The Standardization of the Emergency Department Response to Chemical, Biological, Radiological, and Nuclear (CBRN) Events: Human Factors/Ergonomics Approach.

OBJECTIVE: To provide standardized recommendations for the emergency department (ED) response to chemical, biological, radiological, and nuclear (CBRN) events by combining the human factors/ergonomics method of hierarchical task analysis with the theoretical framework for Work as Imagined versus Work as Done. METHODS: Document analyses were used to represent CBRN response operational procedures. Semi-structured interviews using scenario cards were carried out with 57 first receivers (ED staff) to represent CBRN practice at 2 acute hospitals in England. RESULTS: Variability existed in general organizational responsibilities associated with the CBRN response. Variability was further evident in top level CBRN tasks and CBRN phases at both EDs. Operational procedures focused on tasks such as documentation, checking, and timing. CBRN practice focused on patient needs through assessment, treatment, and diagnosis. CONCLUSION: The findings provide top-down and bottom-up insights to enhance the ED CBRN response through standardization. The standardized CBRN action card template embeds the choice approach to standardization. The standardized CBRN framework implements the streamlined categorization of CBRN phases. Work as Imagined versus Work as Done is a useful theoretical framework to unpack a complex sociotechnical system, and hierarchical task analysis is an effective system mapping tool in health care.

From Raising Awareness to a Behavioural Change: A Case Study of Indoor Air Quality Improvement Using IoT and COM-B Model.

The topic of indoor air pollution has yet to receive the same level of attention as ambient pollution. We spend considerable time indoors, and poorer indoor air quality affects most of us, particularly people with respiratory and other health conditions. There is a pressing need for methodological case studies focusing on informing households about the causes and harms of indoor air pollution and supporting changes in behaviour around different indoor activities that cause it. The use of indoor air quality (IAQ) sensor data to support behaviour change is the focus of our research in this paper. We have conducted two studies-first, to evaluate the effectiveness of the IAQ data visualisation as a trigger for the natural reflection capability of human beings to raise awareness. This study was performed without the scaffolding of a formal behaviour change model. In the second study, we showcase how a behaviour psychology model, COM-B (Capability, Opportunity, and Motivation-Behaviour), can be operationalised as a means of digital intervention to support behaviour change. We have developed four digital interventions manifested through a digital platform. We have demonstrated that it is possible to change behaviour concerning indoor activities using the COM-B model. We have also observed a measurable change in indoor air quality. In addition, qualitative analysis has shown that the awareness level among occupants has improved due to our approach of utilising IoT sensor data with COM-B-based digital interventions.

Bus passenger injury prevention: Learning from onboard incidents.

OBJECTIVE: Bus travel is relatively safe: however there remains a lack of understanding of passenger injury incidents onboard buses. The objective of this study was to understand more about onboard passenger incidents to help inform injury mitigation. METHODS: The UK national STATS19 data and Transport for London bus incident data (IRIS) were used to determine the size of the problem in Greater London. Other data including onboard incident reports from two bus operators and CCTV footage of 70 incidents were used to understand passenger injury in more depth and identify common themes and challenges. RESULTS: The STATS19 and IRIS analysis showed that there was a difference between nationally reported bus incidents compared to locally reported bus incidents. Non-collision incidents are prevalent in the data suggesting there is a large problem to tackle. The CCTV and bus incident data identified braking to be the single largest problem in onboard bus passenger injury incidents. Inconsistent reporting of passenger incidents and injury descriptions make it difficult to identify injury patterns and trends. Areas on the bus appear to contribute to higher injury incidents namely those seats facing and closest to the wheelchair area. Other challenges relating to expected passenger and driver behaviors were noted where blame for the incident and outcome can be attributed to both parties. CONCLUSIONS: This combined analysis of incident reports and CCTV footage has enabled a better understanding of the events leading to on-board passenger injury incidents. Preventing harsh braking would appear to be the most effective way of reducing passenger injuries. Additionally improved data collection would assist both transport authorities and bus operators to identify and monitor the effect of bus safety improvements.

Mental health and other factors associated with work productivity after injury in the UK: multicentre cohort study.

INTRODUCTION: Mental health conditions are a major contributor to productivity loss and are common after injury. This study quantifies postinjury productivity loss and its association with preinjury and postinjury mental health, injury, demographic, health, social and other factors. METHODS: Multicentre, longitudinal study recruiting hospitalised employed individuals aged 16-69 years with unintentional injuries, followed up at 1, 2, 4 and 12 months. Participants completed questionnaires on injury, demographic factors, health (including mental health), social factors, other factors and on-the-job productivity upon return to work (RTW). ORs were estimated for above median productivity loss using random effects logistic regression. RESULTS: 217 adults had made an RTW at 2, 4 or 12 months after injury: 29% at 2 months, 66% at 4 months and 83% at 12 months. Productivity loss reduced over time: 3.3% of working time at 2 months, 1.7% at 4 months, 1% at 12 months. Significantly higher productivity loss was associated with preinjury psychiatric conditions (OR 21.40, 95% CI 3.50 to 130.78) and post-traumatic stress avoidance symptoms at 1 month (OR for 1-unit increase in score 1.15, 95% CI 1.07 to 1.22). Significantly lower productivity loss was associated with male gender (OR 0.32, 95% CI 0.14 to 0.74), upper and lower limb injuries (vs other body regions, OR 0.15, 95% CI 0.03 to 0.81) and sports injuries (vs home, OR 0.18, 95% CI 0.04 to 0.78). Preinjury psychiatric conditions and gender remained significant in analysis of multiply imputed data. CONCLUSIONS: Unintentional injury results in substantial productivity loss. Females, those with preinjury psychiatric conditions and those with post-traumatic stress avoidance symptoms experience greater productivity loss and may require additional support to enable successful RTW.

'Over to you': using a STAMP control structure analysis to probe deeper into the control of UK road safety at a municipal level - the case of Cambridgeshire.

The UK has seen little progress in reducing road death over the last decade and as a result, the government has been criticised by industry stakeholders for a lack of leadership, including the removal of national targets in 2011 and the devolution of powers to a municipal level. The aim of this paper is to understand how decision-making at a municipal level takes place from a systems perspective, using the case study of Cambridgeshire. Actors involved were mapped using a STAMP control structure analysis and highlighted a key role for formal and informal partnerships between local and national government agencies and non-government organisations at the same level in the control structure. The changing international context of the model for the UK is also discussed in relation to the UK's withdrawal from the European Union and provides a useful tool for future analysis of its effect on policy and decision-making. Practitioner summary: This paper uses a STAMP control structure analysis to understand how decision-making at a municipal level takes place from a systems perspective, using the case study of Cambridgeshire. It highlights a key role for formal and informal partnerships between organisations at the same level in the control structure. Abbreviations: STAMP: System Theoretic Accident Model and Processes; STAMP-CAST: Systems-Theoretic Accident Model and Processes - Causal Analysis using Systems Theory; FRAM: Functional Resonance Analysis Method; HFACS: Human Factors Analysis and Classification Scheme; NGO: Non-Government organisation; iRAP: International Road Assessment Programme; EuroRAP: European Road Assessment Programme; NCAP: New Car Assessment Programme; CCG: Clinical Commissioning Group; GP: General Practitioner; PPE: Personal Protective Equipment; SD: standard deviation; Beds: Bedfordshire; Cambs: Cambridgeshire; Herts: Hertfordshire; Pboro: Peterborough.

Characterisation of mobile colistin resistance genes (mcr-3 and mcr-5) in river and storm water in regions of the Western Cape of South Africa.

BACKGROUND: Colistin is regarded as a last-resort antimicrobial against multi-drug resistant Gram-negative bacteria (GNB), therefore the dissemination of colistin resistance in the environment is of great concern. Horizontal transfer of mobile colistin resistance (mcr) genes to potential pathogens poses a serious problem. This study aimed to describe the presence of colistin resistant GNB and mcr genes in river and storm water in regions of the Western Cape. METHODS: Water samples were collected from three rivers during May 2019 and January 2020 and two storm water samples were collected in November 2019. Colistin resistant GNB were cultured on MacConkey agar containing colistin and identified by MALDI-TOF. Colistin resistance was confirmed using broth microdilution (BMD). mcr-1-5 genes were detected by PCR performed directly on the water samples and on the colistin resistant isolates. mcr functionality was assessed by BMD after cloning the mcr genes into pET-48b(+) and expression in SHuffle T7 E. coli. RESULTS: mcr-5.1 and various mcr-3 gene variants were detected in the Plankenburg-, Eerste- and Berg rivers and in storm water from Muizenberg, and only mcr-5.1 was detected in storm water from Fish Hoek. Colistin resistant GNB were isolated from all of the water sources. Aeromonas spp. were the most common colistin resistant organisms detected in the water sources; 25% (6/24) of colistin resistant Aeromonas spp. isolated from the Berg river contained novel mcr-3 variants; mcr-3.33 (n = 1), mcr-3.34 (n = 1) mcr-3.35 (n = 1) mcr-3.36 (n = 2) and mcr-3.37 (n = 1), which were confirmed to confer colistin resistance. CONCLUSIONS: The mcr-5.1 and mcr-3 colistin resistance gene variants were present in widely dispersed water sources in regions of the Western Cape. The mcr genes were only detected in water sampled downstream of and alongside communities, suggesting that their presence is driven by human influence/contamination. This is the first documentation of mcr-3 and mcr-5 gene variants in any setting in South Africa. Spill-over of these genes to communities could result in horizontal gene transfer to pathogenic bacteria, exacerbating the challenge of controlling multidrug resistant GNB infections.

Traffic-related air pollution reduction at UK schools during the Covid-19 lockdown.

Elevated urban Nitrogen Dioxide (NO2) is a consequence of road traffic and other fossil-fuel combustion sources, and the road transport sector provides a significant contribution to UK NO2 emissions. The inhalation of traffic-related air pollution, including NO2, can cause a range of problems to human health. Due to their developing organs, children are particularly susceptible to the negative effects of air pollution inhalation. Accordingly, schools and associated travel behaviours present an important area of study for the reduction of child exposure to these harmful pollutants. COVID-19 reached the UK in late January 2020. On the 23rd of March that year, the UK government announced a nationwide stay-at-home order, or lockdown, banning all non-essential travel and contact with people outside of their own homes. The lockdown was accompanied by the closure of schools, public facilities, amenities, businesses and places of worship. The current study aims to assess the significance of nationwide NO2 reductions at schools in England as a consequence of the lockdown in order to highlight the benefits of associated behavioural changes within the context of schools in England and potential child exposure. NO2 data were collected from all AURN (Automatic Urban and Rural Network) monitoring sites within 500 m of nurseries, primary schools, secondary schools and colleges in England. A significant reduction of mean NO2 concentrations was observed in the first month of the UK lockdown at background (-35.13%) and traffic (-40.82%) sites. Whilst lockdown restrictions are undoubtedly unsustainable, the study results demonstrate the possible reductions of NO2 at schools in England and potential reductions of child exposure that are achievable when public behaviours shift towards active travel, work from home policies and generally lower use of polluting vehicles.

Development of an expert derived ICD-AIS map for serious AIS3+ injury identification.

Objective: The objective of the mapping project was to develop an expert derived map between the International Statistical Classification of Diseases and Related Health Problems (ICD) clinical modifications (CM) and the Abbreviated Injury Scale (AIS) to be able to relate AIS severity to ICD coded data road traffic collision data in EU datasets. The maps were developed to enable the identification of serious AIS3+ injury and provide details of the mapping process for assumptions to be made about injury severity from mass datasets. This article describes in detail the mapping process of the International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM) and the International Classification of Diseases Tenth Revision, Clinical Modification (ICD-10-CM) codes to the Abbreviated Injury Scale 2005, Update 2008 (AIS08) codes to identify injury with an AIS severity of 3 or more (AIS3+ severity) to determine 'serious' (MAIS3+) road traffic injuries.Methods: Over 19,000 ICD codes were mapped from the following injury categories; injury ICD-9-CM (Chapter 17) codes between '800 and 999.9' and injury ICD-10-CM (Chapter 19) 'S' and 'T' prefixed codes were reviewed and mapped to an AIS08 category and then relate the severity to three groups; AIS3+, AIS < =2 and AIS 9 (no-map). The mapping was undertaken by ICD coding experts and certified AIS specialists from Europe, North America, Australia and Canada in face-to-face working groups and subsequent webinars between May 2014 and October 2015. During the process, the business rules were documented to define guidelines for the mapping process and enable inter-rater discrepancies to be resolved.Results: In total 2,504 ICD-9-CM codes were mapped to the AIS, of which 780 (31%) were assigned an AIS3+ severity. For the16,508 ICD-10-CM mapped codes a total of 2,323 (14%) were assigned an AIS3+ severity. Some 17% (n = 426) and 27% (n = 4,485) of ICD-9-CM and ICD-10-CM codes respectively were assigned to AIS9 (no-map) following the mapping process. It was evident there were 'problem' codes that could not be easily mapped to an AIS code to reflect severity. Problem maps affect the specificity of the map and severity when used to translate historical data in large datasets.Conclusions: The Association for the Advancement in Automotive Medicine, AAAM-endorsed expert-derived map offers a unique tool to road safety researchers to establish the number of MAIS3+ serious injuries occurring on the roads. The detailed process offered in this paper will enable researchers to understand the decision making and identify limitations when using the AIS08/ICD map on country-specific data. The results could inform protocols for dealing with problem codes to enable country comparisons of MAIS3+ serious injury rates.

Emergency Department Response to Chemical, Biological, Radiological, Nuclear, and Explosive Events: A Systematic Review.

IntroductionA Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) event is an emergency which can result in injury, illness, or loss of life. The emergency department (ED) as a health system is at the forefront of the CBRNe response with staff acting as first receivers. Emergency departments are under-prepared to respond to CBRNe events - recognizing key factors which underlie the ED CBRNe response is crucial to provide evidence-based knowledge to inform policies and, most importantly, clinical practice.ProblemChallenges in detection, decontamination, and diagnosis are associated with the ED CBRNe response when faced with self-presenting patients. METHODS: A systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). An in-depth search strategy was devised to identify studies which focused on the ED and CBRNe events. The inclusion criteria were stringent in terms of the environment (ED), participants (first receivers), situation (CBRNe response), and actions (detection, decontamination, and diagnosis). Fifteen databases and topic-specific journals were searched. Studies were critically appraised using the Mixed Methods Appraisal Tool (MMAT). Papers were thematically coded and synthesized using NVivo 10 (QSR International Ltd, Melbourne, Australia). RESULTS: Sixty-seven full-text papers were critically appraised using the MMAT; 70% were included (n = 60) as medium- or high-quality studies. Data were grouped into four themes: preparedness, response, decontamination, and personal protective equipment (PPE) problems.DiscussionThis study has recognized the ED as a system which depends on four key factors - preparedness, response, decontamination, and PPE problems - which highlight challenges, uncertainties, inconsistencies, and obstacles associated with the ED CBRNe response. This review suggests that response planning and preparation should be considered at three levels: organizational (policies and procedures); technological (decontamination, communication, security, clinical care, and treatment); and individual (willingness to respond, PPE, knowledge, and competence). Finally, this study highlighted that there was a void specific to detection and diagnosis of CBRNe exposure on self-presenting patients in the ED. CONCLUSION: The review identified concerns for both knowledge and behaviors which suggests that a systems approach would help understand the ED response to CBRNe events more effectively. The four themes provide an evidence-based summary for the state of science in ED CBRNe response, which can be used to inform future policies and clinical procedures. RazakS, HignettS, BarnesJ. Emergency department response to chemical, biological, radiological, nuclear, and explosive events: a systematic review. Prehosp Disaster Med. 2018;33(5):543-549.

Urban local air quality management framework for non-attainment areas in Indian cities.

Increasing urban air pollution level in Indian cities is one of the major concerns for policy makers due to its impact on public health. The growth in population and increase in associated motorised road transport demand is one of the major causes of increasing air pollution in most urban areas along with other sources e.g., road dust, construction dust, biomass burning etc. The present study documents the development of an urban local air quality management (ULAQM) framework at urban hotspots (non-attainment area) and a pathway for the flow of information from goal setting to policy making. The ULAQM also includes assessment and management of air pollution episodic conditions at these hotspots, which currently available city/regional-scale air quality management plans do not address. The prediction of extreme pollutant concentrations using a hybrid model differentiates the ULAQM from other existing air quality management plans. The developed ULAQM framework has been applied and validated at one of the busiest traffic intersections in Delhi and Chennai cities. Various scenarios have been tested targeting the effective reductions in elevated levels of NOx and PM2.5 concentrations. The results indicate that a developed ULAQM framework is capable of providing an evidence-based graded action to reduce ambient pollution levels within the specified standard level at pre-identified locations. The ULAQM framework methodology is generalised and therefore can be applied to other non-attainment areas of the country.

Early childhood caries and dental treatment need in low socio-economic communities in Cape Town, South Africa.

BACKGROUND: Early childhood caries (ECC) is a particularly severe problem in low socio-economic communities which impacts the overall health and well-being of children. The extensive waiting lists for general anaesthesia and sedation services at the only tertiary dental care centre in the study area for the treatment of children with ECC were an indication of the extent of the problem. The true extent of the problem in this area was, however, not known. This information is crucial in order to plan and execute remedial measures. AIM: To assess the prevalence of oral and dental problems, especially ECC, in children under six years of age in the study population, and ascertain their need for dental treatment. METHODS: A cross-sectional survey of 659 children from selected schools and clinics in the study area was carried out between 2010 and 2013. RESULTS: A caries prevalence of 71.6% (472/659) was recorded. Of these, 67.5% (445/659) of children were in need of dental treatment. CONCLUSION: Over the last decade, there has been no improvement in the caries status of children in the study population, and no organised measures have been put in place to address this problem. Awareness needs to be raised so that governments, especially in developing countries, can take appropriate measures to alleviate this public health problem. Time and resources have to be invested in the education of all health professionals dealing with children, by raising their awareness of the early stages of the disease so that timeous referrals can be made.

Identifying MAIS 3+ injury severity collisions in UK police collision records.

OBJECTIVE: This study represents the first stage of a project to identify serious injury, at the level of Maximum Abbreviated Injury Scale (MAIS) 3 + (excluding fatal collisions) from within the police collision data. The resulting data will then be used to identify the vehicle drivers concerned and in later studies these will be culpability scored and profiled to allow targeting of interventions. METHOD: UK police collision data known as STATS19 for the county of Cambridgeshire were linked using Stata with Trauma Audit and Research Network (TARN) hospital trauma patient data for the same geographical area for the period April 2012 to March 2017. Linking was 2-stage: A deterministic process followed by a probabilistic process. RESULTS: The linked records represent an individual trauma patient from TARN data linked to an individual trauma casualty from STATS19 data. Full collision data for the incident resulting in the trauma casualty were extracted. The resulting subset of collisions has the MAIS 3+ injury criteria applied. From the 10,498 recorded collisions, the deterministic linking process was successful in linking 257 MAIS 3+ trauma patients to collision injury subjects from 232 separate collisions with the probabilistic process linking a further 22 MAIS 3+ subjects from 21 collision events. The combined collision data for the 253 collisions involved 434 motor vehicle drivers. CONCLUSIONS: We produced viable results from the available data to identify MAIS 3+ collisions from the overall collision data.

Transcriptional memory of cells of origin overrides ß-catenin requirement of MLL cancer stem cells.

While ß-catenin has been demonstrated as an essential molecule and therapeutic target for various cancer stem cells (CSCs) including those driven by MLL fusions, here we show that transcriptional memory from cells of origin predicts AML patient survival and allows ß-catenin-independent transformation in MLL-CSCs derived from hematopoietic stem cell (HSC)-enriched LSK population but not myeloid-granulocyte progenitors. Mechanistically, ß-catenin regulates expression of downstream targets of a key transcriptional memory gene, Hoxa9 that is highly enriched in LSK-derived MLL-CSCs and helps sustain leukemic self-renewal. Suppression of Hoxa9 sensitizes LSK-derived MLL-CSCs to ß-catenin inhibition resulting in abolishment of CSC transcriptional program and transformation ability. In addition, further molecular and functional analyses identified Prmt1 as a key common downstream mediator for ß-catenin/Hoxa9 functions in LSK-derived MLL-CSCs. Together, these findings not only uncover an unexpectedly important role of cells of origin transcriptional memory in regulating CSC self-renewal, but also reveal a novel molecular network mediated by ß-catenin/Hoxa9/Prmt1 in governing leukemic self-renewal.

Psychological morbidity and return to work after injury: multicentre cohort study.

BACKGROUND: The benefits of work for physical, psychological, and financial wellbeing are well documented. Return to work (RTW) after unintentional injury is often delayed, and psychological morbidity may contribute to this delay. The impact of psychological morbidity on RTW after a wide range of unintentional injuries in the UK has not been adequately quantified. AIM: To quantify the role of psychological factors, including anxiety, depression, and post-traumatic distress, on RTW following unintentional injuries. DESIGN AND SETTING: A longitudinal multicentre prospective study was undertaken in Nottingham, Bristol, Leicester, and Guildford, UK. METHOD: Participants (n = 273) were 16-69-year-olds admitted to hospital following unintentional injury, who were in paid employment prior to injury. They were surveyed at baseline, then at 1, 2, 4, and 12 months following injury; demographic data were collected along with injury characteristics, psychological morbidity, and RTW status. Associations between demographic, injury and psychological factors, and RTW between 2 and 12 months after injury were quantified using random effects logistic regression. RESULTS: The odds of RTW between 2 and 12 months after injury reduced as depression scores early in the recovery period (1 month after injury) increased (odds ratio [OR] 0.87, 95% confidence interval [CI] = 0.79 to 0.95) and as length of hospital stay increased (OR 0.91, 95% CI] = 0.86 to 0.96). For those experiencing threatening life events following injury (OR 0.27, 95% CI = 0.10 to 0.72) and with higher scores on the Crisis Support Scale (OR 0.93, 95% CI] = 0.88 to 0.99), the odds of RTW between 2 and 12 months after injury were lower. Multiple imputation analysis found similar results, but those relating to crisis support did not remain statistically significant. CONCLUSION: Primary care professionals can identify patients at risk of delayed RTW who may benefit from management of psychological morbidity and support to RTW.

Fatal and serious collisions involving pedal cyclists and trucks in London between 2007 and 2011.

OBJECTIVE: Increased numbers of people riding pedal cycles have led to a greater focus on pedal cycle safety. The aim of this article is to explore factors that are associated with fatal and a small number of serious-injury pedal cyclist crashes involving trucks that occurred in London between 2007 and 2011. METHODS: Data were collected from police collision files for 53 crashes, 27 of which involved a truck (≥3.5 tonnes) and a pedal cycle. A systematic case review approach was used to identify the infrastructure, vehicle road user, and management factors that contributed to these crashes and injuries and how these factors interacted. RESULTS: Trucks turning left conflicting with pedal cyclists traveling straight ahead was a common crash scenario. Key contributory factors identified included the pedal cyclists not being visible to the truck drivers, road narrowing, and inappropriate positioning of pedal cyclists. CONCLUSIONS: Crashes involving trucks and pedal cyclists are complex events that are caused by multiple interacting factors; therefore, multiple measures are required to prevent them from occurring.