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According to the United States Eye Injury Registry, eye injury is the leading cause of monocular blindness, and there are approximately 2.4 million eye injuries occurring annually in the US, resulting in 500,000 years of lost eyesight annually.1 These injuries occur more often in males (>70%), and 95% of occupational injuries occur in males.2,3 This chapter will describe the approach to the patient with eye trauma in the emergency department (ED), including how to perform a detailed history and physical examination related to eye injuries, as well as covering the traumatic presentations in Table 9.1.
A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.
Emergency department (ED) access block, the inability to provide timely care for high acuity patients, is the leading safety concern in First World EDs. The main cause of ED access block is hospital access block with prolonged boarding of inpatients in emergency stretchers. Cumulative emergency access gap, the product of the number of arriving high acuity patients and their average delay to reach a care space, is a novel access measure that provides a facility-level estimate of total emergency care delays. Many health leaders believe these delays are too large to be solved without substantial increases in hospital capacity. Our objective was to quantify cumulative emergency access blocks (the problem) as a fraction of inpatient capacity (the potential solution) at a large sample of Canadian hospitals.
In this cross-sectional study, we collated 2015 administrative data from 25 Canadian hospitals summarizing patient inflow and delays to ED care space. Cumulative access gap for high acuity patients was calculated by multiplying the number of Canadian Triage Acuity Scale (CTAS) 1-3 patients by their average delay to reach a care space. We compared cumulative ED access gap to available inpatient bed hours to estimate fractional access gap.
Study sites included 16 tertiary and 9 community EDs in 12 cities, representing 1.79 million patient visits. Median ED census (interquartile range) was 66,300 visits per year (58,700-80,600). High acuity patients accounted for 70.7% of visits (60.9%-79.0%). The mean (SD) cumulative ED access gap was 46,000 stretcher hours per site per year (± 19,900), which was 1.14% (± 0.45%) of inpatient capacity.
ED access gaps are large and jeopardize care for high acuity patients, but they are small relative to hospital operating capacity. If access block were viewed as a “whole hospital” problem, capacity or efficiency improvements in the range of 1% to 3% could profoundly mitigate emergency care delays.
Diversity and inclusion in science, technology, engineering, and mathematics (STEM) fields is a global issue. The challenging issues facing the world relating to STEM diversity cross national borders and require leveraging the talents of diverse constituents.1 Active international efforts at inclusive talent development are being undertaken to empower persons from groups historically underrepresented in STEM communities.2,3 The US National Action Council for Minorities in Engineering (NACME) reports that in the United States, African Americans are one of the most underrepresented minority groups in engineering relative to their population. This is in spite of a great deal of progress in “growing African American scientists, engineers, and technologists since the Howard University School of Engineering opened in 1910.”4 The number of African Americans in engineering at all degree levels is not representative of their percentage in the US population. Table I shows a sampling of 2016 data from a National Science Foundation (NSF) survey of doctoral recipients in engineering.5 Figure 1 illustrates a snapshot of African American representation in US colleges of engineering. These statistics show that African Americans remain underrepresented relative to US demographics.6–8
A total of 592 people reported gastrointestinal illness following attendance at Street Spice, a food festival held in Newcastle-upon-Tyne, North East England in February/March 2013. Epidemiological, microbiological and environmental investigations were undertaken to identify the source and prevent further cases. Several epidemiological analyses were conducted; a cohort study; a follow-up survey of cases and capture re-capture to estimate the true burden of cases. Indistinguishable isolates of Salmonella Agona phage type 40 were identified in cases and on fresh curry leaves used in one of the accompaniments served at the event. Molecular testing indicated entero-aggregative Escherichia coli and Shigella also contributed to the burden of illness. Analytical studies found strong associations between illness and eating food from a particular stall and with food items including coconut chutney which contained fresh curry leaves. Further investigation of the food supply chain and food preparation techniques identified a lack of clear instruction on the use of fresh uncooked curry leaves in finished dishes and uncertainty about their status as a ready-to-eat product. We describe the investigation of one of the largest outbreaks of food poisoning in England, involving several gastrointestinal pathogens including a strain of Salmonella Agona not previously seen in the UK.
D-dimer testing is an important component of the workup for pulmonary embolism (PE). However, age-related increases in D-dimer concentrations result in false positives in older adults, leading to potentially unnecessary imaging utilization. The objective of this study was to quantify the test characteristics of an age-adjusted D-dimer cut-off for ruling out PE in older patients investigated in actual clinical practice.
This observational study used administrative data from four emergency departments from July 2013 to January 2015. Eligible patients were ages 50 and older with symptoms of PE who underwent D-dimer testing. The primary outcome was 30-day diagnosis of PE, confirmed by imaging reports. Test characteristics of the D-dimer assay were calculated using the standard reference value (500 ng/ml), the local reference value (470 ng/ml), and an age-adjusted threshold (10 ng/ml × patient’s age).
This cohort includes 6,655 patients ages 50 and older undergoing D-dimer testing for a possible PE. Of these, 246 (3.7%) were diagnosed with PE. Age-adjusted D-dimer cut-offs were more specific than standard cut-offs (75.4% v. 63.8%) but less sensitive (90.3% v. 97.2%). The false-negative risk in this population was 0.49% using age-adjusted D-dimer cut-offs compared with 0.15% with traditional cut-offs.
Age-adjusted D-dimer cut-offs are substantially more specific than traditional cut-offs and may reduce CT utilization among older patients with suspected PE. We observed a loss of sensitivity, with an increased risk of false-negatives, using age-adjusted cut-offs. We encourage further evaluation of the safety and accuracy of age-adjusted D-dimer cut-offs in actual clinical practice.
OBJECTIVES/SPECIFIC AIMS: Smoking during pregnancy (SDP) is associated with negative health outcomes, both proximal (e.g., preterm labor, cardiovascular changes, low birth weight) and distal (e.g., increased child externalizing behaviors and attention deficit/hyperactivity disorder (ADHD) symptoms, increased risk of child smoking). As pregnancy provides a unique, strong incentive to quit smoking, investigating SDP allows analysis of individual predictive factors of recalcitrant smoking behaviors. Utilizing a female twin-pair cohort provides a model system for characterizing genotype×environment interactions using statistical approaches. METHODS/STUDY POPULATION: Using women from the Missouri Adolescent Female Twin Study, parental report of twin ADHD inattentive and hyperactive symptoms at twin median age 15, and twin report of DSM-IV lifetime diagnosis of major depressive disorder, trauma exposure (physical assault and childhood sexual abuse), collected at median age 22, were merged with Missouri birth record data for enrolled twins, leading to 1553 individuals of European ancestry and 163 individuals of African-American ancestry included in final analyses. A SDP propensity score was calculated from sociodemographic variables (maternal age, marital status, educational attainment, first born child) and used as a 6-level ordinal covariate in subsequent logistic regressions. RESULTS/ANTICIPATED RESULTS: For European ancestry individuals, parental report of hyperactive ADHD symptoms and exposure to childhood sexual abuse were predictive of SDP, while a lifetime diagnosis of major depressive disorder, parental report of inattentive ADHD symptoms, and exposure to assaultive trauma were all not significantly predictive of future SDP. For African-American individuals, none of these variables were significant in predicting future SDP. DISCUSSION/SIGNIFICANCE OF IMPACT: Understanding this relationship of risk-mechanisms is important for clinical understanding of early predictors of SDP and tailoring interventions to at risk individuals. Ultimately, the focus of this research is to mitigate risk to pregnant smokers and their children. Additionally, the cohort-ecological approach informs how well research and administrative (vital record) data agree. This allows for evaluation of whether administrative data improve prediction in research cohorts, and conversely if research data improve prediction over standard sociodemographic variables available in administrative data.
Shamans can have efficacy at healing through botanical remedies and in observational and advisory functions through cognitive strengths, while shamanic acts of strangeness are likely honest signals of these qualities. Given this potential for shamanic practices to have true efficacy and the capacity for honest signaling, we expect efficacy will influence the spread, persistence, and loss of shamanic practices.
Fee-for-service payment may motivate physicians to see more patients and achieve higher productivity. In 2015, emergency physicians at one Vancouver hospital switched to fee-for-service payment, while those at a sister hospital remained on contract, creating a natural experiment where the compensation method changed, but other factors remained constant. Our hypothesis was that fee-for-service payment would increase physician efficiency and reduce patient wait times.
This interrupted time series with concurrent control analysed emergency department (ED) performance during a 42-week period, encompassing the intervention (fee for service). Data were aggregated by week and plotted in a time series fashion. We adjusted for autocorrelation and developed general linear regression models to assess level and trend changes. Our primary outcome was the wait time to physician.
Data from 142,361 ED visits were analysed. Baseline wait times rose at both sites during the pre-intervention phase. Immediately post-intervention, the median wait time increased by 2.4 minutes at the control site and fell by 7.2 minutes at the intervention site (difference=9.6 minutes; 95% confidence interval, 2.9-16.4; p=0.007). The wait time trend (slope) subsequently deteriorated by 0.5 minutes per week at the intervention site relative to the expected counterfactual (p for the trend difference=0.07). By the end of the study, cross-site differences had not changed significantly from baseline.
Fee-for-service payment was associated with a 9.6-minute (24%) reduction in wait time, compatible with an extrinsic motivational effect; however, this was not sustained, and the intervention had no impact on other operational parameters studied. Physician compensation is an important policy issue but may not be a primary determinant of ED operational efficiency.
Rumen protected fats are often included in dairy cow rations in order to increase the energy density of the ration without compromising rumen function. Various studies have examined the effects of protected fats, with some studies reporting an improvement in various fertility parameters (McNamara et al., 2003). This study examined the effect of feeding protected fat (Megalac™) on production parameters, and on the reproductive performance of high-yielding Holstein-Friesian dairy cattle.
Middens (nests and caches) of Late Pleistocene arctic ground squirrels (Urocitellus parryii) that are preserved in the permafrost of Beringia archive valuable paleoecological data. Arctic ground squirrels selectively include the plant material placed in middens. To account for this selectivity bias, we used a multi-proxy approach that includes ancient DNA (aDNA) and macro- and microfossil analyses. Here, we provide insight into Pleistocene vegetation conditions using macrofossils, pollen, phytoliths and non-pollen palynomorphs, and aDNA collected from one such midden from the Yukon Territory (Canada), which was formed between 30,740 and 30,380 cal yr BP. aDNA confirmed the midden was constructed by U. parryii. We recovered 39 vascular plant and bryophyte genera and 68 fungal genera from the midden samples. Grass and other herbaceous families dominated vegetation assemblages according to all proxies. aDNA data yielded several records of vascular plants that are outside their current biogeographic range, while some of the recovered fungi yielded additional evidence for local occurrence of Picea trees during glacial conditions. We propose that future work on fossil middens should combine the study of macro- and microfossils with aDNA analysis to get the most out of these environmental archives.
Whether monozygotic (MZ) and dizygotic (DZ) twins differ from each other in a variety of phenotypes is important for genetic twin modeling and for inferences made from twin studies in general. We analyzed whether there were differences in individual, maternal and paternal education between MZ and DZ twins in a large pooled dataset. Information was gathered on individual education for 218,362 adult twins from 27 twin cohorts (53% females; 39% MZ twins), and on maternal and paternal education for 147,315 and 143,056 twins respectively, from 28 twin cohorts (52% females; 38% MZ twins). Together, we had information on individual or parental education from 42 twin cohorts representing 19 countries. The original education classifications were transformed to education years and analyzed using linear regression models. Overall, MZ males had 0.26 (95% CI [0.21, 0.31]) years and MZ females 0.17 (95% CI [0.12, 0.21]) years longer education than DZ twins. The zygosity difference became smaller in more recent birth cohorts for both males and females. Parental education was somewhat longer for fathers of DZ twins in cohorts born in 1990–1999 (0.16 years, 95% CI [0.08, 0.25]) and 2000 or later (0.11 years, 95% CI [0.00, 0.22]), compared with fathers of MZ twins. The results show that the years of both individual and parental education are largely similar in MZ and DZ twins. We suggest that the socio-economic differences between MZ and DZ twins are so small that inferences based upon genetic modeling of twin data are not affected.
Elemental, chemical, and structural analysis of polycrystalline materials at the micron scale is frequently carried out using microfocused synchrotron X-ray beams, sometimes on multiple instruments. The Maia pixelated energy-dispersive X-ray area detector enables the simultaneous collection of X-ray fluorescence (XRF) and diffraction because of the relatively large solid angle and number of pixels when compared with other systems. The large solid angle also permits extraction of surface topography because of changes in self-absorption. This work demonstrates the capability of the Maia detector for simultaneous measurement of XRF and diffraction for mapping the short- and long-range order across the grain structure in a Ni polycrystalline foil.
The contemporary relevance of archaeology would be greatly enhanced if archaeologists could develop theory that frames human societies of all scales in the same terms. We present evidence that an approach known as settlement scaling theory can contribute to such a framework. The theory proposes that a variety of aggregate socioeconomic properties of human networks emerge from individuals arranging themselves in space so as to balance the costs of movement with the benefits of social interactions. This balancing leads to settlements that concentrate human interactions and their products in space and time in an open-ended way. The parameters and processes embedded in settlement scaling models are very basic, and this suggests that scaling phenomena should be observable in the archaeological record of middle-range societies just as readily as they have been observed in contemporary first-world nations. In this paper, we show that quantitative scaling relationships observed for modern urban systems, and more recently for early civilizations, are also apparent in settlement data from the Central Mesa Verde and northern Middle Missouri regions of North America. These findings suggest that settlement scaling theory may help increase the practical relevance of archaeology for present-day concerns.
Negative symptoms significantly contribute to disability and lack of community participation for low functioning individuals with schizophrenia. Cognitive therapy has been shown to improve negative symptoms and functional outcome in this population. Elucidation of the mechanisms of the therapy would lead to a better understanding of negative symptoms and the development of more effective interventions to promote recovery. The objective of this study was to determine (1) whether guided success at a card-sorting task will produce improvement in defeatist beliefs, positive beliefs about the self, mood, and card-sorting performance, and (2) whether these changes in beliefs and mood predict improvements in unguided card-sorting.
Individuals with schizophrenia having prominent negative symptoms and impaired neurocognitive performance (N = 35) were randomized to guided success (n = 19) or a control (n = 16) condition.
Controlling for baseline performance, the experimental group performed significantly better, endorsed defeatist beliefs to a lesser degree, reported greater positive self-concept, and reported better mood than the control condition immediately after the experimental session. A composite index of change in defeatist beliefs, self-concept, and mood was significantly correlated with improvements in card-sorting.
This analogue study supports the rationale of cognitive therapy and provides a general therapeutic model in which experiential interventions that produce success have a significant immediate effect on a behavioral task, mediated by changes in beliefs and mood. The rapid improvement is a promising indicator of the responsiveness of this population, often regarded as recalcitrant, to cognitively-targeted behavioral interventions.