Addressing the Challenge of COVID-19: One Health Care Site's Leadership Response to the Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic created an extremely disruptive challenge for health care leaders that required a rapid, dynamic, and innovative response. The purpose of this manuscript is to share the leadership actions and decisions at Mayo Clinic in Florida during the first 6 months of the pandemic (February to July 2020). We note 4 strategies that contributed to an effective response: (1) leverage experience with disaster preparedness and mobilize regional and national networks; (2) use surge models to anticipate and to address supply chain issues as well as practical and financial effects of the pandemic; (3) adapt creatively to establish new safety and procedural protocols in various areas for various populations; and (4) communicate timely information effectively and be the common source of truth. Mayo Clinic in Florida was able to address the surges of patients with COVID-19, to provide ongoing tertiary care, and to restore function within the first 6 months with new, strengthened practices and protocols.

A BRIEF OVERVIEW OF COMPARTMENTAL MODELING FOR INTAKE OF PLUTONIUM VIA WOUNDS.

The aim of this study is to present several approaches that have been used to model the behavior of radioactive materials (specifically Pu) in contaminated wounds. We also review some attempts by the health physics community to validate and revise the National Council on Radiation Protection and Measurements (NCRP) 156 biokinetic model for wounds, and present some general recommendations based on the review. Modeling of intake via the wound pathway is complicated because of a large array of wound characteristics (e.g. solubility and chemistry of the material, type and depth of the tissue injury, anatomical location of injury). Moreover, because a majority of the documented wound cases in humans are medically treated (excised or treated with chelation), the data to develop biokinetic models for unperturbed wound exposures are limited. Since the NCRP wound model was largely developed from animal data, it is important to continue to validate and improve the model using human data whenever plausible.

Cracking the whip: spatial voting with party discipline and voter polarization.

The spatial voting theory literature has generally focused on either parties or candidates as the unit of analysis and ignored strategic interactions between them. I study a game theoretic spatial model of elections with many heterogeneous constituencies in which both party and candidate behavior are modeled. Parties choose a platform and a 'whip rate,' representing the proportion of final policy that will be made by the party, as opposed to by the successful candidates. Candidates are office-motivated and can choose both a platform and a level of advertising in order to defeat their opponent. It is shown that the introduction of whipping as a choice variable can cause party platforms to diverge and that parties will whip on some but not all issues, reflecting the empirical reality of parties influencing rather than determining policy outcomes exclusively. Further, parties respond to sharper voter polarization by reducing the power of the whip as well as distinguishing their platforms from one another, while more voter uncertainty has the opposite effect. Other real-world phenomena, including 'safe seats' and legislators voting with their party even when unwhipped, are also shown to be predicted by the model.

Obstetric team simulation program challenges.

OBJECTIVE: To describe the challenges associated with the development and assessment of an obstetric emergency team simulation program. DESIGN: The goal was to develop a hybrid, in-situ and high fidelity obstetric emergency team simulation program that incorporated weekly simulation sessions on the labor and delivery unit, and quarterly, education protected sessions in the simulation center. All simulation sessions were video-recorded and reviewed. SETTING: Labor and delivery unit and simulation center. PARTICIPANTS: Medical staff covering labor and delivery, anesthesiology and obstetric residents and obstetric nurses. MEASUREMENTS: Assessments included an on-line knowledge multiple-choice questionnaire about the simulation scenarios. This was completed prior to the initial in-situ simulation session and repeated 3 months later, the Clinical Teamwork Scale with inter-rater reliability, participant confidence surveys and subjective participant satisfaction. A web-based curriculum comprising modules on communication skills, team challenges, and team obstetric emergency scenarios was also developed. MAIN RESULTS: Over 4 months, only 6 labor and delivery unit in-situ sessions out of a possible 14 sessions were carried out. Four high-fidelity sessions were performed in 2 quarterly education protected meetings in the simulation center. Information technology difficulties led to the completion of only 18 pre/post web-based multiple-choice questionnaires. These test results showed no significant improvement in raw score performance from pre-test to post-test (P=.27). During Clinical Teamwork Scale live and video assessment, trained raters and program faculty were in agreement only 31% and 28% of the time, respectively (Kendall's W=.31, P<.001 and W=.28, P<.001). Participant confidence surveys overall revealed confidence significantly increased (P<.05), from pre-scenario briefing to after post-scenario debriefing. CONCLUSION: Program feedback indicates a high level of participant satisfaction and improved confidence yet further program refinement is required.

Acute popliteal pseudoaneurysm rupture secondary to distal femoral osteochondroma in a patient with hereditary multiple exostoses.

A 21-year-old man with known hereditary multiple exostoses presented with a 24-hour history of atraumatic bruising and swelling of the posterior thigh. A leaking popliteal pseudoaneurysm was diagnosed on ultrasonography and an emergency saphenous vein bypass graft procedure performed. The patient required a post-operative blood transfusion but otherwise made a full recovery. Vascular complications from osteochondromas are rare and include vessel displacement, stenosis, occlusion, arteriovenous fistulas and pseudoaneurysm formation. Pseudoaneurysms usually present as an enlarging mass behind the knee. Acute rupture of an occult popliteal pseudoaneurysm caused by a distal femoral exostosis has not been reported previously.

Evaluation of Onion Cultivars for Resistance to Enterobacter cloacae in Storage.

Sixty-nine storage onion (Allium cepa) cultivars (seven white, five red, and 57 yellow cultivars) were evaluated in the Washington State University Onion Cultivar Trials in the semiarid Columbia Basin of central Washington in 2007-08 and/or 2008-09. Each cultivar was inoculated with Enterobacter cloacae, cured, stored under commercial storage conditions, and evaluated for bacterial storage rot symptoms approximately 4.5 months after storage. Noninoculated bulbs of each cultivar served as a control treatment in each experiment. In addition, bulbs injected with water served as a second control treatment in the 2008-09 experiment. Inoculation of onion bulbs with E. cloacae resulted in significantly higher incidence and severity of Enterobacter bulb decay compared to noninoculated bulbs and bulbs injected with sterile water. For bulbs inoculated with E. cloacae, mean severity of bacterial storage rot per cultivar ranged from 5 to 19% of the cross-section evaluated for each onion bulb in 2007-08 and from 9 to 29% in 2008-09. For noninoculated bulbs, mean severity ranged from 0 to 1% in 2007-08 and 0 to 3% in 2008-09. For bulbs injected with water in the 2008-09 experiment, severity of bulb rot ranged from 0 to 10% per cultivar, with four cultivars (OLYX05-26, RE-E, Redwing, and Talon) displaying bulb rot ratings significantly greater than 0%. For the 33 cultivars included in both experiments, a significant correlation in bulb rot severity ratings was detected for the 2007-08 versus 2008-09 experiments (r = 0.43 at P = 0.013). Redwing, Red Bull, T-433, Centerstone, and Salsa had low severity ratings in both experiments; whereas Montero, OLYS05N5, Caveat, and Granero had severe bulb rot ratings in both experiments. The results demonstrate that it should be possible to select for increased resistance to Enterobacter bulb decay in storage onion cultivars.

Uncertainties in internal doses calculated for Mayak workers--a study of 63 cases.

This study makes use of 63 cases of Mayak workers exposed to Pu-239 with autopsy data and some late-time urine bioassay data. In addition, air-concentration data--used to construct monthly average values--are available for each case, which provide the time dependence and potential magnitudes of normal inhalation intakes for each case. The purpose of the study is to develop and test Bayesian methods of dose calculation for the Mayak workers. The first part of the study was to quantitatively characterise the uncertainties of the bioassay data. Then, starting with three different published biokinetic models, the data are fit by varying intake and model perturbation parameters, e.g., parameters influencing the lung, thoracic lymph nodes, liver and bone retention. Statistical self-consistency arguments are used to check the measurement uncertainty parameters within the Poisson-lognormal model. The second part of the study is to set up and test Bayesian dose calculations, which use the point determinations of biokinetic parameters from the study cases within a discrete, empirical Bayes approximation. The main conclusion of the study is that these methods are now ready to be applied to the entire Mayak worker population.

Choice of antenatal testing significantly effects a patient's work obligations.

OBJECTIVE: We sought to compare two approaches to antenatal testing for their impact on the workforce. STUDY DESIGN: This is a prospective observational study of women who presented for antenatal testing. All women were given a survey upon presentation. As per hospital protocol, nonstress testing (NST) was performed semiweekly and biophysical profile (BPP) was performed weekly. The choice of testing was determined by the attending physician. chi2- and Student's t-tests were performed where appropriate. A P-value of <0.05 was considered significant. RESULT: A total of 195 women were surveyed. Among them, 94 women had an NST and 101 had a BPP. Overall, 59.2% were multiparous, 33.1% had to arrange for child care and 97.2% felt reassured by the testing. There were no differences in demographic characteristics, education, type of insurance or employment status between the groups. Women who had NSTs were more likely to lose time from work than those who had BPPs (218.4 versus 68.9 min; P<0.001). Of the women who had semiweekly NSTs, 80.6% would have preferred weekly testing. If the 94 women who received semiweekly testing had weekly testing, a total of 534.4 h would have been available for the workforce. CONCLUSION: Twice-weekly NST results in a significant increase in time lost from the workforce compared with weekly BPP.

Neonatal hearing assessment in very low birth weight infants exposed to antenatal steroids.

OBJECTIVE: We sought to evaluate neonatal hearing assessment by the otoacoustic emission (OAE) test in very low birth weight (VLBW) infants exposed to antenatal steroids. STUDY DESIGN: This is a retrospective cohort study of infants <1500 g delivered between July 1998 and July 2004 who completed hearing screens on discharge. All screens were performed by the OAE. Only infants who failed or passed the exam were included in the analysis. Infants with a partial or an inadequate exam were excluded. Neonates exposed to antenatal steroids were then compared to unexposed infants for the results of their OAE. RESULT: A total of 68,000 deliveries were performed during the study period. There were 703 VLBW infants who had hearing exams, of which 548 (78%) passed the screen, 95 (14%) failed and 59 (8%) were indeterminate. Gestational age, birth weight, score for neonatal acute physiology and severe intraventricular hemorrhage were associated with a failed screen (P<0.01). Antenatal steroid exposure was not associated with a failed screen (odds ratio: 0.83 (95% confidence interval 0.5-1.4), P=0.43). CONCLUSION: In our population, antenatal steroids were not associated with a positive or negative effect on hearing assessment of VLBW infants.

Interventions to reduce low-back injury risk among youth who perform feed handling and scooping tasks on farms.

Children and adolescents who perform farm chores are exposed to cumulative trauma injury risks, particularly to the low back. For example, they may routinely handle heavy materials and need to adopt awkward postures during farm chores. Two potential interventions aimed at reducing low-back injury risk were examined in the laboratory: the use of a rugged cart and proper orienting of feed bags to ease feed transport; and the use of a modified feed bin, intended to allow easier access to product scooped from the bin at different levels. A lumbar motion monitor device was used to quantify trunk movement and determine injury risk level. Fourteen male and female youth who regularly perform these farm chores participated in the study. The cart significantly reduced low-back injury risk by nearly 10%, compared with manual feed bag lifting and carrying. The modified feed bin did not significantly reduce low-back injury risk, compared with traditional scooping. Regardless of the method used, however, scooping feed from the top of the bin reduced lower back disorder risk by 50% or more compared to the two lower levels. This study showed that relatively simple and low-cost solutions can be applied to farm environments to help protect the low backs of youth who perform farm chores.

New procedure for assessing sequential manual lifting jobs using the revised NIOSH lifting equation.

A sequential manual lifting job is defined as a job where workers rotate between a series of manual lifting rotation slots or elements at specified time intervals during the course of a work shift. The original NIOSH lifting equation lacked a method for assessing the physical demands of these types of jobs. This paper presents the sequential lifting index (SLI), a new conceptual method for assessing the physical demands for sequential manual lifting jobs. The new method is similar to the composite lifting index (CLI) method that was provided by NIOSH for assessing multi-task jobs. The SLI method expands upon the methods originally provided by NIOSH by providing a simple method for estimating the relative magnitude of physical stress for sequential manual lifting jobs. It should also be useful in assisting safety and health specialists to prioritize or rank hazardous jobs within a plant.

Percutaneous dynamic hip screw.

We present the results of a technique of dynamic hip screw insertion through a very small incision, typically 2-2.5 cm. The technique is performed using a standard dynamic hip screw set and requires no additional equipment. We compared the results to those of an age and sex-matched group who had undergone the operation through a traditional approach. We compared the time spent in theatre, the pre- and post-operative haemoglobin concentration, haematocrit and prevalence of wound infection. Thirteen consecutive cases were performed by one surgeon using the percutaneous technique. There were nine females and four males with a mean age of 84 years (range 62-96 years). Each had a 135 degrees four-hole plate. The mean post-operative drop in haemoglobin concentration in the percutaneous group was 2.2 g/dl (range 0-4.4 g/dl) compared to 3.5 g/dl (range 1.2-5.4 g/dl) in the control group (p = 0.014). The mean haematocrit drop was 0.07 (range 0-0.12) in the percutaneous group compared to 0.10 (range 0.03-0.17) in the control group (p = 0.017). The mean theatre time with the percutaneous technique was 57 min (range 40-75 min) and in the control group, 60 min (range 30-95 min). There were no wound problems. It is likely that this minimally invasive technique offers a better clinical outcome at no extra expense and warrants further evaluation in a larger study.

Physical demands and low-back injury risk among children and adolescents working on farms.

Little information currently exists regarding the risk of low-back disorders among youth who perform physically demanding farm activities. Thus, afield study was conducted in which children and adolescents who engage in farm work were recruited, fitted with a lumbar motion monitoring system, and then observed performing their usual chores. The lumbar motion monitor was used to record the trunk movements required while youth were performing routine manual material handling tasks on a farm. Workplace factors and motions from both males and females were recorded on over 40 farm tasks, such as feeding animals, lifting bales of hay and straw, and other miscellaneous farm chores. Although the sample size and number of observations in this study were small, the results showed that the magnitude of several work-related factors, such as weight and horizontal moment arm, and trunk motions for many farm activities were equal to or greater than those associated with high injury risk jobs previously assessed in industrial workplaces. In this study, we quantified the physical demands of tasks performed by children and adolescents on farms. In addition, the specific farm chores more likely to load the spines of youth and thereby contribute to musculoskeletal injury were identified.

Medical school attended as a predictor of medical malpractice claims.

OBJECTIVES: Following earlier research which showed that certain types of physicians are more likely to be sued for malpractice, this study explored (1). whether graduates of certain medical schools have consistently higher rates of lawsuits against them, (2). if the rates of lawsuits against physicians are associated with their school of graduation, and (3). whether the characteristics of the medical school explain any differences found. DESIGN: Retrospective analysis of malpractice claims data from three states merged with physician data from the AMA Masterfile (n=30288). STUDY SUBJECTS: All US medical schools with at least 5% of graduates practising in three study states (n=89). MAIN OUTCOME MEASURES: Proportion of graduates from a medical school for a particular decade sued for medical malpractice between 1990 and 1997 and odds ratio for lawsuits against physicians from high and low outlier schools; correlations between the lawsuit rates of successive cohorts of graduates of specific medical schools. RESULTS: Medical schools that are outliers for malpractice lawsuits against their graduates in one decade are likely to retain their outlier status in the subsequent decade. In addition, outlier status of a physician's medical school in the decade before his or her graduation is predictive of that physician's malpractice claims experience (p<0.01). All correlations of cohorts were relatively high and all were statistically significant at p<0.001. Comparison of outlier and non-outlier schools showed that some differences exist in school ownership (p<0.05), years since established (p<0.05), and mean number of residents and fellows (p<0.01). CONCLUSIONS: Consistent differences in malpractice experience exist among medical schools. Further research exploring alternative explanations for these differences needs to be conducted.

Patellar resurfacing in total knee arthroplasty. A prospective, randomized study.

BACKGROUND: Anterior knee pain following total knee arthroplasty is a common complaint and typically is attributed to the patellofemoral joint. The purpose of the present study was to compare the outcome of resurfacing and nonresurfacing of the patella, particularly with regard to anterior knee pain, and to clarify the indications for patellar resurfacing at the time of total knee arthroplasty. METHODS: We performed a prospective, randomized study of 514 consecutive primary press-fit condylar total knee replacements. The patients were randomized to either resurfacing or retention of the patella. They were also randomized to either a cruciate-substituting or a cruciate-retaining prosthesis as part of a separate trial. The mean duration of follow-up was 5.3 years (range, two to 8.5 years), and the patients were assessed with use of the Knee Society rating, a clinical anterior knee pain score, and the British Orthopaedic Association patient-satisfaction score. The assessment was performed without the examiner knowing whether the patella had been resurfaced. At the time of follow-up, there were 474 knees. Thirty-five patients who had a bilateral knee replacement underwent resurfacing on one side only. RESULTS: The overall prevalence of anterior knee pain was 25.1% (fifty-eight of 231 knees) in the nonresurfacing group, compared with 5.3% (thirteen of 243 knees) in the resurfacing group (p < 0.0001). There was one case of component loosening. Ten of eleven patients who underwent secondary resurfacing had complete relief of anterior knee pain. The overall postoperative knee scores were lower in the nonresurfacing group, and the difference was significant among patients with osteoarthritis (p < 0.01). There was no significant difference between the resurfacing and nonresurfacing groups with regard to the postoperative function score. Patients who had a bilateral knee replacement were more likely to prefer the resurfaced side. CONCLUSIONS: As the present study showed a significantly higher rate of anterior knee pain following arthroplasty without patellar resurfacing, we recommend patellar resurfacing at the time of total knee replacement when technically possible.

Spinal loading when lifting from industrial storage bins.

The study documented three-dimensional spinal loading during lifting from an industrial bin. Two lifting styles and two bin design factors were examined in Phase I. The lifting style measures in Phase I were one hand versus two hand and standing on one foot versus two feet. The bin design variables were region of load in the bin and bin height. The Phase II study examined one-handed lifting styles with and without supporting body weight with the free hand on the bin as well as region and the number of feet. Twelve male and 12 female subjects lifted an 11.3 kg box from the bin. Spinal compression, lateral shear and anterior - posterior shear forces were estimated using a validated EMG-assisted biomechanical model. Phase I results indicated that the bin design factor of region had the greatest impact on spinal loading. The upper front region minimized spinal loading for all lifting styles. Furthermore, the lifting style of two hands and two feet minimized spinal loading. However, comparing Phase I two-handed lifting with Phase II one-handed supported lifting, the one-handed supported lifting techniques had lower compressive and anterior - posterior shear loads in the lower regions as well as the upper back region of the bin. A bin design that facilitates lifting from the upper front region of the bin reduces spinal loading more effectively than specific lifting styles. Furthermore, a bin design with a hand hold may facilitate workers using a supported lifting style that reduces spinal loading.

Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: preliminary findings.

The effectiveness of a 14-week cognitive-behavioral family treatment protocol for childhood obsessive-compulsive disorder (OCD) was piloted using a volunteer sample of seven children aged 10-14 years. The primary outcome measures were diagnostic status, symptom severity, and global functioning which were assessed at pre- and post-treatment, and at three-month follow-up. A series of self-report measures assessing obsessive-compulsive symptomatology, depression, and family factors were also completed at pre- and post-treatment. The results indicated that six participants no longer met criteria for OCD at post-treatment, with a mean reduction of 60% in symptom severity. Self-reported obsessive-compulsive symptomatology and family involvement in the disorder also significantly decreased across time. The findings support the efficacy of cognitive-behavioral treatment with a structured family component for childhood OCD. Further research investigating the comparative efficacy of treatment with and without family involvement is warranted.

Heat illness: tips for recognition and treatment.

Heat stroke, an acute, life-threatening emergency, results from an overload or impairment of heat-dissipating mechanisms. At risk are the elderly, infants, the obese, people with hyperthyroidism, and those taking certain drugs. Early recognition and rapid cooling are essential--the more rapid the cooling, the lower the mortality.

Physician-system alignment: introductory overview.

The papers in this Special Supplement are based on research funded by the participating members of the joint Center for Health Management Research (CHMR) and Center for Organized Delivery Systems (CODS), and supported by the National Science Foundation under its Industry-University Cooperative Research Center Program. This 3-year research initiative from 1996 through 1999 involved 69 physician organizations (primarily organized medical groups as opposed to IPAs) associated with 14 organized delivery systems. The groups ranged in size from three to 958 with an average size of 76.4 and a median size of 25.0. Comparisons of the study groups with United States physician groups overall are shown in Table 1. The study groups are larger and more likely to be multispecialty than all groups in the United States. The organized delivery systems range in size from one hospital to 80 hospitals with an average of 21 hospitals per system and a median of 11 hospitals per system. They average 4.6 affiliated medical groups with a range from one to 23. The organized delivery systems range in total revenues in 1998 from $340 million to $6.2 billion with an average of $2.1 billion. All the study systems are not-for-profit. Most are located in single market areas, but several are located in multiple markets. For the most part, they represent some of the larger most experienced organized delivery systems in the country. Among the primary objectives of the study was to identify the factors most strongly associated with physician alignment with the health care system and the consequences for the implementation of evidence-based care management practices. The study was also designed to identify the barriers and facilitators to achieving such alignment and its consequences.