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The genitourinary (GU) system includes the kidneys, ureters, bladder, urethra, penis, scrotum, and female genitalia. Of the 27.7 million patients per year presenting to emergency departments (ED) for traumatic injury, about 10% of these traumas primarily involve the GU system, and another 10–15% of patients with abdominal trauma will have GU injuries as well.1 GU trauma patients are predominantly young (80% less than the age of 45 years) and male (85% of all patients).2 Delays or missed diagnosis of GU trauma can result in increased morbidity and mortality due to preventable complications with long term consequences.3
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
Global inequity in access to and availability of essential mental health services is well recognized. The mental health treatment gap is approximately 50% in all countries, with up to 90% of people in the lowest-income countries lacking access to required mental health services. Increased investment in global mental health (GMH) has increased innovation in mental health service delivery in LMICs. Situational analyses in areas where mental health services and systems are poorly developed and resourced are essential when planning for research and implementation, however, little guidance is available to inform methodological approaches to conducting these types of studies. This scoping review provides an analysis of methodological approaches to situational analysis in GMH, including an assessment of the extent to which situational analyses include equity in study designs. It is intended as a resource that identifies current gaps and areas for future development in GMH. Formative research, including situational analysis, is an essential first step in conducting robust implementation research, an essential area of study in GMH that will help to promote improved availability of, access to and reach of mental health services for people living with mental illness in low- and middle-income countries (LMICs). While strong leadership in this field exists, there remain significant opportunities for enhanced research representing different LMICs and regions.
Zoysia germplasm exhibit different levels of sensitivity to fluazifop-P-butyl, but the genetic factors responsible for such differences are unknown. Segregation patterns of the fluazifop-P-butyl tolerance trait were studied under greenhouse conditions. In total, 244 F1 lines were generated from multiple crosses between the tolerant line 5337-2 (non–target site tolerance) and three more-sensitive lines (123, 252, and 5330-23). Progeny segregation showed that fluazifop-P-butyl tolerance within zoysiagrass (Zoysia spp.) is expressed as a quantitative trait with a wide range of intermediate phenotypes between parental phenotypes. Transgressive segregation was extensive and largely favored susceptibility in most families, but was especially evident for 5337-2 × 123 and 5337-2 × 5330-23. The segregation patterns for biomass reduction and percent injury were different within reciprocal crosses and among three different family crosses. Reciprocal effects were observed in growth reduction for 5337-2 × 5330-23, in percent injury at 3 wk after the treatment (WAT), and for 5337-2 × 252 at 6 WAT. This indicated that fluazifop-P-butyl tolerance was not completely controlled by nuclear genetic factors in 5337-2 and maternal/cytoplasmic inheritance was also partially responsible. These results suggested that fluazifop-P-butyl tolerance may be attributed to multiple genetic mechanisms, which could present a challenge for future breeding efforts because of the difficulty of fixing multiple traits within a breeding population.
In 2013, a multinational collaboration met to improve the global and nation-specific preparedness and response in managing casualties from nuclear and radiological disasters. From this meeting, a survey was developed and distributed in both Japanese and English. The results published four years later illustrate a lack of understanding about radiation and risks to the health care provider.
To dispel myths and increase understanding regarding trauma treatment and healthcare risks for healthcare providers during a radiologic event.
IRB approved survey and literature review
A total of 418 surveys were analyzed. Although 44% of participants acknowledged that they had taken at least one radiological training course, the majority of the respondents were still not comfortable with radiological emergencies.
Despite the plethora of both online and in-person radiological training availability, healthcare providers are not comfortable with the topic. Based on information from the survey, it is important to dispel myths and educate healthcare providers so that they have reasonable expectations regarding risks and to ensure that they are comfortable coming to work. By doing this, there will be an adequate healthcare presence to help take care of patients who are not only in need of immediate trauma and radiologic exposure care but also with non-affected patients coming for emergent and scheduled health care needs.
The Dallas Convention Center received over 3800 evacuees because of the unprecedented flooding caused by Hurricane Harvey. A multidisciplinary medical clinic was established onsite to address evacuee needs for medical evaluations, emergency care, chronic disease management, pharmaceuticals, durable medical equipment, and local health services integration. To operate efficiently, the Dallas Mega-Shelter Emergency Operations Center (EOC) worked with the Mega-Shelter Medical Clinic (MMC) under a fluid incident command (IC) structure that was National Incident Management System (NIMS) compliant. Iterations of MMC IC demonstrated maturations in organizational structure while supporting MMC operations that varied from rigid NIMS doctrine.
To explore the use of a fluid IC structure at a large evacuation medical shelter after Hurricane Harvey.
We observed evolutions of IC organizational charts and operational impacts.
Modifications through just-in-time iterations of the IC organizational chart were posted and reviewed with MMC IC and EOC sector chiefs. Changes in the organizational chart were noted to improve identification of logistical needs, supply delivery, coordinate with other agencies, and to make decisions for resource typing and personnel utilization. Adaptations also improved communication, which led to timely situational awareness and reporting accuracy.
MMC medical services were improved by allowing modifications and adaptations to NIMS compliant MMC IC organizational roles and duty assignments. The fluidity of IC structure with ability for just-in-time modifications directly impacted the provision of disaster medical services. Unique situational awareness, coordination of care pathways within the local innate health infrastructure, compliance with health service regulations, and personnel resource typing all contributed to and benefitted from these IC modifications. MMC and EOC IC collaboration facilitated effective communication and maintained an appropriate span of control and efficient activity reporting.
In 2017, members of our workgroup published on the readiness for nuclear and radiological incidents among emergency medical personnel.1 Our findings, along with a review of pertinent literature, suggest that the state of medical preparedness for these incidents is in crisis. A 2018 publication addressing nuclear terrorism preparedness relegates medical preparedness to a low priority and describes it as potentially dangerous.2 The crisis status of medical preparedness for these incidents is addressed.
To establish a prepared medical workforce and trained public for those at risk from nuclear or radiological disasters.
This Institutional Review Board (IRB)-approved survey published an article and used a relevant literature review.
Readiness for nuclear and radiological incidents is lacking in multiple areas including education, training, identifying medical needs, willingness to come to work, and perception of relative risk among medical personnel.1 Confounding this is recent prominent publication downplaying and discouraging medical preparedness for nuclear terrorism.2 The importance of a readied workforce and a prepared public is identified.
In 2013, we formed a multi-national workgroup focused on preparing health professionals and the public for clinical management of casualties during nuclear and radiological disasters. Modeling has demonstrated predictable casualty injury and illness patterns suggesting that early appropriate medical response will save lives. Readiness demands an educated, skillful, and willing-to-engage medical workforce. Our 2017 publication identified several areas that place medical preparedness at risk.1 A significant risk to medical preparedness may lie in prominent publications discouraging the pursuit.2 We firmly believe that medical preparedness is essential and begins with a prepared public.
The US, as well as many countries, are being beseeched by more natural and man-made events; both small (e.g., shootings) and geographically vast (e.g., floods). Due to a myriad of issues, traditional first responders i.e., EMS, fire department, and police cannot be expected to be the only trained lifesavers on the scene. In the US (as in many countries), it is imperative to begin the discussion to better understand the role of the “injured” and “immediate” responders and how they interact with the “first” responders.
To open a discussion amongst disaster experts about the merits of training and subsequent promotion of a curriculum for “immediate” responders.
After recent evaluations of events, it is postulated that there are three categories of responders: the injured, the immediate, and the first (EMS, fire department, police). The premise upon which disaster risk reduction and building community resilience are achieved begin with strengthening, empowering, and equipping local populations with the appropriate tools. This would involve education, skills, and training. With the average general public trained, and if they are one of the first two categories, then the community would not only be better able to assist themselves, but also be able to integrate into the recovery process much more quickly and fully. By doing this, they will be empowered to take care of themselves, neighbors, and community, which in turn increases local resilience.
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.
Hurricane Harvey made landfall in southeast Texas in August 2017, causing unprecedented flooding throughout the Texas coastal region. Residents of affected regions were forced to evacuate to nearby unaffected areas, including Dallas, TX, where a large shelter operation was opened for 23 days to care for those evacuees. Retrospective evaluation of pharmaceutical prescribing patterns for the evacuees who self-presented to the Megashelter Medical Clinic (MMC) established in the shelter contributes to developing evidence-based planning strategies for healthcare delivery in the post-disaster setting.
To describe the pharmacy needs of a displaced population following a large-scale evacuation after a hurricane
De-identified prescription records written and filled at a shelter pharmacy were reviewed, looking at both cost and category of medications dispensed over time.
Approximately 41% of evacuees with a total of 2,654 visits utilized the MMC clinic, resulting in 1,590 prescriptions filled with an associated cost of $78,039. The most commonly prescribed drug categories were cardiovascular (21.2%), neuropsychotropic (15.6%), infectious disease (12.5%), and endocrine (9.6%). While the most commonly dispensed were antihypertensives, diabetes treatment-related prescriptions, antibacterials, antidepressants, and NSAIDs, the costliest individual prescriptions were antiretrovirals and antipsychotics.
Prescribing patterns for the MMC differed from normal prescribing patterns of a general population. Of the prescriptions dispensed at the MMC, pharmaceutical prescription patterns suggest the immediate needs of evacuees differ from later needs. There is a greater need for chronic disease management in the early phase of shelter operations, and an increasing need for neuropsychotropic and infectious disease prescriptions over time. Understanding overall patterns of drug utilization over the duration of the shelter provides valuable insight on post-disaster medical resource utilization in evacuee populations.
Ultrasound applications are widespread, and their utility in resource-limited environments are numerous. In disasters, the use of ultrasound can help reallocate resources by guiding decisions on management and transportation priorities. These interventions can occur on-scene, at triage collection points, during transport, and at the receiving medical facility. Literature related to this specific topic is limited. However, literature regarding prehospital use of ultrasound, ultrasound in combat situations, and some articles specific to disaster medicine allude to the potential growth of ultrasound utilization in disaster response.
To evaluate the utility of point-of-care ultrasound in a disaster response based on studies involving ultrasonography in resource-limited environments.
A narrative review of MEDLINE, MEDLINE InProcess, EPub, and Embase found 20 articles for inclusion.
Experiences from past disasters, prehospital care, and combat experiences have demonstrated the value of ultrasound both as a diagnostic and interventional modality.
Current literature supports the use of ultrasound in disaster response as a real-time, portable, safe, reliable, repeatable, easy-to-use, and accurate tool. While both false positives and false negatives were reported in prehospital studies, these values correlate to accepted false positive and negative rates of standard in-hospital point-of-care ultrasound exams. Studies involving austere environments demonstrate the ability to apply ultrasound in extreme conditions and to obtain high-quality images with only modest training and real-time remote guidance. The potential for point-of-care ultrasound in triage and management of mass casualty incidents is there. However, as these studies are heterogeneous and observational in nature, further research is needed as to how to integrate ultrasound into the response and recovery phases.
After Hurricane Harvey and the flooding that ensued, 3,829 displaced persons were transported from their homes and sheltered in the Dallas Convention Center. This large general population sheltering operation was medically supported by the onsite Mega-Shelter Medical Clinic (MMC). In an altered standard of care environment, a number of multi-disciplinary medical services were provided including emergent management, acute pediatric and adult care, psychiatric/behavioral services, onsite pharmaceutical, and durable medical equipment distribution, epidemiologic surveillance, and select laboratory services.
To describe how onsite medical care in the adapted environment of a large population shelter can provide comparable services and limit the direct impact on the local medical community.
A retrospective chart review of medical records was generated for all clinical encounters at the MMC. Data were sorted by daily census, disease surveillance, medical decision making, treatment, and transport destinations.
40.7% of registered evacuees utilized the MMC accounting for a total of 2,654 clinic visits by 1,560 unique patients representing all age groups. During the sustained MMC operations, 8% of patients required emergency transport and 500 additional patient transports were arranged for clinic appointments. No deaths occurred and no iatrogenic morbidity was reported.
Medical care was provided for a large number of evacuees which mitigated the potential impact on the local medical infrastructure. The provision of medical services in a large population shelter may necessitate adaptation to the standard of care. However, despite the nontraditional clinical setting, care delivery was not compromised.
In the United States, over 50% of people have at least one chronic medical condition, access, or functional limitation. In 2017 during Hurricane Harvey, the establishment of a comprehensive multidisciplinary onsite medical clinic provided health and medical services to over 3,800 evacuees at the Dallas Mega Shelter, providing large-scale general population sheltering support to all evacuees and prioritizing family unit integrity by meeting physical, sensory, and cognitive limitations, and chronic medical conditions. The effectiveness of the Dallas Mega Shelter onsite medical operations supporting this aim is reviewed.
To utilize onsite health and medical resources to meet access and functional needs of evacuees seeking general population mass sheltering in Dallas, Texas during Hurricane Harvey.
Over 3,800 evacuees were evaluated for functional needs support services (FNSS) resulting in over 2,500 evacuee patient encounters during 21 continuous days of onsite health and medical clinic operations.1 A comprehensive array of services were available at no cost to the evacuees and were in accordance with the Federal Emergency Management Association (FEMA) published Guidance on Planning for Integration of Functional Needs Support Service in General Population Shelters.2 The goal to maintain nearly all evacuees choosing to stay in the Mega Shelter was achieved. The challenges, limitations, and risks identified are reviewed.
FNSS guidelines require all persons, regardless of limitations, when evacuated from home be provided all services necessary to allow them to remain in general population sheltering.2 This prioritization of personal choice, functional independence, and family integrity for those with comprehensive FNSS requirements presented notable challenges, including public health and safety risks impacting the wellbeing of others. Meeting these expectations must be balanced with maintaining shelter integrity.
Breeding herbicide tolerance into new cultivars can improve safety and weed control in turfgrass systems. The sensitivity to fluazifop-P-butyl of 27 zoysiagrass (Zoysia spp.) lines was screened under greenhouse conditions to identify potential tolerant germplasm for breeding programs. The herbicide rate that caused 50% biomass reduction (GR50) and the rate that caused 50% injury (ID50) were calculated to select the three most-tolerant and the five most-susceptible lines for studying the physiological mechanisms responsible for fluazifop-P-butyl tolerance. The differences in GR50 and ID50 between susceptible and tolerant lines ranged from 4-fold to more than 10-fold. Cytochrome P450–mediated metabolism was not detected in fluazifop-P-butyl–tolerant lines. Sequencing of the ACCase gene confirmed that none of the seven previously reported mutations conferring resistance to acetyl-CoA carboxylase (ACCase)-inhibiting herbicides in other species were present in any of the tolerant or susceptible zoysiagrass lines studied. An Ala-2073-Thr substitution was identified in two tolerant lines, but this mutation did not completely explain the tolerant phenotype. No clear differences in absorption and translocation rates of 14C-radiolabeled fluazifop-P-butyl were observed among most lines, with the exception of a susceptible line that exhibited greater translocation than two of the tolerant lines. Metabolite profiles did not differ between tolerant and susceptible lines. Our results suggest that the diversity in tolerance to fluazifop-P-butyl in zoysiagrass germplasm is most likely the result of a combination of different, minor, additive non–target site mechanisms such as translocation rate and compartmentation after absorption.
We obtain a non-trivial bound for cancellations between the Kloosterman sums modulo a large prime power with a prime argument running over very short intervals, which in turn is based on a new estimate on bilinear sums of Kloosterman sums. These results are analogues of those obtained by various authors for Kloosterman sums modulo a prime. However, the underlying technique is different and allows us to obtain non-trivial results starting from much shorter ranges.
A multichannel calorimeter system is designed and constructed which is capable of delivering single-shot and broad-band spectral measurement of terahertz (THz) radiation generated in intense laser–plasma interactions. The generation mechanism of backward THz radiation (BTR) is studied by using the multichannel calorimeter system in an intense picosecond laser–solid interaction experiment. The dependence of the BTR energy and spectrum on laser energy, target thickness and pre-plasma scale length is obtained. These results indicate that coherent transition radiation is responsible for the low-frequency component (
1 THz) of BTR. It is also observed that a large-scale pre-plasma primarily enhances the high-frequency component (
3 THz) of BTR.
Hexagonal boron nitride (hBN), a two dimensional (2D) material, has emerged as an important substrate and dielectric for electronic, optoelectronic, and photonic devices based on graphene and other atomically thin two dimensional materials. Here we report on the initial oxidation of (0001) hBN single crystals in ambient air as functions of temperature and time, as determined by atomic force microscopy (AFM) and scanning electron microscope with energy dispersive X-ray spectroscopy (SEM/EDS). For oxidation times of 20 minutes, the first evidence of oxidation appears at 900°C, with the formation of shallow, hexagonal-, and irregular-shaped pits that are less than 100 nm across and several nanometer deep. Oxidation at 1100°C for 20 minutes produced 1.0-2.0-micron size pits with flat and pointed bottoms that were approximately hexagonal-shaped, but with rough and irregular edges, and multiple interior steps. Oxidation was not uniform on the surface of hBN, but starts where dislocations in the crystal intersected the surfaces. Pit depth increased linearly with temperature and oxidation times. In addition to the surface pits, small particles formed on the surface. Elemental analysis of the thermally oxidized hBN crystals by SEM/EDS revealed the major elements of these particles were boron and oxygen.