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As many as 70% of intensive care unit (ICU) survivors suffer from long-term physical, cognitive, and psychological impairments known as post-intensive care syndrome (PICS). We describe how the first ICU survivor clinic in the United States, the Critical Care Recovery Center (CCRC), was designed to address PICS using the principles of Agile Implementation (AI).
The CCRC was designed using an eight-step process known as the AI Science Playbook. Patients who required mechanical ventilation or were delirious ≥48 hours during their ICU stay were enrolled in the CCRC. One hundred twenty subjects who completed baseline HABC-M CG assessments and had demographics collected were included in the analysis to identify baseline characteristics that correlated with higher HABC-M CG scores. A subset of patients and caregivers also participated in focus group interviews to describe their perceptions of PICS.
Quantitative analyses showed that the cognitive impairment was a major concern of caregivers. Focus group data also confirmed that caregivers of ICU survivors (n = 8) were more likely to perceive cognitive and mental health symptoms than ICU survivors (n = 10). Caregivers also described a need for ongoing psychoeducation about PICS, particularly cognitive and mental health symptoms, and for ongoing support from other caregivers with similar experiences.
Our study demonstrated how the AI Science Playbook was used to build the first ICU survivor clinic in the United States. Caregivers of ICU survivors continue to struggle with PICS, particularly cognitive impairment, months to years after discharge. Future studies will need to examine whether the CCRC model of care can be adapted to other complex patient populations seen by health-care professionals.
We present the first general theory of glacier surging that includes both temperate and polythermal glacier surges, based on coupled mass and enthalpy budgets. Enthalpy (in the form of thermal energy and water) is gained at the glacier bed from geothermal heating plus frictional heating (expenditure of potential energy) as a consequence of ice flow. Enthalpy losses occur by conduction and loss of meltwater from the system. Because enthalpy directly impacts flow speeds, mass and enthalpy budgets must simultaneously balance if a glacier is to maintain a steady flow. If not, glaciers undergo out-of-phase mass and enthalpy cycles, manifest as quiescent and surge phases. We illustrate the theory using a lumped element model, which parameterizes key thermodynamic and hydrological processes, including surface-to-bed drainage and distributed and channelized drainage systems. Model output exhibits many of the observed characteristics of polythermal and temperate glacier surges, including the association of surging behaviour with particular combinations of climate (precipitation, temperature), geometry (length, slope) and bed properties (hydraulic conductivity). Enthalpy balance theory explains a broad spectrum of observed surging behaviour in a single framework, and offers an answer to the wider question of why the majority of glaciers do not surge.
The SUPEREDEN3 study, a phase II randomized controlled trial, suggests that social recovery therapy (SRT) is useful in improving functional outcomes in people with first episode psychosis. SRT incorporates cognitive behavioural therapy (CBT) techniques with case management and employment support, and therefore has a different emphasis to traditional CBT for psychosis, requiring a new adherence tool.
This paper describes the SRT adherence checklist and content of the therapy delivered in the SUPEREDEN3 trial, outlining the frequency of SRT techniques and proportion of participants who received a full therapy dose. It was hypothesized that behavioural techniques would be used frequently, consistent with the behavioural emphasis of SRT.
Research therapists completed an adherence checklist after each therapy session, endorsing elements of SRT present. Data from 1236 therapy sessions were reviewed to determine whether participants received full, partial or no therapy dose.
Of the 75 participants randomized to receive SRT, 57.3% received a full dose, 24% a partial dose, and 18.7% received no dose. Behavioural techniques were endorsed in 50.5% of sessions, with cognitive techniques endorsed in 34.9% of sessions.
This report describes an adherence checklist which should be used when delivering SRT in both research and clinical practice. As hypothesized, behavioural techniques were a prominent feature of the SRT delivered in SUPEREDEN3, consistent with the behavioural emphasis of the approach. The use of this adherence tool would be considered essential for anyone delivering SRT looking to ensure adherence to the model.
The Dallas Convention Center received over 3800 evacuees because of the unprecedented flooding caused by Hurricane Harvey. A multidisciplinary medical clinic was established onsite to address evacuee needs for medical evaluations, emergency care, chronic disease management, pharmaceuticals, durable medical equipment, and local health services integration. To operate efficiently, the Dallas Mega-Shelter Emergency Operations Center (EOC) worked with the Mega-Shelter Medical Clinic (MMC) under a fluid incident command (IC) structure that was National Incident Management System (NIMS) compliant. Iterations of MMC IC demonstrated maturations in organizational structure while supporting MMC operations that varied from rigid NIMS doctrine.
To explore the use of a fluid IC structure at a large evacuation medical shelter after Hurricane Harvey.
We observed evolutions of IC organizational charts and operational impacts.
Modifications through just-in-time iterations of the IC organizational chart were posted and reviewed with MMC IC and EOC sector chiefs. Changes in the organizational chart were noted to improve identification of logistical needs, supply delivery, coordinate with other agencies, and to make decisions for resource typing and personnel utilization. Adaptations also improved communication, which led to timely situational awareness and reporting accuracy.
MMC medical services were improved by allowing modifications and adaptations to NIMS compliant MMC IC organizational roles and duty assignments. The fluidity of IC structure with ability for just-in-time modifications directly impacted the provision of disaster medical services. Unique situational awareness, coordination of care pathways within the local innate health infrastructure, compliance with health service regulations, and personnel resource typing all contributed to and benefitted from these IC modifications. MMC and EOC IC collaboration facilitated effective communication and maintained an appropriate span of control and efficient activity reporting.
Hurricane Harvey made landfall in southeast Texas in August 2017, causing unprecedented flooding throughout the Texas coastal region. Residents of affected regions were forced to evacuate to nearby unaffected areas, including Dallas, TX, where a large shelter operation was opened for 23 days to care for those evacuees. Retrospective evaluation of pharmaceutical prescribing patterns for the evacuees who self-presented to the Megashelter Medical Clinic (MMC) established in the shelter contributes to developing evidence-based planning strategies for healthcare delivery in the post-disaster setting.
To describe the pharmacy needs of a displaced population following a large-scale evacuation after a hurricane
De-identified prescription records written and filled at a shelter pharmacy were reviewed, looking at both cost and category of medications dispensed over time.
Approximately 41% of evacuees with a total of 2,654 visits utilized the MMC clinic, resulting in 1,590 prescriptions filled with an associated cost of $78,039. The most commonly prescribed drug categories were cardiovascular (21.2%), neuropsychotropic (15.6%), infectious disease (12.5%), and endocrine (9.6%). While the most commonly dispensed were antihypertensives, diabetes treatment-related prescriptions, antibacterials, antidepressants, and NSAIDs, the costliest individual prescriptions were antiretrovirals and antipsychotics.
Prescribing patterns for the MMC differed from normal prescribing patterns of a general population. Of the prescriptions dispensed at the MMC, pharmaceutical prescription patterns suggest the immediate needs of evacuees differ from later needs. There is a greater need for chronic disease management in the early phase of shelter operations, and an increasing need for neuropsychotropic and infectious disease prescriptions over time. Understanding overall patterns of drug utilization over the duration of the shelter provides valuable insight on post-disaster medical resource utilization in evacuee populations.
Residency education delivery in the United States has migrated from conventional lectures to alternative educational models that include mini-lectures, small group, and learner lead discussions. As training programs struggle with mandated hours of content, prehospital (EMS) and disaster medicine are given limited focus. While the need for prehospital and disaster medicine education in emergency training is understood, no standard curriculum delivery has been proposed and little research has been done to evaluate the effectiveness of any particular model.
To demonstrate a four-hour multi-modal curriculum that includes lecture based discussions and small group exercises, culminating in an interactive multidisciplinary competition that integrates the previously taught information.
EMS and disaster faculty were surveyed on the previous disaster and prehospital educational day experiences to evaluate course content, level of engagement, and participation by faculty. Based on this feedback, the EMS/Disaster divisions developed a schedule for the four hour EMS and Disaster Day that incorporated vital concepts while addressing the pitfalls previously identified. Sessions included traditional lectures, question and answer sessions, small group exercises, and a tabletop competition. Structured similarly to a strategy board game, the tabletop exercise challenged residents to take into account both medical and ethical considerations during a traditional triage exercise.
Compared to past reviews by emergency medical faculty, residents, and medical students, there was a precipitous increase in satisfaction scores on the part of all participants.
This curriculum deviates from the conventional education model and has been successfully implemented at our 3-year residency program of 66 residents. This EMS and Disaster Day promotes active learning, resident and faculty participation, and retention of important concepts while also fostering relationships between disaster managers and the Department of Emergency Medicine.
In the Soviet Union theatre was an arena for cultural transformation. This article focuses on theatre director Les Kurbas’ 1929 production of playwright Mykola Kulish’s Myna Mazailo, a dark comedy about Ukrainianization, to show the construction of “Soviet Ukrainian” culture. While the Ukrainian and the Soviet are often considered in opposition, this article takes the culture of the Ukrainian Soviet Socialist Republic seriously as a category. Well before Stalin’s infamous adage “national in form and socialist in content,” artists like Kulish and Kurbas were engaged in making art that was not “Ukrainian” in a generic Soviet mold, or “Soviet” art in a generic “Ukrainian” mold, but rather art of an entirely new category: Soviet Ukrainian. Far from a mere mouthpiece for state propaganda, early Soviet theatre offered a space for creating new values, social hierarchies, and worldviews. More broadly, this article argues that Soviet nationality policy was not only imposed from above, but also worked out on the stages of the republic by artists, officials, and audiences alike. Tracing productions of Myna Mazailo into the post-Soviet period, moreover, reveals a lingering ambiguity over the content of culture in contemporary Ukraine. The state may no longer sponsor cultural construction, but theater remains a space of cultural contestation.
After Hurricane Harvey and the flooding that ensued, 3,829 displaced persons were transported from their homes and sheltered in the Dallas Convention Center. This large general population sheltering operation was medically supported by the onsite Mega-Shelter Medical Clinic (MMC). In an altered standard of care environment, a number of multi-disciplinary medical services were provided including emergent management, acute pediatric and adult care, psychiatric/behavioral services, onsite pharmaceutical, and durable medical equipment distribution, epidemiologic surveillance, and select laboratory services.
To describe how onsite medical care in the adapted environment of a large population shelter can provide comparable services and limit the direct impact on the local medical community.
A retrospective chart review of medical records was generated for all clinical encounters at the MMC. Data were sorted by daily census, disease surveillance, medical decision making, treatment, and transport destinations.
40.7% of registered evacuees utilized the MMC accounting for a total of 2,654 clinic visits by 1,560 unique patients representing all age groups. During the sustained MMC operations, 8% of patients required emergency transport and 500 additional patient transports were arranged for clinic appointments. No deaths occurred and no iatrogenic morbidity was reported.
Medical care was provided for a large number of evacuees which mitigated the potential impact on the local medical infrastructure. The provision of medical services in a large population shelter may necessitate adaptation to the standard of care. However, despite the nontraditional clinical setting, care delivery was not compromised.
Introduction: Given the current opioid crisis, caregivers have mounting fears regarding use of opioid medication in their children. Since caregivers are often the gatekeepers to their children's pain management, understanding their perspectives on analgesics is essential. For caregivers of children with acute injury presenting to the pediatric emergency department (PED), we aimed to determine caregivers’: a) willingness to accept opioids from emergency care providers, b) reasons for refusing opioids, and c) past experiences with opioids. Methods: A novel 31-item electronic survey was offered, via tablet device, to caregivers of children aged 4-16 years who had a musculoskeletal injury <7 days old and presented to one of two Canadian PEDs between March and November 2017. Primary outcome was caregiver willingness to accept opioids for moderate pain for their children. Results: 517 caregivers completed the survey; mean age was 40.9 +/−7 years with 70.0% (362/517) being mothers. Children included 62.2% (321/516) males with an overall mean age of 10 +/−3.6 years. 49.6% of caregivers (254/512) reported willingness to accept opioids for moderate pain that persisted after non-opioid analgesia, while 37.1% (190/512) were unsure what they would do. Only 33.2% (170/512) of caregivers stated they would accept opioid analgesia upon discharge while 45.5% (233/512) were unsure about at-home use. Caregivers were primarily concerned about side effects, overdose, addiction, and masking of diagnosis. Caregiver fear of addiction (OR 1.12, 95% CI 1.01-1.25) and side effects (OR 1.25, 95% CI 1.11-1.42) increased the odds of rejecting opioids in the emergency department, while fears of addiction (OR 1.19, 95% CI 1.07-1.32) and overdose (OR 1.15, 95% CI 1.04-1.27) increased the odds of rejecting opioids for at-home use. Conclusion: Only half of caregivers reported that they would accept opioids for moderate pain, despite ongoing pain following non-opioid analgesics. Caregiver fears of addiction, side effects, overdose, and masking their child's diagnosis influence their behaviours. These findings are a first step in understanding caregiver decision-making and can guide healthcare providers in their conversations about acute pain treatment with families.
In the United States, over 50% of people have at least one chronic medical condition, access, or functional limitation. In 2017 during Hurricane Harvey, the establishment of a comprehensive multidisciplinary onsite medical clinic provided health and medical services to over 3,800 evacuees at the Dallas Mega Shelter, providing large-scale general population sheltering support to all evacuees and prioritizing family unit integrity by meeting physical, sensory, and cognitive limitations, and chronic medical conditions. The effectiveness of the Dallas Mega Shelter onsite medical operations supporting this aim is reviewed.
To utilize onsite health and medical resources to meet access and functional needs of evacuees seeking general population mass sheltering in Dallas, Texas during Hurricane Harvey.
Over 3,800 evacuees were evaluated for functional needs support services (FNSS) resulting in over 2,500 evacuee patient encounters during 21 continuous days of onsite health and medical clinic operations.1 A comprehensive array of services were available at no cost to the evacuees and were in accordance with the Federal Emergency Management Association (FEMA) published Guidance on Planning for Integration of Functional Needs Support Service in General Population Shelters.2 The goal to maintain nearly all evacuees choosing to stay in the Mega Shelter was achieved. The challenges, limitations, and risks identified are reviewed.
FNSS guidelines require all persons, regardless of limitations, when evacuated from home be provided all services necessary to allow them to remain in general population sheltering.2 This prioritization of personal choice, functional independence, and family integrity for those with comprehensive FNSS requirements presented notable challenges, including public health and safety risks impacting the wellbeing of others. Meeting these expectations must be balanced with maintaining shelter integrity.
Travellers from nations allied to the War on Terror face the unique challenge of an ever-shrinking number of viable destinations. The global struggle against terrorism has rendered an increasing number of countries inaccessible. This inaccessibility has a direct impact on the nature and purpose of postmillennial travel writing. During the 1960s and 1970s, travellers journeyed through countries like Afghanistan, Algeria, Egypt, Iraq, Pakistan, Somalia, the Sudan and Tunisia. Yet many of today's travellers are deterred by war, terrorist attacks and prohibitive insurance costs. The clear exception is the war reporter. War reporters are uniquely equipped, and professionally obliged to enter conflict zones. Moreover, they have a professional investment in providing authoritative news coverage in line with mainstream news values (Youngs and Hulme 2002, 10), and which does not alienate their official sources (Pedelty 1995).
Journalists’ turn to travel writing raises clear questions about travel and ethics. Postcolonial critics have focused on travel writing's colonial origins (Said 1978; Syed 1996), leading to the genre's asymmetrical and unidirectional mode of representation (Clark 1999; Lisle 2006). While much late twentieth-century travel writing negotiates and comments upon the genre's imperialist orientation, war reporters tend to adopt less self-reflexive approaches. The route taken by journalists who produce travel writing has been markedly anthropological. Travel writing in the anthropological mode carries the attendant risk of an unquestioned belief in anthropology's integrity as a discipline.
The anthropological turn in travel writing by war reporters can be largely explained by journalists’ professional frustration at the restrictions placed upon them by the increasingly narrow requirements of transnational, consolidated mainstream news outlets. To remedy this, war reporters have turned to travel writing. As the correspondent Christina Lamb observes, there are ‘details […] you [as a journalist] would like to convey and yet […] you can't get that in; those pieces are very much news-driven’ (Fowler 2007, 256). Elsewhere she notes her frustration with male news editors, who she believes require accounts of actual fighting rather than ‘stuff from behind the scenes’ (258). There is a corresponding concern by many journalists that the strictures of war reporting prevent women's voices being heard due to their association with the domestic sphere. Part of the solution to this dilemma has been to produce longer-length features for weekend newspapers or to write books which offer behind-the-scenes accounts of war zones.
Since the late 1970s, there has been considerable scholarly engagement with questions of travel and ethics within and across the disciplines of anthropology, linguistics, modern languages and literary studies. Three landmarks are Edward W. Said's Orientalism (1978), James Clifford and George E. Marcus's Writing Culture: The Politics and Poetics of Ethnography (1986) and Syed Islam's Travel and Ethics (1996). Said was among the first to take travel writing seriously. His 1978 study inaugurated a focus by postcolonial critics on travel writing's complicity with colonial discourse (see colonialism and orientalism). Concentrating on accounts of the Middle East, Said argued that travel writers have promoted and perpetuated established myths about corrupt despots, fanatical Muslims, labyrinthine thought-processes, noble Arabs and alluring women (Hulme and Youngs 2002, 107). Said's study fostered widespread investigations of his claim that travel writing autocratically denies colonized subjects a history or a voice (107). Islam's book made a major contribution to the subsequent debate. The Ethics of Travel similarly emphasizes travel writing's generic and historical tendency to produce one-sided portrayals of intercultural encounter to which travellees have no right of reply (Islam 1996, 2013).
Today, many scholars have retained Said and Islam's pessimism about travel writing's culturally imperialist nature. Debbie Lisle's (2006, xi) book The Global Politics of Contemporary Travel Writing argues that travel writing overwhelmingly entrenches a ‘conservative political outlook’. Postcolonial scholarship by Steve Clark, Patrick Holland and Graham Huggan claims that, representationally speaking, contemporary travel writing continues to resemble ‘one-way traffic’ (Clark 1999, 6). A common ethical complaint against travel writing is that travellers lack solidarity with the travellees featured in their accounts. Meanwhile, scholars have amassed evidence to support the claim that travel narratives both inherit and entrench established modes of representing particular regions. Paraguay, for example, has been alternately represented as Arcadia, Eden and El Dorado (Fowler 2013, 55). Such patterns are geographically varied and often contradictory. While Afghans have, for instance, traditionally been represented as medieval, unruly, murderous and warlike (Fowler 2007), Paraguay persistently figures as ‘languid and insular, Edenic and apocalyptic, exotic and erotically charged’ (Fowler 2013, 62). Moreover, travel writers demonstrably project their own societal anxieties and preoccupations onto sites of travel elsewhere (55).
To investigate the relative importance of 10 attributes identified in prior studies as essential for effective disaster medical responders and leaders.
Emergency and disaster medical response personnel (N=220) ranked 10 categories of disaster worker attributes in order of their importance in contributing to the effectiveness of disaster responders and leaders.
Attributes of disaster medical leaders and responders were rank ordered, and the rankings differed for leaders and responders. For leaders, problem-solving/decision-making and communication skills were the highest ranked, whereas teamwork/interpersonal skills and calm/cool were the highest ranked for responders.
The 10 previously identified attributes of effective disaster medical responders and leaders include personal characteristics and general skills in addition to knowledge of incident command and disaster medicine. The differences in rank orders of attributes for leaders and responders suggest that when applying these attributes in personnel recruitment, selection, and training, the proper emphasis and priority given to each attribute may vary by role. (Disaster Med Public Health Preparedness. 2019;13:700–703)
OBJECTIVES/SPECIFIC AIMS: The study aims to track and correlate ocular neuropathic symptoms, corneal sensitivity and dry-eye like pain, after scleral buckle and posterior vitrectomy surgeries. The goal is to identify a population of patients that receive these retinal surgeries that experience ocular neuropathic pain. METHODS/STUDY POPULATION: Methods - Prospective and Retrospective cohort studies were designed with the follow cohorts: scleral buckle, posterior vitrectomy, and control. Typical follow up for SB/PV surgeries are: 1 day, 1 week, 1, 3, 6, 12 months post surgery. CS and DELP metrics are measured at each visit. For study interventions, all subjects (from both arms) will undergo the same series of tests, in the same sequence at each visit. Phase 1 of the visit focuses on CS and phase 2 on DELP. These interventions are as follows: first, subjects will receive Drop A; Drop A will be administered in a randomized, double-blinded manner at each visit to either balanced salt solution (control) or Muro 128 5% hypertonic saline (experimental). Drop A will be administered to both eyes. After receiving the drops, subjects will complete a visual analog scale questionnaire to grade their corneal sensitivity. Next, subjects will undergo a five minute washout. After the washout, subjects will receive Drop B; Drop B will be whichever drop was not administered in the Drop A phase. After Drop B is given, subjects will complete the visual analog scale. To begin phase 2, subjects will be given the Ocular Surface Disease Index to record dry eye signs and symptoms. Finally, tear film parameters will be collected using Schirmer’s tear production test and tear film breakup time. Study Population. - Inclusion criteria: For retrospective cohort studies, subjects who have undergone unilateral SB or PV in the past year. For prospective cohort studies, subjects who will undergo unilateral SB or PV in the near future, and age-matched controls. Exclusion criteria: For both retrospective and prospective arms, the same exclusion criteria apply. They include: a previous diagnosis of dry eye; current use of neuropathic pharmacotherapies (including gabapentin, pregabalin, TCAs, SNRIs, carbamazepine, and opioids). RESULTS/ANTICIPATED RESULTS: As of 11/15/18, only the scleral buckle retrospective study arm had enough subjects for any meaningful preliminary report; the arm currently has 8 subjects. Of these 8 subjects, 5/8 subjects report increased surgical-eye corneal sensitivity and 6/8 show discordant dry eye symptoms and tearfilm parameters. Our power analysis showed that N=16 subjects in a group are required to detect a statistical significant difference in corneal sensitivity response. We expect to see a relapsing and remitting pattern of pain (as measured by corneal sensitivity and dry eye questionnaire), as is typical of neuropathic pain. Regarding dry eye symptoms, we anticipate subjects will have prominent dry eye symptoms (as measured by a validated questionnarie), but show no abnormalities in tearfilm parameters. DISCUSSION/SIGNIFICANCE OF IMPACT: To our knowledge, this is the first observational study of neuropathic pain symptoms of corneal sensitivity and dry-eye like pain, in post retinal surgery patients. We recognize the challenge of diagnosing neuropathic pain; currently the gold standard is clinical. However, symptoms of neuropathic pain are non-specific and subtle. Identification of a population suffering from post-retinal surgery ocular neuropathic pain will provide a foundation to test topical naltrexone as a diagnostic tool. If our hypothesis is correct, topical naltrexone could serve as a cheap, easy, and quick diagnostic test for ocular neuropathic pain. We envision this diagnostic test would allow many misdiagnosed and mistreated post-surgical patients to be treated with appropriate therapies aimed at neuropathic etiologies.