Improving clinician agreement and comfort through the development of a pediatric behavioral health huddle tool.

BACKGROUND: Hospitalized pediatric patients with behavioral health (BH) diagnoses awaiting transfer can exhibit behaviors that may lead to workplace violence such as aggression. Workplace violence can lead to discomfort in caring for these patients. Huddles can be used as a tool to identify potential for violence, to help address workplace violence, and improve clinician situational awareness. METHODS: Utilizing QI methodology, a BH specific huddle tool was created and implemented on an Acute Care floor that identified key components such as triggers and behavioral stability. Mixed methods were used to study the intervention including focus groups, surveys and measurement of agreement (surrogate for situational awareness). The aims of this quality improvement (QI) project were to 1) improve situational awareness by increasing agreement between team members 2) improve the overall comfort of the clinical team caring for BH patients by 10%. RESULTS: Agreement between clinicians on patient stability increased by 20%. Comfort in caring for BH patients increased by 4%. Providers reported the tool increased their understanding (89%) and communication (81%) regarding plan of care. APPLICATION TO PRACTICE: Standardized huddle tool can be utilized to increase situational awareness among team members caring for patients with behavioral health diagnoses and may help to address workplace violence.

Biparental incubation behaviour under temperature extremes in sandbank nesting black skimmers.

Birds nesting on riverine beaches are exposed to large temperature fluctuations, while changing water levels pose flooding risks. We used miniature temperature loggers (iButtons®) placed in nests and on the beach surface combined with time-lapse photography to study incubation behaviour in the black skimmer (Rynchops niger) on the Manu River, Peru. Since the species exhibits sexual size dimorphism, we could identify partner switches in images and the contribution to incubation effort by each pair member. Results of the study documented that nest temperature was less affected by ambient temperature and fluctuated less than the surroundings. Despite shorter incubation bouts at midday, black skimmers maintained a close to constant presence at the nest by more frequent nest exchanges. In fact, while female black skimmers generally incubated more and for longer than males, pairs shared incubation most consistently during the hottest part of the day. Incubation probability decreased around dusk, a peak foraging time for the species and a time when beach temperature overlapped with nest temperature. A biparental incubation strategy across the diel cycle appears to allow black skimmers breeding at the Manu River to incubate in challenging thermal conditions, but further studies are needed to determine proximity to thermal limits.

Lung Protection After Severe Thermal Burns With Adenosine, Lidocaine, and Magnesium (ALM) Resuscitation and Importance of Shams in a Rat Model.

The management of severe burns remains a complex challenge. Adenosine, lidocaine, and magnesium (ALM) resuscitation therapy has been shown to protect against hemorrhagic shock and traumatic injury. The aim of the present study was to investigate the early protective effects of small-volume ALM fluid resuscitation in a rat model of 30% total body surface area (TBSA) thermal injury. Male Sprague-Dawley rats (320-340 g; n = 25) were randomly assigned to: 1) Sham (surgical instrumentation and saline infusion, without burn, n = 5), 2) Saline resuscitation group (n = 10), or 3) ALM resuscitation group (n = 10). Treatments were initiated 15-min after burn trauma, including 0.7 mL/kg 3% NaCl ± ALM bolus and 0.25-0.5 mL/kg/h 0.9% NaCl ± ALM drip, with animals monitored to 8.25-hr post-burn. Hemodynamics, cardiac function, blood chemistry, hematology, endothelial injury markers and histopathology were assessed. Survival was 100% for Shams and 90% for both ALM and Saline groups. Shams underwent significant physiological, immune and hematological changes over time as a result of surgical traums. ALM significantly reduced malondialdehyde levels in the lungs compared to Saline (P = .023), and showed minimal alveolar destruction and inflammatory cell infiltration (P < .001). ALM also improved cardiac function and oxygen delivery (21%, P = .418 vs Saline), reduced gut injury (P < .001 vs Saline), and increased plasma adiponectin (P < .001 vs baseline). Circulating levels of the acute phase protein alpha 1-acid glycoprotein (AGP) increased 1.6-times (P < .001), which may have impacted ALM's therapeutic efficacy. We conclude that small-volume ALM therapy significantly reduced lung oxidative stress and preserved alveolar integrity following severe burn trauma. Further studies are required to assess higher ALM doses with longer monitoring periods.

The lethal heat dose for 50% primary human fibroblast cell death is 48 °C.

Understanding the effect of heat on skin cells is important for the prevention of burn injury. Knowledge of the heat dose required to kill cells can be used to study the cellular mechanisms involved in thermal injury cell death, to assist with the development of novel burn treatments. In this study, primary human skin dermal fibroblasts were exposed to temperatures from 37 to 54 °C for 1 h and the relative cell viability of heat-treated and control cells was assessed. Cell damage and viability were assessed by light microscopy, MTT assay and live/dead staining. The LD50 for 1 h of heat exposure was 48 °C for primary fibroblasts; and there was evidence that thermal damage to cells begins to occur at 43 °C. This study presents a reproducible method for examining the effect of heat on primary human cells grown in culture on a cellular level and can be used in the future to study the mechanisms behind heat-induced cell death, to inform burn injury prevention efforts and effective post-burn treatment.

Major surgery leads to a proinflammatory phenotype: Differential gene expression following a laparotomy.

BACKGROUND: The trauma of surgery is a neglected area of research. Our aim was to examine the differential expression of genes of stress, metabolism and inflammation in the major organs of a rat following a laparotomy. MATERIALS AND METHODS: Anaesthetised Sprague-Dawley rats were randomised into baseline, 6-hr and 3-day groups (n = 6 each), catheterised and laparotomy performed. Animals were sacrificed at each timepoint and tissues collected for gene and protein analysis. Blood stress hormones, cytokines, endothelial injury markers and coagulation were measured. RESULTS: Stress hormone corticosterone significantly increased and was accompanied by significant increases in inflammatory cytokines, endothelial markers, increased neutrophils (6-hr), higher lactate (3-days), and coagulopathy. In brain, there were significant increases in M1 muscarinic (31-fold) and α-1A-adrenergic (39-fold) receptor expression. Cortical expression of metabolic genes increased ∼3-fold, and IL-1ß by 6-fold at 3-days. Cardiac ß-1-adrenergic receptor expression increased up to 8.4-fold, and M2 and M1 muscarinic receptors by 2 to 4-fold (6-hr). At 3-days, cardiac mitochondrial gene expression (Tfam, Mtco3) and inflammation (IL-1α, IL-4, IL-6, MIP-1α, MCP-1) were significantly elevated. Haemodynamics remained stable. In liver, there was a dramatic suppression of adrenergic and muscarinic receptor expression (up to 90%) and increased inflammation. Gut also underwent autonomic suppression with 140-fold increase in IL-1ß expression (3-days). CONCLUSIONS: A single laparotomy led to a surgical-induced proinflammatory phenotype involving neuroendocrine stress, cortical excitability, immune activation, metabolic changes and coagulopathy. The pervasive nature of systemic and tissue inflammation was noteworthy. There is an urgent need for new therapies to prevent hyper-inflammation and restore homeostasis following major surgery.

The role of matrix metalloproteinase-9 and its inhibitor TIMP-1 in burn injury: a systematic review.

Matrix metalloproteinase-9 (MMP-9) and its endogenous inhibitor, tissue inhibitor of metalloproteinase-1 (TIMP-1), are key mediators of acute inflammation and regulators of the wound healing process. The aim of this systematic review was to determine the local and systemic involvement of the MMP-9/TIMP-1 system following burn injury. Two databases (Scopus and MEDLINE) were searched for all studies reporting MMP-9 and/or TIMP-1 after burn injury. Based on our eligibility criteria, we reviewed 24 studies involving 508 burns patients in 11 clinical studies and 367 animals in 13 preclinical studies. Local, systemic, and peripheral gene expression, protein levels and activity of MMP-9 and TIMP-1 were assessed. Increased MMP-9 was reported at the site of injury early after burn trauma in all studies, and remained elevated in non-healing wounds. Increased TIMP-1 expression in burn wounds occurred later than MMP-9, and was persistent in hypertrophic burn scars. Similar to local expression, systemic MMP-9 and TIMP-1 concentrations were significantly elevated after burn injury in response to upregulation of proinflammatory cytokines. While no association was found between systemic MMP-9 concentration and extent of injury or outcome, serum or plasma TIMP-1 showed good correlation with survival and burn severity. This review also found evidence of the MMP-9/TIMP-1 system contributing to secondary tissue damage distant from the burn site, including burn-associated musculoskeletal damage and acute lung injury. In addition, increased MMP-9 synthesis and activity in the brain after peripheral burn may lead to blood-brain barrier dysfunction and cerebral edema, a significant contributor to mortality. This systematic review provides an overview of the available evidence of the role of MMP-9 and TIMP-1 in burn injury pathophysiology and finds that TIMP-1 may be a promising biomarker in outcome prognostication of burns patients. Large-scale studies of both pediatric and adult burns patients with increased female representation and repeated sampling are recommended to validate the reliability of TIMP-1 as a prognostic marker following burn injury.

The morbidity associated with paediatric burn wound escharotomies.

INTRODUCTION: An escharotomy is an effective surgical procedure for the rapid decompression of a constricting and unyielding eschar, to permit restoration of blood flow. However, an escharotomy is also a full-thickness incision, which adds additional scarring to the burn injury area. The cosmetic and functional morbidity of escharotomy scarring in children is poorly characterised. METHODS: Children who required a burn wound escharotomy at the Queensland Children's Hospital (QCH) between May 2011 and May 2020 were included. Demographics of these children were described. In addition, the number of operations for revision of escharotomy scars was recorded as an indicator of functional or cosmetic concern. RESULTS: A total of 19 patients required an escharotomy after a burn injury. Children with 1% to 96% TBSA burns required an escharotomy, with a median of 28% (IQR 10-39%) TBSA. Two patients (81% and 96% TBSA) died. Seventy-one percent (12/17) of survivors had operative revisions of their escharotomy scars. The median time from burn to first scar intervention was 35 weeks (IQR 19-70 weeks). CONCLUSION: There is substantial morbidity associated with escharotomies in children. Further investigation of the current methods of decompression after burn injury, and the long-term morbidity of escharotomy, is required.

Community-based conservation with formal protection provides large collateral benefits to Amazonian migratory waterbirds.

Populations of migratory waterbirds are facing dramatic declines worldwide due to illegal hunting, habitat loss and climate change. Conservation strategies to reverse these trends are imperative, especially in tropical developing countries, which almost invariably allocate insufficient levels of investment for environmental protection. Here, we compared the effectiveness of sustainable-use Protected Areas (PAs) and Community-based Conservation (CBC) arrangements for the conservation of migratory waterbirds that breed on seasonal riverine sandy beaches in Brazilian Amazonia. We modeled local population responses of four migratory waterbird species on 155 beaches along a ~1,600 km section of a major tributary of the Amazon, as a function of community enforcement, official protection status, human pressure and landscape features. We show that 21 community-protected beaches within the study area host more than 80% of all sampled birds. Black Skimmers showed the most dramatic response, with breeding numbers 135-fold larger in CBC arrangements compared to beaches with no official protection status. The same pattern was observed for nesting Large-Billed and Yellow-Billed Terns. For the Near Threatened Orinoco Goose, PA status was the strongest predictor of local population size. These dramatic results demonstrate the value of protected refugia, achieved through the concerted action of participating local communities, to support breeding populations of key waterbird species. This highly-effective and low-cost conservation model can potentially be replicated in other regions of the developing world experiencing increasingly intensive exploitation of riverine natural resources.

Traumatic-Induced Coagulopathy as a Systems Failure: A New Window into Hemostasis.

Traumatic-induced coagulopathy (TIC) is often associated with significant bleeding, transfusion requirements, inflammation, morbidity, and mortality. This review considers TIC as a systems failure, not as a single-event manifestation of trauma. After briefly reviewing the meaning of TIC and the bewildering array of fibrinolysis phenotypes, we will discuss the role of platelets and fibrinogen in coagulopathy. Next, we will review the different TIC hypotheses and drill down to a single mechanistic domain comprising (1) thrombin's differential binding to thrombomodulin, (2) the expression of annexin II-S100A10 complex, and (3) the functional integrity of the endothelial glycocalyx. This triad forms the basis of the "switch" hypothesis of TIC. We will next address the potential limitations of current practice in treating a coagulation or fibrinolytic defect, and the next defect, and so on down the line, which often leads to what U.S. surgeon William C. Shoemaker considered "an uncoordinated and sometimes contradictory therapeutic outcome." The treat-as-you-go approach using sequential, single-target treatments appears to be a by-product of decades of highly reductionist thinking and research. Lastly, we will present a unified systems hypothesis of TIC involving three pillars of physiology: the central nervous system (CNS)-cardiovascular system, the endothelial glycocalyx, and mitochondrial integrity. If CNS control of ventriculoarterial coupling is maintained close to unity following trauma, we hypothesize that the endothelium will be protected, mitochondrial energetics will be maintained, and TIC (and inflammation) will be minimized. The Systems Hypothesis of Trauma (SHOT) also helps to answer why certain groups of severely bleeding trauma patients are still dying despite receiving the best care. Currently, no drug therapy exists that targets the whole system.

Seeking Care at Free Episodic Health Care Clinics in Appalachia.

Background: People who live in rural Appalachia experience a wide variety of problems when seeking access to health care. Health care disparities continue to be one of the most complex and prevalent problems, and many barriers exist for impoverished men and women such as a lack of education, complications with health insurance, and personal distrust of healthcare providers. Purpose: A critical gap in the literature is the unheard voice of persons in rural underserved areas. The purpose of this study was to explore the perspectives of persons in rural Appalachia who seek healthcare services at free episodic health care clinics, a common alternative source of care. Methods: In Fall 2017, a qualitative approach was used to discover the perceptions of 12 men and women in rural Appalachia who were seeking medical care at a Remote Area Medical Clinic. A transdisciplinary research group provided insight and assistance with thematic analysis in Spring 2018-Spring 2019. Results: Five overall themes emerged capturing the essence of how rural Appalachians view the experience of seeking healthcare, which include difficulties with insurance/finances, inconsistency in care, isolation in rural areas, seeking solutions, and need to feel valued. Implications: A rich description of participant experiences portrays real-life complexities for Appalachian men and women who seek healthcare. Understanding the perceptions of persons who seek healthcare and the essence of their experiences is the first step in determining future sustainable solutions for social justice.

A new model for standardising and treating thermal injury in the rat.

Thermal burn injury methodologies are inconsistently described within the current literature. To permit the advancement of new treatments there is an urgent need for the development and standardisation of an acute rat model. We describe a rat thermal burn model that involves: anaesthesia, chronic catheterisation, skin preparation, baseline hemodynamic and physiological monitoring, and a quantifiable method to reproduce a severe full-thickness burns injury affecting ∼30% percent of the total body surface area (%TBSA). Following a 15 min post-burn period, treatment commences with an acute monitoring phase lasting up to 8 h, which can be modified according to individual protocols. This model reflects the clinical continuum-of-care from point-of-injury, a 15 min ambulance response time, a 60 min prehospital phase and hospital treatment monitoring phase. The model is validated with histological evidence of full-thickness injury, evidence of the hypermetabolic response (K+, Base Excess, lactate) and changes in complete blood counts. •It has been 50 years since Walker and Mason published their widely popular "A Standard Animal Burn Model".•The model, however, lacks quantifiable methodology for the assessment of burn thickness, surface area burnt and physiological status.•We present a new standardised method for evaluation of drug and interventional therapies that mimic the clinical scenario including ambulance response, pre-hospital and hospital phases after burn.

The role of invasive monitoring in the resuscitation of major burns: a systematic review and meta-analysis.

Increasingly, in major hospitals invasive monitoring endpoints are utilised to guide the acute resuscitation of burns. The aim of this review is to evaluate effects of invasive monitoring for major burns patients (>20% total body surface area) to prevent early organ dysfunction. Five databases were searched for randomised controlled trials and cohort studies that evaluated invasive monitoring within the acute phase (first 24 hours). Invasive monitoring included transesophageal echocardiogram, central venous pressure measurement, and pulmonary artery catheterisation. Primary outcomes included multiple organ failure scores, renal and cardiac dysfunction measurements, compartment syndrome and lactate at 24 hours. Secondary outcomes included mortality and intensive care unit stay. Ten studies involving 401 major burns patients were included. Data pooled from four studies demonstrated significantly improved cardiac index at 24 hours compared to non-invasive endpoints (MD: 0.65, 95% CI: 0.46-0.82, P=0.00001). Five studies pooled showed significantly increased urine output with invasive monitoring (MD: 0.18, 95% CI: 0.03-0.34, P=0.02), whereas there was no difference in blood lactate levels (MD: -0.11, 95% CI: -0.44-0.22, P=0.43). There was a trend for lower mortality in invasive monitoring groups compared with non-invasive controls; however, the difference was not significant. There remains insufficient evidence to determine whether invasive monitoring to guide fluid resuscitation improves patient outcomes after major burn trauma. Although meta-analysis determined significantly improved cardiac index and urine output, further studies are required.

Third stage of labour management practices: A secondary analysis of a prospective cohort study of Australian women and their associated outcomes.

OBJECTIVE: This study aimed to describe practices used during the third stage of labour in a cohort of Australian women and explore clinical outcomes such as postpartum hemorrhage and clinical decision making associated with these practices. DESIGN: This study employed a prospective cohort design and reports a secondary analysis of a primary study that examined factors associated with PPH; specifically relating to third stage management practices. SETTING: It was conducted in three linked sites, in Queensland, Australia: a regional hospital, rural hospital and a private-practising midwifery service. DATA COLLECTED: type of third stage management chosen by the care provider, and why; use of uterotonic medications (including administration timing); determination of cord-clamp timing and why; and, use of controlled cord traction. PARTICIPANTS: Convenience sample of women birthing vaginally between October 2015 and April 2016 (n = 522). FINDINGS: Active management was the most common self-reported third stage management practice across these birth settings despite local health service guidelines advocating modified active management for all births. Modified active third stage was associated with least risk of PPH; however considerable variation in modified active practices was evident, particularly relating to cord clamp timing and oxytocic administration. Professional discipline, birth setting and complications during labour were significantly associated with differences in third stage management. Midwives were more likely to engage in expectant management than obstetricians; while active management was more commonly used in the rural setting and when complications during labour were experienced. KEY CONCLUSIONS: Modified active management was not associated with an increased risk of PPH consistent with contemporary evidence. However, a considerable proportion of providers may not be following evidence-based guidelines supporting modified active management which may be attributed to uncertainty around third stage practice definitions which has implications for education, practice, and policy. IMPLICATIONS FOR PRACTICE: Despite evidence-based guidelines, differences exist within modified active management including cord clamp timing, uterotonic administration and use of controlled cord traction. Modified active management was not associated with an increase in PPH.

Nursing considerations and interdisciplinary coordination in the care of conjoined twins.

Traditional nursing care strategies may require modification to meet the unique needs of conjoined twins. Here we discuss the strategies found to be useful in planning for and responding to distinctive circumstances encountered throughout hospitalization, as well as lessons learned. Areas of focus include ensuring privacy, designing adequate unit accommodations to meet space and equipment needs, staffing considerations and adaptations to typical neonatal intensive care nursing interventions. The utility of a team-based approach to interdisciplinary care coordination is also discussed. With adequate preparation and thoughtful innovation, most tertiary neonatal intensive care units can readily adapt to the unique needs of conjoined twins.

Identifying the risk: a prospective cohort study examining postpartum haemorrhage in a regional Australian health service.

BACKGROUND: In industrialised countries the incidence of postpartum haemorrhage (PPH) is increasing, for which exact etiology is not well understood. Studies have relied upon retrospective data with estimated blood loss as the primary outcome, known to be underestimated by clinicians. This study aimed to explore variables associated with PPH in a cohort of women birthing vaginally in coastal Queensland, Australia, using the gravimetric method to measure blood loss. METHODS: Women were prospectively recruited to participate using an opt-out consent process. Maternal demographics; pregnancy history; model of care; mode of birth; third stage management practices; antenatal, intrapartum and immediate postpartum complications; gravimetric and estimated blood loss; and haematological laboratory data, were collected via a pre-designed data collection instrument. Descriptive statistics were used for demographic, intrapartum and birthing practices. A General Linear Model was used for multivariate analysis to examine relationship between gravimetric blood loss and demographic, birthing practices and intrapartum variables. The primary outcome was a postpartum haemorrhage (blood loss > 500 ml). RESULTS: 522 singleton births were included in the analysis. Maternal mean age was 29 years; 58% were multiparous. Most participants received active (291, 55.7%) or modified active management of third stage (191, 36.6%). Of 451 births with valid gravimetric blood loss recorded, 35% (n = 159) recorded a loss of 500 ml or more and 111 (70%) of these were recorded as PPH. Gravimetric blood loss was strongly correlated with estimated blood loss (r = 0.88; p < 0.001). On average, the estimated blood loss was lower than the gravimetric blood loss, about 78% of the measured value. High neonatal weight, perineal injury, complications during labour, separation of mother and baby, and observation of a gush of blood were associated with PPH. Nulliparity, labour induction and augmentation, syntocinon use were not associated with PPH. CONCLUSIONS: In contrast to previous study findings, nulliparity, labour induction and augmentation were not associated with PPH. Estimation of blood loss was relatively accurate in comparison to gravimetric assessment; raising questions about routine gravimetric assessment of blood loss following uncomplicated births. Further research is required to investigate type and speed of blood loss associated with PPH.

Barriers to Health Care Access for Low Income Families: A Review of Literature.

Having a low-income presents a variety of problems for families and children, with access to health care being the most complex and prevalent. Although there are many challenges for low-income families to access adequate health care in the United States, the key barriers identified in this review of literature are a lack of education, complications with health insurance, and a distrust of health care providers. Each obstacle is influenced by a myriad of factors that affect vulnerable sub-groups of low-income families. Acknowledging the barriers that prevent access to health care for low-income families is the first step towards determining future sustainable solutions.

Immune-inflammatory activation after a single laparotomy in a rat model: effect of adenosine, lidocaine and Mg2+ infusion to dampen the stress response.

Our aim was to examine the effect of low-volume 0.9% NaCl adenosine, lidocaine and Mg2+ (ALM) 'drip' on early immune-inflammatory activation after a single laparotomy with no further manipulation. Male Sprague-Dawley rats were anesthetized and randomly assigned to one of the groups, baseline, 1 h infusion 0.9% NaCl ± ALM and metrics, 1 h infusion and 6-h metrics, and 6 h continuous infusion and metrics. Complete blood count, acid-base balance, systemic levels of IL-6 and IL-10, and coagulation status were measured. After 1 h, there was a disproportionate increase in circulating neutrophils between saline and ALM groups despite an identical 45% fall in lymphocytes. Disproportionate increases also occurred in platelet counts 1 h after surgery, and saline controls had increased respiratory alkalosis at 6 h with higher lactate. Systemic inflammation was also evident after 1 h in both groups (plasma IL-6 increase) and was amplified in saline-controls after 6 h. The ALM group increased anti-inflammatory cytokine IL-10. Surgery was not associated with acute coagulopathy; however, there were significant reductions in fibrinolysis. Following a single laparotomy, ALM infusion appeared to reduce stress-induced release of neutrophils and platelets into the circulation, and reduced acid-base disturbance. After 1 h, both groups had similar IL-6 levels, but ALM animals had increased IL-10, indicating improved inflammatory balance. The uncoupling of inflammation and coagulation activation but not fibrinolysis may offer a unique opportunity to investigate differential activation of innate immunity in response to sterile injury in this model.

Living with the Choice: A Grounded Theory of Iraqi Refugee Resettlement to the U.S.

Though the United States has become a place of increasing resettlement for refugees, particularly Iraqi refugees who have been forced to flee their homeland due to violence, persecution and civil unrest, little is known about Iraqi refugee resettlement in the United States, or the way in which resettlement impacts health and adjustment. A grounded theory study was conducted to develop a substantive theory of Iraqi refugee resettlement. Participants in the qualitative study included 29 Iraqi refugees and 2 community partners who participated in face-to face interviews. Data analysis and interpretation revealed fundamental concepts related to Iraqi refugee resettlement. Results of analysis showed that for Iraqis choosing to resettle here, the outcome is dichotomous: satisfaction or regret. The outcome is influenced by contextual factors as well as facilitating and hindering intervening conditions during the basic social process of resettlement transition. Each refugee's story is unique, yet all share common threads. This study allowed Iraqi refugees the opportunity to voice their personal experiences of resettling in America, and revealed life stories that inspire and illuminate a process that can guide health care delivery as they cope with the stresses of their journey. As a result, an in-depth storyline was established to explain the process of resettlement for Iraqi refugees. The development of this resettlement theory, grounded in Iraqi refugee experience, has the potential to guide nursing education, enhance the efficacy of practice, inform policy development and form the basis for research.

Disaster Impact on Impoverished Area of US: An Inter-Professional Mixed Method Study.

Introduction In the foothills of the Cumberland Mountains, in central Appalachia (a region that spans 13 states in the US), sits an economically distressed and rural community of the United States. Once a thriving coal-mining area, this region now is reported as one of the hardest places to live in the US. Southeastern Kentucky, located in a remote, rocky, mountainous area surrounded by rivers and valleys and prone to flooding, experienced a major flood in Spring 2013 causing significant damage to homes and critical infrastructure. Purpose Aims of the study were to: (1) identify and better understand the contextual variables compounding the impact of a disaster event that occurred in Spring 2013; (2) identify ways participants managed antecedent circumstances, risk, and protective factors to cope with disaster up to 12 months post-event; and (3) further determine implications for community-focused interventions that may enhance recovery for vulnerable populations to promote greater outcomes of adaptation, wellness, and readiness. METHODS: Using an ethnographic mixed-methods approach, an inter-collaborative team conducted face-to-face interviews with (N=12) Appalachian residents about their disaster experience, documented observations and visual assessment of need on an observation tool, and used photography depicting structural and environmental conditions. A Health and Emergency Preparedness Assessment Survey Tool was used to collect demographic, health, housing, environment, and disaster readiness assessment data. Community stakeholders facilitated purposeful sampling through coordination of scheduled home visits. RESULTS: Triangulation of all data sources provided evidence that the community had unique coping strategies related to faith and spirituality, cultural values and heritage, and social support to manage antecedent circumstances, risk, and protective factors during times of adversity that, in turn, enhanced resilience up to 12 months post-disaster. The community was found to have an innate capacity to persevere and utilize resources to manage and transcend adversity and restore equilibrium, which reflected components of resilience that deserve greater recognition and appreciation. CONCLUSION: Resilience is a foundational concept for disaster science. A model of resilience for the rural Appalachia community was developed to visually depict the encompassing element of community-based interventions that may enhance coping strategies, mitigate risk factors, integrate protective factors, and strengthen access. Community-based interventions are recommended to strengthen resilience, yielding improved outcomes of adaptation, health and wellness, and disaster readiness. Banks LH , Davenport LA , Hayes MH , McArthur MA , Toro SN , King CE , Vazirani HM . Disaster impact on impoverished area of US: an inter-professional mixed method study. Prehosp Disaster Med. 2016;31(6):583-592.

Birds of Two Oceans? Trans-Andean and Divergent Migration of Black Skimmers (Rynchops niger cinerascens) from the Peruvian Amazon.

Seasonal flooding compels some birds that breed in aquatic habitats in Amazonia to undertake annual migrations, yet we know little about how the complex landscape of the Amazon region is used seasonally by these species. The possibility of trans-Andes migration for Amazonian breeding birds has largely been discounted given the high geographic barrier posed by the Andean Cordillera and the desert habitat along much of the Pacific Coast. Here we demonstrate a trans-Andes route for Black Skimmers (Rynchops niger cinerascens) breeding on the Manu River (in the lowlands of Manu National Park, Perú), as well as divergent movement patterns both regionally and across the continent. Of eight skimmers tracked with satellite telemetry, three provided data on their outbound migrations, with two crossing the high Peruvian Andes to the Pacific. A third traveled over 1800 km to the southeast before transmissions ended in eastern Paraguay. One of the two trans-Andean migrants demonstrated a full round-trip migration back to its tagging location after traveling down the Pacific Coast from latitude 9° South to latitude 37° S, spending the austral summer in the Gulf of Arauco, Chile. This is the first documentation of a trans-Andes migration observed for any bird breeding in lowland Amazonia. To our knowledge, this research also documents the first example of a tropical-breeding waterbird migrating out of the tropics to spend the non-breeding season in the temperate summer, this being the reverse pattern with respect to seasonality for austral migrants in general.