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Mass casualty incidents (MCI) overwhelm health care systems; however, MCIs are infrequent and require ongoing preparatory efforts. Although there is dedicated disaster medicine education in emergency medicine, most pediatric emergency medicine (PEM) fellows complete pediatric residencies. Pediatric residents have variable exposure to disaster training as part of their curriculum. To improve this, a quality improvement (QI) initiative was implemented to increase MCI comfort and knowledge amongst PEM fellows.
Methods
This study took place in a single-center tertiary pediatric hospital, amongst 1 cohort of PEM fellows. Following a baseline survey, a key driver diagram was developed to guide Plan-Do-Study-Act (PDSA) cycles. A focused disaster curriculum was provided to fellows and specific quick references were developed. Knowledge application interventions included mock triage, response scavenger hunt, and tabletop MCI exercise.
Results
PEM fellow comfort and knowledge of MCI response improved from an average of 2.93 to 6.56 on a 10-point Likert scale, and 3.71 to 6.58 on 10-point Likert scale respectively following the active intervention cycle and showed sustained results over a 6-month period without further interventions.
Conclusions
Utilizing QI methodology, PEM fellow comfort with MCI response, and knowledge of MCI response increased. As MCIs are a rare occurrence, ongoing assessment is necessary to evaluate the need for further interventions to maintain knowledge and comfort levels.
To say that any one person changed the way we think about the way we operationalize economic geography obfuscates the collaborative and iterative ways in which change actually happens in academic disciplines. Considering the contribution of any individual to an academic discipline involves asserting a deterministic role that almost certainly overstates the causality between the individual work and the collective change. Indeed, change is a both a process and a project involving many hands. Thus, naming Susan Christopherson's unique and specific contribution to economic geography must reflect a core argument in her work itself: economic geography is a team sport and further to note that Christopherson played it that way.
That said, Christopherson made a substantial individual contribution to economic geography. This contribution was especially remarkable given that she participated in economic geography from a position literally ‘outside the project’ as a Professor of City and Regional Planning rather than within a Geography department. For most of her faculty career Christopherson sat beyond the formal boundaries of the Geography discipline or its academic departments. And this liminal status has particular significance because it was not unusual for women in US economic geography at the time (and nor is it now) to hold positions in departments of public policy or urban planning rather than geography. Economic geography has closely guarded its membership rolls – and continues to – creating hard boundaries between insiders and outsiders.
Susan Christopherson's contribution to the discipline of economic geography involved expanding the field to include a broader set of epistemologies, methodologies and sites of inquiry. In other words, Christopherson challenged both what counts as an economic geography question and what is considered an economic geography explanation. Christopherson was part of a cohort of academics who pushed the analytical focus beyond the formal functions of traditional economic actors to unpack how institutions and intermediaries operate within regional and national economies to produce different spatial outcomes. And her work exhibited a sustained concern for labour.
Christopherson's work brought contingent and precarious labour into focus before it was a central concern of the discipline. And her work sustained that focus on labour and labour markets across a variety of sectors and industries, including film and new media, energy, high technology, and manufacturing.
Dual modality feeding (DMF) – feeding human milk interchangeably from the breast and from a bottle – comes with unique practical, emotional and relational challenges, as well as support needs. Yet, there is little research that explores the experiences of individuals who use DMF in the Canadian context. The aim of this study is to explore the practices, challenges, reasons and enablers of DMF.
Design:
Repeat, semi-structured one-on-one interviews were conducted at 8 weeks and 22 weeks postpartum. Interview transcripts were thematically analysed using a critical feminist lens.
Setting:
Nova Scotia, Canada.
Participants:
Ten DMF mothers.
Results:
DMF practices were influenced by a mix of social and material circumstances, including breast-feeding challenges, the involvement of support persons, finances and access to lactation support. Individuals who predominantly fed at the breast expressed milk strategically to mitigate transitory breast-feeding challenges, for convenience under specific circumstances, and to share feeding responsibilities with other caregivers for personal and practical reasons. Individuals who mainly bottle-fed did so due to long-term breast-feeding challenges or a need to return to employment. Enablers of successful DMF were consistent between the two groups and included practical, personal and relational aspects.
Conclusions:
DMF is a unique practice compared to feeding human milk solely from the breast or bottle. Despite the potential growing prevalence of DMF, it is currently understudied and inadequately addressed in existing support programmes in Nova Scotia. Tailored programming and public messaging are needed to support DMF families.
Post-traumatic stress disorder (PTSD) after traumatic birth can have a debilitating effect on parents already adapting to significant life changes during the post-partum period. Cognitive therapy for PTSD (CT-PTSD) is a highly effective psychological therapy for PTSD which is recommended in the NICE guidelines (National Institute for Health and Care Excellence, 2018) as a first-line intervention for PTSD. In this paper, we provide guidance on how to deliver CT-PTSD for birth-related trauma and baby loss and how to address common cognitive themes.
Key learning aims
(1) To recognise and understand the development of PTSD following childbirth and baby loss.
(2) To understand how Ehlers and Clark’s (2000) cognitive model of PTSD can be applied to post-partum PTSD.
(3) To be able to apply cognitive therapy for PTSD to patients with perinatal PTSD, including traumatic baby loss through miscarriage or birth.
(4) To discover common personal meanings associated with birth trauma and baby loss and the steps to update them.
Community-Research Advisory Councils (C-RAC) provide a unique mechanism for building sustainable community-academic partnership, fostering bidirectional understanding of complex research issues, disseminating timely research findings, and thereby improving public trust in science. Created in 2009, the Johns Hopkins C-RAC has a mission to achieve diversity, equity, and inclusion (DEI) of stakeholders across the entire research continuum. It has nurtured over a decade of partnership among community and academic stakeholders toward addressing health disparity, health equity, structural racism, and discrimination. Evidence of successful strategies to ensure DEI in partnership and lessons learned are illustrated in this special communication.
We agree with Grossmann that fear often builds cooperative relationships. Yet he neglects much extant literature. Prior researchers have discussed how fear (and other emotions) build cooperative relationships, have questioned whether fear per se evolved to serve this purpose, and have emphasized that human cooperation takes many forms. Grossmann's theory would benefit from a wider consideration of this work.
Patients with social anxiety disorder (SAD) have a range of negative thoughts and beliefs about how they think they come across to others. These include specific fears about doing or saying something that will be judged negatively (e.g. ‘I’ll babble’, ‘I’ll have nothing to say’, ‘I’ll blush’, ‘I’ll sweat’, ‘I’ll shake’, etc.) and more persistent negative self-evaluative beliefs such as ‘I am unlikeable’, ‘I am foolish’, ‘I am inadequate’, ‘I am inferior’, ‘I am weird/different’ and ‘I am boring’. Some therapists may take the presence of such persistent negative self-evaluations as being a separate problem of ‘low self-esteem’, rather than seeing them as a core feature of SAD. This may lead to a delay in addressing the persistent negative self-evaluations until the last stages of treatment, as might be typically done in cognitive therapy for depression. It might also prompt therapist drift from the core interventions of NICE recommended cognitive therapy for social anxiety disorder (CT-SAD). Therapists may be tempted to devote considerable time to interventions for ‘low self-esteem’. Our experience from almost 30 years of treating SAD within the framework of the Clark and Wells (1995) model is that when these digressions are at the cost of core CT-SAD techniques, they have limited value. This article clarifies the role of persistent negative self-evaluations in SAD and shows how these beliefs can be more helpfully addressed from the start, and throughout the course of CT-SAD, using a range of experiential techniques.
Key learning aims
(1) To recognise persistent negative self-evaluations as a key feature of SAD.
(2) To understand that persistent negative self-evaluations are central in the Clark and Wells (1995) cognitive model and how to formulate these as part of SAD.
(3) To be able to use all the experiential interventions in cognitive therapy for SAD to address these beliefs.
Surveys are a powerful technique in cognitive behavioural therapy (CBT). A form of behavioural experiment, surveys can be used to test beliefs, normalise symptoms and experiences, and generate compassionate perspectives. In this article, we discuss why and when to use surveys in CBT interventions for a range of psychological disorders. We also present a step-by-step guide to collaboratively designing surveys with patients, selecting the appropriate recipients, sending out surveys, discussing responses and using key learning as a part of therapy. In doing so, we hope to demonstrate that surveys are a flexible, impactful, time-efficient, individualised technique which can be readily and effectively integrated into CBT interventions.
Key learning aims
After reading this article, it is hoped that readers will be able to:
(1) Conceptualise why surveys can be useful in cognitive behavioural therapy.
(2) Implement collaborative and individualised survey design, delivery and feedback as part of a CBT intervention.
Therapist cognitions about trauma-focused psychological therapies can affect our implementation of evidence-based therapies for post-traumatic stress disorder (PTSD), potentially reducing their effectiveness. Based on observations gleaned from teaching and supervising one of these treatments, cognitive therapy for PTSD (CT-PTSD), ten common ‘misconceptions’ were identified. These included misconceptions about the suitability of the treatment for some types of trauma and/or emotions, the need for stabilisation prior to memory work, the danger of ‘retraumatising’ patients with memory-focused work, the risks of using memory-focused techniques with patients who dissociate, the remote use of trauma-focused techniques, and the perception of trauma-focused CBT as inflexible. In this article, these misconceptions are analysed in light of existing evidence and guidance is provided on using trauma-focused CT-PTSD with a broad range of presentations.
Key learning aims
(1) To recognise common misconceptions about trauma-focused CBT for PTSD and the evidence against them.
(2) To widen understanding of the application of cognitive therapy for PTSD (CT-PTSD) to a broad range of presentations.
(3) To increase confidence in the formulation-driven, flexible, active and creative delivery of CT-PTSD.
Cognitive therapy for social anxiety disorder (CT-SAD) is recommended by NICE (2013) as a first-line intervention. Take up in routine services is limited by the need for up to 14 ninety-min face-to-face sessions, some of which are out of the office. An internet-based version of the treatment (iCT-SAD) with remote therapist support may achieve similar outcomes with less therapist time.
Methods
102 patients with social anxiety disorder were randomised to iCT-SAD, CT-SAD, or waitlist (WAIT) control, each for 14 weeks. WAIT patients were randomised to the treatments after wait. Assessments were at pre-treatment/wait, midtreatment/wait, posttreatment/wait, and follow-ups 3 & 12 months after treatment. The pre-registered (ISRCTN 95 458 747) primary outcome was the social anxiety disorder composite, which combines 6 independent assessor and patient self-report scales of social anxiety. Secondary outcomes included disability, general anxiety, depression and a behaviour test.
Results
CT-SAD and iCT-SAD were both superior to WAIT on all measures. iCT-SAD did not differ from CT-SAD on the primary outcome at post-treatment or follow-up. Total therapist time in iCT-SAD was 6.45 h. CT-SAD required 15.8 h for the same reduction in social anxiety. Mediation analysis indicated that change in process variables specified in cognitive models accounted for 60% of the improvements associated with either treatment. Unlike the primary outcome, there was a significant but small difference in favour of CT-SAD on the behaviour test.
Conclusions
When compared to conventional face-to-face therapy, iCT-SAD can more than double the amount of symptom change associated with each therapist hour.
Early in the COVID-19 pandemic, the World Health Organization stressed the importance of daily clinical assessments of infected patients, yet current approaches frequently consider cross-sectional timepoints, cumulative summary measures, or time-to-event analyses. Statistical methods are available that make use of the rich information content of longitudinal assessments. We demonstrate the use of a multistate transition model to assess the dynamic nature of COVID-19-associated critical illness using daily evaluations of COVID-19 patients from 9 academic hospitals. We describe the accessibility and utility of methods that consider the clinical trajectory of critically ill COVID-19 patients.
To characterize and compare the neuropsychological profiles of patients with primary progressive apraxia of speech (PPAOS) and apraxia of speech with progressive agrammatic aphasia (AOS-PAA).
Method:
Thirty-nine patients with PPAOS and 49 patients with AOS-PAA underwent formal neurological, speech, language, and neuropsychological evaluations. Cognitive domains assessed included immediate and delayed episodic memory (Wechsler Memory Scale-Third edition; Logical Memory; Visual Reproduction; Rey Auditory Verbal Learning Test), processing speed (Trail Making Test A), executive functioning (Trail Making Test B; Delis-Kaplan Executive Functioning Scale – Sorting), and visuospatial ability (Rey-Osterrieth Complex Figure copy).
Results:
The PPAOS patients were cognitively average or higher in the domains of immediate and delayed episodic memory, processing speed, executive functioning, and visuospatial ability. Patients with AOS-PAA performed more poorly on tests of immediate and delayed episodic memory and executive functioning compared to those with PPAOS. For every 1 unit increase in aphasia severity (e.g. mild to moderate), performance declined by 1/3 to 1/2 a standard deviation depending on cognitive domain. The degree of decline was stronger within the more verbally mediated domains, but was also notable in less verbally mediated domains.
Conclusion:
The study provides neuropsychological evidence further supporting the distinction of PPAOS from primary progressive aphasia and should be used to inform future diagnostic criteria. More immediately, it informs prognostication and treatment planning.
The existence of a shared constraint hierarchy is one of the criteria that defines and delimits speech communities. In particular, women and men are thought to differ only in their rates of variable usage, not in the constraints governing their variation; that is, women and men are typically considered to belong to the same speech community. We find that in early twentieth century Southland, New Zealand, women and men had different constraint hierarchies for rhoticity, with a community grammar of rhoticity only developing later. These results may be a product of a particular set of sociohistorical facts thatare not peculiar to Southland. We suggest that further research in other geographical locations may indeed reveal that men and women have different constraint hierarchies for other variables. Speech communities may thus be delimited along social lines in ways that have not been previously considered.
The Inquisitions post mortem (IPMs) are a truly wonderful source for many different aspects of late medieval countryside and rural life. They have recently been made digitally accessible and interrogatable by the Mapping the Medieval Countryside project, and the first fruits of these developments are presented here. The chapters examine IPMs in connection with the landscape and topography of England, in particular markets and fairs and mills; and consider the utility of proofs of age for everyday life on such topics as the Church, retaining, and the wine trade.
Michael Hicks is Emeritus Professor of Medieval History at the University of Winchester.
Contributors: Katie A. Clarke, William S. Deller, Paul Dryburgh, Christopher Dyer, Janette Garrett, Michael Hicks, Matthew Holford, Gordon McKelvie, Stephen Mileson, Simon Payling, Matthew Tompkins, Jennifer Ward.
The Promontory caves (Utah) and Franktown Cave (Colorado) contain high-fidelity records of short-term occupations by groups with material culture connections to the Subarctic/Northern Plains. This research uses Promontory and Franktown bison dung, hair, hide, and bone collagen to establish local baseline carbon isotopic variability and identify leather from a distant source. The ankle wrap of one Promontory Cave 1 moccasin had a δ13C value that indicates a substantial C4 component to the animal's diet, unlike the C3 diets inferred from 171 other Promontory and northern Utah bison samples. We draw on a unique combination of multitissue isotopic analysis, carbon isoscapes, ancient DNA (species and sex identification), tissue turnover rates, archaeological contexts, and bison ecology to show that the high δ13C value was not likely a result of local plant consumption, bison mobility, or trade. Instead, the bison hide was likely acquired via long-distance travel to/from an area of abundant C4 grasses far to the south or east. Expansive landscape knowledge gained through long-distance associations would have allowed Promontory caves inhabitants to make well-informed decisions about directions and routes of movement for a territorial shift, which seems to have occurred in the late thirteenth century.
Optical tracking systems typically trade off between astrometric precision and field of view. In this work, we showcase a networked approach to optical tracking using very wide field-of-view imagers that have relatively low astrometric precision on the scheduled OSIRIS-REx slingshot manoeuvre around Earth on 22 Sep 2017. As part of a trajectory designed to get OSIRIS-REx to NEO 101955 Bennu, this flyby event was viewed from 13 remote sensors spread across Australia and New Zealand to promote triangulatable observations. Each observatory in this portable network was constructed to be as lightweight and portable as possible, with hardware based off the successful design of the Desert Fireball Network. Over a 4-h collection window, we gathered 15 439 images of the night sky in the predicted direction of the OSIRIS-REx spacecraft. Using a specially developed streak detection and orbit determination data pipeline, we detected 2 090 line-of-sight observations. Our fitted orbit was determined to be within about 10 km of orbital telemetry along the observed 109 262 km length of OSIRIS-REx trajectory, and thus demonstrating the impressive capability of a networked approach to Space Surveillance and Tracking.
The inclusion of students with autism spectrum disorder (ASD) is increasing, but there have been no longitudinal studies of included students in Australia. Interview data reported in this study concern primary school children with ASD enrolled in mainstream classes in South Australia and New South Wales, Australia. In order to examine perceived facilitators and barriers to inclusion, parents, teachers, and principals were asked to comment on the facilitators and barriers to inclusion relevant to each child. Data are reported about 60 students, comprising a total of 305 parent interviews, 208 teacher interviews, and 227 principal interviews collected at 6-monthly intervals over 3.5 years. The most commonly mentioned facilitator was teacher practices. The most commonly mentioned barrier was intrinsic student factors. Other factors not directly controllable by school staff, such as resource limitations, were also commonly identified by principals and teachers. Parents were more likely to mention school- or teacher-related barriers. Many of the current findings were consistent with previous studies but some differences were noted, including limited reporting of sensory issues and bullying as barriers. There was little change in the pattern of facilitators and barriers identified by respondents over time. A number of implications for practice and directions for future research are discussed.