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May 15th, 2012 posted by Paul Rega, MD, FACEP May 15, 2012 @ 7:08 pm

Emergency US of the Gall Bladder

Emergency Ultrasound of the Gall Bladder: Comparison of a Concentrated Elective Experience vs. Longitudinal Exposure During Residency
Published online: 30 April 2012
Timothy B. Jang, Wendy Ruggeri, Amy H. Kaji
DOI: 10.1016/j.jemermed.2012.02.029
Journal of Emergency Medicine, The, http://www.jem-journal.com/article/S0736-4679%2812%2900250-8/abstract

Physicians who participated in a 2-week, semi-structured EUS elective demonstrated EUS accuracy for biliary disease that was comparable with those who performed the same number of examinations over a longer period of time.



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May 15th, 2012 posted by Paul Rega, MD, FACEP @ 7:05 pm

ER Residents & Simulation Training

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http://www.medicalnewstoday.com/releases/245333.php

Critical Decision-Making Skills Of ER Residents Honed By Simulation Training

 

Article Date: 14 May 2012 – 1:00 PDT

“A Henry Ford Hospital study found that simulation training improved the critical decision-making skills of medical residents performing actual resuscitations in the Emergency Department.

Researchers say the residents performed better in four key skill areas after receiving the simulation training: leadership, problem solving, situational awareness and communication. Their overall performance also sharpened.

While many studies have shown the benefits of simulation training for honing the skill level of medical professionals, Henry Ford’s study evaluated residents’ decision-making skills before performing simulated resuscitations and then performing the real-life emergency procedure………

“The improved performance from simulation to actual clinical practice was telling,” says Sudhir Baliga, M.D., senior staff physician in Henry Ford’s Emergency Department and the study’s lead author. “This is another important example of simulation training as a teaching tool to prepare residents for actual bedside care.”

Fifteen second-year Emergency Department residents were evaluated during three simulated resuscitations performed in May and June 2011 at Henry Ford’s Center for Simulation, Education and Research, one of the largest simulation facilities in the United States. The residents also received classroom training.

Two months later, the residents were evaluated during three live resuscitations to determine a change in performance……”



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May 15th, 2012 posted by Paul Rega, MD, FACEP @ 7:03 pm

Kids: Battery-Related ER Visits

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“Pediatric Battery-Related Emergency Department Visits in the United States, 1990-2009″; Samantha J. Sharpe, Lynne M. Rochette, and Gary A. Smith; Pediatrics peds.2011-0012; published online 14 May 2012; DOI: 10.1542/peds.2011-0012;

RESULTS: An estimated 65 788 patients <18 years of age presented to US EDs due to a battery-related exposure during the 20-year study period, averaging 3289 battery-related ED visits annually. The average annual battery-related ED visit rate was 4.6 visits per 100 000 children. The number and rate of visits increased significantly during the study period, with substantial increases during the last 8 study years. The mean age was 3.9 years, and 60.2% of patients were boys. Battery ingestion accounted for 76.6% of ED visits, followed by nasal cavity insertion (10.2%), mouth exposure (7.5%), and ear canal insertion (5.7%). Button batteries were implicated in 83.8% of patient visits caused by a known battery type. Most children (91.8%) were treated and released from the ED.

http://pediatrics.aappublications.org/content/early/2012/05/09/peds.2011-0012.abstract



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May 15th, 2012 posted by Paul Rega, MD, FACEP @ 6:54 pm

FDA on multiple sclerosis drug fingolimod (Gilenya)

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http://www.medpagetoday.com/Neurology/MultipleSclerosis/32675

 
FDA Puts New Limits on Oral MS Drug

 

By John Gever, Senior Editor, MedPage TodayPublished: May 14, 2012 
 
 

WASHINGTON — “Reacting to a death associated with the multiple sclerosis drug fingolimod (Gilenya), the FDA said patients with certain cardiac risk factors should not take the oral agent.

The death was reported last year and the agency had promised to investigate it.

In an announcement on Monday, the FDA said it still didn’t know whether fingolimod caused the patient’s death, but nevertheless it was adding new contraindications to the drug’s label, as well as a beefed-up recommendation for monitoring patients after dosing.

According to the revised label, the drug should not be taken by patients with any of the following:



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May 15th, 2012 posted by Paul Rega, MD, FACEP @ 4:34 am

Revise the definition of addiction and it could pose huge consequences for health insurers and taxpayers…..

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http://www.nytimes.com/2012/05/12/us/dsm-revisions-may-sharply-increase-addiction-diagnoses.html?_r=1&nl=todaysheadlines&emc=edit_th_20120512

May 11, 2012
 
Addiction Diagnoses May Rise Under Guideline Changes
By

WASHINGTON — In what could prove to be one of their most far-reaching decisions, psychiatrists and other specialists who are rewriting the manual that serves as the nation’s arbiter of mental illness have agreed to revise the definition of addiction, which could result in millions more people being diagnosed as addicts and pose huge consequences for health insurers and taxpayers.

The…….. Diagnostic and Statistical Manual of Mental Disorders……would expand the list of recognized symptoms for drug and alcohol addiction, while also reducing the number of symptoms required for a diagnosis…….

In addition, the manual for the first time would include gambling as an addiction, and it might introduce a catchall category — “behavioral addiction — not otherwise specified” — that some public health experts warn would be too readily used by doctors, despite a dearth of research, to diagnose addictions to shopping, sex, using the Internet or playing video games……”



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May 15th, 2012 posted by Paul Rega, MD, FACEP @ 4:26 am

Why are there disparities in treatment of children in the ER who have different insurance status?

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http://www.sciencecodex.com/disparities_in_treatment_of_children_in_the_emergency_department_based_on_their_insurance_status-91269

“…..A new study scheduled for publication in The Journal of Pediatrics reports that children with private, public, and no insurance may receive differing levels of treatment in EDs……. Over the 10-year period, researchers found that 45% of children in the ED had private insurance, 43% had public insurance (Medicaid or State Children’s Health Insurance Program), and 12% had no insurance. Compared with children with private insurance, those with public or no insurance were almost 25% less likely than those with private insurance to undergo testing, receive a medication, or undergo any procedure when seeking care in the ED. Although children with public insurance were 20% more likely to be diagnosed with a significant illness compared with children with private insurance, there was no difference in the level of treatment based on insurance status among children with significant illnesses.

It is unclear whether these insurance-based differences represent under treatment in children without private insurance, over treatment in children with private insurance, or appropriate care for all…… Although the authors speculate that the disparities could be due to a variety of reasons, they note that further studies are needed to assess insurance-associated outcomes.”



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May 15th, 2012 posted by Paul Rega, MD, FACEP @ 4:23 am

Sudden Cardiac Death in HIV Patients

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Sudden Cardiac Death in Patients With Human Immunodeficiency Virus Infection

Zian H. Tseng, Eric A. Secemsky, David Dowdy, Eric Vittinghoff, Brian Moyers, Joseph K. Wong, Diane V. Havlir, and Priscilla Y. HsueJ Am Coll Cardiol 2012;59 1891-1896
http://content.onlinejacc.org/cgi/content/abstract/59/21/1891

 Of 230 deaths over a median of 3.7 years of follow-up, 30 (13%) met SCD criteria, 131 (57%) were due to acquired immune deficiency syndrome (AIDS), 25 (11%) were due to other (natural) diseases, and 44 (19%) were due to overdoses, suicides, or unknown causes. SCDs accounted for 86% of all cardiac deaths (30 of 35). The mean SCD rate was 2.6 per 1,000 person-years, 4.5-fold higher than expected. SCDs occurred in older patients than did AIDS deaths (mean 49.0 vs. 44.9 years, p = 0.02). Compared with AIDS and natural deaths combined, SCDs had a higher prevalence of prior myocardial infarction (17% vs. 1%, p < 0.0005), cardiomyopathy (23% vs. 3%, p < 0.0005), heart failure (30% vs. 9%, p = 0.004), and arrhythmias (20% vs. 3%, p = 0.003).



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May 15th, 2012 posted by Paul Rega, MD, FACEP @ 4:15 am

Floodwalls protecting the only hospital in Bartholomew County, Indiana

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http://www.fema.gov/mitigationbp/bestPracticeDetail.do;jsessionid=B41920923423DFCE92D4982AC566183D.Worker2Public3?mitssId=9311

Floodwall with Passive Floodgates Signals Commitment to Patients and Community

Full Mitigation Best Practice Story

 

Bartholomew County, Indiana

Columbus Regional Hospital, the only hospital serving Bartholomew County, Indiana, is now protected from future flooding thanks to hazard mitigation and a floodwall with passive floodgates. The floodwall, built with hazard mitigation funds from the Federal Emergency Management Agency (FEMA) and Columbus Regional Hospital, will protect this vital hospital from catastrophic flood damage, should the area be hit with flooding, as was the case in 2008.

On June 7, 2008, nearby Haw Creek, a small tributary, came out of its banks due to flash flooding in the northern part of the watershed. The floodwater rose quickly as hospital employees worked feverishly to evacuate patients and vital equipment. When the water entered the first floor “that’s when we knew we were in really big trouble…” said Jim Bickel, President and CEO. The unprecedented flooding quickly filled the basement and rose six inches on the first floor of the building, forcing the hospital to evacuate 157 patients and knocking out primary and emergency electrical systems, boilers, chillers, and transport system. The hospital vowed that it would not happen again.

The hospital sustained more than $180 million in damages, a figure that would have been much higher if it wasn’t for the resourcefulness of hospital teams, tireless efforts of employees and close coordination with federal, state, and local officials. Critical functions and equipment had been moved to nearby locations and plans quickly enacted to contain damages and costs.

Working closely with FEMA, insurers, and area contractors, the hospital was able to reopen in 6 months rather than 12-15 months as initially projected.

Once the massive cleanup was completed, the hospital turned its attention to flood mitigation. Columbus Regional Hospital engaged an engineering firm to study the Haw Creek watershed and recommend plans for flood mitigation. The study evaluated possible flood-control measures including diversion channels, retention areas, buyouts of homes in flood-prone areas, and regulations on building in flood-prone areas.

As a critical lifeline entity, FEMA and Columbus Regional Hospital determined that passive flood-mitigation measures should be installed since relocation was not financially practicable. A flood-barrier system encircling the hospital was deemed the most cost effective and reasonable solution.

FEMA approved, and provided 75-percent funding for a floodwall designed to protect the entire hospital campus. Construction on the $4.7 million floodwall started in June 2011 and was completed in March 2012. The 2,400-foot floodwall was built two feet higher than the 100-year-flood elevation and includes 15 passive floodgates at all entry points. The floodgates allow unimpeded access by vehicles and pedestrians during dry times, and automatically deploys without reliance on power or personnel if flooding occurs.

Columbus Regional Hospital has also strengthened its Flood Emergency Response plan to protect against future disasters. Hospital officials are more involved with county emergency management officials and stay abreast of weather conditions, particularly upstream. As Jim Bickel, stated, “We talk about disaster planning a lot… It certainly is a priority. It (the flood) brought it home to us how important it really is.”



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May 15th, 2012 posted by Paul Rega, MD, FACEP @ 4:14 am

Community Safe Rooms (FEMA 361)

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http://www.fema.gov/plan/prevent/saferoom/fema361.shtm

Design and Construction Guidance for Community Safe Rooms (FEMA 361)

Second Edition

This publication presents design, construction, and operation criteria for community safe rooms that will provide near-absolute life safety protection during tornado and hurricane events. It provides guidance for architects, engineers, building officials, local officials and emergency managers, and prospective safe room owners and operators about the design, construction, and operation of community safe rooms in extreme-wind events.

Since the publication of FEMA’s pioneering guides for safe room design and construction, FEMA 320 and FEMA 361, our knowledge and practical experience in mitigating the risks associated with extreme events have expanded and developed substantially. Further, our research and understanding of these hazards and the extreme risks they present to our communities has been expanded. Using the initial FEMA publications as a pre-standard, design and construction professionals led by International Code Council® (ICC®) and the National Storm Shelter Association (NSSA) have joined forces to produce the first ICC/NSSA Standard for the Design and Construction of Storm Shelters (ICC-500). While fully supporting this effort, FEMA decided to continue to promote the new 320 and 361 criteria for those individuals and communities that are looking for “best practices” that are above the minimums prescribed in codes and standards, including the new ICC/NSSA standard. Download the entire FEMA 361 document.

FEMA continues to advocate the design and construction of safe rooms as evidenced by its continuing support of safe room initiatives through several grant programs. Since the initiation of its safe room program, FEMA has provided federal funds totaling over $200 million for the design and construction of more than 500 community safe rooms. Through residential safe room initiatives over the same time, FEMA has provided support for the design and construction of nearly 20,000 residential safe rooms with federal funds totaling more than $50 million.

Why is the term “safe room” being used instead of “shelter”?

The terms “safe room” and “shelter” have been used, for the most part, interchangeably in past publications. Typically the difference in usage was limited to differentiating between residential applications called “safe rooms” and larger projects called “community shelters.” The release of the ICC-500 standard, as well as other national, state, and local protection initiatives, identified a need to distinguish shelters that meet the FEMA criteria for near-absolute protection and those that do not. Although both the FEMA and ICC criteria are designed to ensure life-safety protection for safe rooms and shelters that meet these criteria, only the FEMA criteria provides near-absolute protection from extreme wind events. To help clarify the difference between safe rooms design in FEMA 320 and 361 guidance, the term “safe room” applies to all shelters, buildings, or spaces designed to the FEMA criteria (whether for individuals, residences, small businesses, schools, or communities). This allows for the buildings, shelters, or spaces designed to the ICC-500 standard to be called shelters. All safe room criteria in the FEMA publications meet or exceed the shelter requirements of the ICC-500.

FEMA 361 provides design criteria for all safe rooms; both community and residential. However, most of the discussion presented as commentary on the design criteria center on the purpose of creating protected space for large gatherings of people. For residential and small business applications, FEMA 320 provides interpretations of the FEMA 361 criteria in the form of prescriptive design solutions for up to 16 occupants from a natural hazard event. Read more about FEMA 320.

What is new in the Second Edition?

The first edition of FEMA 361, released in July 2000, set forth design and construction criteria for tornado and hurricane shelters where none had existed before. These criteria were the basis of many community safe rooms that have been designed, constructed, and funded by FEMA since 2000. This second edition of FEMA 361 continues to provide guidance in the design and construction of tornado and hurricane safe rooms by updating and expanding the recommendations and by referencing much of the newly-released ICC-500 Storm Shelter Standard. FEMA supports the development of hazard-resistant codes and standards through the monitoring of, and participation in the process of creating these documents, including the ICC-500.

Specifically, the following are new to the Second Edition of FEMA 361:

Contact the FEMA Publication Warehouse at 1-888-565-3896 for this publication in hardcopy or CD-ROM form.



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May 15th, 2012 posted by Paul Rega, MD, FACEP @ 4:13 am

FEMA: Building a Safe Room For Your Home or Small Business

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http://www.fema.gov/plan/prevent/saferoom/fema320.shtm

FEMA 320 – Taking Shelter From the Storm: Building a Safe Room For Your Home or Small Business

Third Edition

Having a safe room in your home or small business can help provide “near-absolute protection” for you and your family or your employees from injury or death caused by the dangerous forces of extreme winds. Near-absolute protection means that, based on our current knowledge of tornadoes and hurricanes, there is a very high probability that the occupants of a safe room built according to this guidance will avoid injury or death. A safe room can also relieve some of the anxiety created by the threat of an incoming tornado or hurricane. Our knowledge of tornadoes and hurricanes and their effects is based on substantial meteorological records as well as extensive investigation of damage to buildings from extreme winds. All information contained in this publication is applicable to safe rooms for use in homes as well as in small businesses.

This publication will help you decide how best to provide near-absolute protection for yourself, your family, or employees and answers many questions concerning safe rooms. It includes the results of research that has been underway for more than 30 years, by Texas Tech University’s Wind Science and Engineering (WISE; formerly known as the Wind Engineering Research Center or WERC) and other wind engineering research facilities, on the effects of extreme winds on buildings. Download the entire FEMA 320 document.

FEMA 320 also provides safe room designs that will show you and your builder/contractor how to construct a safe room for your home or small business. Design options include safe rooms located in the basement, in the garage, or in an interior room of a new home or small business building. Other options also provide guidance on how to construct an exterior safe room, either buried underground or attached to the existing building, or how to modify an existing home or small business building to add a safe room inside. These safe rooms are designed to provide near-absolute protection for you, your family, or employees from the extreme winds expected during tornadoes and hurricanes and from flying debris that tornadoes and hurricanes usually generate. View a list of the safe room construction plans and specifications.

The safe room designs presented in this publication meet or exceed all tornado and hurricane design criteria of the ICC-500 for both the tornado and hurricane hazards.

 

Why is the term “safe room” being used instead of “shelter”?

The terms “safe room” and “shelter” have been used, for the most part, interchangeably in past publications. Typically the difference in usage was limited to differentiating between residential applications called “safe rooms” and larger projects called “community shelters.” The release of the ICC-500 standard, as well as other national, state, and local protection initiatives, identified a need to distinguish shelters that meet the FEMA criteria for near-absolute protection and those that do not. Although both the FEMA and ICC criteria are designed to provide life-safety protection for safe rooms and shelters that meet these criteria, only the FEMA criteria provides near-absolute protection from extreme wind events. To help clarify the difference between safe rooms design to FEMA 320 and FEMA 361 guidance, the term “safe room” applies to all shelters, buildings, or spaces designed to the FEMA criteria (whether for individuals, residences, small businesses, schools, or communities). This allows for the buildings, shelters, or spaces designed to the ICC-500 standard to be called shelters. All safe room criteria in the FEMA publications meet or exceed the shelter requirements of the ICC-500. Download FEMA 361.

A residential safe room is designed to protect families or small groups of people (up to 16) while a community safe room is defined as a shelter designed and constructed to protect a larger group of people from a natural hazard event. This publication will refer to all shelters constructed to meet the FEMA criteria (whether for individuals, residences, small businesses, schools, or communities) as safe rooms.

The ICC-500 provides the minimum design and construction requirements for extreme-wind storm shelters and is expected to be incorporated (by reference) into the 2009 International Building Code (IBC) and International Residential Code (IRC). It is important that those involved in the design, construction, and maintenance of storm shelters be knowledgeable of both FEMA guidance and ICC standards that pertain to sheltering from extreme winds.

 

What is new in the third edition?

The latest edition of FEMA 320 includes many updates and modifications of recommended designs for residential safe rooms and further expand their applicability to small businesses and public facilities intending to shelter 16 persons or less. The designs comply with the new criteria that has been presented in the updated FEMA 361 and the newly released consensus standard (ICC-500). Updates to FEMA 320 also include:

You can view and download FEMA 320 or the Construction Plans and Specifications from the FEMA Library, or order a hard copy or CD-ROM from the FEMA Distribution Center. To order this or other publications please call 1-800-480-2520 or fax 1-240-699-0525 Monday through Friday 8 a.m. – 5 p.m. EST. You may also email your request to FEMA-Publications-Warehouse@dhs.gov. Please provide the title, item number, short number, and quantity of each publication, along with your name, address, zip code, and daytime telephone number.



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