Sex-Based Differences in Depth of Soft Tissue at the Proximal Tibia Intraosseous Catheter Insertion Site

Background Intraosseous (IO) catheters are commonly used to rapidly obtain vascular access for critically-ill patients in the emergency department (ED). Although the proximal tibia (PT) is a standard IO insertion site for adult subjects, little is known about sex-based variation in the proper depth of insertion. Methods A retrospective cohort study was performed, utilizing CT scans obtained from DMC over a ten-year period (2009-2018) to estimate soft tissue depth overlying the recommended PT-IO insertion site. Depths of soft tissue from skin surface to bone surface (Measurement A) and from skin surface to the opposite bony cortex (Measurement B) were measured using standard radiologic software. Results A total of 217 subjects were enrolled, including 106 (48.9%) males. Body mass index (BMI) was not significantly different between sexes (p=0.188). Measurement A for females (x̄=21.65 mm, σ=8.17) was significantly greater than for males (x̄=13.64 mm, σ=5.52) (p\u3c0.0001). Measurement A was \u3e25-mm in 5.7% of males and 27.0% of females (p\u3c0.001). Measurement B was \u3c45-mm in 24.5% of males and 21.6% of females. Conclusion Our results suggest that sex-based differences exist in soft tissue depth at the PT site, despite similar BMI values. Since common IO needle lengths are 25-mm and 45-mm, these results have profound implications. The 25-mm needle would have been too short for more than one-fourth of female subjects. However, a 45-mm catheter would have been too long for almost one-fourth of all subjects. Further study is needed to determine whether this sex difference exists in a larger cohort of patients

Racemose neurocysticercosis.

BACKGROUND: Neurocysticercosis (NCC) is an invasive parasitic infection of the central nervous system caused by the larval stage of the tapeworm Taenia solium. The clinical manifestations of NCC depend on the parasitic load and location of infection, as well as the developmental stage of the cysticerci and host immune response, with symptoms ranging from subclinical headaches to seizures, cerebrovascular events, and life-threatening hydrocephalus. Racemose NCC represents a particularly severe variant of extraparenchymal NCC characterized by the presence of multiple confluent cysts within the subarachnoid space and is associated with increased morbidity and mortality, as well as a decreased response to treatment. Albendazole is the preferred drug for the treatment of racemose NCC due to its superior cerebrospinal fluid penetration compared to praziquantel and the ability to be used concomitantly with steroids. CASE DESCRIPTION: In this report, we describe a 39-year-old man recently emigrated from Mexico with racemose NCC and hydrocephalus successfully treated with prolonged albendazole treatment, high-dose dexamethasone, and ventriculoperitoneal shunt placement for the relief of obstructive hydrocephalus. CONCLUSIONS: Treatment of racemose NCC represents a significant clinical challenge requiring multimodal intervention to minimize infectious- and treatment-related morbidity. We review the clinical, diagnostic, and therapeutic features relevant to the management of this aggressive form of NCC

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

Genetic correlates of prostate cancer visibility (and invisibility) on mpMRI: It's time to take stock

Multiparametric magnetic resonance imaging (mpMRI) has enhanced risk stratification for men at risk of prostate cancer, through accurate pre‐biopsy detection of high‐risk disease. However, it has become apparent that not all clinically significant prostate cancer is detected by mpMRI. Approximately 10‐20% of significant disease is invisible to mpMRI, depending on the threshold set for significance, and on the quality of mpMRI acquisition and interpretation. The threshold for significance has recently been challenged by the 29‐year follow‐up of the SPCG‐4 study, in which men with overall Gleason score 3 + 4 did not suffer prostate‐cancer‐related death, whilst those with overall Gleason score 4 + 3 did suffer prostate‐cancer related death (adjusted relative risk 5.73; 95% CI 1.59–20.67) potentially suggesting a new threshold for clinically significant disease. This finding is important, given that in PROMIS, no men with overall Gleason score 4 + 3 had negative pre‐biopsy mpMRI, indicating that actually mpMRI may identify all truly significant cancer (if SPCG‐4 is used to guide our threshold). Nonetheless, over the past two years, there has been increasing drive to better understand the nature of mpMRI‐inconspicuous disease, particularly at the molecular level