Retrospective analysis of Methicillin-Resistant Staphylococcus Aureus (MRSA) skin and Soft-Tissue Infections (SSTI) in a university hospital emergency department (ED)

Study Objective: Identify the most frequent risk factors of Community Acquired-MRSA (CA-MRSA) Skin and Soft-tissue Infections (SSTIs) using a case series of patients and characterize them by age, race/ethnicity, gender, abscess location, druguse and intravenous drug-user (IVDU), underlying medical conditions, homelessness, treatment resistance, sepsis, those whose last healthcare visit was within the last 12 months, and describe the susceptibility pattern from this central Texas population that have come into the University Medical Center Brackenridge (UMCB) Emergency Department (ED). ^ Methods: This study was a retrospective case-series medical record review involving a convenience sample of patients in 2007 from an urban public hospital's ED in Texas that had a SSTI that tested positive for MRSA. All positive MRSA cultures underwent susceptibility testing to determine antibiotic resistance. The demographic and clinical variables that were independently associated with MRSA were determined by univariate and multivariate analysis using logistic regression to calculate odds ratios (OR), 95% confidence intervals, and significance (p≤ 0.05). ^ Results: In 2007, there were 857 positive MRSA cultures. The demographics were: males 60% and females 40%, with the average age of 36.2 (std. dev. =13) the study population consisted of non-Hispanic white (42%), Hispanics (38%), and non-Hispanic black (18.8%). Possible risk factors addressed included using recreational drugs (not including IVDU) (27%) homelessness (13%), diabetes status (12.6%) or having an infectious disease, and IVDU (10%). The most frequent abscess location was the leg (26.6%), followed by the arm and torso (both 13.7%). Eighty-three percent of patients had one prominent susceptibility pattern that had a susceptibility rate for the following antibiotics: trimethoprim/sulfamethoxazole (TMP-SMX) and vancomycin had 100%, gentamicin 99%, clindamycin 96%, tetracycline 96%, and erythromycin 56%. ^ Conclusion: The ED is becoming an important area for disease transmission between the sterile hospital environment and the outside environment. As always, it is important to further research in the ED in an effort to better understand MRSA transmission and antibiotic resistance, as well as to keep surveillance for the introduction of new opportunistic pathogens into the population. ^

Clinical trials, informed consent, & emergency medicine: A systematic literature review

Background: In the United States, the Food and Drug Administration (FDA) regulates clinical trials. These regulations address good clinical practices as well as human subject protection (FDA, 2012). One of the most important legal and ethical concerns in clinical trials is informed consent. 21 CFR 50 governs human subjects research. Part 50.24 provides an emergency research exception to the informed consent requirement. Research was conducted to determine the appropriateness of this exception, whether the benefit justifies the exception, and its public health significance.^ Methods: A systematic literature review was conducted and articles were identified from peer-reviewed journals.^ Results: There is some variance in opinions regarding the appropriateness of the exception, but the literature reviewed found the study results of these trials justified the waiver.^ Conclusion: The exception to the informed consent requirement is likely appropriate and justified in emergency research when implemented within the specified guidelines.^

Advance provision of emergency contraception for pregnancy prevention (Review)

Background Emergency contraception can prevent pregnancy when taken after unprotected intercourse.Obtaining emergency contraception within the recommended time frame is difficult for many women. Advance provision could circumvent some obstacles to timely use. Objectives To summarize randomized controlled trials evaluating advance provision of emergency contraception to explore effects on pregnancy rates, sexually transmitted infections, and sexual and contraceptive behaviors. Search strategy In November 2009, we searched CENTRAL, EMBASE, POPLINE,MEDLINE via PubMed, and a specialized emergency contraception article database. We also searched reference lists and contacted experts to identify additional published or unpublished trials. Selection criteria We included randomized controlled trials comparing advance provision and standard access (i.e., counseling whichmay ormay not have included information about emergency contraception, or provision of emergency contraception on request at a clinic or pharmacy). Data collection and analysis Two reviewers independently abstracted data and assessed study quality. We entered and analyzed data using RevMan 5.0.23. Main results Eleven randomized controlled trials met our criteria for inclusion, representing 7695 patients in the United States, China, India and Sweden. Advance provision did not decrease pregnancy rates (odds ratio (OR) 0.98, 95% confidence interval (CI) 0.76 to 1.25 in studies for which we included twelve-month follow-up data; OR 0.48, 95% CI 0.18 to 1.29 in a study with seven-month follow-up data; OR 0.92, 95% CI 0.70 to 1.20 in studies for which we included six-month follow-up data; OR 0.49, 95% CI 0.09 to 2.74 in a study with three-month follow-up data), despite reported increased use (single use: OR 2.47, 95% CI 1.80 to 3.40; multiple use: OR 4.13, 95% CI 1.77 to 9.63) and faster use (weighted mean difference (WMD) -12.98 hours, 95% CI -16.66 to -9.31 hours). Advance provision did not lead to increased rates of sexually transmitted infections (OR 1.01, 95% CI 0.75 to 1.37), increased frequency of unprotected intercourse, or changes in contraceptive methods.Women who received emergency contraception in advance were equally likely to use condoms as other women. Authors’ conclusions Advance provision of emergency contraception did not reduce pregnancy rates when compared to conventional provision. Results from primary analyses suggest that advance provision does not negatively impact sexual and reproductive health behaviors and outcomes. Women should have easy access to emergency contraception, because it can decrease the chance of pregnancy.However, the interventions tested thus far have not reduced overall pregnancy rates in the populations studied.

Thinking Ethically About Emergency Contraception.

http://www.chausa.org/docs/default-source/health-progress/hp1001l-pdf.pdf?sfvrsn=0

Emergency Obstetric Care: Strategy for Reducing Maternal Mortality in Developing Countries

Twenty-five years have passed since the global community agreed in Nairobi to address the high maternal mortality by implementing the Safe Motherhood Initiative. However, every year nearly three million women die due to pregnancy related causes. This tragedy is avoidable if women have timely access to required emergency obstetric care. Emergency obstetric care refers to life-saving services for maternal and neonatal complications provided by skilled health workers. Since the beginning of the 1980’s, several efforts have been intensified to improve maternal and child health status and reducing the high morbidity and mortality. There was built on a worldwide consensus to provide improved maternal and child health care for addressing the high morbidity and mortality. All participant countries agreed to integrate emergency obstetric care services in their national health care system. Emergency obstetric care is one of the strategies for reducing the maternal mortality as pregnancy related complications are unpredictable. However, many women in developing countries do not have access to essential health care services including emergency obstetric care. Basic emergency obstetric care by skilled birth attendants or timely referral for further comprehensive emergency obstetric care can reduce maternal deaths and disabilities significantly. This paper is based on the results published in PubMed, Medline, Lancet, WHO and Google Scholar web pages from 1990 to 2013.

Making Transport Safer: V2V-Based Automated Emergency Braking System

An important goal in the field of intelligent transportation systems (ITS) is to provide driving aids aimed at preventing accidents and reducing the number of traffic victims. The commonest traffic accidents in urban areas are due to sudden braking that demands a very fast response on the part of drivers. Attempts to solve this problem have motivated many ITS advances including the detection of the intention of surrounding cars using lasers, radars or cameras. However, this might not be enough to increase safety when there is a danger of collision. Vehicle to vehicle communications are needed to ensure that the other intentions of cars are also available. The article describes the development of a controller to perform an emergency stop via an electro-hydraulic braking system employed on dry asphalt. An original V2V communication scheme based on WiFi cards has been used for broadcasting positioning information to other vehicles. The reliability of the scheme has been theoretically analyzed to estimate its performance when the number of vehicles involved is much higher. This controller has been incorporated into the AUTOPIA program control for automatic cars. The system has been implemented in Citroën C3 Pluriel, and various tests were performed to evaluate its operation.

A Multi-agent System for Emergency Decision Support

This paper describes the multi-agent organization of a computer system that was designed to assist operators in decision making in the presence of emergencies. The application was developed for the case of emergencies caused by river floods. It operates on real-time receiving data recorded by sensors (rainfall, water levels, flows, etc.) and applies multi-agent techniques to interpret the data, predict the future behavior and recommend control actions. The system includes an advanced knowledge based architecture with multiple symbolic representation with uncertainty models (bayesian networks). This system has been applied and validated at two particular sites in Spain (the Jucar basin and the South basin).

Hydrologic models for emergency decision support using Bayesian networks

In the presence of a river flood, operators in charge of control must take decisions based on imperfect and incomplete sources of information (e.g., data provided by a limited number sensors) and partial knowledge about the structure and behavior of the river basin. This is a case of reasoning about a complex dynamic system with uncertainty and real-time constraints where bayesian networks can be used to provide an effective support. In this paper we describe a solution with spatio-temporal bayesian networks to be used in a context of emergencies produced by river floods. In the paper we describe first a set of types of causal relations for hydrologic processes with spatial and temporal references to represent the dynamics of the river basin. Then we describe how this was included in a computer system called SAIDA to provide assistance to operators in charge of control in a river basin. Finally the paper shows experimental results about the performance of the model.

Epidemiological characteristics and diagnostic approach in patients admitted to the emergency room for transient loos of consciousness: Group for Syncope Study in the Emergency Room (GESINUR) study

Aims: To assess the clinical presentation and acute management of patients with transient loss of consciousness (T-LOC) in the emergency department (ED). Methods and results: A multi-centre prospective observational study was carried out in 19 Spanish hospitals over 1 month. The patients included were 14 years old and were admitted to the ED because of an episode of T-LOC. Questionnaires and corresponding electrocardiograms (ECGs) were reviewed by a Steering Committee (SC) to unify diagnostic criteria, evaluate adherence to guidelines, and diagnose correctly the ECGs. We included 1419 patients (prevalence, 1.14%).ECG was performed in 1335 patients (94%) in the ED: 498 (37.3%) ECGs were classified as abnormal. The positive diagnostic yield ranged from 0% for the chest X-ray to 12% for the orthostatic test. In the ED, 1217 (86%) patients received a final diagnosis of syncope, whereas the remaining 202 (14%) were diagnosed of non-syncopal transient lossof consciousness (NST-LOC). After final review by the SC, 1080 patients (76%) were diagnosed of syncope, whereas 339 (24%) were diagnosed of NST-LOC (P , 0.001). Syncope was diagnosed correctly in 84% of patients. Only 25% of patients with T-LOC were admitted to hospitals. Conclusion Adherence to clinical guidelines for syncope management was low; many diagnostic tests were performed with low diagnostic yield. Important differences were observed between syncope diagnoses at the ED and by SC decision.

Development of a tanks line for waxing landing gear parts

The aim of this article is to define the technical specifications and to design the implementation of a line of tanks that would be used in the process of waxing and de-waxing large pieces. As it is based in a real case, it is also analyzed the process of dismantling the former installation that supported these functions. The origin of this project is due to a new rating for the maintenance of landing gears which makes the previous waxing line that was prepared to work on smaller aircraft?s pieces, no longer adequate to the current workflow and processes.

An approach to stakeholders involvement in the preparedness for nuclear and radiological emergency response & recovery in Spain

The elaboration of a generic decision-making strategy to address the evolution of an emergency situation, from the stages of response to recovery, and including a planning stage, can facilitate timely, effective and consistent decision making by the response organisations at every level within the emergency management structure and between countries, helping to ensure optimal protection of health, environment, and society. The degree of involvement of stakeholders in this process is a key strategic element for strengthening the local preparedness and response and can help a successful countermeasures strategy. A significant progress was made with the multi-national European project EURANOS (2004-2009) which brought together best practice, knowledge and technology to enhance the preparedness for Europe's response to any radiation emergency and long term contamination. The subsequent establishment of a European Technology Platform and the recent launch of the research project NERIS-TP ("Towards a self sustaining European Technology Platform (NERIS-TP) on Preparedness for Nuclear and Radiological Emergency Response and Recovery") are aimed to continue with the remaining tasks for gaining appropriate levels of emergency preparedness at local level in most European countries. One of the objectives of the NERIS-TP project is: Strengthen the preparedness at the local/national level by setting up dedicated fora and developing new tools or adapting the tools developed within the EURANOS projects (such as the governance framework for preparedness, the handbooks on countermeasures, the RODOS system, and the MOIRA DSS for long term contamination in catchments) to meet the needs of local communities. CIEMAT and UPM in close interaction with the Nuclear Safety Council will explore, within this project, the use and application in Spain of such technical tools, including other national tools and information and communication strategies to foster cooperation between local, national and international stakeholders. The aim is identify and involve relevant stakeholders in emergency preparedness to improve the development and implementation of appropriate protection strategies as part of the consequence management and the transition to recovery. In this paper, an overview of the "state of the art" on this area in Spain and the methodology and work Plan proposed by the Spanish group within the project NERIS to grow the stakeholder involvement in the preparedness to emergency response and recovery is presented.

Analysis of ad hoc routing protocols for emergency and rescue scenarios.

A mobile ad hoc network MANET is a collection of wireless mobile nodes that can dynamically configure a network without a fixed infrastructure or centralized administration. This makes it ideal for emergency and rescue scenarios where information sharing is essential and should occur as soon as possible. This article discusses which of the routing strategies for mobile ad hoc networks: proactive, reactive and hierarchical, have a better performance in such scenarios. Using a real urban area being set for the emergency and rescue scenario, we calculate the density of nodes and the mobility model needed for validation. The NS2 simulator has been used in our study. We also show that the hierarchical routing strategies are beffer suited for this type of scenarios.

Seismic Risk Scenarios in Puerto Principe (Haiti). A Tool for Reconstruction and Emergency Planning

The 12 January 2010, an earthquake hit the city of Port-au-Prince, capital of Haiti. The earthquake reached a magnitude Mw 7.0 and the epicenter was located near the town of Léogâne, approximately 25 km west of the capital. The earthquake occurred in the boundary region separating the Caribbean plate and the North American plate. This plate boundary is dominated by left-lateral strike slip motion and compression, and accommodates about 20 mm/y slip, with the Caribbean plate moving eastward with respect to the North American plate (DeMets et al., 2000). Initially the location and focal mechanism of the earthquake seemed to involve straightforward accommodation of oblique relative motion between the Caribbean and North American plates along the Enriquillo-Plantain Garden fault system (EPGFZ), however Hayes et al., (2010) combined seismological observations, geologic field data and space geodetic measurements to show that, instead, the rupture process involved slip on multiple faults. Besides, the authors showed that remaining shallow shear strain will be released in future surface-rupturing earthquakes on the EPGFZ. In December 2010, a Spanish cooperation project financed by the Politechnical University of Madrid started with a clear objective: Evaluation of seismic hazard and risk in Haiti and its application to the seismic design, urban planning, emergency and resource management. One of the tasks of the project was devoted to vulnerability assessment of the current building stock and the estimation of seismic risk scenarios. The study was carried out by following the capacity spectrum method as implemented in the software SELENA (Molina et al., 2010). The method requires a detailed classification of the building stock in predominant building typologies (according to the materials in the structure and walls, number of stories and age of construction) and the use of the building (residential, commercial, etc.). Later, the knowledge of the soil characteristics of the city and the simulation of a scenario earthquake will provide the seismic risk scenarios (damaged buildings). The initial results of the study show that one of the highest sources of uncertainties comes from the difficulty of achieving a precise building typologies classification due to the craft construction without any regulations. Also it is observed that although the occurrence of big earthquakes usually helps to decrease the vulnerability of the cities due to the collapse of low quality buildings and the reconstruction of seismically designed buildings, in the case of Port-au-Prince the seismic risk in most of the districts remains high, showing very vulnerable areas. Therefore the local authorities have to drive their efforts towards the quality control of the new buildings, the reinforcement of the existing building stock, the establishment of seismic normatives and the development of emergency planning also through the education of the population.

Behavior of Ad Hoc routing protocols, analyzed for emergency and rescue scenarios, on a real urban area

A mobile Ad Hoc network (MANET) is a collection of wireless mobile nodes that can dynamically configure a network without a fixed infrastructure or central administration. This makes it ideal for emergency and rescue scenarios, where sharing information is essential and should occur as soon as possible. This article discusses which of the routing strategies for mobile MANETs: proactive, reactive or hierarchical, has a better performance in such scenarios. By selecting a real urban area for the emergency and rescue scenario, we calculated the density of nodes and the mobility model needed for the validation study of AODV, DSDV and CBRP in the routing model. The NS2 simulator has been used for our study. We also show that the hierarchical routing strategies are better suited for this type of scenarios.