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Use of ketamine in the prehospital setting may be advantageous due to its potent analgesic and sedative properties and favorable risk profile. Use in the military setting has demonstrated both efficacy and safety for pain relief. The purpose of this study was to assess ketamine training, use, and perceptions in the civilian setting among nationally certified paramedics (NRPs) in the United States.
A cross-sectional survey of NRPs was performed. The electronic questionnaire assessed paramedic training, authorization, use, and perceptions of ketamine. Included in the analysis were completed surveys of paramedics who held one or more state paramedic credentials, indicated “patient care provider” as their primary role, and worked in non-military settings. Descriptive statistics were calculated.
A total of 14,739 responses were obtained (response rate=23%), of which 10,737 (73%) met inclusion criteria and constituted the study cohort. Over one-half (53%) of paramedics reported learning about ketamine during their initial paramedic training. Meanwhile, 42% reported seeking ketamine-related education on their own. Of all respondents, only 33% (3,421/10,737) were authorized by protocol to use ketamine. Most commonly authorized uses included pain management (55%), rapid sequence intubation (RSI; 72%), and chemical restraint/sedation (72%). One-third of authorized providers (1,107/3,350) had never administered ketamine, with another 32% (1,070/3,350) having administered ketamine less than five times in their career. Ketamine was perceived to be safe and effective as the vast majority reported that they were comfortable with the use of ketamine (94%) and would, in similar situations (95%), use it again.
This was the first large, national survey to assess ketamine training, use, and perceptions among paramedics in the civilian prehospital setting. While training related to ketamine use was commonly reported among paramedics, few were authorized to administer the drug by their agency’s protocols. Of those authorized to use ketamine, most paramedics had limited experience administering the drug. Future research is needed to determine why the prevalence of ketamine use is low and to assess the safety and efficacy of ketamine use in the prehospital setting.
BucklandDM, CroweRP, CashRE, GondekS, MalusoP, SirajuddinS, SmithER, DangerfieldP, ShapiroG, WankaC, PanchalAR, SaraniB. Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States. Prehosp Disaster Med. 2018;33(1):23–28.
Combinatorial auctions enhance our ability to efficiently allocate multiple resources in complex economic environments. They explicitly allow buyers and sellers of goods and services to bid on packages of items with related values or costs. For example, “I bid $10 to buy 1 unit of item A and 2 units of item B, but I won't pay anything unless I get everything.” They also allow buyers, sellers and the auctioneer to impose logical constraints that limit the feasible set of auction allocations. For example, “I bid $12 to buy 2 units of item C OR $15 to buy 3 units of item D, but I don't want both.” Finally, they can handle functional relationships amongst bids or allocations, such as budget constraints or aggregation limits that allow many bids to be connected together. For example, “I won't spend more than a total of $35 on all my bids” or “This auction will allocate no more than a total of 7 units of items F, G and H.”
There are several reasons to prefer to have the bidding message space expanded beyond the simple space used for traditional single commodity auctions. As Bykowsky et al. (2000) point out, when values have strong complementarities, there is a danger of ‘financial exposure’ that results in losses to bidders if combinatorial bidding is not allowed. For example, in the case of complementary items such as airport take-off and landing times, the ability to reduce uncertainty to the bidder by allowing him to precisely declare his object of value, a cycle of slots for an entire daily flight pattern, is obvious: one component slot not acquired ruins the value of the flight cycle. In the same situation substitution possibilities would also be important to consider: if flight cycle A is not won, cycle B may be an appropriate though less valuable substitute for the crew and equipment available. Allocation inefficiencies due to financial exposure in noncombinatorial auctions have been frequently demonstrated in experiments beginning with Rassenti et al. (1982) (see also Porter (1999), Banks et al. (1989), Ledyard et al. (2002) and Kwasnika et al. (1998)).
Abdominal aortic aneurysm is a multifactorial disease that is a leading cause of death in developed countries. Matrix-metalloproteases (MMPs) are part of the disease process, however, assessing their role in disease initiation and progression has been difficult and animal models have become essential. Combining Förster resonance energy transfer (FRET) proteolytic beacons activated in the presence of MMPs with 2-photon microscopy allows for a novel method of evaluating MMP activity within the extracellular matrix (ECM). Single and 2-photon spectra for proteolytic beacons were determined in vitro. Ex vivo experiments using the apolipoprotein E knockout angiotensin II-infused mouse model of aneurysm imaged ECM architecture simultaneously with the MMP-activated FRET beacons. 2-photon spectra of the two-color proteolytic beacons showed peaks for the individual fluorophores that enable imaging of MMP activity through proteolytic cleavage. Ex vivo imaging of the beacons within the ECM revealed both microstructure and MMP activity. 2-photon imaging of the beacons in aneurysmal tissue showed an increase in proteolytic cleavage within the ECM (p<0.001), thus indicating an increase in MMP activity. Our data suggest that FRET-based proteolytic beacons show promise in assessing MMP activity within the ECM and will therefore allow future studies to identify the heterogeneous distribution of simultaneous ECM remodeling and protease activity in aneurysmal disease.
The aim of this study was to examine cross-sectionally whether higher cardiorespiratory fitness (CRF) might favorably modify amyloid-β (Aβ)-related decrements in cognition in a cohort of late-middle-aged adults at risk for Alzheimer’s disease (AD). Sixty-nine enrollees in the Wisconsin Registry for Alzheimer’s Prevention participated in this study. They completed a comprehensive neuropsychological exam, underwent 11C Pittsburgh Compound B (PiB)-PET imaging, and performed a graded treadmill exercise test to volitional exhaustion. Peak oxygen consumption (VO2peak) during the exercise test was used as the index of CRF. Forty-five participants also underwent lumbar puncture for collection of cerebrospinal fluid (CSF) samples, from which Aβ42 was immunoassayed. Covariate-adjusted regression analyses were used to test whether the association between Aβ and cognition was modified by CRF. There were significant VO2peak*PiB-PET interactions for Immediate Memory (p=.041) and Verbal Learning & Memory (p=.025). There were also significant VO2peak*CSF Aβ42 interactions for Immediate Memory (p<.001) and Verbal Learning & Memory (p<.001). Specifically, in the context of high Aβ burden, that is, increased PiB-PET binding or reduced CSF Aβ42, individuals with higher CRF exhibited significantly better cognition compared with individuals with lower CRF. In a late-middle-aged, at-risk cohort, higher CRF is associated with a diminution of Aβ-related effects on cognition. These findings suggest that exercise might play an important role in the prevention of AD. (JINS, 2015, 21, 841–850)
Aging is associated with performance reductions in executive function and episodic memory, although there is substantial individual variability in cognition among older adults. One factor that may be positively associated with cognition in aging is physical activity. To date, few studies have objectively assessed physical activity in young and older adults, and examined whether physical activity is differentially associated with cognition in aging. Young (n=29, age 18–31 years) and older adults (n=31, ages 55–82 years) completed standardized neuropsychological testing to assess executive function and episodic memory capacities. An experimental face-name relational memory task was administered to augment assessment of episodic memory. Physical activity (total step count and step rate) was objectively assessed using an accelerometer, and hierarchical regressions were used to evaluate relationships between cognition and physical activity. Older adults performed more poorly on tasks of executive function and episodic memory. Physical activity was positively associated with a composite measure of visual episodic memory and face-name memory accuracy in older adults. Physical activity associations with cognition were independent of sedentary behavior, which was negatively correlated with memory performance. Physical activity was not associated with cognitive performance in younger adults. Physical activity is positively associated with episodic memory performance in aging. The relationship appears to be strongest for face-name relational memory and visual episodic memory, likely attributable to the fact that these tasks make strong demands on the hippocampus. The results suggest that physical activity relates to cognition in older, but not younger adults. (JINS, 2015, 21, 780–790)
A growing body of literature has explored the influence of physical activity on brain structure and function. While the mechanisms of this relationship remain largely speculative, recent research suggests that one of the effects of physical exercise is an increase in synaptic long-term potentiation (LTP). This has not yet been explored directly in humans due to the difficulty of measuring LTP non-invasively. However, we have previously established that LTP-like changes in visual-evoked potentials (VEPs) can be measured in humans. Here, we investigated whether physical fitness status affects the degree of visual sensory LTP. Using a self-report measure of physical activity, participants were split into two groups: a high-activity group, and a low-activity group. LTP was measured and compared between the two groups using the previously established electroencephalography-LTP paradigm, which assesses the degree to which the N1b component of the VEP elicited by a sine grating is potentiated (enhanced) following a rapid “tetanic” presentation of that grating. Both groups demonstrated increased negativity in the amplitude of the N1b component of the VEP immediately after presentation of the visual “tetanus,” indicating potentiation. However, after a 30-min rest period, the N1b for the high-activity group remained potentiated while the N1b for the low-activity group returned to baseline. This study presents the first evidence for the impact of self-reported levels of physical activity on LTP in humans, and sheds light on potential neurological mechanisms underlying the relationship between physical fitness and cognition. (JINS, 2015, 21, 831–840)
Shale gas development may involve trade-offs between energy development and benefits provided by natural ecosystems. However, current best management practices (BMPs) focus on mitigating localized ecological degradation. We review evidence for cumulative effects of natural gas development on brook trout (Salvelinus fontinalis) and conclude that BMPs should account for potential watershed-scale effects in addition to localized influences. The challenge is to develop BMPs in the face of uncertainty in the predicted response of brook trout to landscape-scale disturbance caused by gas extraction. We propose a decision-analysis approach to formulating BMPs in the specific case of relatively undisturbed watersheds where there is consensus to maintain brook trout populations during gas development. The decision analysis was informed by existing empirical models that describe brook trout occupancy responses to landscape disturbance and set bounds on the uncertainty in the predicted responses to shale gas development. The decision analysis showed that a high efficiency of gas development (e.g., 1 well pad per square mile and 7 acres per pad) was critical to achieving a win-win solution characterized by maintaining brook trout and maximizing extraction of available gas. This finding was invariant to uncertainty in predicted response of brook trout to watershed-level disturbance. However, as the efficiency of gas development decreased, the optimal BMP depended on the predicted response, and there was considerable potential value in discriminating among predictive models through adaptive management or research. The proposed decision-analysis framework provides an opportunity to anticipate the cumulative effects of shale gas development, account for uncertainty, and inform management decisions at the appropriate spatial scales.
Tall fescue toxicosis adversely affects calving rate and weight gains reducing returns to cow-calf producers in the south–central United States. This grazing study estimated animal and economic performance implications of endophyte-infected fescue and calving season. Establishing novel endophyte-infected tall fescue on 25% of pasture acres resulted in improved calving rates (87% vs. 70%), weaning weights (532 lbs vs. 513 lbs), and partial returns per acre ($257 vs. $217). Additionally, fall-calving cows had higher calving rates (91% vs. 67%), weaning weights (550 lbs vs. 496 lbs), and partial returns per acre ($269 vs. $199) than spring calving cows.