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Disaster Medicine (DM) education for Emergency Medicine (EM) residents is highly variable due to time constraints, competing priorities, and program expertise. The investigators’ aim was to define and prioritize DM core competencies for EM residency programs through consensus opinion of experts and EM professional organization representatives.
Investigators utilized a modified Delphi methodology to generate a recommended, prioritized core curriculum of 40 DM educational topics for EM residencies.
The DM topics recommended and outlined for inclusion in EM residency training included: patient triage in disasters, surge capacity, introduction to disaster nomenclature, blast injuries, hospital disaster mitigation, preparedness, planning and response, hospital response to chemical mass-casualty incident (MCI), decontamination indications and issues, trauma MCI, disaster exercises and training, biological agents, personal protective equipment, and hospital response to radiation MCI.
This expert-consensus-driven, prioritized ranking of DM topics may serve as the core curriculum for US EM residency programs.
We have observed the G23 field of the Galaxy AndMass Assembly (GAMA) survey using the Australian Square Kilometre Array Pathfinder (ASKAP) in its commissioning phase to validate the performance of the telescope and to characterise the detected galaxy populations. This observation covers ~48 deg2 with synthesised beam of 32.7 arcsec by 17.8 arcsec at 936MHz, and ~39 deg2 with synthesised beam of 15.8 arcsec by 12.0 arcsec at 1320MHz. At both frequencies, the root-mean-square (r.m.s.) noise is ~0.1 mJy/beam. We combine these radio observations with the GAMA galaxy data, which includes spectroscopy of galaxies that are i-band selected with a magnitude limit of 19.2. Wide-field Infrared Survey Explorer (WISE) infrared (IR) photometry is used to determine which galaxies host an active galactic nucleus (AGN). In properties including source counts, mass distributions, and IR versus radio luminosity relation, the ASKAP-detected radio sources behave as expected. Radio galaxies have higher stellar mass and luminosity in IR, optical, and UV than other galaxies. We apply optical and IR AGN diagnostics and find that they disagree for ~30% of the galaxies in our sample. We suggest possible causes for the disagreement. Some cases can be explained by optical extinction of the AGN, but for more than half of the cases we do not find a clear explanation. Radio sources aremore likely (~6%) to have an AGN than radio quiet galaxies (~1%), but the majority of AGN are not detected in radio at this sensitivity.
Limited research considers the ethnic and cultural diversity among the US Black population, and how this diversity influences diet. The purpose of the present qualitative study is to (1) explore the influence of culture, nativity and ethnicity on the diet of US-born, African-born and Caribbean/Latin American-born Blacks and (2) explore a model of dietary acculturation among the African-born and Caribbean/Latin American-born Blacks. The purposive sample included twenty-two US-born, fifteen Caribbean/Latin American-born and ten African-born Blacks (n 47) living in Boston, who participated in either an in-depth interview (n 12) or a focus group (five groups, size 5–9). Satia-Abouta's model of dietary acculturation informed the interview and focus group questions, which explored the influence of psychosocial factors, taste preferences and environmental factors on dietary changes. NVivo 10 software was utilised for the coding and analysis. Topics based on a priori and posteriori analyses included differences in psychosocial factors and taste preferences and environmental factors by nativity. Caribbean/Latin American-born and African-born Blacks expressed the importance of cultural identity in their dietary preferences and found adaptive strategies to maintain cultural diet, while US-born Blacks demonstrated a variety of preferences for traditionally African American foods. Environmental factors varied by place of birth and residence, with US-born Blacks citing poorer quality and limited affordability of foods. These findings suggest the importance of psychosocial and environmental factors in shaping the diet of the ethnically diverse US Black population and underscore the dietary diversity within and across the different ethnic groups of Blacks.
To evaluate the association between novel pre- and post-operative biomarker levels and 30-day unplanned readmission or mortality after paediatric congenital heart surgery.
Children aged 18 years or younger undergoing congenital heart surgery (n = 162) at Johns Hopkins Hospital from 2010 to 2014 were enrolled in the prospective cohort. Collected novel pre- and post-operative biomarkers include soluble suppression of tumorgenicity 2, galectin-3, N-terminal prohormone of brain natriuretic peptide, and glial fibrillary acidic protein. A model based on clinical variables from the Society of Thoracic Surgery database was developed and evaluated against two augmented models.
Unplanned readmission or mortality within 30 days of cardiac surgery occurred among 21 (13%) children. The clinical model augmented with pre-operative biomarkers demonstrated a statistically significant improvement over the clinical model alone with a receiver-operating characteristics curve of 0.754 (95% confidence interval: 0.65–0.86) compared to 0.617 (95% confidence interval: 0.47–0.76; p-value: 0.012). The clinical model augmented with pre- and post-operative biomarkers demonstrated a significant improvement over the clinical model alone, with a receiver-operating characteristics curve of 0.802 (95% confidence interval: 0.72–0.89; p-value: 0.003).
Novel biomarkers add significant predictive value when assessing the likelihood of unplanned readmission or mortality after paediatric congenital heart surgery. Further exploration of the utility of these novel biomarkers during the pre- or post-operative period to identify early risk of mortality or readmission will aid in determining the clinical utility and application of these biomarkers into routine risk assessment.
White mold caused by the fungus, Sclerotinia sclerotiorum is a devastating disease of soybean (Glycine max) and other leguminous crops, including dry bean (Phaseolus vulgaris). Previous research has demonstrated that no-till planting soybean into rolled–crimped cereal rye residue can enhance weed management, improve soil health and reduce labor requirements in organic production. However, there are limited data on the effects of cereal rye residue on white mold suppression in no-till planted soybean and dry bean. Two field trials were conducted in 2016–2017 (Year 1) and repeated in 2017–2018 (Year 2) to evaluate the potential of cereal rye cover crop residue to suppress white mold in these crops. In each trial (soybean and dry bean), the experimental design was a randomized complete block with two treatments: (1) rolled–crimped cereal rye residue and (2) no cover crop control. Treatment effects on plant population, biomass and yield components varied between the main crops. Compared with the control treatment, cereal rye residue reduced the incidence of white mold in soybean in both years and in dry bean in Year 2. The reduction in white mold in cereal rye residue plots was due to a combination of (1) decreased sclerotial germination (no stipes formed) and (2) increased nonfunctional sclerotial germination defined here as sclerotia that germinated but produced stipes without the expanded cup where asci containing ascospores are formed. Weed density and biomass were lower in cereal rye residue plots in soybean and dry bean, except in Year 1 in soybean when weed biomass was low in both treatments. Our findings indicate that cereal rye residue could help organic and conventional farmers manage white mold in no-till planted soybean and dry bean. Germination of sclerotia resulting in nonfunctional apothecia could potentially exhaust soilborne inoculum in the upper soil profile and reduce infections in subsequent crops.
Introduction: The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, continuously updated Emergency Medical Services (EMS) evidence repository. This summary describes the research evidence for the identification and management of adult patients suffering from sepsis syndrome or septic shock. Methods: PubMed was searched in a systematic manner. One author reviewed titles and abstracts for relevance and two authors appraised each study selected for inclusion. Primary outcomes were extracted. Studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and a three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings based on the studies’ primary outcome for each intervention). LOE and DOE of each intervention were plotted on an evidence matrix (DOE x LOE). Results: Eighty-eight studies were included for 15 interventions listed in PEP. The interventions with the most evidence were related to identification tools (ID) (n = 26, 30%) and early goal directed therapy (EGDT) (n = 21, 24%). ID tools included Systematic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA) and other unique measures. The most common primary outcomes were related to diagnosis (n = 30, 34%), mortality (n = 40, 45%) and treatment goals (e.g. time to antibiotic) (n = 14, 16%). The evidence rank for the supported interventions were: supportive-high quality (n = 1, 7%) for crystalloid infusion, supportive-moderate quality (n = 7, 47%) for identification tools, prenotification, point of care lactate, titrated oxygen, temperature monitoring, and supportive-low quality (n = 1, 7%) for vasopressors. The benefit of prehospital antibiotics and EGDT remain inconclusive with a neutral DOE. There is moderate level evidence opposing use of high flow oxygen. Conclusion: EMS sepsis interventions are informed primarily by moderate quality supportive evidence. Several standard treatments are well supported by moderate to high quality evidence, as are identification tools. However, some standard in-hospital therapies are not supported by evidence in the prehospital setting, such as antibiotics, and EGDT. Based on primary outcomes, no identification tool appears superior. This evidence analysis can guide selection of appropriate prehospital therapies.
Introduction: Early and accurate diagnosis of critical conditions is essential in emergency medical services (EMS). Serum lactate testing may be used to identify patients with worse prognosis, including sepsis. Recently, the use of a point-of-care lactate (POCL) test has been evaluated in guiding treatment in patients with sepsis. Operating as part of the Prehospital Evidence Based Practice (PEP) Program, the authors sought to identify and describe the body of evidence for POCL use in EMS and the emergency department (ED) for patients with sepsis. Methods: Following PEP methodology, in May 2018, PubMed was searched in a systematic manner. Title and abstract screening were conducted by the program coordinator. These studies were collected, appraised and added to the existing body of literature contained within the PEP database. Evidence appraisal was conducted by two reviewers who assigned both a level of evidence (LOE) on a novel three tier scale and a direction of evidence (supportive, neutral or opposing; based on primary outcome). Data on setting and study design were also extracted. Results: Eight studies were included in our analysis. Three of these studies were conducted in the ED setting; each investigating the POCL test's ability to predict severe sepsis, ICU admission or death. All three studies found supportive results for POCL. A systematic review on the use of POCL in the ED determined that this test can also improve time to treatment. Five of the total 8 studies were conducted prehospitally. Two of these studies were supportive of POCL use in the prehospital setting; in terms of feasibility and the ability to predict sepsis. Both of these study sites used this early information as part of initiating a “sepsis alert” pathway. The other three prehospital studies provide neutral support for POCL. One study demonstrated moderate ability of POCL to predict severe illness. Two studies found poor agreement between prehospital POCL and serum lactate values. Conclusion: Limited low and moderate quality evidence suggest POCL may be feasible and helpful in predicting sepsis in the prehospital setting. However, there is sparse and inconsistent support for specific important outcomes, including accuracy.
Acute tonsillitis represents a significant proportion of admissions to ENT departments nationally. Given current hospital pressures, it is vital to look for safe alternatives to admission. This study explores the safe management of patients in an ambulatory medical unit, without the need for admission.
A retrospective review of 48 patients’ notes was carried out. Following the development and implementation of a guideline for acute tonsillitis, a prospective re-audit of 41 patients was carried out, measuring length of stay, overnight admissions and re-admissions.
The rate of overnight admission following implementation of the guideline fell from 0.75 to 0.29, and average length of stay dropped from 19.2 to 9.5 hours. There were two re-admissions in each cycle of the audit, which represents a non-significant increase.
The tonsillitis guideline has significantly reduced admissions and length of stay. Re-admissions remain low, demonstrating that this is a safe and cost-effective intervention.
To ensure that workers in certain industries are not exposed to harmful levels of toxic chemicals, it is necessary to provide regular monitoring of the concentrations of chemical contaminants in the workplace air. In the United Kingdom, monitoring is normally carried out on a routine basis by the factory occupier backed up by periodic visits from the Factory Inspectorate acting on behalf of the Government. The main source of guidance for occupational hygienists in assessing conditions in a factory is the list of threshold limit values (TLVs) published annually by the American Conference of Governmental Industrial Hygienists. Threshold limit values refer to airborne concentrations of substances and represent conditions under which it is believed that nearly all workers may be repeatedly exposed day after day without adverse effect.
Residual stress values in a material are governed by the measurements of the atomic spacings in a specific crystallographic plane and the elastic constant for that plane. It has been reported that the value of the elastic constant depends on microstructure, preferred orientation, plastic deformation and morphology , Thus, the theoretical calculation of the elastic constant may deviate from the intrinsic value for a real alloy.
OBJECTIVES/SPECIFIC AIMS: To establish an effective team of researchers working towards developing and validating prognostic models employing use of image analyses and other numerical metadata to better understand pediatric undernutrition, and to learn how different approaches can be brought together collaboratively and efficiently. METHODS/STUDY POPULATION: Over the past 18 months we have established a transdisciplinary team spanning three countries and the Schools of Medicine, Engineering, Data Science and Global Health. We first identified two team leaders specifically a pediatric physician scientist (SS) and a data scientist/engineer (DB). The leaders worked together to recruit team members, with the understanding that different ideas are encouraged and will be used collaboratively to tackle the problem of pediatric undernutrition. The final data analytic and interpretative core team consisted of four data science students, two PhD students, an undergraduate biology major, a recent medical graduate, and a PhD research scientist. Additional collaborative members included faculty from Biomedical Engineering, the School of Medicine (Pediatrics and Pathology) along with international Global Health faculty from Pakistan and Zambia. We learned early on that it was important to understand what each of the member’s motivation for contributing to the project was along with aligning that motivation with the overall goals of the team. This made us help prioritize team member tasks and streamline ideas. We also incorporated a mechanism of weekly (monthly/bimonthly for global partners) meetings with informal oral presentations which consisted of each member’s current progress, thoughts and concerns, and next experimental goals. This method enabled team leaders to have a 3600 mechanism of feedback. Overall, we assessed the effectiveness of our team by two mechanisms: 1) ongoing team member feedback, including team leaders, and 2) progress of the research project. RESULTS/ANTICIPATED RESULTS: Our feedback has shown that on initial development of the team there was hesitance in communication due to the background diversity of our various member along with different cultural/social expectations. We used ice-breaking methods such as dedicated time for brief introductions, career directions, and life goals for each team member. We subsequently found that with the exception of one, all other team members noted our working environment professional and conducive to productivity. We also learnt from our method of ongoing constant feedback that at times, due to the complexity of different disciplines, some information was lost due to the difference in educational backgrounds. We have now employed new methods to relay information more effectively, with the use of not just sharing literature but also by explaining the content. The progress of our research project has varied over the past 4-6 months. There was a steep learning curve for almost every member, for example all the data science students had never studied anything related to medicine during their education, including minimal if none exposure to the ethics of medical research. Conversely, team members with medical/biology backgrounds had minimal prior exposure to computational modeling, computer engineering and the verbage of communicating mathematical algorithms. While this may have slowed our progress we learned that by asking questions and engaging every member it was easier to delegate tasks effectively. Once our team reached an overall understanding of each member’s goals there was a steady progress in the project, with new results and new methods of analysis being tested every week. DISCUSSION/SIGNIFICANCE OF IMPACT: We expect that our on-going collaboration will result in the development of new and novel modalities to understand and diagnose pediatric undernutrition, and can be used as a model to tackle several other problems. As with many team science projects, credit and authorship are challenges that we are outlining creative strategies for as suggested by International Committee of Medical Journal Editors (ICMJE) and other literature.
In Scotland, the base of the Ballagan Formation has traditionally been placed at the first grey mudstone within a contiguous Late Devonian to Carboniferous succession. This convention places the Devonian–Carboniferous boundary within the Old Red Sandstone (ORS) Kinnesswood Formation. The consequences of this placement are that tetrapods from the Ballagan Formation were dated as late Tournaisian in age and that the ranges of typically Devonian fish found in the Kinnesswood Formation continued into the Carboniferous. The Pease Bay specimen of the fish Remigolepis is from the Kinnesswood Formation. Comparisons with its range in Greenland, calibrated against spores, show it was Famennian in age. Detailed palynological sampling at Burnmouth from the base of the Ballagan Formation proves that the early Tournaisian spore zones (VI and HD plus Cl 1) are present. The Schopfites species that occurs through most of the succession is Schopfites delicatus rather than Schopfites claviger. The latter species defines the late Tournaisian CM spore zone. The first spore assemblage that has been found in Upper ‘ORS' strata underlying the Ballagan Formation (Preston, Whiteadder Water), contains Retispora lepidophyta and is from the early latest Famennian LL spore zone. The spore samples are interbedded with volcaniclastic debris, which shows that the Kelso Volcanic Formation is, in part, early latest Famennian in age. These findings demonstrate that the Ballagan Formation includes most of the Tournaisian with the Devonian–Carboniferous boundary positioned close to the top of the Kinnesswood Formation. The Stage 6 calcrete at Pease Bay can be correlated to the equivalent section at Carham, showing that it represents a time gap equivalent to the latest Famennian glaciation(s). Importantly, some of the recently described Ballagan Formation tetrapods are older than previously dated and now fill the key early part of Romer's Gap.
The aim of the study was to determine the main factors (sociodemographic, anthropometric, lifestyle and health status) associated with high Na excretion in a representative population of Chile.
Na excretion (g/d), a valid marker of Na intake, was determined by urine analysis and Tanaka’s formulas. Blood pressure was measured by trained staff and derived from the mean of three readings recorded after 15 min rest. The associations of Na excretion with blood pressure and the primary correlates of high Na excretion were determined using logistic regression.
Chileans aged ≥15 years.
Participants (n 2913) from the Chilean National Health Survey 2009–2010.
Individuals aged 25 years or over, those who were obese and those who had hypertension, diabetes or metabolic syndrome were more likely to have higher Na excretion. The odds for hypertension increased by 10·2 % per 0·4 g/d increment in Na excretion (OR=1·10; 95 % CI 1·06, 1·14; P < 0·0001). These findings were independent of major confounding factors.
Age, sex, adiposity, sitting behaviours and existing co-morbidities such as diabetes were associated with higher Na excretion levels in the Chilean population. These findings could help policy makers to implement public health strategies tailored towards individuals who are more likely to consume high levels of dietary salt.
Biological invasions are one of the grand challenges facing society, as exotic species introductions continue to rise and can result in dramatic changes to native ecosystems and economies. The scale of the “biological invasions crisis” spans from hyperlocal to international, involving a myriad of actors focused on mitigating and preventing biological invasions. However, the level of engagement among stakeholders and opportunities to collaboratively solve invasives issues in transdisciplinary ways is poorly understood. The Biological Invasions: Confronting a Crisis workshop engaged a broad group of actors working on various aspects of biological invasions in Virginia, USA—researchers, Extension personnel, educators, local, state, and federal agencies, nongovernmental organizations, and land managers—to discuss their respective roles and how they interact with other groups. Through a series of activities, it became clear that despite shared goals, most groups are not engaging with one another, and that enhanced communication and collaboration among groups is key to designing effective solutions. There is strong support for a multistakeholder coalition to affect change in policy, public education/engagement, and solution design. Confronting the biological invasions crisis will increasingly require engagement among stakeholders.
The nature of the association between child psychiatric symptoms and adolescent suicide-related thoughts (SRT) and attempts (SA) remains unclear. Our objective was to assess whether child psychiatric symptoms from 6 to 10 years of age mediate the association between exposure to maternal depressive symptoms in childhood and offspring SRT and SA in adolescence.
A population-based cohort study was constructed by linking all eight cycles from the National Longitudinal Survey of Children and Youth (NLSCY), a nationally representative Canadian panel survey conducted from 1994 to 2009. Self-reported maternal depressive symptoms were measured when offspring were between 0 and 5 years. Maternal-reported child psychiatric symptoms and psychiatric comorbid symptoms were measured from 6 to 10 years, and offspring self-reported SRT and SA were measured between 11 and 19 years. Indirect effects, the effect proportion mediated and their corresponding bootstrapped 95% confidence intervals (CI) were estimated.
Hyperactivity and inattention significantly mediated the association between maternal depressive symptoms in childhood and risk of both SRT and SA from 11 to 19 years, where approximately 60% (SRT 95% CI 23–94%; SA 95% CI 27–95%) of this association was explained by hyperactivity and inattention. Psychiatric comorbid symptoms also significantly mediated this relationship and accounted for 50% (95% CI 18–81%) of this association with SA.
Targeting hyperactivity and inattention, and co-occurring psychiatric symptoms in offspring of depressed mothers could reduce risk of SRT, eventual SA and halt progression towards suicide. However, further understanding of comorbid psychiatric symptoms in childhood that most strongly predict adolescent SA is needed.
Adverse pregnancy outcomes including prematurity and low birth weight (LBW) have been associated with life-long chronic disease risk for the infant. Stress during pregnancy increases the risk of adverse pregnancy outcomes. Many studies have reported the incidence of adverse pregnancy outcomes in Indigenous populations and a smaller number of studies have measured rates of stress and depression in these populations. This study sought to examine the potential association between stress during pregnancy and the rate of adverse pregnancy outcomes in Australian Indigenous women residing in rural and remote communities in New South Wales. This study found a higher rate of post-traumatic stress disorder, depression and anxiety symptoms during pregnancy than the general population. There was also a higher incidence of prematurity and LBW deliveries. Unfortunately, missing post-traumatic stress disorder and depressive symptomatology data impeded the examination of associations of interest. This was largely due to the highly sensitive nature of the issues under investigation, and the need to ensure adequate levels of trust between Indigenous women and research staff before disclosure and recording of sensitive research data. We were unable to demonstrate a significant association between the level of stress and the incidence of adverse pregnancy outcomes at this stage. We recommend this longitudinal study continue until complete data sets are available. Future research in this area should ensure prioritization of building trust in participants and overestimating sample size to ensure no undue pressure is placed upon an already stressed participant.