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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.
Children with congenital heart disease are at high risk for malnutrition. Standardisation of feeding protocols has shown promise in decreasing some of this risk. With little standardisation between institutions’ feeding protocols and no understanding of protocol adherence, it is important to analyse the efficacy of individual aspects of the protocols.
Adherence to and deviation from a feeding protocol in high-risk congenital heart disease patients between December 2015 and March 2017 were analysed. Associations between adherence to and deviation from the protocol and clinical outcomes were also assessed. The primary outcome was change in weight-for-age z score between time intervals.
Increased adherence to and decreased deviation from individual instructions of a feeding protocol improves patients change in weight-for-age z score between birth and hospital discharge (p = 0.031). Secondary outcomes such as markers of clinical severity and nutritional delivery were not statistically different between groups with high or low adherence or deviation rates.
High-risk feeding protocol adherence and fewer deviations are associated with weight gain independent of their influence on nutritional delivery and caloric intake. Future studies assessing the efficacy of feeding protocols should include the measures of adherence and deviations that are not merely limited to caloric delivery and illness severity.
For the past several years the Boeing Aerospace Company has been implementing advanced nondestructive chemical analysis methods to improve product reliability and reduce material inspection costs. Previous testing of incoming material for conformance to vendor test reports or of production materials for verification of alloy composition, had consisted of either time-consuming destructive testing or nondestructive chemical spot testing, which often was insensitive to differences between alloys of similar chemical properties. Beginning in 1974, development of EDXRF techniques was initiated to provide a rapid nondestructive analysis capability for both laboratory and factory use. For materials containing elements easily excited by EDXRF methods, costly destructive sampling and testing can be avoided. Generally, chips, wire, barstock, sheet or plate can be analyzed using an annular radioactive source. The uniformity of the X-ray flux diminishes sample geometry and surface roughness effects.
Social stratification is an important mechanism of human organization that helps to explain health differences between demographic groups commonly associated with socioeconomic gradients. Individuals, or group of individuals, with similar health profiles may have had different stratification experiences. This is particularly true as social stratification is a significant non-measurable source of systematic unobservable differences in both SES indicators and health statuses of disadvantage. The goal of the present study was to expand the bulk of research that has traditionally treated socioeconomic and demographic characteristics as independent, additive influences on health by examining data from the United States. It is hypothesized that variation in an index of multi-system physiological dysregulation – allostatic load – is associated with social differentiation factors, sorting individuals with similar demographic and socioeconomic characteristics into mutually exclusive econo-demographic classes. The data were from the Longitudinal and Biomarker samples of the national Study of Midlife Development in the US (MIDUS) conducted in 1995 and 2004/2006. Latent class analyses and regression analyses revealed that physiological dysregulation linked to socioeconomic variation among black people, females and older adults are associated with forces of stratification that confound socioeconomic and demographic indicators. In the United States, racial stratification of health is intrinsically related to the degree to which black people in general, and black females in particular, as a group, share an isolated status in society. Findings present evidence that disparities in health emerge from group-differentiation processes to the degree that individuals are distinctly exposed to the ecological, political, social, economic and historical contexts in which social stratification is ingrained. Given that health policies and programmes emanate from said legal and political environments, interventions should target the structural conditions that expose different subgroups to different stress risks in the first place.
The epidemic of prescription and non-prescription opioid misuse is of particular importance in pregnancy. The Society of Obstetricians and Gynaecologists of Canada currently recommends opioid replacement therapy with methadone or buprenorphine for opioid-dependent women during pregnancy. This vulnerable segment of the population has been shown to be at increased risk of blood-borne infectious diseases, nutritional insecurity and stress. The objective of this study was to describe an urban cohort of pregnant women on opioid replacement therapy and to evaluate potential effects on the fetus. A retrospective chart review of all women on opioid replacement therapy and their infants who delivered at The Ottawa Hospital General and Civic campuses between January 1, 2013 and March 24, 2017 was conducted. Data were collected on maternal characteristics, pregnancy outcomes, neonatal outcomes and corresponding placental pathology. Maternal comorbidities identified included high rates of infection, tobacco use and illicit substance use, as well as increased rates of placental abruption compared with national averages. Compared with national baseline averages, the mean neonatal birth weight was low, and the incidence of small for gestational age infants and congenital anomalies was high. The incidence of NAS was comparable with estimates from other studies of similar cohorts. Findings support existing literature that calls for a comprehensive interdisciplinary risk reduction approach including dietary, social, domestic, psychological and other supports to care for opioid-dependent women in pregnancy.
Sugars and starch are used as fermentable metabolisable energy (FME) sources in ruminants. Compared with starch, sugars are associated with increased microbial protein supply to the animal when both types of carbohydrates are supplemented to the basal forage diet (Chamberlain et al., 1993). However different sugars respond differently which is associated to differences in their rates of fermentation. Knowledge of the fermentation kinetics of these FME sources is very helpful to synchronize energy and protein supply to the rumen. Limited data are available on the comparative rates of fermentation of starches and sugars. This experiment was conducted to determine fermentation kinetics of selected starch and sugars by measuring gas production, volatile fatty acids (VFA) production and protozoa changes in the fermentation medium
There is controversy in the literature concerning the effect of amino acid (AA) and peptide nitrogen on microbial activity in ruminants fed diets high in structural carbohydrates. Microbial protein is the most variable and uncertain element of current systems of evaluating protein requirements for ruminants (ARC, 1984). Some of the variability is attributed to the multiplicity of techniques for estimating microbial yield, some of which are both imprecise and cumbersome. This study investigates the effects of different forms of nitrogen on microbial activity in sheep fed a rapidly degraded fibrous basal diet and attempts to validate the recently developed purine derivative (PD) technique by comparing it to other procedures used to estimate microbial protein synthesis under the same conditions.
Rumen microbes utilize mainly ammonia as a nitrogen (N) source for their growth but some species also use a variety of amino acids (AA) or peptides. Several studies have shown both an enhanced fibre digestion and efficiency of rumen micro-organisms when N sources such as AA, peptides and protein were provided in addition to ammonia (Griswold et al.,1996). However, no difference either in digestion or in growth of rumen microbes was found in other in vivo(Fujimaki et al.,1989) and in vitro (Kernick, 1991) studies. The objective of this experiment was to investigate the effects of protein, peptides, AA and ammonia on microbial growth and fermentation of an all fibre basal diet in a semicontinuous culture system (RUSITEC; Czerkawski and Breckenridge, 1977).
The estimation of rumen microbial protein synthesis is one of the main points in the nitrogen (N)-rationing systems for ruminants, as microbial protein provides proportionately 0.4 to 0.9 of amino acids entering the small intestine in ruminants receiving conventional diets (Russell et al., 1992). Methods of estimating microbial protein synthesis rely on marker techniques in which a particular microbial constituent is related to the microbial N content. Marker : N values have generally been established in mixed bacteria isolated from the liquid fraction of rumen digesta and it has been assumed that the same relationship holds in the total population leaving the rumen (Merry and McAllan, 1983). However, several studies have demonstrated differences in composition between solid-associated (SAB) and fluid-associated bacteria in vivo (Legay-Carmier and Bauchart, 1989) and in vitro (Molina Alcaide et al, 1996), as well in marker : N values (Pérez et al., 1996). This problem could be more pronounced in the in vitro semi-continuous culture system RUSITEC, in which there are three well defined components (a free liquid phase, a liquid phase associated with the solid phase and a solid phase), each one having associated microbial populations.
The objective of this experiment was to investigate the effect of using different bacterial isolates (BI) on the estimation of microbial production of four different diets in RUSITEC (Czerkawski and Breckenridge, 1977), using (15NH4)2 SO4 as microbial marker, and to assess what effects any differences would have on the comparison of microbial protein synthesis between diets.
This study was conducted in conjunction with an in vitro experiment described by Carro and Miller (1997). Two 14-day incubation trials were carried out with the rumen simulation technique RUSITEC (Czerkawski and Breckenridge, 1977). The general incubation procedure was the one described by Czerkawski and Breckenridge (1977) and more details about the procedures of this experiment are given elsewhere (Carro and Miller, 1997).
The organizers of this symposium invited me to review factors which influence the N needs of ruminants. Such a request seems to imply that, for each class of ruminant, e.g. cattle or sheep, growing or lactating, there is a definitive N or amino acid requirement. If this is known, then diets may be formulated to provide that amount of N or amino acid and the expected level of production should be achieved. As a corollary of this approach, the determination of the nutritional characteristics of the diet, its metabolizable energy (ME), rumen degradable protein (RDP) or undegraded protein (UDP), appears to be a separate issue. While such a simplistic view has advantages for ease of diet formulation, it is unlikely to be entirely correct. In general, animal responses to increasing nutrient supply are curvilinear and do not show sharp break points defining a minimum amount of nutrient to give maximum production. Secondly, animal responses are not independent of diet and, conversely, the energy and protein values of the diet depend on the physiological state of the animal, e.g. the level of food intake influences rate of passage of digesta, the extent and site of digestion and the form of metabolites absorbed.
The History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting.
A prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.
A retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.
Over the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.
Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted.
On August 25, 2017, Hurricane Harvey made landfall near Corpus Christi, Texas. The ensuing unprecedented flooding throughout the Texas coastal region affected millions of individuals.1 The statewide response in Texas included the sheltering of thousands of individuals at considerable distances from their homes. The Dallas area established large-scale general population sheltering as the number of evacuees to the area began to amass. Historically, the Dallas area is one familiar with “mega-sheltering,” beginning with the response to Hurricane Katrina in 2005.2 Through continued efforts and development, the Dallas area had been readying a plan for the largest general population shelter in Texas. (Disaster Med Public Health Preparedness. 2019;13:33–37)
A lot of controversy in literature still surrounds the way in which free amino acids (AA), peptides and true protein nitrogen influence fibre digestion and the activity of bacteria which ferment structural carbohydrates in the rumen. One of the major impediments in the understanding of ruminal microbial protein synthesis is the lack of a simple and accurate procedure for measuring its yield. The aim of this study was two fold: firstly, to make further investigations into the effects of feeding different forms of supplementary nitrogen to a rapidly fermented high fibre diet on microbial activity, and secondly, to compare three different procedures of estimating microbial protein synthesis under the same conditions in continuous culture (CC).
Inclusion of lactose in dairy cow rations increases dry matter intake (DMI) and milk yield (Garnsworthy 1996). This may be due to the relatively slow rate of lactose fermentation ( Hussain and Miller, 1998) sustaining better regulation of rumen pH and also possible consequence for microbial protein synthesis (Chamberlain et al., 1993).This experiment was conducted to study the changes in rumen environment over the adaptation period and effect of these changes on the fermentation of lactose itself.
Three Suffolk wethers (b.wt 56± 7.36 kg) maintained on hay and concentrate (600:400) were offered 50g lactose per day for 16 days. Rumen liquor collected on dayO (before offering lactose), 4, 8, 12 and 16 was used to measure gas production from sucrose and lactose ( Menke et al., 1979). On these days rumen samples were collected at 0, 1, 2, 4, 6 and 8 hrs after the morning feed. Rumen pH, ammonia N (NH3 N) and volatile fatty acids (VFA) were measured. At 8 hrs time rumen samples were also taken for protozoa enumeration. Data obtained were analysed using ANOVA procedure of Genstat 5.
Microbial protein is the most variable and uncertain element of current systems of evaluating protein requirements for ruminants. The variability is partly a result of the multiplicity of techniques used to quantify microbial nitrogen (MN) yield and partly due to unrepresentative sampling of microbial cells. In a number of studies in the literature it is tacitly assumed that marker:N ratios in rumen liquid associated bacteria (LAB), solid associated bacteria (SAB) and duodenal digesta bacteria (DDB) are identical. Under ordinary feeding conditions ruminal SAB are numerically predominant and may comprise 50-75% of the total microbiota (Mitsumori and Minato, 1997). This study highlights the variations in chemical composition in LAB, SAB and DDB and their implications in estimating microbial growth. The study also simultaneously compares four microbial markers in vivo.
Sucrose and lactose are used as energy supplements in ruminant diets. In our previous study (Hussain and Miller, 1998) lactose maintained a higher rumen pH, increased organic matter and neutral detergent fibre digestion in the rumen, reduced the number of rumen protozoa and increased microbial (bacterial) protein flow to the duodenum compared with sucrose. However, it was not clear whether the effect of lactose on pH or on reduction of protozoa was the main factor increasing rumen fermentation and microbial protein flow. The objective of the present study was to examine the effect of isoenergetic amounts of sucrose and lactose as supplements (equivalent to 50 g glucose) on rumen fermentation and metabolism in the presence of sodium bicarbonate to maintain rumen pH.
Because the Anthropocene by definition is an epoch during which environmental change is largely anthropogenic and driven by social, economic, psychological and political forces, environmental social scientists can effectively analyse human behaviour and knowledge systems in this context. In this subject review, we summarize key ways in which the environmental social sciences can better inform fisheries management policy and practice and marine conservation in the Anthropocene. We argue that environmental social scientists are particularly well positioned to synergize research to fill the gaps between: (1) local behaviours/needs/worldviews and marine resource management and biological conservation concerns; and (2) large-scale drivers of planetary environmental change (globalization, affluence, technological change, etc.) and local cognitive, socioeconomic, cultural and historical processes that shape human behaviour in the marine environment. To illustrate this, we synthesize the roles of various environmental social science disciplines in better understanding the interaction between humans and tropical marine ecosystems in developing nations where issues arising from human–coastal interactions are particularly pronounced. We focus on: (1) the application of the environmental social sciences in marine resource management and conservation; (2) the development of ‘new’ socially equitable marine conservation; (3) repopulating the seascape; (4) incorporating multi-scale dynamics of marine social–ecological systems; and (5) envisioning the future of marine resource management and conservation for producing policies and projects for comprehensive and successful resource management and conservation in the Anthropocene.
The Arctic marine environment is undergoing a transition from thick multi-year to first-year sea-ice cover with coincident lengthening of the melt season. Such changes are evident in the Baffin Bay-Davis Strait-Labrador Sea (BDL) region where melt onset has occurred ~8 days decade−1 earlier from 1979 to 2015. A series of anomalously early events has occurred since the mid-1990s, overlapping a period of increased upper-air ridging across Greenland and the northwestern North Atlantic. We investigate an extreme early melt event observed in spring 2013. (~6σ below the 1981–2010 melt climatology), with respect to preceding sub-seasonal mid-tropospheric circulation conditions as described by a daily Greenland Blocking Index (GBI). The 40-days prior to the 2013 BDL melt onset are characterized by a persistent, strong 500 hPa anticyclone over the region (GBI >+1 on >75% of days). This circulation pattern advected warm air from northeastern Canada and the northwestern Atlantic poleward onto the thin, first-year sea ice and caused melt ~50 days earlier than normal. The episodic increase in the ridging atmospheric pattern near western Greenland as in 2013, exemplified by large positive GBI values, is an important recent process impacting the atmospheric circulation over a North Atlantic cryosphere undergoing accelerated regional climate change.
Objectives: The aim of this study was to identify whether the three main primary progressive aphasia (PPA) variants would show differential profiles on measures of visuospatial cognition. We hypothesized that the logopenic variant would have the most difficulty across tasks requiring visuospatial and visual memory abilities. Methods: PPA patients (n=156), diagnosed using current criteria, and controls were tested on a battery of tests tapping different aspects of visuospatial cognition. We compared the groups on an overall visuospatial factor; construction, immediate recall, delayed recall, and executive functioning composites; and on individual tests. Cross-sectional and longitudinal comparisons were made, adjusted for disease severity, age, and education. Results: The logopenic variant had significantly lower scores on the visuospatial factor and the most impaired scores on all composites. The nonfluent variant had significant difficulty on all visuospatial composites except the delayed recall, which differentiated them from the logopenic variant. In contrast, the semantic variants performed poorly only on delayed recall of visual information. The logopenic and nonfluent variants showed decline in figure copying performance over time, whereas in the semantic variant, this skill was remarkably preserved. Conclusions: This extensive examination of performance on visuospatial tasks in the PPA variants solidifies some previous findings, for example, delayed recall of visual stimuli adds value in differential diagnosis between logopenic variant PPA and nonfluent variant PPA variants, and illuminates the possibility of common mechanisms that underlie both linguistic and non-linguistic deficits in the variants. Furthermore, this is the first study that has investigated visuospatial functioning over time in the PPA variants. (JINS, 2018, 24, 259–268)
The acanthocephalan fauna of Australian freshwater fishes was documented from field surveys, a literature survey and examination of specimens registered in Australian museums. From the 4030 fishes, representing 78 of the 354 Australian freshwater fish species (22%), examined for infection seven species of acanthocephalan were recovered. These species comprised five endemic species, three in endemic genera, two species in cosmopolitan genera, one species not fully identified and 1 putative exotic species recovered from eight species of fish. Of these Edmonsacanthus blairi from Melanotaenia splendida, was the only acanthocephalan found at a relatively high prevalence of 38·6%. These findings are indicative of a highly endemic and possibly depauperate acanthocephalan fauna. Species richness was higher in the tropical regions than the temperate regions of the country. Exotic acanthocephalan species have either not been introduced with their exotic hosts or have been unable to establish their life cycles in Australian conditions. Consequently, acanthocephalans have not yet invaded endemic Australian fish hosts.