The latest medical research on Retrieval Medicine

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Regional Anesthesia in the Austere Environment: Lessons Learned from Current Out-of-Hospital Practice.

Wilderness and Environmental Medicine

Pain management for trauma in the extreme environment is vital for both casualty comfort and aiding safe extrication. However, adequate pain management in a resource-limited environment can be challenging and is often limited. We conducted a scoping review of the use of regional anesthesia in the prehospital environment, evaluating which regional anesthetic procedure was performed for various indications, their efficacy, and the type of healthcare provider delivering the anesthetic.

A PRISMA-guided systematic literature review was conducted of Medline, Embase, and Cochrane databases for studies reporting the use of regional anesthesia in the prehospital environment published before June 30, 2022.

Thirty studies met the criteria and were included in the review. The most common types of regional anesthesia were fascia-iliaca compartment block (n = 317, from 12 studies) and femoral nerve block (n = 210, from 8 studies), along with various other blocks for a range of indications. These blocks had good efficacy and a low-risk profile and could be delivered by a wide range of healthcare providers.

Regional anesthesia is an effective and non-resource-heavy pain management tool in prehospital environments, which may be applicable to austere settings. It can cover a wide range of injuries and can avoid systemic complications for casualties that may already be challenging to manage in out-of-hospital settings. Additionally, regional anesthesia can be effectively delivered by a wide range of providers. This review provides a holistic summary of pain management using regional anesthesia in the prehospital environment, with a discussion on its potential use in more extreme settings.

Working towards 2030 road safety targets, the need for specific rural and remote children strategies.

Australian Journal of Rural Health

Despite the importance of child road traffic death, the knowledge about rural child road traffic death in Australia is limited.

To explore the difference of child road traffic death between urban and rural areas.

This study was a retrospective analysis of road traffic death in Australia among children and adolescents aged 0-19 registered between 1 January 2009 and 30 June 2019.

During the study period, there were 1757 child road traffic death in Australia, and the crude mortality rate was 2.96 per 100 000 population. The crude mortality rate in remote (8.83 per 100 000 population) and very remote (11.08 per 100 000 population) areas was much higher than major cities (1.83 per 100 000 population), inner regional (5.14 per 100 000 population) and outer regional (5.91 per 100 000 population).

Specific targets are needed to address the burden of child road traffic death in Australia around rurality, as it is a significant risk factor of child road traffic death.

Acetate Ringer's Solution versus Normal Saline Solution in Sepsis: A Randomized, Controlled Trial.

Shock

Slaine solution (NSS) and Ringer's acetate solution (RAS) are commonly given to critical ill patients as a fundamental fluid therapy. However, the effect of RAS and NSS on sepsis patient outcomes remains unknown.

We conducted a single-center prospective open-label parallel controlled trial to enroll adult patients (>18 years old) diagnosed with sepsis. Participants received either RAS or NSS for intravenous infusion for 5 days. The primary outcome was the incidence of Major adverse kidney events within 28 days (MAKE28). Secondary outcomes included 30-/90-day mortality, acute kidney injury (AKI), and hyperchloremia. The patients were then reclassified as NSS-only, RAS-only, and RAS+NSS groups according to the type of fluid they had received before enrollment. Thereafter, a secondary post hoc analysis was performed.

255 septic patients were screened and 143 patients (51.0% in RAS group and 49.0% in NSS group) were enrolled in the study. Each group received a median 2 L of fluid administration during 5 interventional days. 39.3% of patients had received 500 (500-1000) mL of balanced salt solutions (BSSs) prior to ICU admission. There was no statistical difference among the RAS and NSS group on the primary outcome MAKE28 in the initial analysis (23.3% vs. 20.0%, OR1.2 [0.6 to 2.2], p = 0.69). MAKE28 was observed in 23.3% of RAS-only versus 27.3% of NSS-only group patients (0.82 [0.35-1.94], P = 0.65) in the secondary post hoc analysis. The patients in NSS-only group had a longer Invasive Mechanical Ventilation days and a trend toward the accumulation of serum chloride.

This study observed no statistically significant difference on MAKE28 and secondary outcomes among sepsis patients receiving RAS and NSS. However, it is unclear whether the large amount of fluid resuscitation prior to ICU admission and carrier NSS narrowed the difference between BSSs and NSSs.

The social determinants of Aboriginal and Torres Strait Islander adults who do not smoke in regional Australia.

Australian Journal of Rural Health

Commercial tobacco use was systematically embedded as a valuable commodity through colonisation that continues to be exploited for profit by the Tobacco Industry. There have been significant declines in current smoking prevalence among Aboriginal and Torres Strait Islander peoples 18 years and over, from 55% in 1994 to 43% in 2018-2019. This paper seeks to better understand smoke-free behaviours, and to systematically quantify associations between a range of SDOH and non-smoking/never-smoking among Aboriginal and Torres Strait Islander adults (≥18) living in regional Australia.

To explore the social determinants of health (SDOH) related to non- and never-smoking among Aboriginal and Torres Strait Islander peoples in regional Australia.

Aboriginal and Torres Strait Islander adults (≥18 years) who were selected, consented and asked questions about smoking in the National Aboriginal and Torres Strait Islander Health Survey (NATSIHS 2018/19).

High income was associated with non-smoking (Prevalence Ratio [PR] = 2.07; 95% CI: 1.66-2.57) and never-smoking (PR = 2.02; 1.46-2.79), as was completing year 10 (non-smoking PR = 1.34; 1.12-1.61 and never-smoking PR = 1.56; 1.20-2.03). Better food security was associated with a higher prevalence of never-smoking (PR = 2.42; 1.48-3.98). Lower psychological distress scores were associated with non-smoking (PR = 1.30; 1.10-1.53) and never-smoking (PR = 1.56; 1.21-2.01). Never-smoking was more frequent in participants reporting no experiences of unfair treatment (PR = 1.59; 1.22-2.06). Having a usual healthcare provider was associated with non-smoking (PR = 1.38; 1.02-1.86). Positive exposure to the SDOH were associated with non- and never-smoking among Aboriginal and Torres Strait Islander adults in regional Australia. Structural and systemic changes to address the SDOH, including discrimination and racism, are expected to accelerate non-smoking behaviours and improve health outcomes for Aboriginal and Torres Strait Islander peoples.

Nation-Wide Variation in Presence of Legislation or Protocols for EMS Care of Operational Canines.

Prehosp Disaster Med

Deployment of law enforcement operational canines (OpK9s) risks injuries to the animals. This study's aim was to assess the current status of states' OpK9 (veterinary Emergency Medical Services [VEMS]) laws and care protocols within the United States.

Cross-sectional standardized review of state laws/regulations and OpK9 VEMS treatment protocols was undertaken. For each state and for the District of Columbia (DC), the presence of OpK9 legislation and/or care protocols was ascertained. Information was obtained through governmental records and from stakeholders (eg, state EMS medical directors and state veterinary boards).The main endpoints were proportions of states with OpK9 laws and/or treatment protocols. Proportions are reported with 95% confidence intervals (CIs). Fisher's exact test (P <.05) assessed whether presence of an OpK9 law in a given jurisdiction was associated with presence of an OpK9 care protocol, and whether there was geographic variation (based on United States Census Bureau regions) in presence of OpK9 laws or protocols.

Of 51 jurisdictions, 20 (39.2%) had OpK9 legislation and 23 (45.1%) had state-wide protocols for EMS treatment of OpK9s. There was no association (P = .991) between presence of legislation and presence of protocols. There was no association (P = .144) between presence of legislation and region: Northeast 66.7% (95% CI, 29.9-92.5%), Midwest 50.0% (95% CI, 21.1-78.9%), South 29.4% (95% CI, 10.3-56.0%), and West 23.1% (95% CI, 5.0-53.8%). There was significant (P = .001) regional variation in presence of state-wide OpK9 treatment protocols: Northeast 100.0% (95% CI, 66.4-100.0%), Midwest 16.7% (95% CI, 2.1-48.4%), South 47.1% (95% CI, 23.0-72.2%), and West 30.8% (95% CI, 9.1-61.4%).

There is substantial disparity with regard to presence of OpK9 legal and/or clinical guidance. National collaborative guidelines development is advisable to optimize and standardize care of OpK9s. Additional attention should be paid to educational and training programs to best utilize the limited available training budgets.

The iron status of rural Nigerian women in the second and third trimesters of pregnancy: implications for the iron endowment and subsequent dietary iron needs of their babies.

Rural and Remote Health

The aim of the study was to determine the iron status of rural-dwelling pregnant Nigerian women in the second and third trimesters, and to predict their risk of giving birth to babies with suboptimal iron endowment.

This was a prospective cohort study conducted between April and August 2021. A total of 174 consecutive and consenting pregnant rural dwellers, who met the inclusion criteria, were recruited by convenience sampling from the antenatal clinic of a public hospital in Nsukka, a semirural town in south-east Nigeria. The study participants were aged 21-40 years, and their iron status was determined by measuring blood haemoglobin (Hb) and serum ferritin (SF) concentration. Hb concentration was determined by the cyanmethemoglobin method and the SF concentration was determined by enzyme immunoassay method.

Almost half (47.7%) of the participants had Hb concentrations below 11 g/dL, while about two out of every five (40.8%) had SF concentrations less than 15 &micro;g/L. The prevalence of iron deficiency, iron deficiency anaemia (IDA) and non-iron deficiency anaemia were 40.8%, 23.6% and 24.7%, respectively. The mean SF levels varied with maternal age, gestation stage, pregnancy intervals and the intake of iron supplements. The mean SF concentration was higher in the second trimester than in the third. The mean SF concentration &plusmn; standard deviation (37.10&plusmn;3.02 &micro;g/L) was higher in the group that took iron supplements than in the group that did not (20.76&plusmn;2.11 &micro;g/L). However, two out of five participants in both groups had SF concentrations less than 15.0 &micro;g/L.

The prevalence of IDA was quite high among the participants in both trimesters even with the widespread intake of the recommended oral iron supplements. About four out of 10 of the participants had SF concentrations of less than 15 &micro;g/L and were thus judged at risk of giving birth to babies with poor iron deposits. Therefore, more effective strategies are needed to monitor and prevent IDA among pregnant women in rural populations of Nigeria and, by inference, other parts of tropical Africa.

Prevalence of functional limitations in older remote-living Aboriginal Australians.

Australian Journal of Rural Health

To better tailor prevention and care strategies, there is a need to identify modifiable factors associated with functional impairment in older Aboriginal people, and related service needs.

To investigate the prevalence and associated factors for functional impairment in older Aboriginal people, and related service needs.

Cross-sectional survey of 289 Aboriginal people aged ≥45 years living in the remote Kimberley region of Western Australia. Factors associated with functional impairment were explored with logistic regression.

41.2% (95% CI 35.6%-47.0%) of participants required assistance with at least one I/ADL, and 26.0% (95% CI 21.2%-31.3%) required assistance with two or more I/ADLs. A core activity limitation (required assistance with showering, dressing or cooking) was reported by 15.9% (95% CI 12.1%-20.6%). In multivariable logistic regression analyses, older age, diabetes, difficulty walking, head injury, higher depression score and worse cognition were associated with needing help with two or more I/ADLs, while older age, history of stroke, higher depression score and worse cognition were associated with the presence of a core activity limitation. The proportion of participants receiving support with I/ADLs ranged from 71.2% to 97.6%. Support was generally provided by family and friends rather than service providers.

This study highlights the need for holistic prevention strategies and care for older Aboriginal people with functional limitations and their families.

The landscape of non-psychotic psychiatric illness in rural Canada: a narrative review.

Rural and Remote Health

Canada's rural population has diverse demographic features and accounts for 18.9% of Canada's population. Indigenous Peoples (First Nations, Inuit, and M&eacute;tis), who are highly represented in rural communities, have additional risk factors related to colonialism, and historical and ongoing trauma. Understanding how to best respond to elevated rates of psychiatric illness in rural and remote communities requires an understanding of the unique challenges these communities face in accessing and providing high quality psychiatric services. This article reports a review of published literature on prevalence of non-psychotic psychiatric conditions, as well as the risk and protective factors influencing rates and experience of mental illness in rural and remote communities in Canada to help inform approaches to prevention and treatment.

This focused narrative review of literature related to rural non-psychotic psychiatric illness in rural and remote Canada published over a 20-year period (October 2001 - February 2023). A review of CINAHL, Medline and Academic Search Complete databases supplemented by gray literature (eg federal and provincial documents, position papers, and clinical practice guidelines) identified by checking reference lists of identified articles, and web searches. A textual narrative approach was used to describe the literature included in the final data set.

A total of 32 articles and 13 gray literature documents were identified. Findings were organized and described in relation to depression and anxiety and substance use suicidality and loss; rates for all were noted as elevated in rural communities. Different mental health strategies and approaches were described. Variability in degree of rurality, or proximity to larger metropolitan centers, and different community factors including cohesiveness and industrial basis, were noted to impact mental health risk and highlighted the need for enhancing family physician capacity and responsiveness and innovative community-based interventions, in addition to telepsychiatry.

Further focus on representative community-based research is critical to expand our knowledge. It is also critical to consider strategies to increase psychiatric care access, including postgraduate medical training and telehealth training.

Aquatic Feasibility of Limbs Application of Tourniquets (AFLAT) during a Lifeguard Water Rescue: A Simulation Pilot Study.

Prehosp Disaster Med

Control of massive hemorrhage (MH) is a life-saving intervention. The use of tourniquets has been studied in prehospital and battlefield settings but not in aquatic environments.

The aim of this research is to assess the control of MH in an aquatic environment by analyzing the usability of two tourniquet models with different adjustment mechanisms: windlass rod versus ratchet.

A pilot simulation study was conducted using a randomized crossover design to assess the control of MH resulting from an upper extremity arterial perforation in an aquatic setting. A sample of 24 trained lifeguards performed two randomized tests: one using a windlass-based Combat Application Tourniquet 7 Gen (T-CAT) and the other using a ratchet-based OMNA Marine Tourniquet (T-OMNA) specifically designed for aquatic use on a training arm for hemorrhage control. The tests were conducted after swimming an approximate distance of 100 meters and the tourniquets were applied while in the water. The following parameters were recorded: time of rescue (rescue phases and tourniquet application), perceived fatigue, and technical actions related to tourniquet skills.

With the T-OMNA, 46% of the lifeguards successfully stopped the MH compared to 21% with the T-CAT (P = .015). The approach swim time was 135 seconds with the T-OMNA and 131 seconds with the T-CAT (P = .42). The total time (swim time plus tourniquet placement) was 174 seconds with the T-OMNA and 177 seconds with the T-CAT (P = .55). The adjustment time (from securing the Velcro to completing the manipulation of the windlass or ratchet) for the T-OMNA was faster than with the T-CAT (six seconds versus 19 seconds; P < .001; effect size [ES] = 0.83). The perceived fatigue was high, with a score of seven out of ten in both tests (P = .46).

Lifeguards in this study demonstrated the ability to use both tourniquets during aquatic rescues under conditions of fatigue. The tourniquet with the ratcheting-fixation system controlled hemorrhage in less time than the windlass rod-based tourniquet, although achieving complete bleeding control had a low success rate.

Using High-Fidelity Virtual Reality for Mass-Casualty Incident Training by First Responders - A Systematic Review of the Literature.

Prehosp Disaster Med

First responders' training and learning regarding how to handle a mass-casualty incident (MCI) is traditionally based on reading and/or training through computer-based scenarios, or sometimes through live simulations with actors. First responders should practice in realistic environments to narrow the theory-practice gap, and the possibility of repeating the training is important for learning. High-fidelity virtual reality (VR) is a promising tool to use for realistic and repeatable simulation training, but it needs to be further evaluated. The aim of this literature review was to provide a comprehensive description of the use of high-fidelity VR for MCI training by first responders.

A systematic integrative literature review was used according to Whittemore and Knafl's descriptions. Databases investigated were PubMed, CINAHL Complete, Academic Search Ultimate, Web of Science, and ERIC to find papers addressing the targeted outcome. The electronic search strategy identified 797 potential studies. Seventeen studies were deemed eligible for final inclusion.

Training with VR enables repetition in a way not possible with live simulation, and the realism is similar, yet not as stressful. Virtual reality offers a cost-effective and safe learning environment. The usability of VR depends on the level of immersion, the technology being error-free, and the ease of use.

This integrative review shows that high-fidelity VR training should not rule out live simulation, but rather serve as a complement. First responders became more confident and prepared for real-life MCIs after training with high-fidelity VR, but efforts should be made to solve the technical issues found in this review to further improve the usability.

PRMT6-FoxO3a attenuates apoptosis by upregulating Parkin expression in intestinal ischemia-reperfusion injury.

Shock

Intestinal ischemia-reperfusion injury (IIRI) is a serious disease with high morbidity and mortality. This study aims to investigate the potential ...

Comprehensive Therapeutic Efficacy Analysis of Intravenous Immunoglobulin in Treating Sepsis-induced Coagulopathy: A Single-Center, Retrospective Observational Study.

Shock

To investigate the efficacy of intravenous immunoglobulin (IVIg) in treating sepsis-induced coagulopathy (SIC).

A retrospective controlled analysis was conducted on 230 patients with SIC at Ganzhou People's Hospital from January 2016 to December 2022. All patients were screened using propensity score matching and treated according to the SSC2016 guidelines. Compared to the control group (n = 115), patients in the test group (n = 115) received IVIg (200 mg/kg.d) for 3 consecutive days post-admission. The rating scales, coagulation function, survival, and treatment duration were evaluated.

On day 3 of treatment, both groups exhibited reduced PLT and TEG-MA levels, with the control group showing a more significant decrease (P < 0.05). By the 5th day, these levels had recovered in both groups. However, the test group experienced a significant increase by day 7 (P < 0.05). Coagulation factors II and X began to increase on day 3, and normalization was significantly faster in the test group on day 5 (P < 0.05). The levels of PT, INR, APTT, D-dimer, FIB, FDP, TEG-R, and TEG-K exhibited a notable decline on day 3 and demonstrated significantly faster recovery on day 5 in the test group (P < 0.05). Additionally, both groups showed a reduction in APACHE II, SOFA, DIC, and LAC levels on day 3, but the test group's scores decreased significantly more by day 7 (P < 0.05). Within the test group, WBC count, CRP, PCT, IL-6, and Tmax levels were lower (P < 0.05). Furthermore, the test group demonstrated shorter duration for ICU stay, mechanical ventilation, and CRRT (P < 0.05). No significant differences were observed in the duration of fever or vasoactive drug use between the groups. However, the log-rank method indicated a higher 28-day survival rate in the test group (P < 0.05).

IVIg can successfully increase platelet count and coagulation factors, correct coagulation disorders, enhance organ function, and reduce 28-day mortality in patients with SIC.