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Procedural sedation and analgesia (PSA) is a core competency for emergency physicians (EP) that is commonly practiced.1–4 PSA entails suppressing a patient’s level of consciousness with sedative or dissociative agents to alleviate pain, anxiety, and suffering to enhance medical procedure performance and patient experience (Table 22.1).1,5
New radiocarbon (14C) dates suggest a simultaneous appearance of two technologically and geographically distinct axe production practices in Neolithic Britain; igneous open-air quarries in Great Langdale, Cumbria, and from flint mines in southern England at ~4000–3700 cal BC. In light of the recent evidence that farming was introduced at this time by large-scale immigration from northwest Europe, and that expansion within Britain was extremely rapid, we argue that this synchronicity supports this speed of colonization and reflects a knowledge of complex extraction processes and associated exchange networks already possessed by the immigrant groups; long-range connections developed as colonization rapidly expanded. Although we can model the start of these new extraction activities, it remains difficult to estimate how long significant production activity lasted at these key sites given the nature of the record from which samples could be obtained.
Post-traumatic stress but also aggressive attitudes and behaviour can be found in adolescents living in a context of ongoing community and gang violence in the low-income urban areas of Cape Town, South Africa.
We investigated the long-term effects (15–20 months after therapy) of (a) Narrative Exposure Therapy for Forensic Offender Rehabilitation (FORNET) and (b) the cognitive behavioural intervention ‘Thinking for a Change’ (CBT) on post-traumatic stress disorder (PTSD) and aggression compared with a waiting list.
Fifty-four young males participated in the treatment trial, of which 17 completed the FORNET intervention, 11 the CBT intervention, and 26 were on a waiting list. The primary outcome was the change score for the Appetitive Aggression Scale; secondary outcomes were the PTSD Symptom Scale-Interview change scores, and the number of perpetrated violent event types.
The reduction in scores for PTSD that had been observed in FORNET completers at the first follow-up were still significant at the second long-term follow-up (Cohen’s d = 0.86). In this treatment arm (FORNET), the scores for appetitive aggression were also significantly reduced (Cohen’s d = 1.00). There were no significant changes observed for CBT or for the waiting list.
The study indicates that FORNET can successfully reduce post-traumatic stress as well as the attraction to violence even for individuals living under conditions of continuous traumatic stress.
As the very title of John Mackie's The Cement of the Universe reminds us, causation permeates and holds together our lives, our language, and our laws. Causal claims are part of our everyday discourse, causal assumptions undergird many of our actions, and causal relationships lie at the heart of that large body of laws presupposing such a relationship between the immediate regulatory target and some more foundational governmental concern. Not unexpectedly, the omnipresence of causal relationships and the pervasiveness of our concern with them have generated multiple conceptions of what it is for something to be the cause of something else. Insofar as these various conceptions are cabined within the domains in which they have been developed, and for which they are most useful, little harm comes from mutually coexisting but different conceptions of causation. Yet the inevitable and desirable leakage among disciplines, and among professional, political, and public domains, has as an unfortunate byproduct an increased risk of conceptual confusion as strikingly different conceptions of causation are misleadingly referred to under the same rubric in the same domain.
The Channeled Scabland–Palouse region of the Pacific Northwest (PNW) of the United States preserves geomorphic and pedosedimentary records that inform understanding of late Pleistocene–Holocene paleoclimate change in a region proximal to the last glacial period Cordilleran Ice Sheet. We present a clumped (Δ47) and conventional (δ18O, δ13C) isotopic study of Palouse loess–paleosol carbonates in combination with carbonate radiocarbon (14C) dating to provide new measures of regional late–last glacial (~31–20 cal ka BP) and Holocene soil conditions. Average clumped isotope temperatures (T(Δ47)) for last glacial Palouse loess–paleosol carbonates (9±4°C) are significantly lower than those for Holocene-aged carbonates (T(Δ47)=18±2°C) in study sections. Calculated soil water δ18OVSMOW values (−16±2‰) for last glacial carbonates are also offset relative to those for Holocene-aged samples (−11±1‰), whereas calculated soil CO2 δ13CVPDB values are similar for the Holocene (−16.9±0.2‰) and late–last glacial (−16.7±1.1‰) periods. Together, these paleoclimate metrics indicate late–last glacial conditions of pedogenic carbonate formation in the C3 grassland soils of the Palouse were measurably colder (9±5°C) than during the Holocene and potentially reflect a more arid last glacial paleoclimate across the Palouse, findings in agreement with previous proxy studies and climate model simulations for the region.
In the early 1960s, the College of African Wildlife Management opened in northern Tanzania. The institution was designed to lessen the impact of decolonization by training the first generation of African wildlife wardens in the tradition of their European predecessors. The product of racialized narratives about African violence and the growth of international conservation organizations, the college could be understood as a straightforward neocolonial institution designed to perpetuate British and western influence over land and animals in East Africa. In contrast, this paper pays close attention to the circumstances and context of the college's founding, the debates over funding and control, and its institutional culture. These aspects all suggest that African governments sought to use the college as a vehicle for pursuing the Africanization of the civil service and for formalizing a contractual relationship with international organizations about mutual obligations not only to Tanzania's wildlife sector but also the country's political economy. This focus on a conservation institution created in the early days of independence demonstrates that the work of decolonization continued after independence, and that expatriate personnel and culture remained embedded in new nations, informing our narratives of decolonization, conservation, and nationalism.
The transformation of ocean water masses at high latitudes is closely related to the freezing and melting processes during the year. Downward salt fluxes from brine rejection during freezing increase the salinity and density of the water column underneath. Fresh-water input from river run-off and melting of sea ice reduces the density, mainly of the surface layer. Hydrographic profiles collected in Storfjorden, Svalbard, in spring and summer, show the strong seasonal and interannual variability of the water masses. Using, in addition, data from moorings, a ship-borne acoustic Doppler current profiler and drifting buoys, and results from models of ice drift, polynya evolution, ice formation and convection processes during freezing, we document the seasonal water-mass transformation and try to explain its interannual variability. The advection of ice and water through the two northern sounds and over the sill in the south of the fjord is examined. The release of brine-enriched bottom water over the sill must be balanced by advection from the Barents Sea in the upper layers. The interannual variability of the brine-enriched bottom layer is very high, and higher salinities are observed in a milder winter. The density anomaly resulting from freezing might depend more on the ice cover and geographical position of the polynya than on the total atmospheric forcing during winter.
Select units in the military have improved combat medic training by integrating their functions into routine clinical care activities with measurable improvements in battlefield care. This level of integration is currently limited to special operations units. It is unknown if regular Army units and combat medics can emulate these successes. The goal of this project was to determine whether US Army combat medics can be integrated into routine emergency department (ED) clinical care, specifically medication administration.
This was a quality assurance project that monitored training of combat medics to administer parenteral medications and to ensure patient safety. Combat medics were provided training that included direct supervision during medication administration. Once proficiency was demonstrated, combat medics would prepare the medications under direct supervision, followed by indirect supervision during administration. As part of the quality assurance and safety processes, combat medics were required to document all medication administrations, supervising provider, and unexpected adverse events. Additional quality assurance follow-up occurred via complete chart review by the project lead.
During the project period, the combat medics administered the following medications: ketamine (n=13), morphine (n=8), ketorolac (n=7), fentanyl (n=5), ondansetron (n=4), and other (n=6). No adverse events or patient safety events were reported by the combat medics or discovered during the quality assurance process.
In this limited case series, combat medics safely administered parenteral medications under indirect provider supervision. Future research is needed to further develop this training model for both the military and civilian setting.
SchauerSG, CunninghamCW, FisherAD, DeLorenzoRA. A Pilot Project Demonstrating that Combat Medics Can Safely Administer Parenteral Medications in the Emergency Department. Prehosp Disaster Med. 2017;32(6):679–681.
Ventilation with a bag valve mask (BVM) is a challenging but critical skill for airway management in the prehospital setting.
Tidal volumes received during single rescuer ventilation with a modified BVM with supplemental external handle will be higher than those delivered using a standard BVM among health care volunteers in a manikin model.
This study was a randomized crossover trial of adult health care providers performing ventilation on a manikin. Investigators randomized participants to perform single rescuer ventilation, first using either a BVM modified by addition of a supplemental external handle or a standard unmodified BVM (Spur II BVM device; Ambu; Ballerup, Denmark). Participants performed mask placement and delivery of 10 breaths per minute for three minutes, as guided by a metronome. After a three-minute rest period, they performed ventilation using the alternative device. The primary outcome measure was mean received tidal volume as measured by the manikin (IngMar RespiTrainer model; IngMar Medical; Pittsburgh, Pennsylvania USA). Secondary outcomes included subject device preference.
Of 70 recruited participants, all completed the study. The difference in mean received tidal volume between ventilations performed using the modified BVM with external handle versus standard BVM was 20 ml (95% CI, -16 to 56 ml; P=.28). There were no significant differences in mean received tidal volume based on the order of study arm allocation. The proportion of participants preferring the modified BVM over the standard BVM was 47.1% (95% CI, 35.7 to 58.6%).
The modified BVM with added external handle did not result in greater mean received tidal volume compared to standard BVM during single rescuer ventilation in a manikin model.
ReedP, ZobristB, CasmaerM, SchauerSG, KesterN, AprilMD. Single Rescuer Ventilation Using a Bag Valve Mask with Removable External Handle: A Randomized Crossover Trial. Prehosp Disaster Med. 2017;32(6):625–630.
Interactions between human lysozyme (HL) and the lipopolysaccharide (LPS) of Klebsiella pneumoniae O1, a causative agent of lung infection, were identified by surface plasmon resonance. To characterize the molecular mechanism of this interaction, HL binding to synthetic disaccharides and tetrasaccharides representing one and two repeating units, respectively, of the O-chain of this LPS were studied. pH-dependent structural rearrangements of HL after interaction with the disaccharide were observed through nuclear magnetic resonance. The crystal structure of the HL-tetrasaccharide complex revealed carbohydrate chain packing into the A, B, C, and D binding sites of HL, which primarily occurred through residue-specific, direct or water-mediated hydrogen bonds and hydrophobic contacts. Overall, these results support a crucial role of the Glu35/Asp53/Trp63/Asp102 residues in HL binding to the tetrasaccharide. These observations suggest an unknown glycan-guided mechanism that underlies recognition of the bacterial cell wall by lysozyme and may complement the HL immune defense function.
Mass-casualty (MASCAL) events are known to occur in the combat setting. There are very limited data at this time from the Joint Theater (Iraq and Afghanistan) wars specific to MASCAL events. The purpose of this report was to provide preliminary data for the development of prehospital planning and guidelines.
Cases were identified using the Department of Defense (DoD; Virginia USA) Trauma Registry (DoDTR) and the Prehospital Trauma Registry (PHTR). These cases were identified as part of a research study evaluating Tactical Combat Casualty Care (TCCC) guidelines. Cases that were designated as or associated with denoted MASCAL events were included.
Fifty subjects were identified during the course of this project. Explosives were the most common cause of injuries. There was a wide range of vital signs. Tourniquet placement and pressure dressings were the most common interventions, followed by analgesia administration. Oral transmucosal fentanyl citrate (OTFC) was the most common parenteral analgesic drug administered. Most were evacuated as “routine.” Follow-up data were available for 36 of the subjects and 97% were discharged alive.
The most common prehospital interventions were tourniquet and pressure dressing hemorrhage control, along with pain medication administration. Larger data sets are needed to guide development of MASCAL in-theater clinical practice guidelines.
SchauerSG, AprilMD, SimonE, MaddryJK, CarterR III, DelorenzoRA. Prehospital Interventions During Mass-Casualty Events in Afghanistan: A Case Analysis. Prehosp Disaster Med. 2017;32(4):465–468.
Animal health surveillance enables the detection and control of animal diseases including zoonoses. Under the EU-FP7 project RISKSUR, a survey was conducted in 11 EU Member States and Switzerland to describe active surveillance components in 2011 managed by the public or private sector and identify gaps and opportunities. Information was collected about hazard, target population, geographical focus, legal obligation, management, surveillance design, risk-based sampling, and multi-hazard surveillance. Two countries were excluded due to incompleteness of data. Most of the 664 components targeted cattle (26·7%), pigs (17·5%) or poultry (16·0%). The most common surveillance objectives were demonstrating freedom from disease (43·8%) and case detection (26·8%). Over half of components applied risk-based sampling (57·1%), but mainly focused on a single population stratum (targeted risk-based) rather than differentiating between risk levels of different strata (stratified risk-based). About a third of components were multi-hazard (37·3%). Both risk-based sampling and multi-hazard surveillance were used more frequently in privately funded components. The study identified several gaps (e.g. lack of systematic documentation, inconsistent application of terminology) and opportunities (e.g. stratified risk-based sampling). The greater flexibility provided by the new EU Animal Health Law means that systematic evaluation of surveillance alternatives will be required to optimize cost-effectiveness.
The stellar radial velocity dispersion profiles of elliptical galaxies can be well described by a power-law σ(r)∝r−β. We analyze a set of elliptical galaxies formed by major mergers of isolated disk galaxies with mass ratios of 1:1 and 3:1 for several orbital configurations (Johansson et al. 2009). The galaxies in our sample show a deviation from the power-law at 1 − 3Reff, which we term the σ-bump (Schauer et al. 2014). This feature is most prominent in remnants of 1:1 mergers and weakens for remnants of mergers with smaller mass ratios, indicating that the σ-bump is a signature of an equal mass merger. The σ-bump does not vanish with time but stays constant once it has formed, in contrast to shells. It can be seen under all projections, making it an observable feature in the outskirts of elliptical galaxies. We indeed identify three possible σ-bump candidates in the sample of 12 SLUGGS-survey ellipticals studied by Pota et al. (2013), who use globular clusters as tracers for the outer stellar halos (see Schauer et al. 2014, for more details). For further comparisons, we here provide for the first time a two dimensional map of the velocity dispersion of one simulated σ-bump galaxy, to identify the σ-bump in observations of kinematic maps out to several Reff. The σ-bump appears as a global ring-like feature if seen face-on and as an extended box-like feature in its edge-on projection.
This article examines debates about how to manage elephants in Kenya’s Tsavo National Park as a jumping off point for exploring the relationships among the local, national, and global constituencies that converged in the formulation of wildlife policy in Kenya during the 1950s and 1960s. Bridging the colonial and postcolonial years, the so-called Elephant Problem in Tsavo, while leveraging different international constituencies, pitted different administrative philosophies against one another and drew out different understandings of the application of ecological sciences in national parks. The result was a paralysis of policymaking which sparked an overhaul of the wildlife departments in the 1970s.
The vast majority of industrial scale Carbon Nanotube (CNT) production involves short nanotubes (< 100 microns) that appear as a powder. These products are typically utilized as minor components (usually less than 2%) in polymers where they may or may not impart marginal improvements in composite properties. At Nanocomp Technologies we produce large-format CNT material by floating catalyst chemical vapor deposition. This technique produces very long CNTs (> 1 mm) in the gas phase, where entanglement produces large format material of exceptional strength and electrical conductivity. By manipulating the physics and chemistry of the process, the format and properties of the material can be controlled. Post-production processing further enhances the desired material properties. In this way applications such as Armor, Wiring and Cables for aerospace, and Integrated Energy Storage can be realized.
In this globalized world, the spread of new, exotic and re-emerging diseases has become one of the most important threats to animal production and public health. This systematic review analyses conventional and novel early detection methods applied to surveillance. In all, 125 scientific documents were considered for this study. Exotic (n = 49) and re-emerging (n = 27) diseases constituted the most frequently represented health threats. In addition, the majority of studies were related to zoonoses (n = 66). The approaches found in the review could be divided in surveillance modalities, both active (n = 23) and passive (n = 5); and tools and methodologies that support surveillance activities (n = 57). Combinations of surveillance modalities and tools (n = 40) were also found. Risk-based approaches were very common (n = 60), especially in the papers describing tools and methodologies (n = 50). The main applications, benefits and limitations of each approach were extracted from the papers. This information will be very useful for informing the development of tools to facilitate the design of cost-effective surveillance strategies. Thus, the current literature review provides key information about the advantages, disadvantages, limitations and potential application of methodologies for the early detection of new, exotic and re-emerging diseases.