For more than 2 years, coronavirus disease (COVID-19) has forced worldwide health care systems to adapt their daily practice. These adaptations add to the already stressful demands of providing timely medical care in an overcrowded health care system. Specifically, the COVID-19 pandemic added stress to an already overwhelmed emergency and critical care health care workers (HCWs) on the front lines during the first wave of the pandemic.

This study assessed comparative subjective and objective stress among frontline HCWs using a visual analog scale and biometric data, specifically heart rate variability (HRV).

This is a prospective, observational study using surveys and heart rate monitoring among HCWs who work in 3 frontline health care units (emergency department, mobile intensive care unit, and intensive care unit) in the University Hospital of Clermont-Ferrand, France. Two sessions were performed: 1 during the first wave of the pandemic (April 10 to May 10, 2020) and 1 after the first wave of the pandemic (June 10 to July 15, 2020).

The primary outcome is the difference in stress levels between the 2 time points. Secondary objectives were the impact of overcrowding, sociodemographics, and other variables on stress levels. We also assessed the correlation between subjective and objective stress levels.

Among 199 HCWs, 98 participated in biometric monitoring, 84 had biometric and survey data, and 12 with only biometric data. Subjective stress was higher during the second time point compared to the first (4.39 ± 2.11 vs 3.16 ± 2.34, P = 0.23). There were higher objective stress levels with a decrease in HRV between the first and the second time points. Furthermore, we found higher patient volumes as a source of stress during the second time point. We did not find any significant correlation between subjective and objective stress levels.

HCWs had higher stress levels between the 2 waves of the pandemic. Overcrowding in the emergency department is associated with higher stress levels. We did not find any correlation between subjective and objective stress among intensive care and emergency HCWs during the first wave of the pandemic.

This study investigated the effects of the coronavirus disease 2019 pandemic on tinnitus severity and quality of life in individuals with subjective tinnitus.

The study was carried out during the coronavirus disease 2019 pandemic. Sixty patients were evaluated with the Tinnitus Handicap Inventory and a visual analogue scale on resonance intensity and disturbance, together with questions assessing their emotional states.

There was a significant difference between the visual analogue scale and the Tinnitus Handicap Inventory scores before the pandemic and during the pandemic. It was determined that tinnitus loudness and annoyance were significantly worse in the pandemic and, consequently, that the coronavirus disease 2019 pandemic negatively affected perceptions of tinnitus and quality of life.

Psychological support can affect positively the perception of tinnitus and the change in moods experienced during the pandemic. Because personal contact and quotidian activities are severely limited during the pandemic, internet-based interventions should be prioritised in tinnitus therapy.

As prospective outcomes of septoplasty with or without turbinoplasty beyond the first year are few and have diverging results, this study evaluated later septoplasty results three to four years post-operatively.

Patients undergoing septoplasty completed the Nasal Surgical Questionnaire pre-operatively, and at 6–12 months (early post-operative assessment) and 36–48 months (late post-operative assessment) after surgery. Primary outcome was visual analogue scale ratings for nasal obstruction (with a scale ranging from 0 to 100).

In 604 patients with high response rates, the largest improvements in nasal obstruction were from pre-operative to early post-operative assessments (daytime score reduction = 33.9, night-time reduction 40.5). Nasal obstruction ratings worsened slightly between early and late post-operative assessments (daytime score increase = 5.3, night-time score increase = 9.7). Improvements were better in patients aged over 35 years and in those with pre-operative nasal obstruction scores of more than 62. There were no differences based on surgery type, septal deviation, allergy or smoking.

Septoplasty improves nasal obstruction in both the first and the fourth year after surgery. Post-operative improvements decline slightly over time but remain significant.

Tonsillectomy is a painful surgery performed in cases of recurrent tonsillitis. Application of platelet-rich plasma to diminish the pain and morbidity post-tonsillectomy is gaining importance. This study evaluated post-operative pain and morbidity after autologous platelet-rich plasma application on the tonsil beds during tonsillectomy.

Participants were randomised into group 1 (n = 28, peri-operative platelet-rich plasma intervention) and group 2 (n = 28, control). Post-tonsillectomy, patients were assessed (day 0, 1, 2, 3, 7 and 14) for pain, healing and time taken to return to normal activity. Data were analysed by independent t-test and chi-square test with p ≤ 0.05 as the significance level.

A significant decrease in the mean pain score up to day 7 (p < 0.05) and tonsillar fossae healing on days 2 and 3 (p < 0.05) post-tonsillectomy was noted. The majority of the patients returned to their routine activities after a week post-tonsillectomy.

Platelet-rich plasma application was effective in accentuating healing and reducing post-tonsillectomy pain and morbidity.

A single-centre, single-blinded prospective experimental study was conducted to determine the effectiveness of autologous platelet-rich plasma applied to the tonsillar bed post-operatively in reducing post-operative pain and haemorrhage.

Platelet-rich plasma, prepared prior to surgery, was applied with calcium gluconate to one randomly chosen tonsillar fossa. Pain and haemorrhage were analysed, using a visual analogue scale and a pre-defined grading scale respectively, four times on the day of surgery at 2-hourly intervals, and thrice on the following day.

The pain score and haemorrhage grade on the test side were lower than on the control side. These findings were statistically significant.

This pilot study, conducted in India, revealed valid positive results for a promising new technology. The manual preparation of platelet-rich plasma could be automated in the future to allow a larger sample size.

This study evaluated the effect of mail non-response on the validity of the results of nasal septal surgery.

Six months post-operatively, questionnaires with both prospective and retrospective ratings were mailed to patients. Patients who did not respond (non-responders) were contacted by telephone. This study compared two cohorts of patients using different interviewers (a nurse and a surgeon). Cohort one consisted of 182 patients (with 67 per cent mail response), and cohort two consisted of 454 patients (with 64.8 per cent mail response).

In both cohorts, the improvement in obstruction scores was significantly better among mail responders than among non-responders (telephone interviewees) using prospective ratings, but worse using retrospective ratings.

Mail responders had better improvement in nasal obstruction after septoplasty than non-responders. Therefore, low response rates may cause an overestimation of the results. The retrospective ratings obtained through telephone interviews are less reliable because they are influenced by memory and the patients’ tendency to give socially acceptable answers.

Studies on the nasal cycle can be limited by time-consuming rhinomanometric measurements. However, quantifiable subjective assessment of nasal airflow has been limited by poor correlation with rhinomanometric data, even when investigating patients with a deviated nasal septum.

Thirty healthy participants attended two study days for rhinomanometric and subjective assessment of nasal airflow (using the subjective ordinal scale). A nasal partitioning ratio was calculated for both measures.

Objective and subjective nasal partitioning ratios were compared; strong correlations were seen, with a correlation coefficient of 0.64 (p < 0.00001) on day 1 and 0.68 (p < 0.00001) on day 2.

The use of the subjective ordinal scale and nasal partitioning ratio provides a sensitive tool for assessing relative nasal airflow, with results that correlate strongly with rhinomanometric data. This finding strongly suggests that this combination could be used for future subjective assessment of the nasal cycle.

The primary goal of this study was to compare paramedic first pass success rate between two different video laryngoscopes and direct laryngoscopy (DL) under simulated prehospital conditions in a cadaveric model.

This was a non-randomized, group-controlled trial in which five non-embalmed, non-frozen cadavers were intubated under prehospital spinal immobilization conditions using DL and with both the GlideScope Ranger (GL; Verathon Inc, Bothell, Washington USA) and the VividTrac VT-A100 (VT; Vivid Medical, Palo Alto, California USA). Participants had to intubate each cadaver with each of the three devices (DL, GL, or VT) in a randomly assigned order. Paramedics were given 31 seconds for an intubation attempt and a maximum of three attempts per device to successfully intubate each cadaver. Confirmation of successful endotracheal intubation (ETI) was confirmed by one of the six on-site physicians.

Successful ETI within three attempts across all devices occurred 99.5% of the time overall and individually 98.5% of the time for VT, 100.0% of the time for GL, and 100.0% of the time for DL. First pass success overall was 64.4%. Individually, first pass success was 60.0% for VT, 68.8% for GL, and 64.5% for DL. A chi-square test revealed no statistically significant difference amongst the three devices for first pass success rates (P=.583). Average time to successful intubation was 42.2 seconds for VT, 38.0 seconds for GL, and 33.7 for seconds for DL. The average number of intubation attempts for each device were as follows: 1.48 for VT, 1.40 for GL, and 1.42 for DL.

The was no statistically significant difference in first pass or overall successful ETI rates between DL and video laryngoscopy (VL) with either the GL or VT (adult).

HodnickR, ZitekT, GalsterK, JohnsonS, BledsoeB, EbbsD. A Comparison of Paramedic First Pass Endotracheal Intubation Success Rate of the VividTrac VT-A 100, GlideScope Ranger, and Direct Laryngoscopy Under Simulated Prehospital Cervical Spinal Immobilization Conditions in a Cadaveric Model. Prehosp Disaster Med. 2017;32(6):621–624.

A simple, portable capillary refill time (CRT) simulator is not commercially available. This device would be useful in mass-casualty simulations with multiple volunteers or mannequins depicting a variety of clinical findings and CRTs. The objective of this study was to develop and evaluate a prototype CRT simulator in a disaster simulation context.

A CRT prototype simulator was developed by embedding a pressure-sensitive piezo crystal, and a single red light-emitting diode (LED) light was embedded, within a flesh-toned resin. The LED light was programmed to turn white proportionate to the pressure applied, and gradually to return to red on release. The time to color return was adjustable with an external dial. The prototype was tested for feasibility among two cohorts: emergency medicine physicians in a tabletop exercise and second year medical students within an actual disaster triage drill. The realism of the simulator was compared to video-based CRT, and participants used a Visual Analog Scale (VAS) ranging from “completely artificial” to “as if on a real patient.” The VAS evaluated both the visual realism and the functional (eg, tactile) realism. Accuracy of CRT was evaluated only by the physician cohort. Data were analyzed using parametric and non-parametric statistics, and mean Cohen’s Kappas were used to describe inter-rater reliability.

The CRT simulator was generally well received by the participants. The simulator was perceived to have slightly higher functional realism (P=.06, P=.01) but lower visual realism (P=.002, P=.11) than the video-based CRT. Emergency medicine physicians had higher accuracy on portrayed CRT on the simulator than the videos (92.6% versus 71.1%; P<.001). Inter-rater reliability was higher for the simulator (0.78 versus 0.27; P<.001).

A simple, LED-based CRT simulator was well received in both settings. Prior to widespread use for disaster triage training, validation on participants’ ability to accurately triage disaster victims using CRT simulators and video-based CRT simulations should be performed.

ChangTP, SantillanesG, Claudius I, PhamPK, KovedJ, CheyneJ, Gausche-HillM, KajiAH, SrinivasanS, DonofrioJJ, BirC. Use of a Novel, Portable, LED-Based Capillary Refill Time Simulator within a Disaster Triage Context. Prehosp Disaster Med. 2017;32(4):451–456.

Airway management is one of many challenges that medical providers face in disaster response operations. The use of personal protective equipment (PPE), in particular, was found to be associated with higher failure rates and a prolonged time to achieve airway control.

The objective of this study was to determine whether video laryngoscopy could facilitate the performance of endotracheal intubation by disaster responders wearing Level C PPE.

In this prospective, randomized, crossover study, a convenience sample of practicing prehospital providers were recruited. Following standardized training in PPE use and specific training in the use of airway devices, subjects in Level C PPE were observed while performing endotracheal intubation on a stock airway in a Laerdal Resusci-Anne manikin system (Laerdal Medical; Stavanger, Norway) using one of three laryngoscopic devices in randomized order: a Macintosh direct laryngoscope (Welch Allyn Inc.; New York USA), a GlideScope Ranger video laryngoscope (Verathon Medical; Bothell, Washington USA), and a King Vision video laryngoscope (King Systems; Noblesville, Indiana USA). The primary outcome was time to intubation (TTI), and the secondary outcome was participant perception of the ease of use for each device.

A total of 20 prehospital providers participated in the study: 18 (90%) paramedics and two (10%) Emergency Medical Technicians-Cardiac. Participants took significantly longer when using the GlideScope Ranger [35.82 seconds (95% CI, 32.24-39.80)] to achieve successful intubation than with the Macintosh laryngoscope [25.69 seconds (95% CI, 22.42-29.42); adj. P<.0001] or the King Vision [29.87 seconds (95% CI, 26.08-34.21); adj. P=.033], which did not significantly differ from each other (adj. P=.1017). Self-reported measures of satisfaction evaluated on a 0% to 100% visual analog scale (VAS) identified marginally greater subject satisfaction with the King Vision [86.7% (SD=76.4-92.9%)] over the GlideScope Ranger [73.0% (SD=61.9-81.8%); P=.04] and the Macintosh laryngoscope [69.9% (SD=57.9-79.7%); P=.05] prior to adjustment for multiplicity. The GlideScope Ranger and the Macintosh laryngoscope did not differ themselves (P=.65), and the differences were not statistically significant after adjustment for multiplicity (adj. P=.12 for both comparisons).

Use of video laryngoscopes by prehospital providers in Level C PPE did not result in faster endotracheal intubation than use of a Macintosh laryngoscope. The King Vision video laryngoscope, in particular, performed at least as well as the Macintosh laryngoscope and was reported to be easier to use.

YousifS, MachanJT, AlaskaY, SunerS. Airway Management in Disaster Response: A Manikin Study Comparing Direct and Video Laryngoscopy for Endotracheal Intubation by Prehospital Providers in Level C Personal Protective Equipment. Prehosp Disaster Med. 2017;32(4):352–356.

This study compared the pain associated with the intratympanic injection combined with various local anaesthetics vs without anaesthesia.

The study included 40 patients (aged 18–78 years) who received intratympanic steroid injections for sudden idiopathic hearing loss or tinnitus. Each patient underwent all three injection methods at one-week intervals. Patients received one of two local anaesthetics (lidocaine injection or lidocaine spray) or no anaesthesia before intratympanic injection, and used a visual analogue scale to indicate the pain level after 5 and 45 minutes.

Five minutes after injection, patients who did not receive anaesthesia and those who received lidocaine spray reported lower pain scores than those who received a lidocaine injection (p < 0.05). There was no difference in pain scores for all three methods at 45 minutes after intratympanic injection.

Neither of the local anaesthetics was found to be superior to having no anaesthesia.

Questionnaires are often used to assess the results of nasal septoplasty, but response rates vary widely. The possible bias caused by non-responders was evaluated to determine the validity of questionnaire results.

Post-operative questionnaires employing visual analogue scales for nasal obstruction were mailed to 182 patients. The 62 non-responders (34.1 per cent) were contacted by telephone, 58 (93.5 per cent) of whom were contactable and responded orally to the questionnaire.

Non-responders were younger, but no different from responders with regard to gender, smoking habits or allergies. Post-operative visual analogue scale obstruction scores were slightly, but not statistically, higher in non-responders. However, because non-responders’ pre-operative scores were lower, obstruction scores improved less than in responders. The main reason for not responding was forgetfulness. Some would have preferred an electronic version of the questionnaire.

Although post-operative obstruction scores did not differ between the groups, nasal obstruction scores improved more among responders than non-responders. Thus, low response rates may cause bias.

This study evaluated a nasal surgical questionnaire designed for monitoring surgical outcomes and comparing different techniques.

Eighty-three healthy volunteers answered the same questionnaire twice with a minimum interval of five weeks. Three visual analogue scale items were used to assess nasal obstruction during the day, at night and during exercise. Respondents rated nasal obstruction severity by marking on a 10 cm line, with scores ranging from 0 to 100 (measured in millimetres). Other nasal symptoms, considered secondary outcomes, were graded using four-point Likert scales.

Mean visual analogue scale scores for nasal obstruction severity experienced during the day, at night and during exercise at initial assessment were 9.99, 12.95 and 11.67, respectively. Thirty-eight per cent of scores indicated no obstruction (scores of 0), 47 per cent indicated mild obstruction (scores 1–30), 13 per cent indicated moderate obstruction (scores 31–70) and 2 per cent indicated severe obstruction (scores 71–100). Males had higher scores than females. The scores for the first and second assessment did not differ, except at night for obstruction in allergic individuals which was considered clinically unimportant.

The questionnaire reliably assesses nasal symptoms and may be useful for prospective studies of nasal surgery.

Vital signs remain important clinical indicators in the management of trauma. Tissue injury and ischemia cause tachycardia and hypertension, which are mediated via the sympathetic nervous system (SNS). Spinal immobilization is known to cause discomfort, and it is not known how this might influence the SNS and contribute to abnormal vital signs.

This study aimed to establish whether the pain and discomfort associated with spinal immobilization and the maneuvers commonly used in injured patients (eg, log roll) affect the Heart rate (HR), Systolic Blood Pressure (SBP) and Respiratory rate (RR). The null hypothesis was that there are no effects.

A prospective, unblinded, repeated-measure study of 53 healthy subjects was used to test the null hypothesis. Heart rate, BP and RR were measured at rest (five minutes), after spinal immobilization (10 minutes), following log roll, with partial immobilization (10 minutes) and again at rest (five minutes). A visual analog scale (VAS) for both pain and discomfort were also collected at each stage. Results were statistically compared.

Pain VAS increased significantly during spinal immobilization (3.8 mm, P < .01). Discomfort VAS increased significantly during spinal immobilization, after log roll and during partial immobilization (17.7 mm, 5.8 mm and 8.9 mm, respectively; P < .001). Vital signs however, showed no clinically relevant changes.

Spinal immobilization does not cause a change in vital signs despite a significant increase in pain and discomfort. Since no relationship appears to exist between immobilization and abnormal vital signs, abnormal vital signs in a clinical situation should not be considered to be the result of immobilization. Likewise, pain and discomfort in immobilized patients should not be disregarded due to lack of changes in vital signs.

BruijnsS, GulyH, WallisL. Effect of Spinal Immobilization on Heart Rate, Blood Pressure and Respiratory Rate. Prehosp Disaster Med. 2013;28(2):1-5.

The methodology commonly used to estimate disease burden, featuring ratings of severity of individual conditions, has been criticized for ignoring co-morbidity. A methodology that addresses this problem is proposed and illustrated here with data from the World Health Organization World Mental Health Surveys. Although the analysis is based on self-reports about one's own conditions in a community survey, the logic applies equally well to analysis of hypothetical vignettes describing co-morbid condition profiles.

Face-to-face interviews in 13 countries (six developing, nine developed; n=31 067; response rate=69.6%) assessed 10 classes of chronic physical and nine of mental conditions. A visual analog scale (VAS) was used to assess overall perceived health. Multiple regression analysis with interactions for co-morbidity was used to estimate associations of conditions with VAS. Simulation was used to estimate condition-specific effects.

The best-fitting model included condition main effects and interactions of types by numbers of conditions. Neurological conditions, insomnia and major depression were rated most severe. Adjustment for co-morbidity reduced condition-specific estimates with substantial between-condition variation (0.24–0.70 ratios of condition-specific estimates with and without adjustment for co-morbidity). The societal-level burden rankings were quite different from the individual-level rankings, with the highest societal-level rankings associated with conditions having high prevalence rather than high individual-level severity.

Plausible estimates of disorder-specific effects on VAS can be obtained using methods that adjust for co-morbidity. These adjustments substantially influence condition-specific ratings.