic depth such as the bispectral index and entropy.

Hitsauksen mekanisoinnin ja automatisoinnin oppimisympäristön kehittäminen

Hitsaavan teollisuuden kilpailukyvyn tehostamiseksi yksi keino on hitsauksen mekanisoinnin ja automatisoinnin osuuden lisääminen hitsaustuotannossa. Työn on tehty Etelä-Karjalan aikuisopiston toimeksiannosta hitsauksen mekanisoinnin ja automatisoinnin oppimisympäristön kehittämiseksi paikallisten hitsaavien yritysten koulutustarpeiden mukaisesti. Työ toteutettiin sekä kirjallisuustutkimuksena että haastattelututkimuksena Etelä-Karjalan alueen hitsaavan teollisuuden yrityksissä. Kirjallisuusosiossa on läpikäyty hitsauksen mekanisointia, kappaleenkäsittelyä, orbitaalihitsausta sekä robottihitsausta. Kirjallisen käsittelyn pohjana oli kansainvälisen mekanisoidun-, orbitaali- ja robottihitsauksen henkilöstön operaattorikoulutusohjelma. Operaattorikoulutusohjelmassa koulutuslinjat jaetaan mekanisoituun hitsaukseen, orbitaalihitsaukseen ja robottihitsaukseen. Käytännön osiossa on analysoitu kohdeyrityksille tehdyt haastattelut, määritelty kohdeyritysten hitsauksen automaatiotasot sekä hitsaustyössä käytössä oleva laitekanta. Tutkimuksen tuloksia tullaan käyttämään hyödyksi kehitettäessä Etelä-Karjalan aikuisopiston (AKTIVA) oppimisympäristöä etelä-karjalaisten hitsaavien yritysten tarpeiden mukaisesti.