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Unexpected disasters, such as earthquakes or fires, require preparation to address knowledge gaps that may negatively affect vulnerable patients. Training programs can promote natural disaster readiness to respond and evacuate patients safely, but also require evidence-based information to guide learning objectives.
There is limited evidence on what skills and bedside equipment are most important to include in disaster training and evacuation programs for critically ill infants.
An expert panel was used to create a 13-item mastery checklist of skills for bedside registered nurses (RNs) required to successfully evacuate a critically ill infant. Expert nurses were surveyed, and the Angoff method was used to determine which of the mastery checklist skills a newly graduated nurse (ie, the “minimally competent” nurse) should be able to do. Participants then rated the importance of 26 commonly available pieces of bedside equipment for use in evacuating a hemodynamically unstable, intubated infant during a disaster.
Twenty-three emergency department (ED) and neonatal intensive care unit (NICU) charge RNs responded to the survey with a mean of 19 (SD = 9) years of experience and 30% reporting personal experience with evacuating patients. The skills list scores showed an emphasis on the newly graduated nurse having more complete mastery of skills surrounding thermoregulation, documentation, infection control, respiratory support, and monitoring. Skills for communication, decision making, and anticipating future needs were assessed as less likely for a new nurse to have mastered. On a scale of one (not important) to seven (critically important), the perceived necessity of equipment ranged from a low of 1.6 (breast pump) to a high of 6.9 (face mask). The individual intraclass correlation coefficient (ICC) of 0.55 showed moderate reliability between raters and the average team ICC of 0.97 showed excellent agreement as a group.
Experts rated the ability to manage physiological issues, such as thermoregulation and respiratory support, as skills that every nurse should master. Disaster preparedness activities for nurses in training may benefit from checklists of essential equipment and skills to ensure all nurses can independently manage patients’ physiologic needs when they enter the workforce. Advanced nursing training should include education on decision making, communication during emergencies, and anticipation of future issues to ensure that charge and resource nurses can support bedside nurses during evacuation events.
Deciduous dipterocarp forests throughout Asia provide crucial habitat for several globally threatened species. During the dry season water availability in these forests is primarily limited to perennial rivers and waterholes. Such water sources form an essential part of these dry forests and are used by multiple species, including large mammals and birds, but little is known regarding how waterhole characteristics affect wildlife use. We investigated waterhole utilization by six globally threatened dry forest specialists: banteng Bos javanicus, Eld's deer Rucervus eldii, giant ibis Thaumatibis gigantea, green peafowl Pavo muticus, lesser adjutant Leptoptilos javanicus and Asian woolly-necked stork Ciconia episcopus. We camera-trapped 54 waterholes in Srepok Wildlife Sanctuary, eastern Cambodia, during the dry season of December 2015–June 2016. We measured nine waterhole and landscape characteristics, including indicators of human disturbance. Waterhole depth (measured every 2 weeks) and the area of water at the start of the dry season were the main environmental factors influencing waterhole use. Additionally, waterholes further from villages were more frequently used than those nearer. Our study reaffirmed the importance of waterholes in supporting globally threatened species, especially large grazers, which are critical for maintaining these dry forest ecosystems. The results also suggested that artificially enlarging and deepening selected waterholes, particularly those further from human disturbance, could enhance available habitat for a range of species, including grazers. However, this would need to be conducted in coordination with patrolling activities to ensure waterholes are not targets for illegal hunting, which is a problem throughout South-east Asian protected areas.
To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs).
Descriptive retrospective cohort with nested case-control study.
Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.
Children≤18 years ventilated for≥1 calendar day.
We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria.
Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20–67%; PICU, 0–70%; and NICU, 0–43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test.
Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.
Introduction: Online medical education resources are widely used in emergency medicine (EM), but strategies to assess quality remain elusive. We previously derived the Medical Education Translational Resources: Impact and Quality (METRIQ) 8 instrument to evaluate quality in medical education blog posts. Methods: As part of a subsequent validation study (The METRIQ Blog Study), a mixed-methods usability analysis was performed to obtain user feedback on the quality assessment instrument in order to improve its clarity and reliability. Participants in the METRIQ Study were first asked to rate five blog posts using the METRIQ-8 Score. They then evaluated the METRIQ-8 instruments ease of use and likelihood of being recommended to others using a 7-point Likert scale and free text comments. Participants were also asked to flag and comment on items within the score that they felt were unclear. Global usability ratings were summarized using median scores or percent rated unclear. We used ANOVA to test associations between ease of use and demographic factors. A thematic analysis was performed on the comments. Results: 309 EM medical students, residents, and attendings completed the survey. Global ratings were generally very favorable (median 2 [IQR 2-3], with 7 being the lowest score) for ease of use and likelihood of recommendation, and did not vary by participants country of origin, frequency of blog use, or learner level. Participants stated that the score was structured, systematic, and straightforward. They found it useful for junior learners and for guiding blog creation. Four questions in the score (questions 2, 4, 5, and 7) were identified by 10% of subjects to be unclear. Thematic analysis of comments identified suggested four main themes for improving the score: adding clearer definitions with marking rubrics; shortening the 7-point scale; adding items evaluating blog post presentation and utility; and, rephrasing the wording of certain questions for clarity. Conclusion: A mixed methods usability analysis of the METRIQ-8 instrument for assessing blog quality was globally well received by EM medical students, residents, and attendings. Qualitative analyses revealed multiple areas to improve the instruments clarity and usability. The METRIQ score is a promising instrument for evaluating the quality of blogs; further development and testing is needed to improve its utility.
The commercial release of crops with engineered resistance to 2,4-D and dicamba will alter the spatial and temporal use of these herbicides. This, in turn, has elicited concerns about off-target injury to sensitive crops. In 2014 and 2015, studies were conducted in Tifton, GA, to describe how herbicide (2,4-D and dicamba), herbicide rate (1/75 and 1/250 field use), and application timing (20, 40, and 60 DAP) influence watermelon injury, vine development, yield, and the accumulation of herbicide residues in marketable fruit. In general, greater visual injury and reductions in vine growth, relative to the non-treated check, were observed when herbicide applications were made before watermelon plants had begun to flower. Although the main effects of herbicide and rate were less influential than the timing of applications with respect to plant development, the 1/75 rates were more injurious than the 1/250 rates; dicamba was more injurious than 2,4-D. In 2014, the 1/75 and 1/250 rates of each herbicide reduced marketable fruit numbers 13 to 20%, but only for the 20 DAP application. The 1/75 rate of each herbicide when applied at either 20 or 40 DAP reduced the number of fruit harvested per plot in 2015. Dicamba residues were detected in marketable fruit when the 1/75 rate in 2014 and 2015 and the 1/250 rate in 2015 was applied to plants at 40 or 60 DAP. Residues of 2,4-D were detected in 2015 when the 1/75 and 1/250 rates were applied at 60 DAP. Across both years, the maximum level of residue detected was 0.030 ppm. While early season injury may reduce watermelon yields, herbicide residue detection is more likely in marketable fruit when an off-target contact incident occurs closer to harvest.
The Pivotal Politics model (Krehbiel) has significantly influenced the study of American politics, but its core empirical prediction – that the size of the gridlock interval is negatively related to legislative productivity – has not found strong empirical support. We argue that previous research featured a disconnect between the exclusively ideological theory and tests that relied on outcome variables that were not purely ideological. We remedy this by dividing landmark laws (Mayhew) into two counts – those that invoke ideological preferences and those that do not – and uncover results consistent with Pivotal Politics’ core prediction: the size of the gridlock interval is negatively related to the production of ideological legislation. We also find that the size of the gridlock zone is positively related to the production of nonideological legislation. These results hold up in the face of various sensitivity analyses and robustness checks. We further show that Pivotal Politics explains variation in ideological legislation better than alternative theories based on partisan agenda control.
The illegal trade in rhinoceros horn, driven largely by the demand from East and South-east Asia, is a major impediment to the conservation of rhinoceroses globally. We surveyed the town of Mong La, in eastern Myanmar on the border with China, for the presence of rhinoceros horn. No rhinoceros horn was observed in 2006 or 2009, and other African wildlife was rare or absent. During visits in 2014 and 2015 we observed two horns, presumed to be of the white rhinoceros Ceratotherium simum, and one horn tip, small discs from the horn core, horn powder and horn bangles. Shops selling rhinoceros horn all specialized in high-end and high-value wildlife, mostly for decorative purposes, including whole elephant tusks, carved elephant ivory, carved hippopotamus Hippopotamus amphibius canines, and tiger Panthera tigris skins. Organized criminal syndicates are involved in the wildlife trade between Myanmar and Africa, possibly via China. Mong La's geographical position on the border with China, limited control by the central Myanmar Government, and the presence of the Chinese entertainment industry provide ideal conditions for a global wildlife trade hub catering for the Chinese market. Solutions require more intense collaboration between the Myanmar and Chinese authorities to curb the trade in African rhinoceros horn in this part of Asia.
Low heart rate variability (HRV) predicts sudden cardiac death. Long-chain (LC) n-3 PUFA (C20–C22) status is positively associated with HRV. This cross-sectional study investigated whether vegans aged 40–70 years (n 23), whose diets are naturally free from EPA (20 : 5n-3) and DHA (22 : 6n-3), have lower HRV compared with omnivores (n 24). Proportions of LC n-3 PUFA in erythrocyte membranes, plasma fatty acids and concentrations of plasma LC n-3 PUFA-derived lipid mediators were significantly lower in vegans. Day-time interbeat intervals (IBI), adjusted for physical activity, age, BMI and sex, were significantly shorter in vegans compared with omnivores (mean difference −67 ms; 95 % CI −130, −3·4, P<0·05), but there were no significant differences over 24 h or during sleep. Vegans had higher overall HRV, measured as 24 h standard deviation of normal-to-normal intervals (SDNN) (mean adjusted difference 27 ms; 95 % CI 1, 52, P=0·039). Conversely, vegans presented with decreased 8 h day-time HRV: mean adjusted difference in SDNN −20 ms; 95 % CI −37, −3, P=0·021, with no differences during nocturnal sleep. Day-time parameters of beat-to-beat HRV (root of the mean of the sum of the squares of differences between adjacent normal-to-normal intervals, percentage of adjacent normal-to-normal intervals that differ by >50 % and high-frequency power) were similarly lower in vegans, with no differences during sleep. In conclusion, vegans have higher 24 h SDNN, but lower day-time HRV and shorter day-time IBI relative to comparable omnivores. Vegans may have reduced availability of precursor markers for pro-resolving lipid mediators; it remains to be determined whether there is a direct link with impaired cardiac function in populations with low-n-3 status.
The hill forests of Karen State, Myanmar, were previously inaccessible to biologists and conservationists for security and political reasons. We have, however, now been able to conduct six surveys across the area, using camera traps, for a total of 9,511 trap-nights, to ascertain the presence of threatened mammal species. We obtained 4,191 records of at least 31 mammal species, including 17 categorized as Near Threatened, Vulnerable or Endangered on the IUCN Red List. Carnivores were especially diverse, with 19 species recorded, indicating a globally significant community, including the tiger Panthera tigris, leopard Panthera pardus and dhole Cuon alpinus. Our methodology was not appropriate for estimating relative abundance or occupancy but the species richness of the mammal community, the number of records and the number of locations where species were detected suggest the area is important for the conservation of a globally threatened mammal community that is in decline across the majority of its range. Despite long-standing conservation efforts undertaken by the Karen people, their forests are threatened by hunting and habitat loss. These threats are likely to be exacerbated as political change brings rapid development. Urgent action is thus needed to assist the Karen people to protect one of South-east Asia's last intact rich and diverse ecosystems.
Adult ventilator-associated event (VAE) definitions include ventilator-associated conditions (VAC) and subcategories for infection-related ventilator-associated complications (IVAC) and possible ventilator-associated pneumonia (PVAP). We explored these definitions for children.
Pediatric, cardiac, or neonatal intensive care units (ICUs) in 6 US hospitals
Patients ≤18 years old ventilated for ≥1 day
We identified patients with pediatric VAC based on previously proposed criteria. We applied adult temperature, white blood cell count, antibiotic, and culture criteria for IVAC and PVAP to these patients. We matched pediatric VAC patients with controls and evaluated associations with adverse outcomes using Cox proportional hazards models.
In total, 233 pediatric VACs (12,167 ventilation episodes) were identified. In the cardiac ICU (CICU), 62.5% of VACs met adult IVAC criteria; in the pediatric ICU (PICU), 54.2% of VACs met adult IVAC criteria; and in the neonatal ICU (NICU), 20.2% of VACs met adult IVAC criteria. Most patients had abnormal white blood cell counts and temperatures; we therefore recommend simplifying surveillance by focusing on “pediatric VAC with antimicrobial use” (pediatric AVAC). Pediatric AVAC with a positive respiratory diagnostic test (“pediatric PVAP”) occurred in 8.9% of VACs in the CICU, 13.3% of VACs in the PICU, and 4.3% of VACs in the NICU. Hospital mortality was increased, and hospital and ICU length of stay and duration of ventilation were prolonged among all pediatric VAE subsets compared with controls.
We propose pediatric AVAC for surveillance related to antimicrobial use, with pediatric PVAP as a subset of AVAC. Studies on generalizability and responsiveness of these metrics to quality improvement initiatives are needed, as are studies to determine whether lower pediatric VAE rates are associated with improvements in other outcomes.
The subsurface exploration of other planetary bodies can be used to unravel their geological history and assess their habitability. On Mars in particular, present-day habitable conditions may be restricted to the subsurface. Using a deep subsurface mine, we carried out a program of extraterrestrial analog research – MINe Analog Research (MINAR). MINAR aims to carry out the scientific study of the deep subsurface and test instrumentation designed for planetary surface exploration by investigating deep subsurface geology, whilst establishing the potential this technology has to be transferred into the mining industry. An integrated multi-instrument suite was used to investigate samples of representative evaporite minerals from a subsurface Permian evaporite sequence, in particular to assess mineral and elemental variations which provide small-scale regions of enhanced habitability. The instruments used were the Panoramic Camera emulator, Close-Up Imager, Raman spectrometer, Small Planetary Linear Impulse Tool, Ultrasonic drill and handheld X-ray diffraction (XRD). We present science results from the analog research and show that these instruments can be used to investigate in situ the geological context and mineralogical variations of a deep subsurface environment, and thus habitability, from millimetre to metre scales. We also show that these instruments are complementary. For example, the identification of primary evaporite minerals such as NaCl and KCl, which are difficult to detect by portable Raman spectrometers, can be accomplished with XRD. By contrast, Raman is highly effective at locating and detecting mineral inclusions in primary evaporite minerals. MINAR demonstrates the effective use of a deep subsurface environment for planetary instrument development, understanding the habitability of extreme deep subsurface environments on Earth and other planetary bodies, and advancing the use of space technology in economic mining.
For the past twenty-five years a key piece of evidence for an anti-Semitic subtext in Wagner’s Die Meistersinger has been identified in the Grimm Brothers’ anti-Semitic tale ‘The Jew in the Thorn-bush’ and a possible allusion to this in the text of Walther’s Act I ‘trial song’. This article argues that the passages in question are better explained with reference to a medieval poetic tradition still prevalent in nineteenth-century German culture involving the vocal contest between birds, paradigmatically the owl and the nightingale. Since the twelfth century, the owl and the nightingale have debated the merits of high and low art, religious themes, social forms, poetic diction and more. The associations of pedantry and harsh, coarse vocal character with the figure of the owl maps readily onto the negative traits of Beckmesser, just as the contrasting associations of the melodious nightingale with springtime, courtship and ‘natural’ musicality align with traits of Wagner’s artist-hero, Walther von Stolzing. Rather than displacing the possible anti-Semitic reading of Beckmesser, however, this alternative reading of the Beckmesser–Walther antagonism through the lens of avian conflict or debate poetry relocates that reading within a broader discursive and figurative context, one that is more commensurate with the possible role of anti-Semitic subtexts within Wagner’s music dramas in general.
Flumioxazin is a protoporphyrinogen oxidase inhibitor with potential for POST annual bluegrass control and PRE smooth crabgrass control in bermudagrass. However, flumioxazin applications are often less effective in winter, compared with fall, because of reduced efficacy on mature annual bluegrass. The objective of this research was to evaluate tank-mixtures of flumioxazin with six other herbicide mechanisms of action for POST annual bluegrass control in late winter and residual smooth crabgrass control. Flumioxazin at 0 or 0.42 kg ai ha−1 was evaluated in combination with flazasulfuron at 0.05 kg ai ha−1, glufosinate at 1.26 kg ai ha−1, glyphosate at 0.42 kg ae ha−1, mesotrione at 0.28 kg ai ha−1, pronamide at 1.68 kg ai ha−1, or simazine at 1.12 kg ai ha−1. Flumioxazin alone controlled annual bluegrass 61 to 70% at 8 wk after treatment (WAT) in three experiments from 2012 to 2014 in central Georgia. Flumioxazin tank-mixed with flazasulfuron, glyphosate, glufosinate, pronamide, and simazine provided good (80 to 89%) to excellent (> 90%) control of annual bluegrass at 8 WAT in 2 of 3 yr. These tank-mixtures were also more effective than flumioxazin alone in 2 of 3 yr, and control was greater or equal to the tank-mix partners applied alone. Treatments that included flumioxazin provided excellent (≥ 90%) control of smooth crabgrass at 6 mo after treatment in all 3 yr. Overall, tank-mixing flumioxazin with other herbicide chemistries may improve POST annual bluegrass control, compared with exclusive treatments, and effectively control smooth crabgrass in bermudagrass.
The effectiveness of practice bundles on reducing ventilator-associated pneumonia (VAP) has been questioned.
To implement a comprehensive program that included a real-time bundle compliance dashboard to improve compliance and reduce ventilator-associated complications.
Before-and-after quasi-experimental study with interrupted time-series analysis.
Academic medical center.
In 2007 a comprehensive institutional ventilator bundle program was developed. To assess bundle compliance and stimulate instant course correction of noncompliant parameters, a real-time computerized dashboard was developed. Program impact in 6 adult intensive care units (ICUs) was assessed. Bundle compliance was noted as an overall cumulative bundle adherence assessment, reflecting the percentage of time all elements were concurrently in compliance for all patients.
The VAP rate in all ICUs combined decreased from 19.5 to 9.2 VAPs per 1,000 ventilator-days following program implementation (P<.001). Bundle compliance significantly increased (Z100 score of 23% in August 2007 to 83% in June 2011 [P<.001]). The implementation resulted in a significant monthly decrease in the overall ICU VAP rate of 3.28/1,000 ventilator-days (95% CI, 2.64–3.92/1,000 ventilator-days). Following the intervention, the VAP rate decreased significantly at a rate of 0.20/1,000 ventilator-days per month (95% CI, 0.14–0.30/1,000 ventilator-days per month). Among all adult ICUs combined, improved bundle compliance was moderately correlated with monthly VAP rate reductions (Pearson correlation coefficient, −0.32).
A prevention program using a real-time bundle adherence dashboard was associated with significant sustained decreases in VAP rates and an increase in bundle compliance among adult ICU patients.
Infect. Control Hosp. Epidemiol. 2015;36(11):1261–1267
In North America, terrestrial records of biodiversity and climate change that span Marine Oxygen Isotope Stage (MIS) 5 are rare. Where found, they provide insight into how the coupling of the ocean–atmosphere system is manifested in biotic and environmental records and how the biosphere responds to climate change. In 2010–2011, construction at Ziegler Reservoir near Snowmass Village, Colorado (USA) revealed a nearly continuous, lacustrine/wetland sedimentary sequence that preserved evidence of past plant communities between ~140 and 55 ka, including all of MIS 5. At an elevation of 2705 m, the Ziegler Reservoir fossil site also contained thousands of well-preserved bones of late Pleistocene megafauna, including mastodons, mammoths, ground sloths, horses, camels, deer, bison, black bear, coyotes, and bighorn sheep. In addition, the site contained more than 26,000 bones from at least 30 species of small animals including salamanders, otters, muskrats, minks, rabbits, beavers, frogs, lizards, snakes, fish, and birds. The combination of macro- and micro-vertebrates, invertebrates, terrestrial and aquatic plant macrofossils, a detailed pollen record, and a robust, directly dated stratigraphic framework shows that high-elevation ecosystems in the Rocky Mountains of Colorado are climatically sensitive and varied dramatically throughout MIS 5.
We investigated whether a higher number of fast-food outlets in an individual’s home neighbourhood is associated with increased prevalence of type 2 diabetes mellitus and related risk factors, including obesity.
Three UK-based diabetes screening studies (one general population, two high-risk populations) conducted between 2004 and 2011. The primary outcome was screen-detected type 2 diabetes. Secondary outcomes were risk factors for type 2 diabetes.
In total 10 461 participants (mean age 59 years; 53 % male; 21 % non-White ethnicity).
There was a higher number of neighbourhood (500 m radius from home postcode) fast-food outlets among non-White ethnic groups (P<0·001) and in socially deprived areas (P<0·001). After adjustment (social deprivation, urban/rural, ethnicity, age, sex), more fast-food outlets was associated with significantly increased odds for diabetes (OR=1·02; 95 % CI 1·00, 1·04) and obesity (OR=1·02; 95 % CI 1·00, 1·03). This suggests that for every additional two outlets per neighbourhood, we would expect one additional diabetes case, assuming a causal relationship between the fast-food outlets and diabetes.
These results suggest that increased exposure to fast-food outlets is associated with increased risk of type 2 diabetes and obesity, which has implications for diabetes prevention at a public health level and for those granting planning permission to new fast-food outlets.