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The provision of pensions for Civil Servants and other employees in public office, such as the police, as well as in large private businesses, became more widespread in the second half of the nineteenth century. Such pensions, and other non-pay benefits, including sick pay, not only helped with recruitment but also provided a means of managing the retirement of workers who were deemed to be incapable of performing their roles. The rules governing eligibility to receive a pension in the Metropolitan Police in London were closely linked to the certification of poor health. Police doctors restricted the certification of sickness as a reason for retirement because it impacted the size of the force, resulted in the loss of more experienced men, and added to the cost of the pension fund. This strategy generated conflict with the workforce, resulting in industrial unrest. Piecemeal reforms failed to address workers’ concerns until 1890, when the rights to receive a pension were improved. These reforms, rather than stricter vigilance by police doctors, were an effective way of retaining experienced officers in the police force.
In September 2023, the UK Health Security Agency identified cases of Salmonella Saintpaul distributed across England, Scotland, and Wales, all with very low genetic diversity. Additional cases were identified in Portugal following an alert raised by the United Kingdom. Ninety-eight cases with a similar genetic sequence were identified, 93 in the United Kingdom and 5 in Portugal, of which 46% were aged under 10 years. Cases formed a phylogenetic cluster with a maximum distance of six single nucleotide polymorphisms (SNPs) and average of less than one SNP between isolates. An outbreak investigation was undertaken, including a case–control study. Among the 25 UK cases included in this study, 13 reported blood in stool and 5 were hospitalized. One hundred controls were recruited via a market research panel using frequency matching for age. Multivariable logistic regression analysis of food exposures in cases and controls identified a strong association with cantaloupe consumption (adjusted odds ratio: 14.22; 95% confidence interval: 2.83–71.43; p-value: 0.001). This outbreak, together with other recent national and international incidents, points to an increase in identifications of large outbreaks of Salmonella linked to melon consumption. We recommend detailed questioning and triangulation of information sources to delineate consumption of specific fruit varieties during Salmonella outbreaks.
Hematological disorders are a heterogeneous group that may be inherited or acquired. During pregnancy the condition may improve, stabilize, or deteriorate due to normal physiological changes. Major risks in women are hemorrhage or thrombosis; inherited conditions may affect fetus as well. A multidisciplinary team is required to manage the pregnancy, delivery, and postpartum. This chapter reviews and summarizes the literature on maternal and fetal outcomes with a focus on anesthetic considerations and publications.
Diversification of the medical and cardiothoracic surgical workforce represents an ongoing need. A congenital cardiac surgery shadowing programme for undergraduate students was implemented at the University of Florida Congenital Heart Center.
Methods:
Students shadowing in the Congenital Heart Center from 17 December 2020 through 20 July 2021 were sent a survey through Qualtrics to evaluate the impact of their shadowing experience. The main objectives of the survey were to determine the personal relationship(s) of the students to physicians prior to shadowing, how the presence or absence of physicians in the family of a given student related to the exposure of the student to a medical setting prior to shadowing, and the interest of the students in medicine and cardiothoracic surgery prior to and after the shadowing experience. Survey responses included “Yes/No” questions, scaled responses using a Likert scale, selection lists, and free text responses. When applicable, t-tests were utilised to assess differences between student groups.
Results:
Of the 37 students who shadowed during the study period, 26 (70%) responded. Most students were female (58%, n = 15), and the mean age was 20.9 ± 2.4 years. Students spent a mean duration of 95 ± 138 hours shadowing providers as part of the shadowing programme. Likert scale ratings of interest in the professions of medicine, surgery, and cardiothoracic surgery all increased after the shadowing experience (p < 0.01). Students with a family member in medicine had more clinical exposure prior to the shadowing programme (p < 0.01).
Conclusion:
A surgical shadowing programme at a Congenital Heart Center may have an important formative impact on the views of undergraduate students regarding potential careers in surgery and medicine. Additionally, students without family members in medicine tend to have less prior exposure to medicine and could likely benefit more from this type of shadowing programme.
In 1584, Baltasar de Obregón described the people he met in the Casas Grandes Valley (CGV), Northwest Chihuahua, Mexico. He juxtaposed these “rustic” people with the sophistication of the ancient builders of Paquimé who had lived in the CGV. Seventy years later, the Spanish missionaries called the people in the CGV “Suma” and enlisted them to build Mission San Antonio de Padua de Casas Grandes. Scholars have examined Obregón's and later administrators’ accounts to argue that the Suma were a small-scale society and unrelated to the ancient people of Paquimé (~AD 1200–1430). We reevaluate this interpretation. First, we contextualize the documentary evidence within contemporary frameworks. Second, using data from the 1958–1961 Joint Casas Grandes Expedition, we compare Paquimé and Suma material culture. We argue that the Suma were likely long-term residents of the Valley, organized into horticulture villages, and exhibiting cultural practices linked to Paquimé. After critiquing previous arguments about Suma origins, we consider how this criticism relates broadly to exploring Native Americans’ reactions to colonial settings.
Following a quarantine breach in April 2021, Fiji went from no cases of COVID-19 to having the highest number per capita in the world. Fiji was relatively well-prepared to respond to COVID-19 as it has strong emergency management response systems. Nevertheless, due to the rapid increase, the public health system was quickly overwhelmed. The problem was particularly acute at the main tertiary hospital in Suva.
Objectives:
To describe the effects of an overwhelming COVID-19 outbreak on nurses working in the Emergency Department of Colonial War Memorial Hospital in Fiji, in 2021.
To describe the lessons learned and recommendations for the future.
Method/Description:
Focus Group Discussion with two groups of nurses: (1) ED nurse and (2) nurses seconded to provide a surge workforce in the most acute phase.
Results/Outcomes:
Preliminary findings show that nurses were lacking in confidence and frightened about the growing epidemic. Resources, material and human, were initially in short supply. The agency of the nurses as result of their post-graduate study and due to the collegial environment in ED resulted in increased supplies of PPE and changes to nursing practice (eg, web-based handover). Final results pending.
Conclusion:
The preliminary findings of this research illustrate that even in low-resource settings, with the right support and effective nursing leadership, nurses can provide safe and effective care to patients. The research illustrates the benefits of sound, relevant education, the crucial importance of teamwork, the importance of networks, the important benefits of early deployment of the MET, and the need for effective nursing leadership.
The federal Safe Drinking Water Act (SDWA), as amended in 1996, enables benefit-cost analysis (BCA) to be used in setting federal drinking water standards, known as MCLs. While BCAs are typically conceived of as a tool to inform efficiency considerations by helping to identify MCL options that maximize net social benefits, in this paper we also illustrate how important equity and affordability considerations can be brought to light by suitably applying BCAs to drinking water regulations, especially in the context of communities served by relatively small water systems. We examine the applicability and relevance of health-health analysis (HHA), and provide an empirical evaluation of the risk tradeoffs that may be associated with the MCL established for arsenic. We find that the cost-associated risks may offset a nontrivial portion of the cancer risk reduction benefits attributed to the MCL (e.g., the additional adverse health impacts from the costs may be roughly half as large as the number of cancer cases avoided). This reveals the relevance of using the HHA approach for examining net benefits of MCLs in small drinking water utilities, and raises issues related to whether and how these cost-associated health risks should be considered in BCAs for drinking water standards.
Disaster Medicine (DM) education for Emergency Medicine (EM) residents is highly variable due to time constraints, competing priorities, and program expertise. The investigators’ aim was to define and prioritize DM core competencies for EM residency programs through consensus opinion of experts and EM professional organization representatives.
Methods:
Investigators utilized a modified Delphi methodology to generate a recommended, prioritized core curriculum of 40 DM educational topics for EM residencies.
Results:
The DM topics recommended and outlined for inclusion in EM residency training included: patient triage in disasters, surge capacity, introduction to disaster nomenclature, blast injuries, hospital disaster mitigation, preparedness, planning and response, hospital response to chemical mass-casualty incident (MCI), decontamination indications and issues, trauma MCI, disaster exercises and training, biological agents, personal protective equipment, and hospital response to radiation MCI.
Conclusions:
This expert-consensus-driven, prioritized ranking of DM topics may serve as the core curriculum for US EM residency programs.
In gynecologic surgery, laparotomy is the preferred approach when full access to the pelvis and/or upper abdomen are desired, particularly when pelvic adhesions are suspected or exploration of the retroperitoneal space may be required. Pelvic or abdominal masses, suspected carcinoma, a history of prior abdominal surgery, and suspected retroperitoneal pathology are all indications for considering laparotomy over laparoscopy. The abdomen and pelvis may be accessed through either a longitudinal or transverse approach. The choice of incision is based on the area in which surgical exposure is desired while reducing patient discomfort and postoperative complications. Proper surgical technique and the judicious use of self-retaining retractors with awareness of abdominal and pelvic neuroanatomy can minimize postoperative complications. Incision closure technique has changed dramatically since the advent of longer-lasting absorbable suture material, resulting in fewer incisional complications, improved patient satisfaction, and reduced hospitalization.
Scope of the Problem
The widespread development of minimally invasive and robotic techniques for gynecologic and general surgery in urban and teaching hospitals has made the laparotomy a less commonly performed procedure. Availability of open and vaginal hysterectomies has diminished to the point that American residency programs are concerned about appropriate laparotomy experience for each resident. Gynecologic oncology services, long a source of laparotomies and hysterectomies for ovarian cancer cytoreduction and radical hysterectomies for cervical cancer, have reduced the use of laparotomy in favor of robotic procedures. The “open” abdominal hysterectomy is at risk of becoming a “lost art,” with some residency graduates unable to confidently perform the procedure in general practice. In a recent survey of gynecologic oncology fellowship directors, half of the respondents reported that their incoming fellows could not independently perform an abdominal hysterectomy, and 40 percent could not recognize anatomy and tissue planes. As the number of open teaching cases declines, it becomes more important that the surgeon maintain a conscious awareness of proper surgical technique and practices that optimize patient safety. Application of good surgical technique with reusable instruments can make the open hysterectomy a cost-effective alternative to laparoscopic and robotic procedures.
Prevention of Venous Thromboembolic Events
A number of factors must be considered when choosing the appropriate venous thromboembolic prophylaxis regimen for each patient. Patient age, expected length of time of surgery, history of prior thromboembolism, and diagnosis of inherited thrombophilia all influence the risk of postoperative thromboembolism.
We describe the investigation of two temporally coincident illness clusters involving salmonella and Staphylococcus aureus in two states. Cases were defined as gastrointestinal illness following two meal events. Investigators interviewed ill persons. Stool, food and environmental samples underwent pathogen testing. Alabama: Eighty cases were identified. Median time from meal to illness was 5·8 h. Salmonella Heidelberg was identified from 27 of 28 stool specimens tested, and coagulase-positive S. aureus was isolated from three of 16 ill persons. Environmental investigation indicated that food handling deficiencies occurred. Colorado: Seven cases were identified. Median time from meal to illness was 4·5 h. Five persons were hospitalised, four of whom were admitted to the intensive care unit. Salmonella Heidelberg was identified in six of seven stool specimens and coagulase-positive S. aureus in three of six tested. No single food item was implicated in either outbreak. These two outbreaks were linked to infection with Salmonella Heidelberg, but additional factors, such as dual aetiology that included S. aureus or the dose of salmonella ingested may have contributed to the short incubation periods and high illness severity. The outbreaks underscore the importance of measures to prevent foodborne illness through appropriate washing, handling, preparation and storage of food.
We assess how the propagation of high-frequency elastic-flexural waves through an ice shelf is modified by the presence of spatially periodic crevasses. Analysis of the normal modes supported by the ice shelf with and without crevasses reveals that a periodic crevasse distribution qualitatively changes the mechanical response. The normal modes of an ice shelf free of crevasses are evenly distributed as a function of frequency. In contrast, the normal modes of a crevasse-ridden ice shelf are distributed unevenly. There are ‘band gaps’, frequency ranges over which no eigenmodes exist. A model ice shelf that is 50 km in lateral extent and 300 m thick with crevasses spaced 500 m apart has a band gap from 0.2 to 0.38 Hz. This is a frequency range relevant for ocean-wave/ice-shelf interactions. When the outermost edge of the crevassed ice shelf is oscillated at a frequency within the band gap, the ice shelf responds very differently from a crevasse-free ice shelf. The flexural motion of the crevassed ice shelf is confined to a small region near the outermost edge of the ice shelf and effectively ‘blocked’ from reaching the interior.
We compute the eigenmodes (seiches) of the barotropic and baroclinic hydrodynamic equations for an idealized fjord having length and depth scales similar to those of Ilulissat Icefjord, Greenland, into which Jakobshavn Isbræ (also known as Sermeq Kujalleq) discharges. The purpose of the computation is to determine the fjord’s seiche behavior when forced by iceberg calving, capsize and melange movement. Poorly constrained bathymetry and stratification details are an acknowledged obstacle. We are, nevertheless, able to make general statements about the spectra of external and internal seiches using numerical simulations of ideal one-dimensional channel geometry. Of particular significance in our computation is the role of weakly coupled ice melange, which we idealize as a simple array of 20 icebergs of uniform dimensions equally spaced within the fjord. We find that the presence of these icebergs acts to (1) slow down the propagation of both external and internal seiches and (2) introduce band gaps where energy propagation (group velocity) vanishes. If energy is introduced into the fjord within the period range covered by a band gap, it will remain trapped as an evanescent oscillatory mode near its source, thus contributing to localized energy dissipation and ice/melange fragmentation.
The Numeniini is a tribe of 13 wader species (Scolopacidae, Charadriiformes) of which seven are Near Threatened or globally threatened, including two Critically Endangered. To help inform conservation management and policy responses, we present the results of an expert assessment of the threats that members of this taxonomic group face across migratory flyways. Most threats are increasing in intensity, particularly in non-breeding areas, where habitat loss resulting from residential and commercial development, aquaculture, mining, transport, disturbance, problematic invasive species, pollution and climate change were regarded as having the greatest detrimental impact. Fewer threats (mining, disturbance, problematic native species and climate change) were identified as widely affecting breeding areas. Numeniini populations face the greatest number of non-breeding threats in the East Asian-Australasian Flyway, especially those associated with coastal reclamation; related threats were also identified across the Central and Atlantic Americas, and East Atlantic flyways. Threats on the breeding grounds were greatest in Central and Atlantic Americas, East Atlantic and West Asian flyways. Three priority actions were associated with monitoring and research: to monitor breeding population trends (which for species breeding in remote areas may best be achieved through surveys at key non-breeding sites), to deploy tracking technologies to identify migratory connectivity, and to monitor land-cover change across breeding and non-breeding areas. Two priority actions were focused on conservation and policy responses: to identify and effectively protect key non-breeding sites across all flyways (particularly in the East Asian- Australasian Flyway), and to implement successful conservation interventions at a sufficient scale across human-dominated landscapes for species’ recovery to be achieved. If implemented urgently, these measures in combination have the potential to alter the current population declines of many Numeniini species and provide a template for the conservation of other groups of threatened species.
By
Sarah Browne, University of Dundee,
David Christmas, Ninewells Hospital and Medical School, Dundee,
Douglas Steele, Ninewells Hospital and Medical School, Dundee,
M. Sam Eljamel, Ninewells Hospital and Medical School, Dundee,
Keith Matthews, Ninewells Hospital and Medical School, Dundee
Electroconvulsive therapy prescribers, practitioners and many patients will be aware of an emerging clinical evidence base for non-ECT brain stimulation treatments. Although the previous edition of The ECT Handbook made no mention of brain stimulation treatments, a review of the status of the three most studied therapies is now relevant. These therapies are:
• repetitive transcranial magnetic stimulation
• vagus nerve stimulation
• deep brain stimulation.
In this chapter, we consider the use of these therapies in the management of depression and how they might relate to the ECT treatment pathway.
Repetitive transcranial magnetic stimulation (rTMS)
Repetitive transcranial magnetic stimulation is a non-invasive technique causing modification of brain activity by focal stimulation of the superficial layers of the cerebral cortex using a train of magnetic pulses via an external wire coil. The impetus for studies of rTMS in psychiatry has arisen from the need for a viable alternative to ECT with a lower burden of adverse effects and greater patient acceptability. A substantial literature, including several systematic reviews and meta-analyses, now exists on the use of rTMS in the management of depression. In 2008 the US Food and Drug Administration approved a TMS system ‘for the treatment of Major Depressive Disorder in adult patients who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode’.
However, NICE published a technology appraisal in 2007, restating the core recommendations in the 2010 depression guideline update, which is consistent with the absence of convincing evidence of superior efficacy for rTMS over sham treatment and with the paucity of efficacy data extending beyond 4–6 weeks of treatment. The status of the technique is summarised as follows:
‘Current evidence suggests that there are no major safety concerns associated with transcranial magnetic stimulation (TMS) for severe depression. There is uncertainty about the procedure's clinical efficacy, which may depend on higher intensity, greater frequency, bilateral application and/or longer treatment durations than have appeared in the evidence to date. TMS should therefore be performed only in research studies designed to investigate these factors.’ (National Institute for Health and Clinical Excellence, 2007)
In our opinion, on the basis of current evidence, rTMS remains an interesting but experimental therapy which should not be considered a viable alternative to treatment with ECT.
Over 300 wood fossils were collected from the Ziegler Reservoir fossil site near Snowmass Village in central Colorado, USA. Wood fossils range from fragments of stems and branches only a few centimeters in diameter and length to whole logs >50 cm diameter and >10 m length. Many of the fossils were collected from a “beach” horizon, where they appear to have been washed up on the side of the interglacial lake and buried. The wood is mainly fir (Abies sp.) or Douglas-fir (Pseudotsuga menziesii), with some spruce (Picea sp.), pine (Pinus sp.), and at least one other unidentified conifer species. Douglas-fir and species of fir, spruce, and pine are common in the area today. Dendrochronological analyses compared annual growth rings in fossil wood to similar data from modern trees. Results suggest that fossil trees from the beach horizon grew under similar environmental conditions and annual climate variability as today. Three Douglas-firs and several fir logs also appear to have been alive at the same time based on crossdating of ring widths and other ring characteristics. These trees may have died at the same time, suggesting a stand mortality event in the surrounding forest that resulted in numerous logs being buried synchronously in the beach horizon.
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.
Here is an exercise to try with your students or colleagues regarding wildlife conservation and management. Tell them they are managing an area containing a population of an endangered, charismatic, flagship wildlife species, say mountain nyala in Bale Mountains National Park, Ethiopia. Invite them to write down the one or two things they would most want to know in order to best manage the population. The answers will vary. Some may inquire into the population size or density; others may want to know what the nyala are eating; others may want to know about the nyalas’ levels of genetic heterozygosity. But what we really want to know is “what is the state of the population in terms of growth rate and relationship to resource density?” “what are the threats to the population?” and “what are the population's prospects for the future?” Are these questions we can answer? Will knowledge of population size or genetics or diet allow us to answer these? Or can answers best be obtained from other information? If so, how can such information be acquired? What are the best indicators?
Ideally, indicators of population well-being must be reliable. Further, they should be easy to measure, respond quickly to environmental change and forecast the future. Measurements of population sizes are frequently used in management decisions and may excel in identifying when small population issues are of concern, but are woefully inadequate as indicators of population processes. Such metrics do not necessarily respond quickly to environmental change. Most populations experience time-lagged dynamics. But time lags mean that density is a trailing indicator of current conditions. We must search elsewhere for leading indicators – indicators that predict the future rather than simply recapitulating the past. Perhaps we can find our indicators in the traits of organisms that have been shaped by evolution (Grafen 1982, Lucas & Grafen 1985, Mitchell & Valone 1990). One attractive class of characteristics comes from foraging theory and measures of behavior (Stephens & Krebs 1986). These can be classified into behavioral indicators based on diet, patch use or habitat selection.
Consider indicators of population well-being further. An example involving the Baltic tellin (Macoma balthica) illustrates this well. Baltic tellins, benthic bivalves from the Dutch Wadden Sea, suffer predation from red knots (Calidris canutus) (van Gils et al. 2009).