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While child self-regulation is shaped by the environment (e.g., the parents’ caregiving behaviors), children also play an active role in influencing the care they receive, indicating that children's individual differences should be integrated in models relating early care to children's development. We assessed 409 children's observed temperamental behavioral inhibition (BI), effortful control (EC), and the primary caregiver's parenting at child ages 3 and 5. Parents reported on child behavior problems at child ages 3, 5, and 8. Mediation analyses were conducted to examine relations between child temperament and parenting in predicting child problems. BI at age 3 was positively associated with structured parenting at age 5, which was negatively related to child internalizing and attention-academic problems at age 8. In contrast, parenting at child age 3 did not predict child BI or EC at age 5, nor did age 3 EC predict parenting at age 5. Findings indicate that child behavior may shape the development of caregiving and, in turn, long-term child adjustment, suggesting that studies of caregiving and child outcomes should consider the role of child temperament toward developing more informative models of child–environment interplay.
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.
Reflection is an important component in design skill development that helps designers better understand their design problem, develop better solutions, and improve their design approaches. This study explored the information that a student design team reflected on as part of a needs finding experience and the outcomes from these reflections. During the needs finding experience, the team exhibited reflection-in- action behavior as they used available data to form and iterate on explanatory hypotheses about potential community needs. After the needs finding experience, the team exhibited reflection-on-action behavior as they drew connections between their interview approaches and stakeholder responses and discussed changes they might make in the future. The team also identified situations where contextual factors of the stakeholder impacted their interviews, but during these reflections did not indicate how they might adapt their approaches to account for such factors in the future. These findings show that student designers can use reflection as a tool to improve their needs finding process but would benefit from pedagogical structures that might help them reflect more effectively.
Structural characterization and X-ray reference powder pattern determination have been conducted for the Co- and Zn-containing tridymite derivatives Ba(Co1−xZnx)SiO4 (x = 0.2, 0.4, 0.6, 0.8). The bright blue series of Ba(Co1−xZnx)SiO4 crystallized in the hexagonal P63 space group (No. 173), with Z = 6. While the lattice parameter “a” decreases from 9.126 (2) Å to 9.10374(6) Å from x = 0.2 to 0.8, the lattice parameter “c” increases from 8.69477(12) Å to 8.72200(10) Å, respectively. Apparently, despite the similarity of ionic sizes of Zn2+ and Co2+, these opposing trends are due to the framework tetrahedral tilting of (ZnCo)O4. The lattice volume, V, remains comparable between 626.27 Å3 and 626.017 (7) Å3 from x = 0 to x = 0.8. UV-visible absorption spectrum measurements indicate the band gap of these two materials to be ≈3.3 and ≈3.5 eV, respectively, therefore potential UV photocatalytic materials. Reference powder X-ray diffraction patterns of these compounds have been submitted to be included in the Powder Diffraction File (PDF).
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.
Background: Microglia and macrophages (MMs) are the largest component of the inflammatory infiltrate in glioblastoma (GBM). However, whether there are immunophenotypic differences in isocitrate dehydrogenase (IDH)-mutated and -wildtype GBMs is unknown. Studies on specimens of untreated IDH-mutant GBMs are rare given they comprise 10% of all GBMs and often receive treatment at lower grades that can drastically alter MM phenotypes. Methods: We obtained large samples of untreated IDH-mutant and -wildtype GBMs. Using immunofluorescence techniques with single-cell automated segmentation, and comparison between single-cell RNA-sequencing (scRNA-seq) databases of human GBM, we discerned dissimilarities between GBM-associated MMs (GAMMs). Results: There are significantly fewer but more pro-inflammatory GAMMs in IDH-mutant GBMs, suggesting this contributes to the better prognosis of these tumors. Our pro-inflammatory score which combines the expression of inflammatory markers (CD68/HLA-A, -B, -C/TNF/CD163/IL10/TGFB2), Iba1 intensity, and GAMM surface area also indicates more pro-inflammatory GAMMs are associated with longer overall survival independent of IDH status. scRNA-seq analysis demonstrates microglia in IDH-mutants are mainly pro-inflammatory, while anti-inflammatory macrophages that upregulate genes such as FCER1G and TYROBP predominate in IDH-wildtype GBM. Conclusions: Taken together, these observations are the first head-to-head comparison of GAMMs in treatment-naïve IDH-mutant versus -wildtype GBMs that highlight biological disparities that can be exploited for therapeutic purposes.
Archaeological research on food-production systems has focused heavily on the origins of agriculture and animal domestication; the agricultural practices of early states are comparatively less well understood. This article explores archaeological evidence for crop cultivation, field-management practices and the use of farming implements at the Western Han (202 BC–AD 8) village of Sanyangzhuang in Henan Province, China. The authors analyse the implications of these practices for the newly developed smallholder mode of production. By combining diverse strands of evidence, this investigation provides new insights into the status of agricultural production in the Central Plains during the Western Han Dynasty.
Two-dimensional particle-in-cell (PIC) simulations have been used to investigate the interaction between a laser pulse and a foil exposed to an external strong longitudinal magnetic field. Compared with that in the absence of the external magnetic field, the divergence of proton with the magnetic field in radiation pressure acceleration (RPA) regimes has improved remarkably due to the restriction of the electron transverse expansion. During the RPA process, the foil develops into a typical bubble-like shape resulting from the combined action of transversal ponderomotive force and instabilities. However, the foil prefers to be in a cone-like shape by using the magnetic field. The dependence of proton divergence on the strength of magnetic field has been studied, and an optimal magnetic field of nearly 60 kT is achieved in these simulations.
Using a multiscale blood flow solver, the complete diffusion tensor of nanoparticles (NPs) in sheared cellular blood flow is calculated over a wide range of shear rate and haematocrit. In the short-time regime, NPs exhibit anomalous dispersive behaviors under high shear and high haematocrit due to the transient elongation and alignment of the red blood cells (RBCs). In the long-time regime, the NP diffusion tensor features high anisotropy. Particularly, there exists a critical shear rate (
) around which the shear-rate dependence of the diffusivity tensor changes from linear to nonlinear scale. Above the critical shear rate, the cross-stream diffusivity terms vary sublinearly with shear rate, while the longitudinal term varies superlinearly. The dependence on haematocrit is linear in general except at high shear rates, where a sublinear scale is found for the vorticity term and a quadratic scale for the longitudinal term. Through analysis of the suspension microstructure and numerical experiments, the nonlinear haemorheological dependence of the NP diffusion tensor is attributed to the streamwise elongation and cross-stream contraction of RBCs under high shear, quantified by a capillary number. The RBC size is shown to be the characteristic length scale affecting the RBC-enhanced shear-induced diffusion (RESID), while the NP submicrometre size exhibits negligible influence on the RESID. Based on the observed scaling behaviours, empirical correlations are proposed to bridge the NP diffusion tensor to specific shear rate and haematocrit. The characterized NP diffusion tensor provides a constitutive relation that can lead to more effective continuum models to tackle large-scale NP biotransport applications.
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.
Introduction: In recent years, there has been growing interest in the field of physician wellness and burnout. Past research has shown that the prevalence of burnout is non-uniform between specialties and is most prevalent amongst emergency medicine physicians. Additionally, burnout can be observed amongst individuals early in their medical careers, including medical students and residents. To date, there is no national perspective of burnout amongst Canadian Royal College of Emergency Medicine (EM) residents. Our study looks to provide a national survey of burnout in this population as well as characterize mentorship programs at training sites. Methods: An anonymous electronic survey was e-mailed to Canadian EM residents via local program directors. Characteristics of mentor-mentee relationships and quality of residents’ mentorship experiences were assessed on a 6-point Likert scale. The Maslach Burnout Inventory – Human Services Survey (MBI-HSS) for medical personnel was used to assess burnout on three dimensions (emotional exhaustion, depersonalization and personal accomplishment). Burnout was dichotomized as present or absent if the MBI criteria are met (emotional exhaustion score > 26 or depersonalization score > 9 or personal accomplishment <34). Results: To date, 52 responses have been collected. Respondents are primarily male (63%) and in their PGY year 1-3 (71%). Responses were collected from 6/14 (43%) of eligible programs. 84% of residents currently had an emergency medicine mentor. Of these, 8% were dissatisfied with their residency's mentorship program and 55% were satisfied/very satisfied. 72% of residents met the threshold for burnout in at least one dimension of the MBI (3 dimensions = 17%; 2 dimensions = 17%; 1 dimension = 38%) and 13% cited considering suicide during their training. Conclusion: Results thus far suggest significant burnout amongst Royal College of Emergency Medicine residents. Alarmingly, 13% of responders cited having contemplated suicide during their training. These results point to an important opportunity to better support EM residents during their training to improve wellness and reduce burnout. Our findings suggest a high prevalence of residents with established mentors and future analyses will examine the correlation between mentorship characteristics and resident burnout levels.
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.
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.
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.
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.
This study explored the efficacy of aerobic training (AT) in mitigating white matter hyperintensity (WMH) progression and whether these changes are sex dependent. This was an exploratory analysis of a randomized controlled trial assessing the effect of AT on cognition in people with vascular cognitive impairment. Participants were randomized to a 6 month AT or usual care (control [CON]) group. A subset completed magnetic resonance imaging to quantify WMH volume. Using an analysis of covariance model, we found a significant sex × group interaction (p = .03). Over the 6 month study, AT females demonstrated greater WMH progression than CON females (p = .05). Among males, there was no significant between-group difference (p = .31). Within the AT group, males demonstrated significantly less WMH progression than females (p = .01) at 6 months. Therefore, the effects of AT on WMH progression may vary by sex; that is, AT may curtail WMH progression in males but not females.
Community-acquired pneumonia (CAP) results in substantial numbers of hospitalisations and deaths in older adults. There are known lifestyle and medical risk factors for pneumococcal disease but the magnitude of the additional risk is not well quantified in Australia. We used a large population-based prospective cohort study of older adults in the state of New South Wales (45 and Up Study) linked to cause-specific hospitalisations, disease notifications and death registrations from 2006 to 2015. We estimated the age-specific incidence of CAP hospitalisation (ICD-10 J12-18), invasive pneumococcal disease (IPD) notification and presumptive non-invasive pneumococcal CAP hospitalisation (J13 + J18.1, excluding IPD), comparing those with at least one risk factor to those with no risk factors. The hospitalised case-fatality rate (CFR) included deaths in a 30-day window after hospitalisation. Among 266 951 participants followed for 1 850 000 person-years there were 8747 first hospitalisations for CAP, 157 IPD notifications and 305 non-invasive pneumococcal CAP hospitalisations. In persons 65–84 years, 54.7% had at least one identified risk factor, increasing to 57.0% in those ⩾85 years. The incidence of CAP hospitalisation in those ⩾65 years with at least one risk factor was twofold higher than in those without risk factors, 1091/100 000 (95% confidence interval (CI) 1060–1122) compared with 522/100 000 (95% CI 501–545) and IPD in equivalent groups was almost threefold higher (18.40/100 000 (95% CI 14.61–22.87) vs. 6.82/100 000 (95% CI 4.56–9.79)). The CFR increased with age but there were limited difference by risk status, except in those aged 45 to 64 years. Adults ⩾65 years with at least one risk factor have much higher rates of CAP and IPD suggesting that additional risk factor-based vaccination strategies may be cost-effective.