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The lack of radiation knowledge among the general public continues to be a challenge for building communities prepared for radiological emergencies. This study applied a multi-criteria decision analysis (MCDA) to the results of an expert survey to identify priority risk reduction messages and challenges to increasing community radiological emergency preparedness.
Professionals with expertise in radiological emergency preparedness, state/local health and emergency management officials, and journalists/journalism academics were surveyed following a purposive sampling methodology. An MCDA was used to weight criteria of importance in a radiological emergency, and the weighted criteria were applied to topics such as sheltering-in-place, decontamination, and use of potassium iodide. Results were reviewed by respondent group and in aggregate.
Sheltering-in-place and evacuation plans were identified as the most important risk reduction measures to communicate to the public. Possible communication challenges during a radiological emergency included access to accurate information; low levels of public trust; public knowledge about radiation; and communications infrastructure failures.
Future assessments for community readiness for a radiological emergency should include questions about sheltering-in-place and evacuation plans to inform risk communication.
We tested if an adjunctive sleep health (SH) intervention improved smoking cessation treatment response by increasing quit rates. We also examined if baseline sleep, and improvements in sleep in the first weeks of quitting, were associated with quitting at the end of treatment.
Treatment-seeking smokers (N = 29) aged 21–65 years were randomized to a SH intervention (n = 16), or general health (GH) control (n = 13) condition. Participants received six counseling sessions across 15-weeks: SH received smoking cessation + SH counseling; GH received smoking cessation + GH counseling. Counseling began 4-weeks before the target quit date (TQD), and varenicline treatment began 1-week prior to TQD. Smoking status and SH were assessed at baseline (week 1), TQD (week 4), 3 weeks after cessation (week 7), week 12, and at the end of treatment (EOT; week 15).
SH versus GH participants had higher Carbon Monoxide (CO) -verified, 7-day point prevalence abstinence at EOT (69% vs. 54%, respectively; adjusted odds ratio (aOR) = 2.10, 95% confidence interval (CI) = 0.40–10.69, P = 0.77). Higher baseline sleep efficiency (aOR = 1.42, 95% CI = 1.03–1.96, P = 0.03), predicted higher EOT cessation. Models were adjusted for age, sex, education, and baseline nicotine dependence.
Improving SH in treatment-seeking smokers prior to cessation warrants further examination as a viable strategy to promote cessation.
Between 1934 and the time of the 1940 Census, the US government built and leased 30,151 units of public housing, but we know little about the residents who benefited from this housing. We use a unique methodology that compares addresses of five public housing developments to complete-count data from the 1940 Census to identify residents of public housing in New York City at the time of the census. We compare these residents to the larger pool of residents living in New York City in 1940 who were eligible to apply for the housing to assess how closely housing authorities adhered to the intent of the National Industrial Recovery Act (1933) and the Housing Act of 1937. This comparison produces a picture of whom public housing administrators considered deserving of this public benefit at the dawn of the public housing program in the United States. Results indicate a shift toward serving households with lower incomes over time. All the developments had a consistent preference for households with a “nuclear family” structure, but policies favoring racial segregation and other discretion on the part of housing authorities for tenant selection created distinct populations across housing developments. Households headed by a naturalized citizen were favored over households headed by a native-born citizen in nearly all the public housing projects. This finding suggests a more nuanced understanding of who public housing administrators considered deserving of the first public housing than archival research accounts had previously indicated.
External aortic compression (EAC) has long been used to control exsanguinating post-partum hemorrhage, but it has only recently been described in the prehospital trauma setting. This paper reports four cases where manual EAC was used during transport to manage life-threatening bleeding, twice from stab wounds, once from ruptured ectopic pregnancy, and once from severe lower-limb trauma. It showed that EAC has life-saving potential in the prehospital setting, but that safety and efficacy during transport requires the use of a hands-free compression device, such as an aortic tourniquet.
Twin-twin transfusion syndrome (TTTS) complicates 10–15% of monochorionic twin pregnancies. In the majority of cases, and for still unexplained reasons, the condition usually presents between 16 and 26 weeks’ gestation. When left untreated, mid-trimester TTTS carries a very high mortality rate, either due to preterm birth as a result of the ever-present polyhydramnios , or due to fetal death as a result of cardiac failure [2,3].
We designed, developed, and implemented a new hospital-based health technology assessment (HB-HTA) program called Smart Innovation. Smart Innovation is a decision framework that reviews and makes technology adoption decisions. Smart Innovation was meant to replace the fragmented and complex process of procurement and adoption decisions at our institution. Because use of new medical technologies accounts for approximately 50 percent of the growth in healthcare spending, hospitals and integrated delivery systems are working to develop better processes and methods to sharpen their approach to adoption and management of high cost medical innovations.
The program has streamlined the decision-making process and added a robust evidence review for new medical technologies, aiming to balance efficiency with rigorous evidence standards. To promote system-wide adoption, the program engaged a broad representation of leaders, physicians, and administrators to gain support.
To date, Smart Innovation has conducted eleven HB-HTAs and made clinician-led adoption decisions that have resulted in over $5 million dollars in cost avoidance. These are comprised of five laboratory tests, three software-assisted systems, two surgical devices, and one capital purchase.
Smart Innovation has achieved cost savings, avoided uncertain or low-value technologies, and assisted in the implementation of new technologies that have strong evidence. The keys to its success have been the program's collaborative and efficient decision-making systems, partnerships with clinicians, executive support, and proactive role with vendors.
The diet of most adults is low in fish and, therefore, provides limited quantities of the long-chain, omega-3 fatty acids (LCn-3FAs), eicosapentaenoic and docosahexaenoic acids (EPA, DHA). Since these compounds serve important roles in the brain, we sought to determine if healthy adults with low-LCn-3FA consumption would exhibit improvements in neuropsychological performance and parallel changes in brain morphology following repletion through fish oil supplementation.
In a randomized, controlled trial, 271 mid-life adults (30–54 years of age, 118 men, 153 women) consuming ⩽300 mg/day of LCn-3FAs received 18 weeks of supplementation with fish oil capsules (1400 mg/day of EPA and DHA) or matching placebo. All participants completed a neuropsychological test battery examining four cognitive domains: psychomotor speed, executive function, learning/episodic memory, and fluid intelligence. A subset of 122 underwent neuroimaging before and after supplementation to measure whole-brain and subcortical tissue volumes.
Capsule adherence was over 95%, participant blinding was verified, and red blood cell EPA and DHA levels increased as expected. Supplementation did not affect performance in any of the four cognitive domains. Exploratory analyses revealed that, compared to placebo, fish oil supplementation improved executive function in participants with low-baseline DHA levels. No changes were observed in any indicator of brain morphology.
In healthy mid-life adults reporting low-dietary intake, supplementation with LCn-3FAs in moderate dose for moderate duration did not affect neuropsychological performance or brain morphology. Whether salutary effects occur in individuals with particularly low-DHA exposure requires further study.
We investigate the problem of cost-optimal planning in ASP. Current ASP planners can be trivially extended to a cost-optimal one by adding weak constraints, but only for a given makespan (number of steps). It is desirable to have a planner that guarantees global optimality. In this paper, we present two approaches to addressing this problem. First, we show how to engineer a cost-optimal planner composed of two ASP programs running in parallel. Using lessons learned from this, we then develop an entirely new approach to cost-optimal planning, stepless planning, which is completely free of makespan. Experiments to compare the two approaches with the only known cost-optimal planner in SAT reveal good potentials for stepless planning in ASP.
We compared systematic and random survey techniques to estimate breeding population sizes of burrow-nesting petrel species on Marion Island. White-chinned (Procellaria aequinoctialis) and blue (Halobaena caerulea) petrel population sizes were estimated in systematic surveys (which attempt to count every colony) in 2009 and 2012, respectively. In 2015, we counted burrows of white-chinned, blue and great-winged (Pterodroma macroptera) petrels within 52 randomized strip transects (25 m wide, total 144 km). Burrow densities were extrapolated by Geographic Information System-derived habitat attributes (geology, vegetation, slope, elevation, aspect) to generate island-wide burrow estimates. Great-winged petrel burrows were found singly or in small groups at low densities (2 burrows ha−1); white-chinned petrel burrows were in loose clusters at moderate densities (3 burrows ha−1); and blue petrel burrows were in tight clusters at high densities (13 burrows ha−1). The random survey estimated 58% more white-chinned petrels but 42% fewer blue petrels than the systematic surveys. The results suggest that random transects are best suited for species that are widely distributed at low densities, but become increasingly poor for estimating population sizes of species with clustered distributions. Repeated fixed transects provide a robust way to monitor changes in colony density and area, but might fail to detect the formation/disappearance of new colonies.
Sleep disturbance is a symptom of and a well-known risk factor for depression. Further, atypical functioning of the HPA axis has been linked to the pathogenesis of depression. The purpose of this study was to examine the role of adolescent HPA axis functioning in the link between adolescent sleep problems and later depressive symptoms. Methods: A sample of 157 17–18 year old adolescents (61.8% female) completed the Pittsburgh Sleep Quality Inventory (PSQI) and provided salivary cortisol samples throughout the day for three consecutive days. Two years later, adolescents reported their depressive symptoms via the Center for Epidemiological Studies Depression Scale (CES-D). Results: Individuals (age 17–18) with greater sleep disturbance reported greater depressive symptoms two years later (age 19–20). This association occurred through the indirect effect of sleep disturbance on the cortisol awakening response (CAR) (indirect effect = 0.14, 95%CI [.02 -.39]). Conclusions: One pathway through which sleep problems may lead to depressive symptoms is by up-regulating components of the body’s physiological stress response system that can be measured through the cortisol awakening response. Behavioral interventions that target sleep disturbance in adolescents may mitigate this neurobiological pathway to depression during this high-risk developmental phase.
‘Theory’ is taken for granted as an object of historical study, especially in relation to the history of political thought, and most historiography proceeds as if little were lost by construing authors such as Aristotle, Machiavelli, and Smith as ‘theorists’. This article argues that the costs are likely to be high, and that in consequence ‘theory’ ought not to be considered a generic category capable of neutrally describing a given piece of thinking from the past. On the one hand, ascribing theoretical argument can obscure the nature of rival idioms for making claims regarding political life, such as biblical criticism, the common law, and ‘office talk’. On the other hand, the evidence suggests that the ‘political theorist’, as an avowed identity, only emerged in Britain late in the eighteenth century, tentatively and under the force of peculiar pressures. It follows that it will rarely be appropriate to use the term before c. 1800, and considerable caution will still be necessary when using the label in the post-1800 period. Abiding by this discipline is likely to lead to new discoveries in what has been a flat terrain of ‘political theory’.
During ECT, a variety of observations and physiological measures should be made simultaneously, including: visible evidence of the length and quality of a motor response, blood pressure, heart rate, oxygen saturation, ECG monitoring, EEG activity and sometimes electromyogram (EMG) measurement. Here we will discuss typical observations regarding the ictal motor activity, cardiovascular response and EEG recordings.
Creutzfeldt-Jakob disease (CJD) is a fatal neurological illness for which accurate diagnosis is paramount. Real-time quaking-induced conversion (RT-QuIC) is a prion-specific assay with high sensitivity and specificity for CJD. The Canadian endpoint quaking-induced conversion (EP-QuIC) test is similar, but unlike RT-QuIC there is little data regarding its diagnostic utility in clinical practice. In this exploratory predictive value analysis of EP-QuIC in CJD, the negative predictive value (NPV) and positive predictive value (PPV) was 100% and 83%, respectively, with one false-positive result identified. Re-testing this sample with an optimized EP-QuIC protocol eliminated this false-positive result, leading to a PPV of 100%.
Vehicles stranded in rising water account for the majority of swiftwater rescues (SWR) during urban and small stream flash flooding. Multiple simultaneous SWR incidents are commonplace during severe storms. Historically, SWR teams have pursued a “reach, throw, row, go” strategy. However, reach and throw attempts are usually futile. Boat operations and/or in-water rescue attempts can be technically complicated, time-consuming, and a drain on rescuer resources.
To design an ideal SWR modality for use during urban and small stream roadway flooding.
SWR objectives, strategy, and tactics were mapped against various transportation modalities to develop the safest solution for urban and small stream flood response.
High water vehicles (HWV), such as the “deuce and a half” 6 × 6 military truck, represent a new standard for SWR practicality and safety as they can reduce rescuer time in-water. HWVs are heavy and high enough to be stable on roadways in most flash flooding conditions. A properly designed emergency response package includes a fording kit, multi-directional floodlights for nighttime operations, public safety radios, and a siren that doubles as a public address system to coach victims as a rescue is initiated. Deployable ladders enable rescuer egress from and victim access to a covered lighted cargo bed that holds PPE, throw bags, and rescue rings; a deployable “boat in a bag” for victims who require ferrying; and a heated seating area where medical evaluation can be conducted while staying dry.
SWRs are dangerous resource-intensive incidents which account for more rescuer morbidity/mortality than all other technical rescue sub-types combined. These incidents will increase in frequency and severity worldwide due to climate change and overdevelopment. If rescue conditions are still tenable, HWVs are the most efficient and effective platform for conducting SWR from flooded roadways while decreasing safety risks to first responders and victims.
Climate change and overdevelopment increase the intensity and frequency of flash flooding, which may generate more swiftwater rescue (SWR) incidents. Rescue personnel may fail to properly risk stratify (triage) these victims due to limited medical and/or variable SWR training, or due to an adverse rescuer-to-victim ratio. Some victims may attempt to refuse medical evaluation due to lack of awareness of incident-related morbidity and/or comprehension of risk.
To develop an SWR emergency medical triage tool.
A cross-sectional literature search identified SWR-related medical conditions. A flow diagram reliant upon incident history, chief complaint, and observational exam rather than interpretation of vital signs was created to guide medical decision-making.
Every SWR victim should receive a medical screening exam focused on six clinical categories—drowning, hypothermia, hazmat exposure, physical trauma, psychological trauma and exacerbation of pre-existing disease. Drowning potential is identified by dyspnea, new cough or a history of (even brief) submersion. Shivering SWR victims and those with altered mental status but no shivering are assumed to be hypothermic. Any victim with open skin lesions/wounds who was immersed in floodwater and anyone who has swallowed floodwater is contaminated; these victims require decontamination and possible antibiotic therapy. SWR victims injured upon entering the water or from contact with either water-borne stationary or floating objects require trauma evaluation. Distraught victims and those who exhibit exacerbation of pre-existing organ-system disease also require ED evaluation.
Most SWR course curricula are oriented towards technical rescue; they do not address comprehensive medical decision-making. We present a rapid medical screening exam designed to determine which SWR victims require an ED evaluation. Such a triage tool will assist rescuers to simultaneously honor patient autonomy and avoid risky and uninformed refusal of medical aid. Simplified medical decision-making should enable the application of this tool worldwide.
The swiftwater rescue (SWR) concept of operations (CONOPS) is to access as many victims as quickly as possible using strategies and tactics that maximize safety and minimize risk to all involved. “Reach, throw, row, go” has defined the primary water rescue strategy for 50+ years. However, this paradigm, originally designed for rescue from swimming pools, ponds and lakes, slow-moving rivers, and the ocean, is not conducive to SWR incidents involving submerged vehicles, which is the most common scenario during urban and small stream flash flooding.
To present a new SWR strategy for urban and small stream flood response.
Water rescue strategies and tactics were mapped against the SWR CONOPS to determine which ones are most likely to be successful in the rescue of victims trapped in submerged vehicles.
Rescue should be attempted via high water vehicles (HWVs) whenever possible, followed by watercraft and “go rescues” using advanced line systems techniques and/or tethered rescuers, dependent on incident characteristics. Positioning HWVs at the incident site permits rescuers to access victims quickly from the rear or sides of the vehicle, thereby reducing rescuer time in floodwaters. Multiple sequential rescues can be made since victims are held and medically monitored in the cargo area rather than transporting them to shore individually.
SWR from submerged vehicles is unique among emergency incidents because neither shelter-in-place nor self-evacuation are tenable options until the water recedes. "Reach" and "throw" rescue attempts are only possible if the victim is close to shore. Watercraft operations, whether motorized or manually pulled, can be technically complex, require numerous rescuers, and typically take 30-60 minutes per vehicle. Use of HWVs meets the CONOPS for SWR on flooded roadways since this strategy facilitates the rescue of multiple victims quickly while reducing the time rescuers spend in the water.
Acute blood loss represents a leading cause of death in both civilian and battlefield trauma, despite the prioritization of massive hemorrhage control by well-adopted trauma guidelines. Current Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) guidelines recommend the application of a tourniquet to treat life-threatening extremity hemorrhages. While extremely effective at controlling blood loss, the proper application of a tourniquet is associated with severe pain and could lead to transient loss of limb function impeding the ability to self-extricate or effectively employ weapons systems. As a potential alternative, Innovative Trauma Care (San Antonio, Texas USA) has developed an external soft-tissue hemostatic clamp that could potentially provide effective hemorrhage control without the aforementioned complications and loss of limb function. Thus, this study sought to investigate the effectiveness of blood loss control by an external soft-tissue hemostatic clamp versus a compression tourniquet.
The external soft-tissue hemostatic clamp would be non-inferior at controlling intravascular fluid loss after damage to the femoral and popliteal arteries in a normotensive, coagulopathic, cadaveric lower-extremity flow model using an inert blood analogue, as compared to a compression tourniquet.
Using a fresh cadaveric model with simulated vascular flow, this study sought to compare the effectiveness of the external soft-tissue hemostatic clamp versus the compression tourniquet to control fluid loss in simulated trauma resulting in femoral and posterior tibial artery lacerations using a coagulopathic, normotensive, cadaveric-extremity flow model. A sample of 16 fresh, un-embalmed, human cadaver lower extremities was used in this randomized, balanced two-treatment, two-period, two-sequence, crossover design. Statistical significance of the treatment comparisons was assessed with paired t-tests. Results were expressed as the mean and standard deviation (SD).
Mean intravascular fluid loss was increased from simulated arterial wounds with the external soft-tissue hemostatic clamp as compared to the compression tourniquet at the lower leg (119.8mL versus 15.9mL; P <.001) and in the thigh (103.1mL versus 5.2mL; P <.001).
In this hemorrhagic, coagulopathic, cadaveric-extremity experimental flow model, the use of the external soft-tissue hemostatic clamp as a hasty hemostatic adjunct was associated with statistically significant greater fluid loss than with the use of the compression tourniquet.
Paquette R, Bierle R, Wampler D, Allen P, Cooley C, Ramos R, Michalek J, Gerhardt RT. External soft-tissue hemostatic clamp compared to a compression tourniquet as primary hemorrhage control device in pilot flow model study. Prehosp Disaster Med. 2019;34(2):175–181