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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.
Climate variability can complicate efforts to interpret any long-term glacier mass-balance trends due to anthropogenic warming. Here we examine the impact of climate variability on the seasonal mass-balance records of 14 glaciers throughout Norway, Sweden and Svalbard using dynamical adjustment, a statistical method that removes orthogonal patterns of variability shared between each mass-balance record and sea-level pressure or sea-surface temperature predictor fields. For each glacier, the two leading predictor patterns explain 27–81% of the winter mass-balance variability and 24–69% of the summer mass-balance variability. The spatial and temporal structure of these patterns indicates that accumulation variability for all of the glaciers is strongly related to the North Atlantic Oscillation (NAO), with the Atlantic Multidecadal Oscillation (AMO) also modulating accumulation variability for the northernmost glaciers. Given this result, predicting glacier change in the region may depend on NAO and AMO predictability. In the raw mass-balance records, the glaciers throughout southern Norway have significantly negative summer trends, whereas the glaciers located closer to the Arctic have negative winter trends. Removing the effects of climate variability suggests it can bias trends in mass-balance records that span a few decades, but its effects on most of the longer-term mass-balance trends are minimal.
To assess the feasibility and acceptability of a beverage intervention in Hispanic adults.
Eligible individuals identified as Hispanic, were 18–64 years old and had BMI 30·0–50·0 kg/m2. Participants were randomized 2:2:1 to one of three beverages: Mediterranean lemonade (ML), green tea (GT) or flavoured water control (FW). After a 2-week washout period, participants were asked to consume 32 oz (946 ml) of study beverage daily for 6 weeks and avoid other sources of tea, citrus, juice and sweetened beverages; water was permissible. Fasting blood samples were collected at baseline and 8 weeks to assess primary and secondary efficacy outcomes.
Tucson, AZ, USA.
Fifty-two participants were recruited over 6 months; fifty were randomized (twenty-one ML, nineteen GT, ten FW). Study population mean (sd) age 44·6 (sd 10·2) years, BMI 35·9 (4·6) kg/m2; 78 % female.
Forty-four (88 %) completed the 8-week assessment. Self-reported adherence was high. No significant change (95 % CI) in total cholesterol (mg/dl) from baseline was shown −1·7 (−14·2, 10·9), −3·9 (−17·2, 9·4) and −13·2 (−30·2, 3·8) for ML, GT and FW, respectively. Mean change in HDL-cholesterol (mg/dl) −2·3 (−5·3, 0·7; ML), −1·0 (−4·2, 2·2; GT), −3·9 (−8·0, 0·2; FW) and LDL-cholesterol (mg/dl) 0·2 (−11·3, 11·8; ML), 0·5 (−11·4, 12·4; GT), −9·8 (−25·0, 5·4; FW) were also non-significant. Fasting glucose (mg/dl) increased significantly by 5·2 (2·6, 7·9; ML) and 3·3 (0·58, 6·4; GT). No significant change in HbA1c was demonstrated. Due to the small sample size, potential confounders and effect modifiers were not investigated.
Recruitment and retention figures indicate that a larger-scale trial is feasible; however, favourable changes in cardiometabolic biomarkers were not demonstrated.
The Pueblo population of Chaco Canyon during the Bonito Phase (AD 800–1130) employed agricultural strategies and water-management systems to enhance food cultivation in this unpredictable environment. Scepticism concerning the timing and effectiveness of this system, however, remains common. Using optically stimulated luminescence dating of sediments and LiDAR imaging, the authors located Bonito Phase canal features at the far west end of the canyon. Additional ED-XRF and strontium isotope (87Sr/86Sr) analyses confirm the diversion of waters from multiple sources during Chaco’s occupation. The extent of this water-management system raises new questions about social organisation and the role of ritual in facilitating responses to environmental unpredictability.
Objectives: Amphetamine improves vigilance as assessed by continuous performance tests (CPT) in children and adults with attention deficit hyperactivity disorder (ADHD). Less is known, however, regarding amphetamine effects on vigilance in healthy adults. Thus, it remains unclear whether amphetamine produces general enhancement of vigilance or if these effects are constrained to the remediation of deficits in patients with ADHD. Methods: We tested 69 healthy adults (35 female) on a standardized CPT (Conner’s CPT-2) after receiving 10- or 20-mg d-amphetamine or placebo. To evaluate potential effects on learning, impulsivity, and perseveration, participants were additionally tested on the Iowa Gambling Task (IGT) and Wisconsin Card Sorting Task (WCST). Results: Participants receiving placebo exhibited the classic vigilance decrement, demonstrated by a significant reduction in attention (D’) across the task. This vigilance decrement was not observed, however, after either dose of amphetamine. Consistent with enhanced vigilance, the 20-mg dose also reduced reaction time variability across the task and the ADHD confidence index. The effects of amphetamine appeared to be selective to vigilance since no effects were observed on the IGT, WCST, or response inhibition/perseveration measures from the CPT. Conclusions: The present data support the premise that amphetamine improves vigilance irrespective of disease state. Given that amphetamine is a norepinephrine/dopamine transporter inhibitor and releaser, these effects are informative regarding the neurobiological substrates of attentional control. (JINS, 2018, 24, 283–293)
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.
We are all members of the National Social Inclusion Programme's Reference Group and here we reflect on our experiences of carers or of being a carer for people with severe and enduring mental health problems. David and Rosemary have family members with mental health problems and Rosemary also uses mental health services herself; Michael works as a volunteer with carers and Susan is a carer of her elderly mother; they both also have experience of mental health services. Our experiences are both similar and distinct and reflect the differences between carer and service user viewpoints. For people who act as carers, particularly those who have family members with mental health problems, there is more than one individual who experiences exclusion and the journey of recovery. The four perspectives here reflect this and illustrate the potential tensions that engagement with services and the desire for different outcomes and choices can engender. Admittedly, many of the causes and solutions to exclusion involve political and social changes, but we will be concentrating on how mental health professionals and services can help in facilitating inclusion or how they may hinder the process of recovery.
David: Caring for a spouse
I have been a carer to my spouse who suffers from bipolar disorder for the past 15 years. She has not had an in-patient episode for over 7 years and we both have learnt to manage the condition and our lives. As our situation became more stable and we began to enjoy more of a ‘normal’ life again, I began to realise that our recovery was intimately linked to increasing experiences of social inclusion, and that much of our distress was exacerbated, even caused, by our experience of exclusion. This exclusion was experienced in many ways and for me was a reflection of my personal needs and altered personal relationships, my experiences of employment and financial difficulties, the increasing isolation from people and social contacts, my experience of health services and my need for information on matters about which I was previously ignorant.
Thinking back to my wife's first admission, it strikes me how alone and vulnerable I was. To be fair, there were people around, so I was not technically alone, but I was very lonely.
The mitigation hierarchy is a decision-making framework designed to address impacts on biodiversity and ecosystem services through first seeking to avoid impacts wherever possible, then minimizing or restoring impacts, and finally by offsetting any unavoidable impacts. Avoiding impacts is seen by many as the most certain and effective way of managing harm to biodiversity, and its position as the first stage of the mitigation hierarchy indicates that it should be prioritized ahead of other stages. However, despite an abundance of legislative and voluntary requirements, there is often a failure to avoid impacts. We discuss reasons for this failure and outline some possible solutions. We highlight the key roles that can be played by conservation organizations in cultivating political will, holding decision makers accountable to the law, improving the processes of impact assessment and avoidance, building capacity, and providing technical knowledge. A renewed focus on impact avoidance as the foundation of the mitigation hierarchy could help to limit the impacts on biodiversity of large-scale developments in energy, infrastructure, agriculture and other sectors.
To evaluate the impact of no-touch terminal room no-touch disinfection using ultraviolet wavelength C germicidal irradiation (UVGI) on C. difficile infection (CDI) rates on inpatient units with persistently high rates of CDI despite infection control measures.
Interrupted time-series analysis with a comparison arm.
3 adult hematology-oncology units in a large, tertiary-care hospital.
We conducted a 12-month prospective valuation of UVGI. Rooms of patients with CDI or on contact precautions were targeted for UVGI upon discharge using an electronic patient flow system. Incidence rates of healthcare-onset CDI were compared for the baseline period (January 2013–December 2013) and intervention period (February 2014–January 2015) on study units and non–study units using a mixed-effects Poisson regression model with random effects for unit and time in months.
During a 52-week intervention period, UVGI was deployed for 542 of 2,569 of all patient discharges (21.1%) on the 3 study units. The CDI rate declined 25% on study units and increased 16% on non-study units during the intervention compared to the baseline period. We detected a significant association between UVGI and decrease in CDI incidence (incidence rate ratio [IRR], 0.49; 95% confidence interval [CI], 0.26–0.94; P=.03) on the study units but not on the non-study units. The impact of UVGI use on average room-cleaning time and turnaround time was negligible compared to the baseline period.
Targeted deployment of UVGI to rooms of high-risk patients at discharge resulted in a substantial reduction of CDI incidence without adversely impacting room turnaround.
The use of spacecraft for studying the physical properties of the asteroid belt can be approached in several ways. Certainly the simplest approach is to send a spacecraft into the asteroid belt and measure the effects of the environment encountered; this has the advantage of not requiring a vehicle to be targeted to any particular destination. With such an approach, properties may be obtained for those classes of objects that are populous enough to provide a significant number of encounters within the measurement range of the spacecraft. Unfortunately, the large asteroids do not constitute such a class of objects; the probability of an undirected spacecraft passing within measurement range of an asteroid having a diameter of 1 or more km is negligible.
National Institute for Health and Care Excellence have recommended faecal calprotectin (FC) testing as an option in adults with lower gastrointestinal symptoms for whom specialist investigations are being considered, if cancer is not suspected and it is used to support a diagnosis of inflammatory bowel disease (IBD) or irritable bowel syndrome. York Hospital and Vale of York Clinical Commissioning Group have developed an evidence-based care pathway to support this recommendation for use in primary care. It incorporates a higher FC cut-off value, a ‘traffic light’ system for risk and a clinical management pathway.
To evaluate this care pathway.
The care pathway was introduced into five primary care practices for a period of six months and the clinical outcomes of patients were evaluated. Negative and positive predictive values (NPV and PPV) were calculated. GP feedback of the care pathway was obtained by means of a web-based survey. Comparator gastroenterology activity in a neighbouring trust was obtained.
The care pathway for FC in primary care had a 97% NPV and a 40% PPV. This was better than GP clinical judgement alone and doubled the PPV compared with the standard FC cut-off (<50 mcg/g), without affecting the NPV. In total, 89% of patients with IBD had an FC>250 mcg/g and were diagnosed by ‘straight to test’ colonoscopy within three weeks. The care pathway was considered helpful by GPs and delivered a higher diagnostic yield after secondary care referral (21%) than the conventional comparator pathway (5%).
A care pathway for the use of FC that incorporates a higher cut-off value, a ‘traffic light’ system for risk and supports clinical decision making can be achieved safely and effectively. It maintains the balance between a high NPV and an acceptable PPV. A modified care pathway for the use of FC in primary care is proposed.
“Dizzy’s attachment to moderate Oxfordism is something like Bonaparte’s to moderate Mahomedanism’, observed George Smythe in 1842. ‘Could I only satisfy myself, wrote his fellow Young Englander, Lord John Manners, a year later, ‘that d’Israeli believed all that he said, I should be more happy: his historical views are quite mine, but does he believe them?’ As a politician, Disraeli was and remains a man of mystery, an identity which he took some care to cultivate. His protean career in public life found a counterpart in his literary works, in which likewise over the years he appeared to assume a range of different positions. His religious allegiance is similarly elusive. He had attended a Unitarian school, and his theological position, with little sense of the divinity of Jesus, reflected that branch of Christianity most akin to Judaism. On the other hand, he was fascinated by the rituals of Roman Catholicism and the cult of the Virgin Mary, and it was perhaps natural that he should find his spiritual home in the Church of England, that house of many mansions which to his mind reflected the rich diversity of national life. How far there was an underlying principle in Disraeli’s life and art is a question that has intrigued numerous historians, and it will be the chief concern also of this essay in respect of two key issues: religion and national identity.
This study investigated pain coping profiles using the Coping Strategies Questionnaire-24 (CSQ-24) in a sample of 171 workers’ compensation clients with chronic musculoskeletal pain from Canada. Cluster analysis identified three distinct coping profiles: mixed coping, catastrophising, and positive coping. Multivariate analysis of variance (MANOVA) results revealed that the positive coping group had lower levels of activity interference and depression as well as higher levels of quality of life than the mixed coping and catastrophising groups. Study findings indicate clients with chronic musculoskeletal pain can be categorised according to pain coping strategies, and pain coping strategies used are related to rehabilitation outcomes. The implications of these pain coping profiles for rehabilitation counselling practice are discussed.
A trend toward greater body size in dizygotic (DZ) than in monozygotic (MZ) twins has been suggested by some but not all studies, and this difference may also vary by age. We analyzed zygosity differences in mean values and variances of height and body mass index (BMI) among male and female twins from infancy to old age. Data were derived from an international database of 54 twin cohorts participating in the COllaborative project of Development of Anthropometrical measures in Twins (CODATwins), and included 842,951 height and BMI measurements from twins aged 1 to 102 years. The results showed that DZ twins were consistently taller than MZ twins, with differences of up to 2.0 cm in childhood and adolescence and up to 0.9 cm in adulthood. Similarly, a greater mean BMI of up to 0.3 kg/m2 in childhood and adolescence and up to 0.2 kg/m2 in adulthood was observed in DZ twins, although the pattern was less consistent. DZ twins presented up to 1.7% greater height and 1.9% greater BMI than MZ twins; these percentage differences were largest in middle and late childhood and decreased with age in both sexes. The variance of height was similar in MZ and DZ twins at most ages. In contrast, the variance of BMI was significantly higher in DZ than in MZ twins, particularly in childhood. In conclusion, DZ twins were generally taller and had greater BMI than MZ twins, but the differences decreased with age in both sexes.