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A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.
Optimal transition from child to adult services involves continuity, joint care, planning meetings and information transfer; commissioners and service providers therefore need data on how many people require that service. Although attention-deficit hyperactivity disorder (ADHD) frequently persists into adulthood, evidence is limited on these transitions.
To estimate the national incidence of young people taking medication for ADHD that require and complete transition, and to describe the proportion that experienced optimal transition.
Surveillance over 12 months using the British Paediatric Surveillance Unit and Child and Adolescent Psychiatry Surveillance System, including baseline notification and follow-up questionnaires.
Questionnaire response was 79% at baseline and 82% at follow-up. For those aged 17–19, incident rate (range adjusted for non-response) of transition need was 202–511 per 100 000 people aged 17–19 per year, with successful transition of 38–96 per 100 000 people aged 17–19 per year. Eligible young people with ADHD were mostly male (77%) with a comorbid condition (62%). Half were referred to specialist adult ADHD and 25% to general adult mental health services; 64% had referral accepted but only 22% attended a first appointment. Only 6% met optimal transition criteria.
As inclusion criteria required participants to be on medication, these estimates represent the lower limit of the transition need. Two critical points were apparent: referral acceptance and first appointment attendance. The low rate of successful transition and limited guideline adherence indicates significant need for commissioners and service providers to improve service transition experiences.
To this date ψ Per is the only classical Be star that was angularly resolved in radio (by the VLA at λ = 2 cm). Gaussian fit to the azimuthally averaged visibility data indicates a disk size (FWHM) of ~500 stellar radii (Dougherty & Taylor 1992). Recently, we obtained new multi-band cm flux density measurements of ψ Per from the enhanced VLA. We modeled the observed spectral energy distribution (SED) covering the interval from ultraviolet to radio using the Monte Carlo radiative transfer code HDUST (Carciofi & Bjorkman 2006). An SED turndown, that occurs between far-IR and radio wavelengths, is explained by a truncated viscous decretion disk (VDD), although the shallow slope of the radio SED suggests that the disk is not simply cut off, as is assumed in our model. The best-fit size of a truncated disk derived from the modeling of the radio SED is 100+5−15 stellar radii, which is in striking contrast with the result of Dougherty & Taylor (1992). The reasons for this discrepancy are under investigation.
We examined the cross-language relations among Spanish-speaking preschoolers’ (N = 125; M age = 53 months, SD = 4.58) English and Spanish vocabulary, letter–word, and math skills; the changes they exhibited in those skills during 1 year of preschool; and the extent to which Spanish skills were associated with English skill gains. The results revealed that children's Spanish and English vocabulary skills were unassociated across languages, whereas their letter–word and math skills were positively associated. Children exhibited gains in vocabulary, letter–word, and math skills in English, with letter–word and math skills in Spanish at the start of preschool being positively associated with the development of those skills in English. Children also gained math skills in Spanish. However, their Spanish vocabulary and letter–word skills did not appear to change. Vocabulary skills showed positive within-language relations with children's letter–word and math skills. The findings highlight cross-language linkages between Spanish-speaking preschoolers’ academic skills in English and Spanish and how Spanish skills associate with their English academic readiness.
To examine the use of vitamin D supplements during infancy among the participants in an international infant feeding trial.
Information about vitamin D supplementation was collected through a validated FFQ at the age of 2 weeks and monthly between the ages of 1 month and 6 months.
Infants (n 2159) with a biological family member affected by type 1 diabetes and with increased human leucocyte antigen-conferred susceptibility to type 1 diabetes from twelve European countries, the USA, Canada and Australia.
Daily use of vitamin D supplements was common during the first 6 months of life in Northern and Central Europe (>80 % of the infants), with somewhat lower rates observed in Southern Europe (>60 %). In Canada, vitamin D supplementation was more common among exclusively breast-fed than other infants (e.g. 71 % v. 44 % at 6 months of age). Less than 2 % of infants in the USA and Australia received any vitamin D supplementation. Higher gestational age, older maternal age and longer maternal education were study-wide associated with greater use of vitamin D supplements.
Most of the infants received vitamin D supplements during the first 6 months of life in the European countries, whereas in Canada only half and in the USA and Australia very few were given supplementation.
This study examined the combined and unique contributions of home, teacher, and peer English exposure levels on Spanish-speaking preschoolers’ (N = 107) English receptive and expressive vocabulary skills. The combined levels of English exposure during the fall of preschool were positively associated with children's English receptive and expressive vocabulary skills in the spring. Furthermore, English exposure levels at home were uniquely and positively associated with children's English receptive and expressive vocabularies, whereas peer English exposure levels were uniquely and positively associated with children's English expressive vocabulary. Teachers’ English exposure levels were not uniquely associated with children's English vocabulary. The findings highlight the importance of the home environment and peer experiences in the classroom for maximizing Spanish-speaking children's early English vocabulary skills.
The provision of surgery within humanitarian crises is complex, requiring coordination and cooperation among all stakeholders. During the 2011 Humanitarian Action Summit best practice guidelines were proposed to provide greater accountability and standardization in surgical humanitarian relief efforts. Surgical humanitarian relief planning should occur early and include team selection and preparation, appropriate disaster-specific anticipatory planning, needs assessment, and an awareness of local resources and limitations of cross-cultural project management. Accurate medical record keeping and timely follow-up is important for a transient surgical population. Integration with local health systems is essential and will help facilitate longer term surgical health system strengthening.
Limb amputations are frequently performed as a result of trauma inflicted during conflict or disasters. As demonstrated during the 2010 earthquake in Haiti, coordinating care of these patients in austere settings is complex. During the 2011 Humanitarian Action Summit, consensus statements were developed for international organizations providing care to limb amputation patients during disasters or humanitarian emergencies. Expanded planning is needed for a multidisciplinary surgical care team, inclusive of surgeons, anesthesiologists, rehabilitation specialists and mental health professionals. Surgical providers should approach amputation using an operative technique that optimizes limb length and prosthetic fitting. Appropriate anesthesia care involves both peri-operative and long-term pain control. Rehabilitation specialists must be involved early in treatment, ideally before amputation, and should educate the surgical team in prosthetic considerations. Mental health specialists must be included to help the patient with community reintegration. A key step in developing local health systemsis the establishment of surgical outcomes monitoring. Such monitoring can optimizepatient follow-up and foster professional accountability for the treatment of amputation patients in disaster settings and humanitarian emergencies.
The incidence of eating disorders appears stable overall, but may be increasing in younger age groups. Data on incidence, clinical features and outcome of early-onset eating disorders are sparse.
To identify new cases of early-onset eating disorders (<13 years) presenting to secondary care over 1 year and to describe clinical features, management and 1-year outcomes.
Surveillance over 14 months through the established British Paediatric Surveillance System, and a novel child and adolescent psychiatry surveillance system set up for this purpose.
Overall incidence was 3.01/100 000 (208 individuals). In total, 37% met criteria for anorexia nervosa; 1.4% for bulimia nervosa; and 43% for eating disorder not otherwise specified. Nineteen per cent showed determined food avoidance and underweight without weight/shape concerns. Rates of comorbidity were 41%; family history of psychiatric disorder 44%; and early feeding difficulties 21%. Time to presentation was >8 months. A total of 50% were admitted to hospital, typically soon after diagnosis. Outcome data were available for 76% of individuals. At 1 year, 73% were reported improved, 6% worse and 10% unchanged (11% unknown). Most were still in treatment, and seven were hospital in-patients for most of the year.
Childhood eating disorders represent a significant clinical burden to paediatric and mental health services. Efforts to improve early detection are needed. These data provide a baseline to monitor changing trends in incidence.
Physical activity is influenced by genetic factors whose expression may change with age. We employed an extension to the classical twin model that allows a modifier variable, age, to interact with the effects of the latent genetic and environmental factors. The model was applied to self-reported data from twins aged 19 to 50 from seven countries that collaborated in the GenomEUtwin project: Australia, Denmark, Finland, Norway, Netherlands, Sweden and United Kingdom. Results confirmed the importance of genetic influences on physical activity in all countries and showed an age-related decrease in heritability for 4 countries. In the other three countries age did not interact with heritability but those samples were smaller or had a more restricted age range. Effects of shared environment were absent, except in older Swedish participants. The study confirms the importance of taking age effects into account when exploring the genetic and environmental contribution to physical activity. It also suggests that the power of genome-wide association studies to identify the genetic variants contributing to physical activity may be larger in young adult cohorts.
Despite improvements in outcomes after completion of the Fontan circulation, long-term functional state varies. We sought to identify pre- and postoperative characteristics associated with overall function.
Methods and Results
We analyzed data from 476 survivors with the Fontan circulation enrolled in the Pediatric Heart Network Fontan Cross-sectional Study. Mean age at creation of the Fontan circulation was 3.4 plus or minus 2.1 years, with a range from 0.7 to 17.5 years, and time since completion was 8.7 plus or minus 3.4 years, the range being from 1.1 to 17.3 years. We calculated a functional score for the survivors by averaging the percentile ranks of ventricular ejection fraction, maximal consumption of oxygen, the physical summary score for the Child Health Questionnaire, and a function of brain natriuretic peptide. The mean calculated score was 49.5 plus or minus 17.3, with a range from 3 to 87. After adjustment for time since completion of the circulation, we found that a lower score, and hence worse functional state, was associated with: right ventricular morphology (p less than 0.001), higher ventricular end-diastolic pressure (p equals 0.003) and lower saturations of oxygen (p equals 0.047) prior to completion of the Fontan circulation, lower income for the caregiver (p equals 0.003), and, in subjects without a prior superior cavopulmonary anastomosis, arrhythmias after completion of the circulation (p equals 0.003). The model explained almost one-fifth (18%) of the variation in the calculated scores. The score was not associated with surgical centre, sex, age, weight, fenestration, or the period of stay in hospital after completion of the Fontan circuit. A validation model, using 71 subjects randomly excluded from initial analysis, weakly correlated (R equals 0.17, p equals 0.16) with the score calculated from the dataset.
Right ventricular morphology, higher ventricular end-diastolic pressure and lower saturations of oxygen prior to completion of the Fontan circuit, lower income for the provider of care, and arrhythmias after creation of the circuit, are all associated with a worse functional state. Unmeasured factors also influence outcomes.
Acknowledgments: This work was supported, in part, by grant K23-AA015616 from the National Institute on Alcohol Abuse and Alcoholism (RDB and LMF).
Alcohol and drug use disorders are significant problems among older patients. These problems may be underappreciated by health care professionals because of limited clinical evidence and research data to form practice guidelines, insufficient training, and rushed office visits that tend to focus on acute and chronic physical problems, which can easily consume all the clinician's attention leaving little time to screen, diagnose, and perform an intervention for a substance use disorder.
Diagnosis of a substance use disorder can be difficult in the older patient. Embarrassment, shame, and fear of disapproval by family members may lead older individuals to conceal their drinking or drug use. Family members, who would be unlikely to ignore alcohol or drug abuse in a young person, may tolerate alcohol or drug abuse in an older person because they may think that after a long life the person “deserves it,” or that “it makes no difference anyway.” Family members may also believe that an oversedated elderly patient is “more manageable.” Furthermore, the signs and symptoms of substance abuse often mimic the clinical presentation of other common medical or psychiatric disorders and health care providers may perceive their diagnostic role as being directed mainly toward the chief complaint.
There is a confusing array of terms used to describe individuals who use and misuse alcohol and other drugs: “alcohol abuse,” “alcoholism,” “chemical dependency,” “drug addiction,” and “substance abuse.”