Penicillin Allergy Assessment and Skin Testing in the Outpatient Setting

Penicillin allergies are among of the most commonly reported allergies, yet only 10% of these patients are truly allergic. This leads to potential inadvertent negative consequences for patients and makes treatment decisions challenging for clinicians. Thus, allergy assessment and penicillin skin testing (PST) are important management strategies to reconcile and clarify labeled penicillin allergies. While PST is more common in the inpatient setting where the results will immediately impact antibiotic management, this process is becoming of increasing importance in the outpatient setting. PST in the outpatient setting allows clinicians to proactively de-label and educate patients accordingly so beta-lactam antibiotics may be appropriately prescribed when necessary for future infections. While allergists have primarily been responsible for PST in the outpatient setting, there is an increasing role for pharmacist involvement in the process. This review highlights the importance of penicillin allergy assessments, considerations for PST in the outpatient setting, education and advocacy for patients and clinicians, and the pharmacist’s role in outpatient PST

Avian perching deterrents on ultrasonic sensors at airport wind-shear alert systems

Preventing birds from perching on the sensor units of the Federal Aviation Administration’s Low Level Wind-shear Alert System (LLWAS) is crucial to its successful operation. In this study we evaluated, under controlled conditions, responses of brownheaded cowbirds (Molothrus ater), fish crows (Corvus ossifragus), great horned owls (Bubo virginianus), barred owls (Strix varia), and black vultures (Coragyps atratus) to several anti-perching devices. No device was totally successful against every species. Of the 5 original test devices, the most effective perching deterrent was a set of 17 stout spikes (“AgSpikes”) secured to the central portion of the sensor unit that point up 0o to 30o from the vertical. The central spikes were subsequently redesigned and combined with 9 metal bushings (3 for each arm of the sensor unit) that fit loosely on the sensor arms and that were armed with 5 sharp spikes each. This “AgSpikes and SpikedSpinner” combination unit was as effective as the original AgSpikes for all birds except owls, which were able to place their feet within the open spaces of the redesigned AgSpike portion of the device and perch on the 3 horizontal spikes. The combination units should adequately discourage most large and small birds from perching on LLWAS sensors. The availability of alternate perches in the field will likely enhance the effectiveness of the deterrent. Monitoring performance of the combination units deployed in the field is recommended to verify that they are working as expected

Responses of Captive Birds to Candidate Perching Deterrents on FAA LLWAS Units

Successful operation of the FAA’s Low-Level Windshear Alert System (LLWAS) depends largely on birds not perching on the wind-sensing units which are installed atop poles 40-45 m tall. Because new LLWAS units will be erected at airports throughout North America, anti- perching devices must deter numerous avian species ranging widely in body size and behavioral pattern. To determine the most promising devices, we conducted pen trials with brown-headed cowbirds, fish crows, barred owls, great horned-owls and black vultures. Birds were given free access to an unmodified sensor unit mounted on a tripod for 24 hours, during which the only alternative perch was a tree branch at ground level. This was followed by 24 h with a perching deterrent installed on the sensor unit. Trials were video-taped 10 hours daily and the sensors were connected to a computer so that failures in acquisition of wind data due to perching activity were continuously recorded. Smaller birds (cowbirds, crows) tended to perch on the 3 arms of the sensor units and were mostly deterred by “Bird Spinners”, metal bushings slipped onto the sensor arms that turned freely and prevented the birds from obtaining a stable perch. Owls and vultures were not affected by “Bird Spinners”, but “AgSpikes” (sharp, stout spikes emanating from a central base) reduced perching 95-98%. With the “AgSpikes” or “AgCone” (a smooth, solid aluminum cone) installed, owls and vultures attempted to perch but departed when they were not able to obtain a comfortable, stable grip. Commercial bird spikes and a monofilament web attached to the sensor arms were each ineffective regardless of species. It appears that a single perch deterrent device will not suffice for all birds, but a combination of “Bird Spinners” with “AgSpikes” or “AgCone” should be appropriate for most situations. Verification of these findings with field testing is needed

What Offshore Sailing Captains Teach us about Leadership

This qualitative and exploratory study examines how leadership is demonstrated in the context of offshore sailing through the sea stories of sailing captains’ experiences where there was potential for massive physical, psychological, or material consequences to the crew and/or the boat. The analysis of their stories shows that offshore sailing captains demonstrate the characteristics of in extremis leaders, consistent with prior research, which include inherent and intrinsic motivation, effective sense-making and sense giving during the extreme event, and developing a collaborative team without hierarchy built on trust engendered from demonstrating competence and confidence. The study also revealed a model of how these captains demonstrate dynamic system leadership through continuous learning and acting which prepares the captains to prevent or minimize the effects of the extreme situations they encounter at sea. Through their self-development, technical skills, emotional intelligence, planning and preparation, team management, and constant scanning of the environment they build situation awareness for quick risk assessment and decision-making in moments of in extremis. The captain’s goal at all times is to keep the crew and the boat safe, both physically and psychologically, through normal conditions and during in extremis events, using appropriate decisions and actions, and always remaining calm

The Establishment of Norms for Two Selected Tennis Skills Tests at North Texas State University

The purposes of this study were 1) to establish validity and reliability for a modified service test, 2) to determine male and female norms for the service test, and 3) to establish norms for the Kemp-Vincent Rally Test. Subjects were 677 students enrolled in beginning and intermediate tennis classes at North Texas State University, Denton, Texas. Data were analyzed by the two-way analysis of variance to establish reliability. Norms were established by converting raw scores to normalized standard T-scores. Conclusions of the investigation were 1) the modified service test is valid and reliable, and 2) there is a need for separate male and female norms when the skill is governed by strength

Penicillin Allergy Skin Testing in the Inpatient Setting

The consequences of a documented penicillin allergy in the medical record are especially troublesome in acutely ill, hospitalized patients. A penicillin allergy label may lead to alternative or second line therapies resulting in adverse drug events, negative clinical outcomes and increased costs. Reconciling penicillin allergies is a necessity to facilitate early, optimal therapy and is a shared responsibility among the healthcare team. Penicillin skin testing (PST) has been utilized successfully in hospitalized patients to de-label erroneous penicillin allergies and optimize antibiotic therapy. This targeted review aims to discuss the practical development and implementation of PST in the inpatient setting. This includes a needs assessment checklist with common considerations allowing for customization to one’s institution based on available personnel, time, and technological resources

Flamingo Vol. IX N 2

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Evaluation of Trapping to Reduce Monk Parakeet Populations at Electric Utility Facilities

Through accidental and intentional introductions, the monk parakeet, native to South America, is now established in several parts of the United States. In Florida, it occurs in 21 of 67 counties. Monk parakeets build a bulky nest structure of sticks, and they often build on electric utility substations and support structures for distribution and transmission lines. This nesting activity is incompatible with reliable electric service because nest material creates short circuits that cause power outages. Nest removal by electric utility personnel is ongoing but provides only short-term relief, as buds readily rebuild their nests. In h s study, we evaluated passive and active methods to trap monk parakeets, and we documented the effectiveness of trapping to reduce rates of nest rebuilding on distribution poles. At electric substations, we tested two passive trap designs: a drop-in style trap, and a walk-in style trap. Monk parakeets were wary of traps, however, and were not easily captured even with extensive pre-baiting and the use of decoy birds. At distribution poles, we actively trapped birds at 47 nest sites using specially designed nets placed over nest entrances at night while birds roosted. Birds were then caught as they flew out of the nests into the net. Capture success at individual nest sites ranged from 0 to 100% with an overall average of 51%. Of the 47 sites where birds were trapped at night, 43 nests were removed immediately or shortly after netting. Subsequent monitoring revealed that higher nest site capture rates resulted in slower rates of nest rebuilding. We conclude that while more research is needed to design an effective passive trapping system, monk parakeets can be readily trapped from distribution pole nests at night thereby enhancing nest removal efforts

Indiana Emergency Medical Services Needs Assessment: Workforce and Training Issues

A mail survey was conducted to assess issues related to the EMS workforce and EMS workforce training in Indiana. Responses were received from approximately 45% of individuals and EMS organization contacted. Major findings are: Evidence exists of a shortage of EMS personnel in Indiana due to high vacancy rates. This is particularly acute in volunteer organizations, which report the greatest difficulty in recruiting EMS personnel. Paid EMS personnel work on average significantly more than a standard 40 hour week, and high percentages of EMS personnel add a second job. Because excessive working hours have been linked to low quality healthcare, this may indicate potential problems with the quality of EMS care. Differences in training needs and training received in areas related to cardiac care indicate potential disparities in the quality of care for heart attacks between rural and urban areas. Contrary to the Indiana requirements for recertification, it appears that a significant proportion of Indiana EMS personnel and organizations are not using audits as a tool for ensuring quality and developing skills. A wide variety of training needs have been identified. While some clinical skill areas (basic and advanced life support) are needed, many of these areas are in important non-clinical areas, such as automobile extrication, foreign languages, safety, and incident management. The training environment, both in terms of initial and continuing training, is so varied that it cannot realistically be considered a “system.” In the abstract, EMS personnel prefer “hands-on” type training, but when presented with specific scenarios they indicate a greater affinity for locally-delivered mechanisms such as classroom courses at a local school or computer-based training. This probably reflects the tradeoff between time and utility, and is consistent with findings that time is the largest barrier to continuing education and the high percentage EMS personnel who hold second jobs. Self-assessment of preparedness levels by EMS personnel reveals that the EMS system in rural areas is likely to be less prepared and capable than in urban areas. Volunteer organizations rate themselves as less capable than paid organizations, although this is largely not reflected in self-assessments by volunteer EMS personnel