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In March 2018, the US Department of Defense (DOD) added the smallpox vaccination, using ACAM2000, to its routine immunizations, increasing the number of persons receiving the vaccine. The following month, Fort Hood reported a cluster of 5 myopericarditis cases. The Centers for Disease Control and Prevention and the DOD launched an investigation.
The investigation consisted of a review of medical records, establishment of case definitions, causality assessment, patient interviews, and active surveillance. A 2-sided exact rate ratio test was used to compare myopericarditis incidence rates.
This investigation identified 4 cases of probable myopericarditis and 1 case of suspected myopericarditis. No alternative etiology was identified as a cause. No additional cases were identified. There was no statistically significant difference in incidence rates between the observed cluster (5.23 per 1000 vaccinated individuals, 95% CI: 1.7–12.2) and the ACAM2000 clinical trial outcomes for symptomatic persons, which was 2.29 per 1000 vaccinated individuals (95% CI: 0.3–8.3).
Vaccination with ACAM2000 is the presumptive cause of this cluster. Caution should be exercised before considering vaccination campaigns for smallpox given the clinical morbidity and costs incurred by a case of myopericarditis. Risk of myopericarditis should be carefully weighed with risk of exposure to smallpox.
Psychological attachment to political parties can bias people’s attitudes, beliefs, and group evaluations. Studies from psychology suggest that self-affirmation theory may ameliorate this problem in the domain of politics on a variety of outcome measures. We report a series of studies conducted by separate research teams that examine whether a self-affirmation intervention affects a variety of outcomes, including political or policy attitudes, factual beliefs, conspiracy beliefs, affective polarization, and evaluations of news sources. The different research teams use a variety of self-affirmation interventions, research designs, and outcomes. Despite these differences, the research teams consistently find that self-affirmation treatments have little effect. These findings suggest considerable caution is warranted for researchers who wish to apply the self-affirmation framework to studies that investigate political attitudes and beliefs. By presenting the “null results” of separate research teams, we hope to spark a discussion about whether and how the self-affirmation paradigm should be applied to political topics.
The first demonstration of laser action in ruby was made in 1960 by T. H. Maiman of Hughes Research Laboratories, USA. Many laboratories worldwide began the search for lasers using different materials, operating at different wavelengths. In the UK, academia, industry and the central laboratories took up the challenge from the earliest days to develop these systems for a broad range of applications. This historical review looks at the contribution the UK has made to the advancement of the technology, the development of systems and components and their exploitation over the last 60 years.
Marine litter and waste has become one of the major environmental issues of the early twenty-first century. Around 6.4 million tonnes of litter are deposited into the oceans each year (UNEP, 2005), a figure that continues to grow as a result of a variety of social and economic factors, including consumerism and the purchase of single-use products, coastal urbanization, shipping, poor waste management and the use of plastics. Indeed, as Bergmann et al. (2015, p. x) noted, ‘The ubiquity of litter in the open ocean is prominently illustrated by numerous images of floating debris from the ocean garbage patches and by the fact that the search for the missing Malaysia Airlines flight MH370 in March 2014 produced quite a few misidentifications caused by litter floating at the water surface.’ Eriksen et al. (2014) estimated that there was a minimum of 5.25 trillion plastic particles weighing 268,940 tons afloat in the sea, but this figure does not include debris on beaches or on the sea floor. Galgani et al. (2015, p. 29) suggest that plastics ‘typically constitute the most important part of marine litter sometimes accounting for up to 100 % of floating litter’, while 90 per cent of litter caught in benthic trawls is also plastic (Galgani et al., 2015). However, it is important to note that even though the amount of plastic that is produced is increasing, and is expected to continue to do so in the future (Taylor, 2017), the ‘predominance of plastics in litter is not the result of relatively more plastics being littered compared to paper, paperboard or wood products reaching the oceans, but because of the exceptional durability or persistence of plastics in the environment’ (Andrady, 2015, p. 58).
The coronavirus disease 2019 (COVID-19) pandemic forced American medical systems to adapt to high patient loads of respiratory disease. Its disruption of normal routines also brought opportunities for broader reform. The purpose of this article is to describe how the Carl R. Darnall Army Medical Center (CRDAMC), a medium-sized Army hospital, capitalized on opportunities to advance its strategic aims during the pandemic. Specifically, the hospital sequentially adopted virtual video visits, surged on preventative screenings, and made-over its image to appeal to patients seeking urgent care. These campaigns supported COVID-19 efforts and larger strategic goals simultaneously, and they will endure for years to come. Predictably, CRDAMC encountered obstacles in the course of its transformation. These obstacles and their follow-on lessons are provided to assist future medical leaders seeking quantum change in the opportunities made available by health crises.
A number of genomic conditions caused by copy number variants (CNVs) are associated with a high risk of neurodevelopmental and psychiatric disorders (ND-CNVs). Although these patients also tend to have cognitive impairments, few studies have investigated the range of emotion and behaviour problems in young people with ND-CNVs using measures that are suitable for those with learning difficulties.
A total of 322 young people with 13 ND-CNVs across eight loci (mean age: 9.79 years, range: 6.02–17.91, 66.5% male) took part in the study. Primary carers completed the Developmental Behaviour Checklist (DBC).
Of the total, 69% of individuals with an ND-CNV screened positive for clinically significant difficulties. Young people from families with higher incomes (OR = 0.71, CI = 0.55–0.91, p = .008) were less likely to screen positive. The rate of difficulties differed depending on ND-CNV genotype (χ2 = 39.99, p < 0.001), with the lowest rate in young people with 22q11.2 deletion (45.7%) and the highest in those with 1q21.1 deletion (93.8%). Specific patterns of strengths and weaknesses were found for different ND-CNV genotypes. However, ND-CNV genotype explained no more than 9–16% of the variance, depending on DBC subdomain.
Emotion and behaviour problems are common in young people with ND-CNVs. The ND-CNV specific patterns we find can provide a basis for more tailored support. More research is needed to better understand the variation in emotion and behaviour problems not accounted for by genotype.
Resident education in emergency medicine (EM) relies upon a variety of teaching platforms and mediums, including real-life clinical scenarios, simulation, academic day (lectures, small group sessions), journal clubs, and teaching learners. However, the coronavirus disease 2019 (COVID-19) pandemic has disrupted teaching and learning, forcing programs to adapt to ensure residents can progress in their training.1 Suddenly, academic days cannot be held in person, emergency department (ED) volumes are dynamically changing, and the role of residents in ED procedures has been questioned. Furthermore, medical student rotations through the ED have been cancelled, decreasing resident exposure to undergraduate teaching. These changes to resident education threaten resident wellness and will have downstream effects on training and personal professional development. In response, programs must develop strategies to ensure that residents continue receiving high-quality training in a safe learning environment. In this review, we will cover recommended strategies put forth by two large EM programs in Ontario (Table 1).
Emergency medicine (EM) training programs incorporate simulation for teaching as well as formative and summative assessment. The development of a simulation curriculum for Canadian postgraduate EM programs is underway and would be facilitated by a standardized, user-friendly, nationally endorsed simulation template. We convened a nationally representative group of simulation educators to participate in a three-phase process to develop and refine a simulation case template for Canadian EM educators. Participants provided feedback by means of free text comments and focus groups which were analyzed to inform modification of the template. We anticipate that this template will facilitate the sharing of cases across sites and the development of standardized cases for simulation-based assessment.
OBJECTIVES/GOALS: The development of early university technologies for commercialization is largely inefficient and exhibits a high rate of failure, often due to a lack of researcher time and commercialization experience. We have created the Translational Fellow role to address these needs and increase the throughput of university technology transfer. METHODS/STUDY POPULATION: Translational Fellows will first build their initial competencies to identify, evaluate, and develop new technologies through internships with intake organizations within the university ecosystem, including the Office of Technology Management, the LEAP gap-funding mechanism, and local venture capital firms. Following this training, Fellows will provide tailored support to validated projects by establishing development milestones, liaising with industry experts, navigating regulatory requirements, and drafting marketing materials such as executive summaries and financial projections. Lastly, Fellows will partner with a highly developed project to facilitate the commercialization of the technology, whether through a SBIR/STTR grant, direct licensing event, or startup creation. RESULTS/ANTICIPATED RESULTS: We anticipate that implementation of this mechanism will increase the proportion of university-generated inventions that undergo successful commercialization events, as well as increase the rate at which these projects develop after initial validation. Furthermore, we expect that the skills acquired through this program will allow Fellows to successfully transition to a variety of roles in the biotech space. We also expect that Fellows will be capable of training other scientific teams in the preparation of SBIR/STTR grants, further expanding opportunities for commercialization in the research space. DISCUSSION/SIGNIFICANCE OF IMPACT: Translational Fellows fill a unique interdisciplinary niche, allowing them to address common barriers faced by academic inventors. Improving commercialization throughput further capitalizes on the wealth of ideas generated in universities, thereby driving innovation in the biomedical space and directly contributing to improved human health. CONFLICT OF INTEREST DESCRIPTION: The authors have no conflicts of interest.
Although lignin has been negatively correlated with neutral-detergent fibre (NDF) digestibility (NDFD) in ruminants and used to predict potential extent of NDF digestion of forages, selection of an analysis, Klason lignin (KL) or acid-detergent lignin (ADL), to describe that the nutritionally relevant lignin has not been resolved. Dismissed as an artifact is the difference between KL and ADL (ΔL). A question is whether ΔL influences NDFD. We evaluated the relationships of ΔL, KL and ADL with NDFD in order to determine the nutritionally homogeneous or heterogeneous nature of KL. Data sets from two laboratories (DS1 and DS2) were used that included ADL, KL and in vitro NDFD at 48 h (NDFD48). DS1 contained seven C3 grasses, seventeen C4 maize forages and nineteen alfalfas, and DS2 had fifteen C3 grasses, eight C4 forages and six alfalfas. Mean ΔL was greater than ADL in C3 and C4 samples and less in alfalfas. Within forage type and laboratory, ΔL was not correlated with NDFD48 (r −0·34–0·49; all P > 0·17). ADL was more consistently correlated with NDFD48 (r −0·47–−0·95; P < 0·01–0·21) than with KL (r 0·03–−0·91; P < 0·01–0·94). ΔL as a proportion of KL was correlated with NDFD48 in C3 and C4 samples (r 0·44–0·76; P < 0·01–0·08). The differing behaviours of ΔL and ADL relative to NDFD48 indicate that KL is a nutritionally heterogeneous fraction, the behaviour of which may vary by forage type and ratios of ADL and ΔL present.
Over the past twenty years, several taxonomies of personality and psychopathology have been developed. More recently, many studies have compared dimensional models of personality pathology to categorical diagnoses of personality disorders. Altogether, this proliferation of research suggests the value of articulating the desirable properties of a good taxonomic system. Here, the authors extend basic research in cognitive science on the limitations of representational capacity, which suggests that humans need to compress complex clinical presentations to make good judgments. With this in mind, the authors propose that information compression and information fidelity are two principles that are essential to good taxonomy. The principle of information compression is that taxonomies should prune the complexities of a detailed clinical presentation to focus on important sources of covariation. The principle of information fidelity is that a good taxonomy should maintain essential features that reasonably approximate the structure of an individual or the population. They conclude with the claim that the overarching goal of taxonomic science in classifying personality pathology is to provide clinicians and researchers with empirically based informative priors that help to bias thinking toward useful clinical distinctions.
Behaviour that challenges in people with intellectual disability is associated with higher healthcare, social care and societal costs. Although behavioural therapies are widely used, there is limited evidence regarding the cost and quality-adjusted life-years (QALYs).
We aimed to assess the incremental cost per QALY gained of therapist training in positive behaviour support (PBS) and treatment as usual (TAU) compared with TAU using data from a cluster randomised controlled trial (Clinical Trials.gov registration: NCT01680276).
We conducted a cost-utility analysis (cost per QALY gained) of 23 teams randomised to PBS or TAU, with a total of 246 participants followed up over 36 months. The primary analysis was from a healthcare cost perspective with a secondary analysis from a societal cost perspective.
Over 36 months the intervention resulted in an additional 0.175 QALYs (discounted and adjusted 95% CI −0.068 to 0.418). The total cost of training in and delivery of PBS is £1598 per participant plus an additional cost of healthcare of £399 (discounted and adjusted 95% CI −603 to 1724). From a healthcare cost perspective there is an 85% probability that the intervention is cost-effective compared with TAU at a £30 000 willingness to pay for a QALY threshold.
There was a high probability that training in PBS is cost-effective as the cost of training and delivery of PBS is balanced out by modest improvements in quality of life. However, staff training in PBS is not supported given we found no evidence for clinical effectiveness.
The prevalence and impact of motor coordination difficulties in children with copy number variants associated with neurodevelopmental disorders (ND-CNVs) remains unknown. This study aims to advance understanding of motor coordination difficulties in children with ND-CNVs and establish relationships between intelligence quotient (IQ) and psychopathology.
169 children with an ND-CNV (67% male, median age = 8.88 years, range 6.02–14.81) and 72 closest-in-age unaffected siblings (controls; 55% male, median age = 10.41 years, s.d. = 3.04, range 5.89–14.75) were assessed with the Developmental Coordination Disorder Questionnaire, alongside psychiatric interviews and standardised assessments of IQ.
The children with ND-CNVs had poorer coordination ability (b = 28.98, p < 0.001) and 91% of children with an ND-CNV screened positive for suspected developmental coordination disorder, compared to 19% of controls (OR = 42.53, p < 0.001). There was no difference in coordination ability between ND-CNV genotypes (F = 1.47, p = 0.184). Poorer coordination in children with ND-CNV was associated with more attention deficit hyperactivity disorder (ADHD) (β = −0.18, p = 0.021) and autism spectrum disorder trait (β = −0.46, p < 0.001) symptoms, along with lower full-scale (ß = 0.21, p = 0.011), performance (β = −0.20, p = 0.015) and verbal IQ (β = 0.17, p = 0.036). Mediation analysis indicated that coordination ability was a full mediator of anxiety symptoms (69% mediated, p = 0.012), and a partial mediator of ADHD (51%, p = 0.001) and autism spectrum disorder trait symptoms (66%, p < 0.001) as well as full scale IQ (40%, p = 0.002), performance IQ (40%, p = 0.005) and verbal IQ (38%, p = 0.006) scores.
The findings indicate that poor motor coordination is highly prevalent and closely linked to risk of mental health disorder and lower intellectual function in children with ND-CNVs. Future research should explore whether early interventions for poor coordination ability could ameliorate neurodevelopmental risk.
The impact of hurricanes on emergency services is well-known. Recent history demonstrates the need for prehospital and emergency department coordination to serve communities during evacuation, storm duration, and cleanup. The use of telehealth applications may enhance this coordination while lessening the impact on health-care systems. These applications can address triage, stabilization, and diversion and may be provided in collaboration with state and local emergency management operations through various shelters, as well as during other emergency medical responses.
Surgical site infections (SSIs) are common surgical complications that lead to increased costs. Depending on payer type, however, they do not necessarily translate into deficits for every hospital.
We investigated how surgical site infections (SSIs) influence the contribution margin in 2 reimbursement systems based on diagnosis-related groups (DRGs).
This preplanned observational health cost analysis was nested within a Swiss multicenter randomized controlled trial on the timing of preoperative antibiotic prophylaxis in general surgery between February 2013 and August 2015. A simulation of cost and income in the National Health Service (NHS) England reimbursement system was conducted.
Of 5,175 patients initially enrolled, 4,556 had complete cost and income data as well as SSI status available for analysis. SSI occurred in 228 of 4,556 of patients (5%). Patients with SSIs were older, more often male, had higher BMIs, compulsory insurance, longer operations, and more frequent ICU admissions. SSIs led to higher hospital cost and income. The median contribution margin was negative in cases of SSI. In SSI cases, median contribution margin was Swiss francs (CHF) −2045 (IQR, −12,800 to 4,848) versus CHF 895 (IQR, −2,190 to 4,158) in non-SSI cases. Higher ASA class and private insurance were associated with higher contribution margins in SSI cases, and ICU admission led to greater deficits. Private insurance had a strong increasing effect on contribution margin at the 10th, 50th (median), and 90th percentiles of its distribution, leading to overall positive contribution margins for SSIs in Switzerland. The NHS England simulation with 3,893 patients revealed similar but less pronounced effects of SSI on contribution margin.
Depending on payer type, reimbursement systems with DRGs offer only minor financial incentives to the prevention of SSI.
Simulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM).
Simulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators.
Twenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology.
This study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.
Background: Cervical spondylotic myelopathy (CSM) is the leading cause of spinal cord impairment. In a public healthcare system, wait times to see spine specialists and eventually access surgical treatment for CSM can be substantial. The goals of this study were to determine consultation wait times (CWT) and surgical wait times (SWT), and identify predictors of wait time length. Methods: Consecutive patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) prospective and observational CSM study from March 2015 to July 2017 were included. A data-splitting technique was used to develop and internally validate multivariable models of potential predictors. Results: A CSORN query returned 264 CSM patients for CWT. The median was 46 days. There were 31% mild, 35% moderate, and 33% severe CSM. There was a statistically significant difference in median CWT between moderate and severe groups; 207 patients underwent surgical treatment. Median SWT was 42 days. There was a statistically significant difference in SWT between mild/moderate and severe groups. Short symptom duration, less pain, lower BMI, and lower physical component score of SF-12 were predictive of shorter CWT. Only baseline pain and medication duration were predictive of SWT. Both CWT and SWT were shorter compared to a concurrent cohort of lumbar stenosis patients (p <0.001). Conclusions: Patients with shorter duration (either symptoms or medication) and less neck pain waited less to see a spine specialist in Canada and to undergo surgical treatment. This study highlights some of the obstacles to overcome in expedited care for this patient population.
A fine-grained, up to 3-m-thick tephra bed in southwestern Saskatchewan, herein named Duncairn tephra (Dt), is derived from an early Pleistocene eruption in the Jemez Mountains volcanic field of New Mexico, requiring a trajectory of northward tephra dispersal of ~1500 km. An unusually low CaO content in its glass shards denies a source in the closer Yellowstone and Heise volcanic fields, whereas a Pleistocene tephra bed (LSMt) in the La Sal Mountains of Utah has a very similar glass chemistry to that of the Dt, supporting a more southerly source. Comprehensive characterization of these two distal tephra beds along with samples collected near the Valles caldera in New Mexico, including grain size, mineral assemblage, major- and trace-element composition of glass and minerals, paleomagnetism, and fission-track dating, justify this correlation. Two glass populations each exist in the Dt and LSMt. The proximal correlative of Dt1 is the plinian Tsankawi Pumice and co-ignimbritic ash of the first ignimbrite (Qbt1g) of the 1.24 Ma Tshirege Member of the Bandelier Tuff. The correlative of Dt2 and LSMt is the co-ignimbritic ash of Qbt2. Mixing of Dt1 and Dt2 probably occurred during northward transport in a jet stream.