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Following an outbreak of highly pathogenic avian influenza virus (HPAIV) in a poultry house, control measures are put in place to prevent further spread. An essential part of the control measures based on the European Commission Avian Influenza Directive 2005/94/EC is the cleansing and disinfection (C&D) of infected premises. Cleansing and disinfection includes both preliminary and secondary C&D, and the dismantling of complex equipment during secondary C&D is also required, which is costly to the owner and also delays the secondary cleansing process, hence increasing the risk for onward spread. In this study, a quantitative risk assessment is presented to assess the risk of re-infection (recrudescence) occurring in an enriched colony-caged layer poultry house on restocking with chickens after different C&D scenarios. The risk is expressed as the number of restocked poultry houses expected before recrudescence occurs. Three C&D scenarios were considered, namely (i) preliminary C&D alone, (ii) preliminary C&D plus secondary C&D without dismantling and (iii) preliminary C&D plus secondary C&D with dismantling. The source-pathway-receptor framework was used to construct the model, and parameterisation was based on the three C&D scenarios. Two key operational variables in the model are (i) the time between depopulation of infected birds and restocking with new birds (TbDR) and (ii) the proportion of infected material that bypasses C&D, enabling virus to survive the process. Probability distributions were used to describe these two parameters for which there was recognised variability between premises in TbDR or uncertainty due to lack of information in the fraction of bypass. The risk assessment estimates that the median (95% credible intervals) number of repopulated poultry houses before recrudescence are 1.2 × 104 (50 to 2.8 × 106), 1.9 × 105 (780 to 5.7 × 107) and 1.1 × 106 (4.2 × 103 to 2.9 × 108) under C&D scenarios (i), (ii) and (iii), respectively. Thus for HPAIV in caged layers, undertaking secondary C&D without dismantling reduces the risk by 16-fold compared to preliminary C&D alone. Dismantling has an additional, although smaller, impact, reducing the risk by a further 6-fold and thus around 90-fold compared to preliminary C&D alone. On the basis of the 95% credible intervals, the model demonstrates the importance of secondary C&D (with or without dismantling) over preliminary C&D alone. However, the extra protection afforded by dismantling may not be cost beneficial in the context of reduced risk of onward spread.
Twain’s two most important contemporaries were William Dean Howells and Henry James. Howells was a friend and champion of both writers, although Twain and James expressed distaste toward each other. Each in his own way was an important figure in the emerging literary realism. Although Twain claimed that he preferred reading history and biography over novels and literature, he was an avid reader of his contemporaries’ works, even if he often criticized them. Harriet Beecher Stowe was his next-door neighbor, and he entertained fellow writers in his Hartford mansion. Twain was a champion of some younger writers, although he wearied at the constant demands for advice and help from emerging writers.
The impact of traumatic brain injury (TBI) extends beyond the person who was injured. Family caregivers of adults with moderate to severe TBI frequently report increased burden, stress and depression. Few studies have examined the well-being of family members in the mild TBI population despite the latter representing up to 95% of all TBIs.
Five areas of well-being were examined in 99 family members (including parents, partners, siblings, other relatives, adult children, friends or neighbours) of adults (aged ≥16 years) with mild TBI. At 6- and 12-month post-injury, family members completed the Bakas Caregiver Outcomes Scale, Short Form-36 Health Survey, EQ-5D-3L, Hospital Anxiety and Depression Scale and the Pittsburgh Sleep Quality Index. Outcomes and change over time and associated factors were examined.
At 6 months, group mean scores for health-related quality of life for mental and physical components and overall health status were similar to the New Zealand (NZ) population. Mean scores for sleep, anxiety and depression were below clinically significant thresholds. From 6 to 12 months, there were significant improvements in Bakas Caregiver Outcomes Scale scores by 2.61 (95% confidence interval: 0.72–4.49), health-related quality of life (mental component) and EQ-5D-3L overall health (P = 0.01). Minimally clinically important differences were observed in overall health, anxiety, health-related quality of life and depression at 12 months. Female family members reported significant improvements in physical health over time, and more positive life changes were reported by those caring for males with TBI.
The findings suggest diminished burden over time for family members of adults with mild TBI.
The psychedelic research renaissance is gaining traction. Preliminary clinical studies of the hallucinogenic fungi, psilocybin, with psychological support, have indicated improvements in mood, anxiety and quality of life. A seminal, open-label study demonstrated marked reductions in depression symptoms in participants with treatment-resistant depression (TRD). The associated neurobiological processes involve alterations in brain connectivity, together with altered amygdala and default mode network activity. At the cellular level, psychedelics promote synaptogenesis and neural plasticity. Prompted by the promising preliminary studies, a randomized, double-blind trial has recently been launched across Europe and North America to investigate the efficacy of psilocybin in TRD. One of these centres is based in Ireland – CHO Area 7 and Tallaght University Hospital. The outcome of this trial will determine whether psilocybin with psychological support will successfully translate into the psychiatric clinic for the benefit of patients.
Concurrent chemotherapy with radiotherapy is the standard treatment for locoregionally advanced nasopharyngeal cancer. Cetuximab can be used in the treatment of head and neck squamous cell carcinoma. However, the randomised studies that led to approval for its use in this setting excluded nasopharyngeal cancer. In the context of limited data for the use of cetuximab in nasopharyngeal cancer in the medical literature, this review aimed to summarise the current evidence for its use in both primary and recurrent or metastatic disease.
A literature search was performed using the keywords ‘nasopharyngeal neoplasm’, ‘cetuximab’ and ‘Erbitux’.
Twenty studies were included. There were no randomised phase III trials, but there were nine phase II trials. The use of cetuximab in the treatment of nasopharyngeal carcinoma has been tested in various settings, including in combination with induction chemotherapy and concurrent chemoradiotherapy, and in the palliative setting.
There is no evidence of benefit from the addition of cetuximab to standard management protocols, and there is some evidence of increased toxicity. There is more promise for its use in metastatic or locally recurrent settings. This review draws together the existing evidence and could provide a focus for future studies.
With generous support from the National Science Foundation, we have spent the past four years developing an archaeological radiocarbon database for the United States. Here, we highlight the importance of spatial data for open-access, national-scale archaeological databases and the development of paleodemography research. We propose a new method for analyzing radiocarbon time series in the context of paleoclimate models. This method forces us to confront one of the central challenges to realizing the full potential of national-scale databases: the quality of the spatial data accompanying radiocarbon dates. We seek to open a national discussion on the use of spatial data in open-source archaeological databases.
The primary aim of the Michigan State University Twin Registry (MSUTR) is to examine developmental differences in genetic, environmental, neural, epigenetic, and neurobiological influences on psychopathology and resilience, particularly during childhood and adolescence. The MSUTR has two broad components: a large-scale, population-based registry of child, adolescent, and adult twins and their families (current N ~30,000) and a series of more focused and in-depth studies drawn from the registry (projected N ~7200). Participants in the population-based registry complete a family health and demographic questionnaire via mail. Families can then be recruited for one or more of the intensive, in-person studies from the population-based registry, using any one of several recruitment strategies (e.g., population-based, based on their answers to the registry questionnaire). These latter studies target a variety of biological, genetic, and environmental phenotypes, including multi-informant measures of psychiatric and behavioral phenotypes, functional and structural neuroimaging, comprehensive measures of the twin family environment (e.g., census and neighborhood informant reports of twin neighborhood characteristics, videotaped interactions of child twin families), buccal swab and salivary DNA samples, and/or assays of adolescent and adult steroid hormone levels. This article provides an overview of the MSUTR and describes current and future research directions.
The experiments reported in this research paper aimed to investigate differences in the levels of chlorate (CHLO), perchlorate (PCHLO), trichloromethane (TCM) and iodine residues in bulk tank (BT) milk produced at different milk production periods, and to monitor those levels throughout a skim milk powder (SMP) production chain (BTs, collection tankers [CTs], whole milk silo [WMS] and skim milk silo [SMS]). Chlorate, PCHLO and iodine were measured in SMP, while TCM was measured in the milk cream. The CHLO, TCM and iodine levels in the mid-lactation milk stored in the WMS were lower than legislative and industrial specifications (0.0100 mg/kg, 0.0015 mg/kg and 150 µg/l, respectively). However, in late-lactation, these levels were numerically higher than the mid-lactation levels and specifications. Trichloromethane accumulated in the cream portion after separation. Perchlorate was not detected in any of the samples. Regarding iodine, the levels in mid-lactation reconstituted SMP were higher than that required by manufacturers (100 µg/l), indicating that the levels in milk should be lower than 142 µg/l. The higher residue levels observed in late-lactation could be related to the low milk volume produced during that period and changes in sanitation practices, while changes in feed management could have affected iodine levels. This study could assist in controlling and setting limits for CHLO, TCM and iodine levels in milk, ensuring premium quality dairy products.
Clinical Enterobacteriacae isolates with a colistin minimum inhibitory concentration (MIC) ≥4 mg/L from a United States hospital were screened for the mcr-1 gene using real-time polymerase chain reaction (RT-PCR) and confirmed by whole-genome sequencing. Four colistin-resistant Escherichia coli isolates contained mcr-1. Two isolates belonged to the same sequence type (ST-632). All subjects had prior international travel and antimicrobial exposure.
Prior work has robustly suggested that social processes in the neighborhood (i.e. informal social control, social cohesion, norms) influence child conduct problems (CP) and related outcomes, but has yet to consider how these community-level influences interact with individual-level genetic risk for CP. The current study sought to do just this, evaluating neighborhood-level social processes as etiologic moderators of child CP for the first time.
We made use of two nested samples of child and adolescent twins within the Michigan State University Twin Registry (MSUTR): 5649 families who participated in in the Michigan Twins Project (MTP) and 1013 families who participated in the Twin Study of Behavioral and Emotional Development (TBED-C). The neighborhood social processes of informal social control, social cohesion, and norms were assessed using neighborhood sampling techniques, in which residents of each twin family's neighborhood reported on the social processes in their neighborhood. Standard biometric GxE analyses evaluated the extent to which they moderated the etiology of CP.
The ‘no moderation’ model provided the best fit to the data in nearly all cases, arguing against neighborhood social processes as etiologic moderators of youth CP.
The neighborhood social processes evaluated here do not appear to exert their effects on child CP via etiologic moderation. The documented links between neighborhood social processes and child CP are thus likely to reflect a different etiologic process. Possibilities include environmental main effects of neighborhood social processes on child CP, or genotype-environment correlations.
Background: While recent clinical trials have demonstrated immense efficacy of mechanical thrombectomy (MT) in the setting of acute stroke, there remains debate over the safety in performing this procedure under general anesthesia (GA). In the Saskatchewan Acute Stroke Pathway, all patients presenting with LVO have endovascular thrombectomy performed under GA. Methods: Data was retrospectively reviewed on 108 consecutive LVO in 2016-2017. All MT were done under GA. Anatomical location of LVO, pre-MT ASPECTS score, post-MT TICI scores and 90-day NIHSS and mRS were recorded. Results: Of 108 LVO, 103 went on to have MT. 44 were right anterior circulation, 50 were left anterior circulation and 9 were posterior circulation. Of 94 anterior circulation strokes, 47 (50.0%), 43 (45.7%) and 4 (4.3%) had good, moderate and poor collateral circulation respectively, and the average pre-MT ASPECTS was 8.6. The average pre-MT NIHSS was 14.7. 81/90 (90.0%) achieved thrombolysis in cerebral infarction (TICI) perfusion scale grade of 2b/3 after recanalization. Average documented 90-day NIHSS was 2.4 and mRS was 2.5. Overall mortality was 21/103 (20.4%). Conclusions: In the Saskatchewan acute stroke pathway, general anesthesia is a safe modality for MT. This adds to the body of evidence supporting GA as a viable option for sedation in MT.
Hurricane Harvey made landfall in southeast Texas in August 2017, causing unprecedented flooding throughout the Texas coastal region. Residents of affected regions were forced to evacuate to nearby unaffected areas, including Dallas, TX, where a large shelter operation was opened for 23 days to care for those evacuees. Retrospective evaluation of pharmaceutical prescribing patterns for the evacuees who self-presented to the Megashelter Medical Clinic (MMC) established in the shelter contributes to developing evidence-based planning strategies for healthcare delivery in the post-disaster setting.
To describe the pharmacy needs of a displaced population following a large-scale evacuation after a hurricane
De-identified prescription records written and filled at a shelter pharmacy were reviewed, looking at both cost and category of medications dispensed over time.
Approximately 41% of evacuees with a total of 2,654 visits utilized the MMC clinic, resulting in 1,590 prescriptions filled with an associated cost of $78,039. The most commonly prescribed drug categories were cardiovascular (21.2%), neuropsychotropic (15.6%), infectious disease (12.5%), and endocrine (9.6%). While the most commonly dispensed were antihypertensives, diabetes treatment-related prescriptions, antibacterials, antidepressants, and NSAIDs, the costliest individual prescriptions were antiretrovirals and antipsychotics.
Prescribing patterns for the MMC differed from normal prescribing patterns of a general population. Of the prescriptions dispensed at the MMC, pharmaceutical prescription patterns suggest the immediate needs of evacuees differ from later needs. There is a greater need for chronic disease management in the early phase of shelter operations, and an increasing need for neuropsychotropic and infectious disease prescriptions over time. Understanding overall patterns of drug utilization over the duration of the shelter provides valuable insight on post-disaster medical resource utilization in evacuee populations.
After Hurricane Harvey and the flooding that ensued, 3,829 displaced persons were transported from their homes and sheltered in the Dallas Convention Center. This large general population sheltering operation was medically supported by the onsite Mega-Shelter Medical Clinic (MMC). In an altered standard of care environment, a number of multi-disciplinary medical services were provided including emergent management, acute pediatric and adult care, psychiatric/behavioral services, onsite pharmaceutical, and durable medical equipment distribution, epidemiologic surveillance, and select laboratory services.
To describe how onsite medical care in the adapted environment of a large population shelter can provide comparable services and limit the direct impact on the local medical community.
A retrospective chart review of medical records was generated for all clinical encounters at the MMC. Data were sorted by daily census, disease surveillance, medical decision making, treatment, and transport destinations.
40.7% of registered evacuees utilized the MMC accounting for a total of 2,654 clinic visits by 1,560 unique patients representing all age groups. During the sustained MMC operations, 8% of patients required emergency transport and 500 additional patient transports were arranged for clinic appointments. No deaths occurred and no iatrogenic morbidity was reported.
Medical care was provided for a large number of evacuees which mitigated the potential impact on the local medical infrastructure. The provision of medical services in a large population shelter may necessitate adaptation to the standard of care. However, despite the nontraditional clinical setting, care delivery was not compromised.
The Dallas Convention Center received over 3800 evacuees because of the unprecedented flooding caused by Hurricane Harvey. A multidisciplinary medical clinic was established onsite to address evacuee needs for medical evaluations, emergency care, chronic disease management, pharmaceuticals, durable medical equipment, and local health services integration. To operate efficiently, the Dallas Mega-Shelter Emergency Operations Center (EOC) worked with the Mega-Shelter Medical Clinic (MMC) under a fluid incident command (IC) structure that was National Incident Management System (NIMS) compliant. Iterations of MMC IC demonstrated maturations in organizational structure while supporting MMC operations that varied from rigid NIMS doctrine.
To explore the use of a fluid IC structure at a large evacuation medical shelter after Hurricane Harvey.
We observed evolutions of IC organizational charts and operational impacts.
Modifications through just-in-time iterations of the IC organizational chart were posted and reviewed with MMC IC and EOC sector chiefs. Changes in the organizational chart were noted to improve identification of logistical needs, supply delivery, coordinate with other agencies, and to make decisions for resource typing and personnel utilization. Adaptations also improved communication, which led to timely situational awareness and reporting accuracy.
MMC medical services were improved by allowing modifications and adaptations to NIMS compliant MMC IC organizational roles and duty assignments. The fluidity of IC structure with ability for just-in-time modifications directly impacted the provision of disaster medical services. Unique situational awareness, coordination of care pathways within the local innate health infrastructure, compliance with health service regulations, and personnel resource typing all contributed to and benefitted from these IC modifications. MMC and EOC IC collaboration facilitated effective communication and maintained an appropriate span of control and efficient activity reporting.
Residency education delivery in the United States has migrated from conventional lectures to alternative educational models that include mini-lectures, small group, and learner lead discussions. As training programs struggle with mandated hours of content, prehospital (EMS) and disaster medicine are given limited focus. While the need for prehospital and disaster medicine education in emergency training is understood, no standard curriculum delivery has been proposed and little research has been done to evaluate the effectiveness of any particular model.
To demonstrate a four-hour multi-modal curriculum that includes lecture based discussions and small group exercises, culminating in an interactive multidisciplinary competition that integrates the previously taught information.
EMS and disaster faculty were surveyed on the previous disaster and prehospital educational day experiences to evaluate course content, level of engagement, and participation by faculty. Based on this feedback, the EMS/Disaster divisions developed a schedule for the four hour EMS and Disaster Day that incorporated vital concepts while addressing the pitfalls previously identified. Sessions included traditional lectures, question and answer sessions, small group exercises, and a tabletop competition. Structured similarly to a strategy board game, the tabletop exercise challenged residents to take into account both medical and ethical considerations during a traditional triage exercise.
Compared to past reviews by emergency medical faculty, residents, and medical students, there was a precipitous increase in satisfaction scores on the part of all participants.
This curriculum deviates from the conventional education model and has been successfully implemented at our 3-year residency program of 66 residents. This EMS and Disaster Day promotes active learning, resident and faculty participation, and retention of important concepts while also fostering relationships between disaster managers and the Department of Emergency Medicine.
In the United States, over 50% of people have at least one chronic medical condition, access, or functional limitation. In 2017 during Hurricane Harvey, the establishment of a comprehensive multidisciplinary onsite medical clinic provided health and medical services to over 3,800 evacuees at the Dallas Mega Shelter, providing large-scale general population sheltering support to all evacuees and prioritizing family unit integrity by meeting physical, sensory, and cognitive limitations, and chronic medical conditions. The effectiveness of the Dallas Mega Shelter onsite medical operations supporting this aim is reviewed.
To utilize onsite health and medical resources to meet access and functional needs of evacuees seeking general population mass sheltering in Dallas, Texas during Hurricane Harvey.
Over 3,800 evacuees were evaluated for functional needs support services (FNSS) resulting in over 2,500 evacuee patient encounters during 21 continuous days of onsite health and medical clinic operations.1 A comprehensive array of services were available at no cost to the evacuees and were in accordance with the Federal Emergency Management Association (FEMA) published Guidance on Planning for Integration of Functional Needs Support Service in General Population Shelters.2 The goal to maintain nearly all evacuees choosing to stay in the Mega Shelter was achieved. The challenges, limitations, and risks identified are reviewed.
FNSS guidelines require all persons, regardless of limitations, when evacuated from home be provided all services necessary to allow them to remain in general population sheltering.2 This prioritization of personal choice, functional independence, and family integrity for those with comprehensive FNSS requirements presented notable challenges, including public health and safety risks impacting the wellbeing of others. Meeting these expectations must be balanced with maintaining shelter integrity.
The experiments reported in this research paper aimed to track the microbiological load of milk throughout a low-heat skim milk powder (SMP) manufacturing process, from farm bulk tanks to final powder, during mid- and late-lactation (spring and winter, respectively). In the milk powder processing plant studied, low-heat SMP was produced using only the milk supplied by the farms involved in this study. Samples of milk were collected from farm bulk tanks (mid-lactation: 67 farms; late-lactation: 150 farms), collection tankers (CTs), whole milk silo (WMS), skim milk silo (SMS), cream silo (CS) and final SMP. During mid-lactation, the raw milk produced on-farm and transported by the CTs had better microbiological quality than the late-lactation raw milk (e.g., total bacterial count (TBC): 3.60 ± 0.55 and 4.37 ± 0.62 log 10 cfu/ml, respectively). After pasteurisation, reductions in TBC, psychrotrophic (PBC) and proteolytic (PROT) bacterial counts were of lower magnitude in late-lactation than in mid-lactation milk, while thermoduric (LPC—laboratory pasteurisation count) and thermophilic (THERM) bacterial counts were not reduced in both periods. The microbiological quality of the SMP produced was better when using mid-lactation than late-lactation milk (e.g., TBC: 2.36 ± 0.09 and 3.55 ± 0.13 cfu/g, respectively), as mid-lactation raw milk had better quality than late-lactation milk. The bacterial counts of some CTs and of the WMS samples were higher than the upper confidence limit predicted using the bacterial counts measured in the farm milk samples, indicating that the transport conditions or cleaning protocols could have influenced the microbiological load. Therefore, during the different production seasons, appropriate cow management and hygiene practices (on-farm and within the factory) are necessary to control the numbers of different bacterial groups in milk, as those can influence the effectiveness of thermal treatments and consequently affect final product quality.