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Over the last 20 years disasters have increasingly involved children, and pediatric disaster medicine research is growing. However, this research is largely reactive, has not been categorized in terms of the disaster cycle, and the quality of the research is variable. To understand the gaps in current literature and highlight areas for future research, we conducted a scoping review of pediatric disaster medicine literature. This work will help create recommendations for future pediatric disaster medicine research.
Using a published framework for scoping reviews, we worked with a medical librarian and a multi-institutional team to define the research question, develop eligibility criteria, and to identify a search strategy. We conducted a comprehensive Medline search from 2001-2022, which was distributed to nine reviewers. Each article was independently screened for inclusion by two reviewers. Discrepancies were resolved by a third reviewer.
Inclusion criteria included articles published in English, related to all stages of the disaster cycle, and disaster education, focused on or included pediatric populations; published in academic, peer-reviewed journals, and policies from professional societies.
967 pediatric disaster medicine articles were imported for screening and 35 duplicates were removed. 932 articles were screened for relevance and 109 were excluded. In 2000, three articles met inclusion criteria and 66 in 2021. We noticed reactive spikes in the number of articles after major disasters. Most articles focused on preparedness and response, with only a few articles on recovery, mitigation, and prevention. Methodology used for most studies was either qualitative or retrospective. Most were single site studies and there were < 10 meta-analyses over the 20 years.
This scoping review describes the trends in and quality of existing pediatric disaster medicine literature. By identifying the gaps in this body of literature, we can better prioritize future research.
Admission laboratory screening for asymptomatic coronavirus disease 2019 (COVID-19) has been utilized to mitigate healthcare-associated severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission. An understanding of the impact of such testing across a variety of patient populations is needed.
SARS-CoV-2 nucleic acid amplification admission testing results for all asymptomatic patients across 4 distinct inpatient facilities between April 20, 2020, and June 14, 2021, were analyzed. Positivity rates and the number needed to test (NNT) to identify 1 asymptomatic infected patient were calculated. Admission results were compared to COVID-19 community incidence rates for the system’s surrounding metropolitan service area. Using a national survey of hospital epidemiologists, a clinically meaningful NNT of 1:100 was identified.
In total, 51,187 tests were collected (positivity rate, 1.8%). During periods of high transmission, the NNT met the clinically relevant threshold in all populations. The NNT approached or met the threshold for most locations during periods of lower transmission. For all transmission levels, the NNT for fully vaccinated patients did not meet the threshold.
Implementing an asymptomatic patient admission testing program can provide clinically relevant data based on the NNT, even during periods of lower transmission and among different patient populations. Limiting admission testing to non–fully vaccinated patients during periods of lower transmission may be a strategy to address resource concerns around this practice. Although the impact of such testing on healthcare-associated COVID-19 among patients and healthcare workers could not be clearly determined, these data provide important information as facilities weigh the costs and benefits of such testing.
Many male prisoners have significant mental health problems, including anxiety and depression. High proportions struggle with homelessness and substance misuse.
This study aims to evaluate whether the Engager intervention improves mental health outcomes following release.
The design is a parallel randomised superiority trial that was conducted in the North West and South West of England (ISRCTN11707331). Men serving a prison sentence of 2 years or less were individually allocated 1:1 to either the intervention (Engager plus usual care) or usual care alone. Engager included psychological and practical support in prison, on release and for 3–5 months in the community. The primary outcome was the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), 6 months after release. Primary analysis compared groups based on intention-to-treat (ITT).
In total, 280 men were randomised out of the 396 who were potentially eligible and agreed to participate; 105 did not meet the mental health inclusion criteria. There was no mean difference in the ITT complete case analysis between groups (92 in each arm) for change in the CORE-OM score (1.1, 95% CI –1.1 to 3.2, P = 0.325) or secondary analyses. There were no consistent clinically significant between-group differences for secondary outcomes. Full delivery was not achieved, with 77% (108/140) receiving community-based contact.
Engager is the first trial of a collaborative care intervention adapted for prison leavers. The intervention was not shown to be effective using standard outcome measures. Further testing of different support strategies for prison with mental health problems is needed.
Maternal trauma has intergenerational implications, including worse birth outcomes, altered brain morphology, and poorer mental health. Research investigating intergenerational effects of maternal trauma on infant stress reactivity and regulation is limited. Maternal mental health during pregnancy may be a contributor: psychopathology is a sequela of trauma exposure and predictor of altered self-regulatory capacity in offspring of affected mothers. We assessed associations among maternal lifetime trauma and infant stress responsivity, mediated by psychological symptoms in pregnancy. Mothers reported lifetime trauma history and anxiety, depressive, and posttraumatic stress symptoms during pregnancy. At infant age 6 months, stress reactivity and regulation were assessed via maternal behavior ratings (Infant Behavior Questionnaire-Revised, IBQ-R) and behavioral (negative mood) and physiological (respiratory sinus arrhythmia, RSA) markers during a laboratory stressor (Still-Face Paradigm). Maternal trauma was directly associated with lower infant physiological regulation and indirectly associated with lower levels of both infant behavioral and physiological regulation via higher maternal anxiety during pregnancy. Maternal trauma was also indirectly associated with higher infant reactivity via higher maternal anxiety during pregnancy. Post hoc analyses indicated differential contributions of maternal prenatal versus postnatal anxiety to infant outcomes. Findings highlight potential contributory mechanisms toward maladaptive child stress response, which has been associated with poor behavioral, cognitive, and academic outcomes.
Background: Admission laboratory screening for asymptomatic COVID-19 has been utilized to mitigate healthcare-associated SARS-CoV-2 transmission. A better understanding of the impact of such testing across a variety of patient populations is needed. Methods: Beginning April 2020, every patient admitted within an academic healthcare system underwent SARS-CoV-2 PCR testing upon admission. Between April 20, 2020 through June 14, 2021, results were analyzed in asymptomatic patients across 4 inpatient facilities: a tertiary-care adult hospital, a free-standing pediatric hospital, a community-based hospital, and a behavioral health hospital. Positivity rates and the number needed to test (NNT) to identify 1 asymptomatic infected patient were calculated overall, by hospital type, by patient vaccination status, and by CDC-defined levels of community transmission. Weekly community incidence rates of COVID-19 for the system’s metropolitan service area (8 central Tennessee counties) were obtained from Tennessee Department of Health records. Weekly COVID-19 incidence rates per 100,000 people were calculated using US Census Bureau data. Using a national survey of hospital epidemiologists, a clinically meaningful NNT was identified (ie, 1 positive patient per 100 patients tested). A crude admission testing cost (covering testing supplies, reagents, and lab personnel costs) was obtained from operational data ($50 per test) to assess testing utility. Results: In total, 51,187 tests were collected during the study period with a positivity rate of 1.8%. No periods of low transmission were observed (Table 1). During high transmission periods, the NNT met the clinically relevant threshold in all populations. In addition, the NNT approached or met the 1:100 threshold for most locations during periods of less transmission, suggesting continued benefit even as infection rates decline. In all transmission periods, the NNT for non–fully vaccinated patients met the clinically meaningful threshold, in contrast to testing of fully vaccinated patients (Table 2). Discussion: Implementing an asymptomatic patient admission testing program can provide clinically relevant value based on the NNT, even during lower periods of transmission and in different patient populations. Limiting admission testing to non–fully vaccinated patients during periods of lower transmission may be a strategy to address cost and resource concerns around this practice. Further investigations into the impact of booster vaccination and newer SARS-CoV-2 variants on admission testing programs are also necessary. Although the impact of such testing on healthcare-associated COVID-19 among patients and healthcare workers could not be clearly determined, these data provide important information as facilities weigh the costs and benefits of such testing.
Multiple risk behaviours (MRBs), typically beginning in adolescence, are associated with increased risk of adverse health and social outcomes. The association between autism and MRBs is little understood.
Data were from the Avon Longitudinal Study of Parents and Children, an UK-based longitudinal, birth cohort study. Exposures were diagnosed autism and four autistic traits: social communication difficulties, pragmatic language, repetitive behaviours and reduced sociability. Outcomes were participation in up to 14 risk behaviours, including alcohol consumption, smoking, risky sexual behaviours and physical inactivity. Outcome data were collected at ages approximately 12, 14, 16 and 18.
Up to 4300 participants were included in latent basis growth curve analyses with adjustment for confounders. Social communication difficulties were associated with an above average level of MRBs engagement at ~12 years (mean difference β 0.26; 95% CI 0.13–0.40), and above average rate of engagement from ages ~12–18 (β 0.08; 95% CI 0.02–0.13). Repetitive behaviours were associated with above average levels of engagement in MRBs at ~12 years (β 0.24; 95% CI 0.09–0.38). Contrastingly, reduced sociability was associated with a reduced rate of engagement in MRBs from ages ~12–18 (β −0.06; 95% CI −0.11 to −0.02). In sex-specific analyses, persisting differences in MRB engagement patterns from ages ~12–18 were observed in males with social communication difficulties and females with reduced sociability temperament.
Having elevated levels of some autistic traits appear to have differentiated effects on MRB engagement patterns. These findings could reflect difficulties fitting in and/or coping mechanisms relating to difficulties with fitting in.
This Element reviews literature on the physiological influences of music during perception and action. It outlines how acoustic features of music influence physiological responses during passive listening, with an emphasis on comparisons of analytical approaches. It then considers specific behavioural contexts in which physiological responses to music impact perception and performance. First, it describes physiological responses to music that evoke an emotional reaction in listeners. Second, it delineates how music influences physiology during music performance and exercise. Finally, it discusses the role of music perception in pain, focusing on medical procedures and laboratory-induced pain with infants and adults.
It is not clear to what extent associations between schizophrenia, cannabis use and cigarette use are due to a shared genetic etiology. We, therefore, examined whether schizophrenia genetic risk associates with longitudinal patterns of cigarette and cannabis use in adolescence and mediating pathways for any association to inform potential reduction strategies.
Associations between schizophrenia polygenic scores and longitudinal latent classes of cigarette and cannabis use from ages 14 to 19 years were investigated in up to 3925 individuals in the Avon Longitudinal Study of Parents and Children. Mediation models were estimated to assess the potential mediating effects of a range of cognitive, emotional, and behavioral phenotypes.
The schizophrenia polygenic score, based on single nucleotide polymorphisms meeting a training-set p threshold of 0.05, was associated with late-onset cannabis use (OR = 1.23; 95% CI = 1.08,1.41), but not with cigarette or early-onset cannabis use classes. This association was not mediated through lower IQ, victimization, emotional difficulties, antisocial behavior, impulsivity, or poorer social relationships during childhood. Sensitivity analyses adjusting for genetic liability to cannabis or cigarette use, using polygenic scores excluding the CHRNA5-A3-B4 gene cluster, or basing scores on a 0.5 training-set p threshold, provided results consistent with our main analyses.
Our study provides evidence that genetic risk for schizophrenia is associated with patterns of cannabis use during adolescence. Investigation of pathways other than the cognitive, emotional, and behavioral phenotypes examined here is required to identify modifiable targets to reduce the public health burden of cannabis use in the population.
The suboptimal provision of analgesia to children in the emergency department (ED) is well-described. A yet unexplored barrier is caregiver or child refusal of analgesia. We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED.
We conducted a two-centre cross-sectional study of 743 caregivers of children 4–17 years presenting to the pediatric ED with an acutely painful condition using a survey and medical record review. The primary outcome was the proportion of children/caregiver pairs who accepted analgesia in the ED.
The median (IQR) age of children was 11 (7) years, and 339/743 (45.6%) were female. The overall survey response rate was 73% (743/1018). In the 24 hours preceding ED arrival, the median (IQR) maximal pain score rated by children and caregivers was 8/10 (4) and 5/10 (2), respectively, and 30.4% (226/743) of caregivers offered analgesia. In the ED, children reported a median (IQR) pain score of 8/10 (2) and 54.9% (408/743) were offered analgesia. When offered in the ED, analgesia was accepted by 91% (373/408). Overall, 55.7% (414/743) of children received some form of analgesia.
Most caregivers/children accept analgesia when offered by ED personnel, suggesting refusal is not a major barrier to optimal management of children’s pain and highlighting the importance of ED personnel in encouraging adequate analgesia. A large proportion of children in pain are not offered analgesia by caregivers or ED personnel. Educational strategies for recognizing and treating pain should be directed at children, caregivers, and ED personnel.
Variation in human cognitive ability is of consequence to a large number of health and social outcomes and is substantially heritable. Genetic linkage, genome-wide association, and copy number variant studies have investigated the contribution of genetic variation to individual differences in normal cognitive ability, but little research has considered the role of rare genetic variants. Exome sequencing studies have already met with success in discovering novel trait-gene associations for other complex traits. Here, we use exome sequencing to investigate the effects of rare variants on general cognitive ability. Unrelated Scottish individuals were selected for high scores on a general component of intelligence (g). The frequency of rare genetic variants (in n = 146) was compared with those from Scottish controls (total n = 486) who scored in the lower to middle range of the g distribution or on a proxy measure of g. Biological pathway analysis highlighted enrichment of the mitochondrial inner membrane component and apical part of cell gene ontology terms. Global burden analysis showed a greater total number of rare variants carried by high g cases versus controls, which is inconsistent with a mutation load hypothesis whereby mutations negatively affect g. The general finding of greater non-synonymous (vs. synonymous) variant effects is in line with evolutionary hypotheses for g. Given that this first sequencing study of high g was small, promising results were found, suggesting that the study of rare variants in larger samples would be worthwhile.
Amphiphilic diacetylenes (DAs) can self-assemble into photopolymerizable liposomes that can be used to construct effective pathogen sensors. Here, modified commercial inkjet printers are used to disperse DAs into water, facilitating self-assembly. The liposomes are of similar size, but are significantly less polydisperse than liposomes formed using conventional sonication methods. The process is efficient, readily scalable and tolerant of structural modification. The derivitization of approximately 5% of the DA head groups and the incorporation of fluorophores into the hydrophobic bilayer allows for the preparation of novel multifluorophore PDA sensing systems that can provide enhanced bacterial discrimination in a single experiment by way of a fluorescent fingerprint.
Amultidisciplinary collaborative study examining cognition in a large sample of twins is outlined. A common experimental protocol and design is used in The Netherlands, Australia and Japan to measure cognitive ability using traditional IQ measures (i.e., psychometric IQ), processing speed (e.g., reaction time [RT] and inspection time [IT]), and working memory (e.g., spatial span, delayed response [DR] performance). The main aim is to investigate the genetic covariation among these cognitive phenotypes in order to use the correlated biological markers in future linkage and association analyses to detect quantitativetrait loci (QTLs). We outline the study and methodology, and report results from our preliminary analyses that examines the heritability of processing speed and working memory indices, and their phenotypic correlation with IQ. Heritability of Full Scale IQ was 87% in the Netherlands, 83% in Australia, and 71% in Japan. Heritability estimates for processing speed and working memory indices ranged from 33–64%. Associations of IQ with RT and IT (−0.28 to −0.36) replicated previous findings with those of higher cognitive ability showing faster speed of processing. Similarly, significant correlations were indicated between IQ and the spatial span working memory task (storage [0.31], executive processing [0.37]) and the DR working memory task (0.25), with those of higher cognitive ability showing better memory performance. These analyses establish the heritability of the processing speed and working memory measures to be used in our collaborative twin study of cognition, and support the findings that individual differences in processing speed and working memory may underlie individual differences in psychometric IQ.
Focus groups are a means of gathering qualitative data from a group of participants who discuss a given topic. This method has been used in health care research for the past 30 years, but has seen limited use in radiation therapy research. Focus group discussions are a useful tool for investigating a variety of educational, training and clinical issues from the perspective of practitioners, students and patients. This paper reviews the issues associated with using focus groups as a means of data collection. In particular, it addresses some of the decisions which have to be made about group composition and conduct of the discussions. The literature review is contextualised using a recent example of how the authors used focus groups to investigate fitness to practise in radiation therapy. Other challenges such as familiarity between participants and researchers, power relationships and anonymity are addressed. The paper concludes with a consideration of data analysis.
Folic acid (pteroylmonoglutamic acid) has historically been used as the reference folate in human intervention studies assessing the relative bioavailability of dietary folate. Recent studies using labelled folates indicated different plasma response kinetics to folic acid than to natural (food) folates, thus obviously precluding its use in single-dose experiments. Since differences in tissue distribution and site of biotransformation were hypothesised, the question is whether folic acid remains suitable as a reference folate for longer-term intervention studies, where the relative bioavailability of natural (food) folate is assessed based on changes in folate status. Healthy adults aged 18–65 years (n 163) completed a 16-week placebo-controlled intervention study in which the relative bioavailability of increased folate intake (453 nmol/d) from folate-rich foods was assessed by comparing changes in plasma and erythrocyte folate concentration with changes induced by an equal reference dose of supplemental (6S)-5-methyltetrahydrofolic acid or folic acid. The relative increase in plasma folate concentration in the food group was 31 % when compared with that induced by folic acid, but 39 % when compared with (6S)-5-methyltetrahydrofolic acid. The relative increase in erythrocyte folate concentration in the food group when compared with that induced by folic acid was 43 %, and 40 % when compared with (6S)-5-methyltetrahydrofolic acid. When recent published observations were additionally taken into account it was concluded that, in principle, folic acid should not be used as the reference folate when attempting to estimate relative natural (food) folate bioavailability in longer-term human intervention studies. Using (6S)-5-methyltetrahydrofolic acid as the reference folate would avoid future results' validity being questioned.
The purpose of the present paper is to review our current understanding of the chemistry and biochemistry of folic acid and related folates, and to discuss their impact on public health beyond that already established in relation to neural-tube defects. Our understanding of the fascinating world of folates and C1 metabolism, and their role in health and disease, has come a long way since the discovery of the B-vitamin folic acid by Wills (1931), and its first isolation by Mitchell et al. (1941). However, there is still much to do in perfecting methods for the measurement of folate bioavailability, and status, with a high extent of precision and accuracy. Currently, examination of the relationships between common gene polymorphisms involved in C1 metabolism and folate bioavailability and folate status, morbidity, mortality and longevity is evaluated as a series of individual associations. However, in the future, examination of the concurrent effects of such common gene polymorphisms may be more beneficial.
In the mathematical world, one occasionally encounters some rare individuals who seem to have the ability to hold an image in their minds of a four or higher-dimensional object. Even the ability to visualise three-dimensional geometry is a reasonably uncommon gift, and most of us have to get by with two (and sometimes much less) dimensional images in our heads.
The space of quasifuchsian once-punctured torus groups is described by two complex or four real parameters (the traces), which means it is one of these high-dimensional objects. Our approach to studying it has been to look at two-dimensional ‘slices’, meaning that we specify one of the complex trace parameters and then plot those values of the remaining parameter which correspond to quasifuchsian groups (or single cusps, in the case of the Maskit slice).
The samples we have given, Maskit's slice and the trace 3 slice, offer an impression of a object with a somewhat pointy boundary, which is however not terribly complicated otherwise. In recent years, as more detailed plots have emerged, this simple picture has begun to change. Exactly how the slices all fit together is a puzzle of very current interest.