Human information processing under stress.

This article is a review of literature focused on how human beings process information under stress. Three major theories on information processing are reviewed: cue utilization theory, attentional control theory, and working memory capacity theory. Different conditions that can cause an individual to feel stress are examined, how stress affects information processing, ways which stress may be beneficial, and different ways to mitigate stress, so they may process information more accurately and efficiently. Throughout the article, examples of how stress can affect incident commanders responding to a disaster situation are used to illustrate research findings.

Use of laser-scanning confocal microscopy in the detection of diagenesis in bone.

This research demonstrates the value of laser scanning confocal microscopy (LSCM) as a research tool in osteological studies, and diagenetic studies in particular. LSCM combines properties of light and scanning electron microscopy using laser light to excite fluorophores throughout the z-axis, developing a 3-D image. Using differential staining and selecting for specific wavelengths of light, one can image targeted materials. This research is divided into two parts: visualizing bone structures such as proteins and their decompositional products and visualizing diagenesis. Part one of this study utilized pig bones as a means of testing the overall ability of LSCM to fluoresce bone. Twenty-three samples were imaged, including 13 samples from a decompositional study conducted 5 years previous, and 10 "fresh" samples collected from a commercial butcher. This part of the study determined that protein and organic components of the bone could be fluoresced and diagenetic alteration could be imaged. The second part of the study used human samples as a means of imaging and mapping diagenetic alterations. The second part of the study used 13 samples, including 4 clinical, 7 ancient, and 2 modern controls. The pig study used Basic Fuchsin and SlowFade Gold stains, while the human study used toluidine blue. Images were also taken with unstained elements. The results of the non-human study found that a fresh bone fluoresced differently than that of a 5-year subset, while the results of the human study confirmed these findings and determined that the bone diagenesis can be mapped using LSCM.

Evaluating the morphological and metric sex of human crania using 3-dimensional (3D) technology.

Identifying the skeletal remains of an unidentified individual is a priority for the medico-legal system because identification increases the chances of finding the person responsible and provides closure to the family. The purpose of this research was to develop a combined morphological and metric cranial sex assessment method using 3D technology that accommodates the medico-legal system, and their use of 3D models facilitates the technological transition to digitally archived skeletal collections. A total of 91 individuals of European biogeographical ancestry from the William M. Bass Donated Skeletal Collection (University of Tennessee Knoxville) were imaged using photogrammetry, turned into 3D models using Agisoft PhotoScan, and digitally evaluated using 3D Studio Max. This novel method digitally evaluated five cranial traits, including the nasal aperture height, nasal aperture width, mastoid length, the general size and architecture, and the supraorbital ridges, combining techniques that can only be done digitally with those that can be completed on the actual bone. Preliminary statistical tests demonstrate an overall accuracy rate of 90% when tested against the training sample (20 males, 20 females) and 75% when tested against the test sample (51 individuals). Although no intra- or inter-observer error rate tests were done, and further testing on other skeletal collections is necessary, this method allows forensic anthropologists to perform relatively easy point-to-point measurements, the quantification of traditionally non-quantified traits, the possibility of reproducible results, and the ability for future analyses or research.

Standardization of clinical care pathway leads to sustained decreased length of stay following Nuss pectus repair: A multidisciplinary quality improvement initiative.

BACKGROUND AND PURPOSE: Postoperatively, standardized clinical care pathways (SCCPs) help patients reach necessary milestones for discharge. The objective of this study was to achieve 90% compliance with a pectus specific SCCP within 9 months of implementation. We hypothesized that adherence to a pectus SCCP following the Nuss procedure would decrease postsurgical length of stay (LOS). METHODS: A multidisciplinary team implemented the pectus SCCP, including goals for mobility, lung recruitment, pain control, intake, and output. The full protocol included 42 components, tracked using chart reviews and a patient-directed checklist. The primary process measure was compliance with the pectus SCCP. The primary outcome measure was LOS; secondary outcomes were patient charges, patient satisfaction, and hospital readmission. RESULTS: Total study patients were n = 509: 159 patients pre-intervention, 350 patients post-intervention (80 implementation group; 270 sustain group). SCCP compliance data were collected on 164 patients post-intervention - 80 implementation, 84 sustain. LOS, ED visits, and hospital readmissions were recorded for all 509 patients. Mean LOS decreased from 4.5 days to 3.4 days, with >90% adherence to the pectus SCCP postintervention. There were no readmissions owing to pain despite earlier termination of epidural analgesia. Total patient charges decreased by 30% and patient satisfaction was high. CONCLUSION: Using quality improvement methodology with strict adherence to a pectus SCCP, we had significant reduction in LOS and patient charge without compromising effective postoperative pain management or patient satisfaction. TYPE OF STUDY: Clinical research; quality improvement. LEVEL OF EVIDENCE: V.

Reprint of: Breaking the binary: The identification of trans-women in forensic anthropology.

In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty, to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Breaking the binary: The identification of trans-women in forensic anthropology.

In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Resolving Reflection and Resolution in 3D Imaging of Fresh Bone.

Structured light scanning is a noninvasive, accurate, and cost-effective 3D imaging technique, but due to reflection issues is yet to be utilized for tool mark analysis on fresh bone. During imaging, reflection from shiny surfaces, such as greasy bone, disrupts image formation. This study tested the David SLS-1 scanner's ability to image saw marks and explored six strategies to reduce reflection by [1] dulling the surface or [2] altering the projected light. The surface was dulled by freezing, talcum powder, dulling spray, or compressed air. The projected light was altered with a diffuser or limited to single pattern-coded. Results demonstrated that the resolution was insufficient for capturing minute details of striae. All six tests failed to reduce reflection sufficiently to produce complete images, but projecting vertical pattern-coded light showed the most promise. Future research is required concentrating on enhancing resolution and exploring the role of pattern-coded light in reducing reflection.

The Accuracy and Applicability of 3D Modeling and Printing Blunt Force Cranial Injuries.

The purpose of this study was to determine the factors affecting the accuracy of 3D models and 3D prints of cranial blunt force trauma, to evaluate the applicability and limitations of modeling such injuries. Three types of cranial blunt force lesions were documented (hinge, depressed, and comminuted) using three forms of surface scanning (laser, structured light scanner, and photogrammetry) at two different quality settings (standard and high). 3D printed models of the lesions were produced using two different materials (a gypsum-like composite powder called VisiJet® PXL and an acrylic engineered composite plastic called VisiJet® M3 in crystal colour). The results of these analyzes indicate the prints in this study exhibit some statistically significant differences from the actual bone lesions, but details of the lesions can be reproduced to within 2 mm accuracy.

An Evaluation of the Calce Method for Age Estimation.

The Calce method of skeletal age estimation (Am J Phys Anthropol, 148, 2012 and 11) uses the acetabular surface of the os coxa and was developed using 90 individuals from the J.C.B. Grant Skeletal collection. From this collection, pilot tests using a combined sample size of 55 randomized individuals yielded an accuracy of 54.5%. To eliminate the possible issue of variation within the collection, 30 individuals from those that Calce specifically used were assessed by two analysts. Accuracies of 53.3% and 56.7% were obtained, compared with Calce's reported accuracy of 81% (Am J Phys Anthropol, 148, 2012 and 11). This study also used 30 Japanese individuals from the Nagasaki University modern cadaver collection. Due to the high interobserver error (43.3%) and the low accuracies achieved (40% and 46.7%), the Calce method does not perform well on Japanese samples. The low accuracy of this method in general suggests that the trait descriptions should be refined to assist analysts in properly utilizing the method.

A collaborative evaluation of pharmacy interventions in the care of inpatients in community hospitals.

OBJECTIVES: To quantify medication-related errors, in particular prescribing errors, identified by pharmacists and assess their potential impact on inpatients in community hospitals. METHODS: Pharmacists recorded all interventions to optimise medication for community hospital inpatients over 14 days in November 2013. Interventions were subsequently classified by type (prescribing error; omitted or delayed drug administration; or attributable to other issues) and rated for potential clinical impact. RESULTS: 15 organisations participated in the study reporting on 4077 medication charts. In total, 52 033 medication orders were screened by pharmacists. A medication-related intervention was made on 1 in 3 charts for one or more medications. A total of 2782 interventions were recorded. The majority were categorised as a prescriber error (67%, 1872/2782). The remainder (33%, 910/2782) were not directly attributable to prescriber error; of these omitted and delayed medicine administration accounted for 11% (298/2782). Of the 1872 interventions classed as prescriber error, a third, if left undetected, might have caused moderate or severe patient harm. The prescribing error rate was 3.6 errors per 100 medication orders. CONCLUSIONS: Pharmacists reported intervening to improve the care provided to over a third of patients in this study. Two-thirds of interventions were in response to prescribing errors, a third of which, if left undetected, could have led to harm. The results suggest that inpatients in community hospitals are subject to prescribing errors at a rate comparable to those seen in acute and mental health hospitals. A clinical pharmacy service is vital to ensure patient safety in community hospitals.

Improving efficiency and safety for patients who are unable to self-administer insulin.

A one-day 'snapshot' study was conducted to determine the nature and extent of specific safety issues faced by community nurses who care for patients unable to self-administer insulin. Community teams from 19 NHS trusts reported 607 patients requiring support with insulin administration. In total, 15.1% of insulin administration documents had an abbreviation for the word 'units', which is a serious safety hazard where any resulting serious harm would be classed as a 'never event'. Pens or disposable devices were used for 52.9% of all administrations, with 16.7% using an insulin device without any previous device-specific training. Major differences were discovered between trusts in many aspects of practice and insulin use, and comparative data can be used to benchmark activity and drive safety and cost improvement For example, 50.9% of patients had insulin administered more than once a day, but individual trusts reported figures ranging from 25.9% to 66.7%. If it were possible for all 19 trusts to manage 60% of patients on once-daily regimens, total annual service costs could be reduced by about pounds 200,000, or by pounds 3.5 million across the U.K.s.

Evaluation of age estimation technique: testing traits of the acetabulum to estimate age at death in adult males.

This study evaluates the accuracy and precision of a skeletal age estimation method, using the acetabulum of 100 male ossa coxae from the Grant Collection (GRO) at the University of Toronto, Canada. Age at death was obtained using Bayesian inference and a computational application (IDADE2) that requires a reference population, close in geographic and temporal distribution to the target case, to calibrate age ranges from scores generated by the technique. The inaccuracy of this method is 8 years. The direction of bias indicates the acetabulum technique tends to underestimate age. The categories 46-65 and 76-90 years exhibit the smallest inaccuracy (0.2), suggesting that this method may be appropriate for individuals over 40 years. Eighty-three percent of age estimates were ±12 years of known age; 79% were ±10 years of known age; and 62% were ±5 years of known age. Identifying a suitable reference population is the most significant limitation of this technique for forensic applications.

Implementation and enforcement of ventilator-associated pneumonia prevention strategies in trauma patients.

BACKGROUND: We hypothesized that strict enforcement of ventilator-associated pneumonia (VAP) prevention (VAPP) strategies would decrease the incidence of VAP and improve patient outcomes. METHODS: This retrospective study examined 696 consecutive ventilated patients in a Level One trauma center. Three study groups were compared: Pre-VAPP, VAPP implementation, and VAPP enforcement. Ventilator days were compared with occurrences of VAP, defined by the U.S. Centers for Disease Control and Prevention National Nosocomial Infection Surveillance criteria. Patients with and without VAP were compared to evaluate the effect of VAP on patient outcome. Fisher exact, Kruskal-Wallis, and chi-square analyses were used, and p < 0.05 was considered significant. RESULTS: During the pre-VAPP protocol period, 5.2 cases of VAP occurred per 1,000 days of ventilator support. The number of cases of VAP decreased to 2.4/1,000 days (p = 0.172) and 1.2/1,000 days (p = 0.085) in the implementation and enforcement periods, respectively. However, when including all trauma patients, regardless of head Abbreviated Injury Score (AIS) score, the difference in the rate of VAP was statistically significant in the enforcement period, but not in the implementation period, compared with the pre-VAPP period (p = 0.014 and 0.062, respectively). A significant decrease was seen in the mortality rate (p = 0.024), total hospital days (p = 0.007), intensive care unit days (p = 0.002), ventilator days (p = 0.002), and hospital charges (p = 0.03) in patients without VAP compared with patients having VAP. CONCLUSIONS: There was a statistically significant decrease in the occurrence of VAP with strict enforcement of a VAPP protocol, regardless of head AIS score. Although the difference in patients with a head AIS score <3 was not statistically significant, it was clinically meaningful, decreasing the already-low rate of VAP by half. Strict enforcement of VAPP protocols may be cost efficient for hospitals and prevent decreased reimbursement under the Medicare pay-for-performance strategies.

Positive personal identification of human remains based on thoracic vertebral margin morphology.

Radiography has long been used by anthropologists to establish positive personal identification of human remains in forensic cases. These methods have been largely ad hoc and depend upon specific congenital or pathological bone markers. Court rulings, such as Daubert and Mohan have, however, pushed the discipline toward more statistically supportable methods of identification. This study describes the use of normal morphological variation of the thoracic vertebrae to identify human remains. Radiographs from healthy, male individuals, aged 18-55 were examined to identify normally varying features of vertebral morphology. The frequency of occurrence of these features was calculated, tested, and found to be stable in the given sample. The frequencies were compared to establish which sets of traits varied independently of one another. Finally, unknown radiographs were compared to known samples to test the applicability of this method in determining positive identification, with 21 of 24 (87.5%) unknown radiographs positively identified.

Personal identification using the frontal sinus.

The frontal sinuses are known to be unique to each individual; however, no one has tested the independence of the frontal sinus traits to see if probability analysis through trait combination is a viable method of identifying an individual using the frontal sinuses. This research examines the feasibility of probability trait combination, based on criteria recommended in the literature, and examines two other methods of identification using the frontal sinuses: discrete trait combinations and superimposition pattern matching. This research finds that most sinus traits are dependent upon one another and thus cannot be used in probability combinations. When looking at traits that are independent, this research finds that metric methods are too fraught with potential errors to be useful. Discrete trait combinations do not have a high enough discriminating power to be useful. Only superimposition pattern matching is an effective method of identifying an individual using the frontal sinuses.

Soft tissue decomposition of submerged, dismembered pig limbs enclosed in plastic bags.

This study examines underwater soft tissue decomposition of dismembered pig limbs deposited in polyethylene plastic bags. The research evaluates the level of influence that disposal method has on underwater decomposition processes and details observations specific to this scenario. To our knowledge, no other study has yet investigated decomposing, dismembered, and enclosed remains in water environments. The total sample size consisted of 120 dismembered pig limbs, divided into a subsample of 30 pig limbs per recovery period (34 and 71 days) for each treatment. The two treatments simulated non-enclosed and plastic enclosed disposal methods in a water context. The remains were completely submerged in Lake Ontario for 34 and 71 days. In both recovery periods, the non-enclosed samples lost soft tissue to a significantly greater extent than their plastic enclosed counterparts. Disposal of remains in plastic bags therefore results in preservation, most likely caused by bacterial inhibition and reduced oxygen levels.

The effects of soil environment on postmortem interval: a macroscopic analysis.

Burial environment, in particular soil moisture, has a significant impact on the type, rate, and extent of bone degradation, which ultimately affects estimations of the postmortem interval (PMI). The purpose of this research is to determine the effects of soil moisture on the color, weight, condition, and texture of bone as it relates to the PMI. Bone changes occurring over two different time intervals (2 and 5 months) were examined using 120 sus scrofa leg bones. During each time interval bones were buried in two soil environments, one of which was drier than the other. The bones in both environments lost weight over time but the net weight loss was greater for bones in the higher moisture environment. There was no change in color, texture, or overall condition, indicating that 150 days is not long enough for such alterations to occur, regardless of the moisture level of the burial environment.

Reconstructing the sequence of events surrounding body disposition based on color staining of bone*.

Literature regarding bone color is limited to determining location of primary and secondary dispositions. This research is the first to use bone color to interpret the sequence of events surrounding body disposition. Two scenarios were compared-bones buried and then exposed on the ground surface and bones exposed then buried. Forty juvenile pig humeri with minimal tissue were used in each scenario with an additional 20 controls to determine if decomposing tissue affects bone color. Munsell Color Charts were used to record bone color of surface and 2.5 cm cross-sections. Results reveal five main surface colors attributed to soil, sun, hemolysis, decomposition, and fungi. Fungi on buried bones suggests prior surface exposure. Cross-sections of strictly buried bones are identical to buried then exposed bone, stressing the importance of bone surface analysis. Cross-sectioning may help verify remains have been exposed then buried. Decomposition of excess tissue creates minimal color staining.