Cysteine induces mitochondrial reductive stress in glioblastoma through hydrogen peroxide production.

Glucose and amino acid metabolism are critical for glioblastoma (GBM) growth, but little is known about the specific metabolic alterations in GBM that are targetable with FDA-approved compounds. To investigate tumor metabolism signatures unique to GBM, we interrogated The Cancer Genome Atlas for alterations in glucose and amino acid signatures in GBM relative to other human cancers and found that GBM exhibits the highest levels of cysteine and methionine pathway gene expression of 32 human cancers. Treatment of patient-derived GBM cells with the FDA-approved single cysteine compound N-acetylcysteine (NAC) reduced GBM cell growth and mitochondrial oxygen consumption, which was worsened by glucose starvation. Normal brain cells and other cancer cells showed no response to NAC. Mechanistic experiments revealed that cysteine compounds induce rapid mitochondrial H2O2 production and reductive stress in GBM cells, an effect blocked by oxidized glutathione, thioredoxin, and redox enzyme overexpression. From analysis of the clinical proteomic tumor analysis consortium (CPTAC) database, we found that GBM cells exhibit lower expression of mitochondrial redox enzymes than four other cancers whose proteomic data are available in CPTAC. Knockdown of mitochondrial thioredoxin-2 in lung cancer cells induced NAC susceptibility, indicating the importance of mitochondrial redox enzyme expression in mitigating reductive stress. Intraperitoneal treatment of mice bearing orthotopic GBM xenografts with a two-cysteine peptide induced H2O2 in brain tumors in vivo. These findings indicate that GBM is uniquely susceptible to NAC-driven reductive stress and could synergize with glucose-lowering treatments for GBM.

Astrocytes as Drivers and Disruptors of Behavior: New Advances in Basic Mechanisms and Therapeutic Targeting.

Astrocytes are emerging as key regulators of cognitive function and behavior. This review highlights some of the latest advances in the understanding of astrocyte roles in different behavioral domains across lifespan and in disease. We address specific molecular and circuit mechanisms by which astrocytes modulate behavior, discuss their functional diversity and versatility, and highlight emerging astrocyte-targeted treatment strategies that might alleviate behavioral and cognitive dysfunction in pathologic conditions. Converging evidence across different model systems and manipulations is revealing that astrocytes regulate behavioral processes in a precise and context-dependent manner. Improved understanding of these astrocytic functions may generate new therapeutic strategies for various conditions with cognitive and behavioral impairments.

Assessing message deployment during public health emergencies through social media: An empirical test of optimizing content for effective dissemination.

BACKGROUND: During an infodemic, the need for timely, reliable, and accessible information is crucial to combat the proliferation of health misinformation. Message testing can provide vital information to make data-informed decisions, but traditional methods tend to be time and resource intensive. Recognizing this need, we developed the Rapid Message Testing at Scale (RMTS) approach to allow communicators to repurpose existing social media advertising tools and understand the full spectrum of audience engagement. OBJECTIVE: We had two main objectives: a) to demonstrate the use of the RMTS approach for message testing, especially when resources are limited and there is a need to act in a timely manner, and (b) to propose and test the efficacy of an outcome variable that measures engagement along a continuum of viewing experience. METHODS: We developed 12 versions of a single video that was created for a vaccine confidence project in India. We manipulated video length, aspect ratio, and use of subtitles. The videos were tested across four demographic groups (women/men, younger/older). We assessed user engagement along a continuum of viewing experience: getting attention, sustaining attention, conveying the message, and inspiring action. These were measured by percentage of video watched and clicks on the call-to-action link. RESULTS: The video ads were placed on Facebook over four consecutive days at the cost of $450 (U.S.) and garnered a total of 3.34 million impressions. Overall, we found that the best performing video was the shorter version presented in portrait aspect ratio and without subtitles. There was a significant but small association between the length of the video and users' level of engagement at key points along the continuum of viewing experience (N=1,032,888; 〖χ^2〗_4=48,261.97; P<.001; V=.22). We found that for the longer video, those with subtitles held viewers longer after 25% video watch time than those without subtitles (n=15,597; 〖χ^2〗_1=7.33; P<.01; V=.02). While we found some significant associations between the aspect ratio, the use of subtitles, and the number of users watching the video and clicking on the call-to-action link, the effect size for those were extremely small. CONCLUSIONS: This test served as a proof of concept for the RMTS approach. We obtained rapid feedback on formal message attributes from a very large sample in a very short timeframe. The results of this test reinforce the need for platform-specific tailoring of communications. While our data showed a general preference for the short video in portrait orientation and without subtitles among our target audiences on Facebook, that may not necessarily be the case in other social media platforms such as YouTube or TikTok, where users go primarily to watch videos. RMTS testing highlights nuances that communication professionals can address instead of being limited to a 'one size fits all' approach.

Differentiating radiation necrosis from tumor recurrence: a systematic review and diagnostic meta-analysis comparing imaging modalities.

PURPSOSE: Cerebral radiation necrosis (RN) is often a delayed phenomenon occurring several months to years after the completion of radiation treatment. Differentiating RN from tumor recurrence presents a diagnostic challenge on standard MRI. To date, no evidence-based guidelines exist regarding imaging modalities best suited for this purpose. We aim to review the current literature and perform a diagnostic meta-analysis comparing various imaging modalities that have been studied to differentiate tumor recurrence and RN. METHODS: A systematic search adherent to PRISMA guidelines was performed using Scopus, PubMed/MEDLINE, and Embase. Pooled sensitivities and specificities were determined using a random-effects or fixed-effects proportional meta-analysis based on heterogeneity. Using diagnostic odds ratios, a diagnostic frequentist random-effects network meta-analysis was performed, and studies were ranked using P-score hierarchical ranking. RESULTS: The analysis included 127 studies with a total of 220 imaging datasets, including the following imaging modalities: MRI (n = 10), MR Spectroscopy (MRS) (n = 28), dynamic contrast-enhanced MRI (n = 7), dynamic susceptibility contrast MRI (n = 36), MR arterial spin labeling (n = 5), diffusion-weighted imaging (n = 13), diffusion tensor imaging (DTI) (n = 2), PET (n = 89), and single photon emission computed tomography (SPECT) (n = 30). MRS had the highest pooled sensitivity (90.7%). DTI had the highest pooled specificity (90.5%). Our hierarchical ranking ranked SPECT and MRS as most preferable, and MRI was ranked as least preferable. CONCLUSION: These findings suggest SPECT and MRS carry greater utility than standard MRI in distinguishing RN from tumor recurrence.

Production of vaccination videos in India: learnings from a science-art partnership.

BACKGROUND: Cross-cultural communication, often conceptualized along culture and language dimensions, is an important issue for collaborative teams that include both scientists and artists. Such teams must balance the standardization needs of rigorous scientific methods, on the one hand, with openness for artistic creativity, on the other. The scientific literature does not provide clear guidance on how to structure such collaborations. DISCUSSION: We created eight videos manipulating the type of appeal, message tone, and gender of the vaccine promoter in a 2 × 2 × 2 between-subjects experiment. The four stages of the filmmaking process were 1) conceptualizing filmmaking and script writing through a scientific lens, 2) pilot testing and finalizing the script, 3) video production and editing, and 4) dissemination. We describe the process and learnings from a collaboration that included filmmakers, researchers, and vaccine experts from India and the United States in producing, disseminating, and evaluating videos that promoted vaccine uptake in Odisha, India. CONCLUSIONS: When projects require close collaborations between scientists and artists, committing to a unified vision is essential for facilitating open, bidirectional communication and building trust between the partners. Clearly denoting research boundaries ensures that the scientific needs of the project are met while simultaneously welcoming space for the filmmakers' creativity, fostering a sense of ownership, and enhancing the final product.

Postprandial glycine as a biomarker of satiety: A dose-rising randomised control trial of whey protein in overweight women.

This study aimed to identify biomarkers of appetite response, modelled using a dose-rising whey protein preload intervention. Female participants (n = 24) with body mass index (BMI) between 23 and 40 kg/m2 consumed preload beverages (0 g protein water control, WC; 12.5 g low-dose protein, LP; or 50.0 g high-dose protein, HP) after an overnight fast, in a randomised cross over design. Repeated venous blood samples were collected to measure plasma biomarkers of appetite response, including glucose, glucoregulatory peptides, gut peptides, and amino acids (AAs). Appetite was assessed using Visual Analogue Scales (VAS) and ad libitum energy intake (EI). Dose-rising protein beverage significantly changed the postprandial trajectory of almost all biomarkers (treatment*time, p < 0.05), but did not suppress postprandial appetite (treatment*time, p > 0.05) or EI (ANOVA, p = 0.799). Circulating glycine had the strongest association with appetite response. Higher area under the curve (AUC0-240) glycine was associated with lower EI (p = 0.026, trend). Furthermore, circulating glycine was associated with decreased Hunger in all treatment groups, whereas the associations of glucose, alanine and amylin with appetite were dependent on treatment groups. Multivariate models, incorporating multiple biomarkers, improved the estimation of appetite response (marginal R2, range: 0.13-0.43). In conclusion, whilst glycine, both alone and within a multivariate model, can estimate appetite response to both water and whey protein beverage consumption, a large proportion of variance in appetite response remains unexplained. Most biomarkers, when assessed in isolation, are poor predictors of appetite response, and likely of utility only in combination with VAS and EI.

Operationalizing Community Assessment Results to Enhance Preparedness for a Radiological Emergency.

OBJECTIVE: A radiological emergency such as the detonation of a radiological dispersal device would have catastrophic health, environmental, and economic consequences. Community assessments can provide useful information about radiological and other emergency preparedness at the household level. Tools such as logic models can be applied to link data collected in a community assessment to planned activities and targeted outcomes. This study sought to answer how public health departments can use the results of a community assessment to improve preparedness for radiological and other types of emergencies and to present a sample logic model demonstrating how questions asked in a community assessment can be used to drive intended outcomes. DESIGN: Surveys were fielded in 2019 to professionals with experience in radiological emergency preparedness, state and local health and emergency management, and journalism. Questions included the role of health departments in radiological emergency preparedness, the operationalization of results from a community assessment for preparedness, and information sharing in a radiological emergency. Descriptive statistics and a modified framework approach were used for open-ended questions. RESULTS: Nearly three-fourths of state/local officials reported that it would be at least somewhat difficult (73%; 11 of 15 state/local officials) for a local health department to operationalize the results of a community health assessment for radiological emergency preparedness. Potential barriers included competing priorities, lack of funds, and limited staff. Resources such as pretested communication materials, tailored messaging, and technical tools and training can assist health departments and emergency management agencies in using the information collected from a community assessment. CONCLUSIONS: To address implementation challenges in operationalizing the results of a community assessment, officials can use tools such as logic models to illustrate how the information gathered from a community health assessment will create an intended preparedness outcome and to advocate for funds for this type of assessment.

Public Health Emergency Response Leadership Training: A Qualitative Assessment of Existing Educational Opportunities and Perceived Facilitators, Barriers, and Priorities in Professional Development.

OBJECTIVE: We aimed to understand the current training environment for developing public health emergency response leaders and highlight facilitators and barriers in accessing targeted training. DESIGN: We designed 4 focus groups to gather organizational perspectives on public health emergency response leadership development. Discussions were recorded, transcribed, coded, and analyzed to synthesize key themes. SETTING: Focus groups were convened at the 2019 Preparedness Summit (March 27-28) in St Louis, Missouri. PARTICIPANTS: Twenty-three public health professionals from 9 Public Health Emergency Preparedness (PHEP) Cooperative Agreement award recipient jurisdictions and 12 local health departments participated. MAIN OUTCOME MEASURES: We examined the current availability, relevance, specificity, and utility of educational content and delivery modalities. Facilitators and barriers were identified as opportunities to improve training access. RESULTS: Generic emergency management training is considered important and widely available but with limited application in public health practice. Existing leadership training opportunities in public health emergency response are limited and not widely known. While organizational support and accessible training facilitate participation, resource constraints (ie, funding, time, and staff) exist as key barriers. In addition, frequent staff turnover and attrition that result in loss of institutional knowledge likely hinder effective public health emergency responses. CONCLUSION: Effective public health emergency response depends on capable leaders not only well versed in specialized technical disciplines and practices but also familiar with-or preferably fluent in-emergency management principles and functions. This study demonstrated that well-aimed training strategies and organizational planning are essential in developing public health emergency response leaders. Specifically, leadership development may accrue considerable benefit from a standardized training curriculum. In addition, scalable training programs developed through public, private, and academic partnerships may lessen resource demands on individual organizations to facilitate training access. Finally, training practicums (eg, mentoring, shadowing) may provide opportunities to facilitate active learning and preserve institutional knowledge through leadership transitions.

Building Collective Efficacy to Support Public Health Workforce Development.

CONTEXT: Leaders in public health have made great advances in workforce development over the past 30 years, while shifting from an emphasis based in training on individual, technical skills to a more holistic development approach, which boosts crosscutting skills. Efforts to increase public health workforce capabilities remain focused on workers as individuals, rather than the workforce as a collective unit. PROGRAM: Research has shown that a strategic adult learning approach can improve both individual capabilities and the collective performance of the workforce, which can be explained using social cognitive theory and the concept of collective efficacy, or the collective belief of workers in the ability of the group to succeed. We explain how a prior training program pushed us to explore this approach. IMPLEMENTATION: The proposed approach covers proposed implementation strategies to build collective efficacy as part of existing workforce development initiatives, with a focus on 5 key steps. EVALUATION: Experience in fields as diverse as sports psychology and organizational development has shown that it is possible to evaluate changes in collective efficacy using measures that can be adopted in public health. DISCUSSION: Adjusting existing public health workforce development initiatives to build collective efficacy can help link workforce self-confidence to performance. More actionable data are needed to determine the best methods for achieving those goals in the field of public health.

An Analysis of After Action Reports From Texas Hurricanes in 2005 and 2017.

OBJECTIVE: To review and analyze After Action Reports from jurisdictions in Texas following Hurricanes Katrina and Rita in 2005 and Hurricane Harvey in 2017 in order to assess the utility of AARs as a quality improvement measurement tool. METHODS: The authors searched the Homeland Security Digital Library, the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange, and Google Scholar for any AARs that covered the response phase of at least one of the 3 hurricanes, mentioned the state of Texas, and suggested solutions to problems. The authors applied public health emergency management (PHEM) domains, as outlined by Rose et al, to frame the AAR analysis. AARs were coded by 2 reviewers independently, with a third acting as adjudicator. As an example, the problem statements in 2005 and 2017 AARs from 1 statewide agency were compared. RESULTS: Sixteen AARs met the inclusion criteria. There were 500 identified problem-solution sets mapped to a PHEM domain. The content was unevenly distributed, with most issues coming under PHEM 2: Policies, Plans, Procedures, and Partnerships at 45.2% in the 2005 hurricanes and 39.9% in 2017. AARs lacked consistent format and were often prepared by the response agencies themselves. Five consistent issues were raised in 2005 and again in 2017. These were volunteer management and credential verification, donations management, information sharing, appropriately identifying those requiring a medical needs shelter, and inadequate transportation to support evacuation. CONCLUSION: Because of the lack of objective data, inconsistent format, unevenly distributed content, and lack of adherence to any framework, AARs are fraught with shortcomings as a tool for PHEM. Inclusion of more objective reporting measures is urgently needed.

Automated Identification and Quantification of Signals in Multichannel Immunofluorescence Images: The SignalFinder-IF Platform.

Multimarker fluorescence analysis of tissue specimens offers the opportunity to probe the expression levels and locations of multiple markers in a single sample. Software is needed to fully capitalize on the advantages of this technology for sensitive, quantitative, and multiplexed data collection. A major challenge has been the automated identification and quantification of signals. We report on the software SignalFinder-IF, which meets that need. SignalFinder-IF uses a newly developed algorithm called Segment-Fit Thresholding, which showed robust performance for automated signal identification in side-by-side comparisons with several current methods. Two utilities provided with SignalFinder-IF enable downstream analyses. The first allows the quantification and mapping of relationships between an unlimited number of markers through user-defined sequences of AND, OR, and NOT operators. The second produces composite pictures of the signals or colocalization analysis on brightfield hematoxylin and eosin images, which is useful for understanding the morphologies and locations of cells meeting specific marker criteria. SignalFinder-IF enables high-throughput, rigorous analyses of whole-slide, multimarker data, and it promises to open new possibilities in many research and clinical applications.

Anesthesiologists and Disaster Medicine: A Needs Assessment for Education and Training and Reported Willingness to Respond.

BACKGROUND: Anesthesiologists provide comprehensive health care across the emergency department, operating room, and intensive care unit. To date, anesthesiologists' perspectives regarding disaster medicine and public health preparedness have not been described. METHODS: Anesthesiologists' thoughts and attitudes were assessed via a Web-based survey at 3 major academic institutions. Frequencies, percentages, and odds ratios (ORs) were used to assess self-reported perceptions of knowledge and skills, as well as attitudes and beliefs regarding education and training, employee development, professional obligation, safety, psychological readiness, efficacy, personal preparedness, and willingness to respond (WTR). Three representative disaster scenarios (natural disaster [ND], radiological event [RE], and pandemic influenza [PI]) were investigated. Results are reported as percent or OR (95% confidence interval). RESULTS: Participants included 175 anesthesiology attendings (attendings) and 95 anesthesiology residents (residents) representing a 47% and 51% response rate, respectively. A minority of attendings indicated that their hospital provides adequate pre-event preparation and training (31% [23-38] ND, 14% [9-21] RE, and 40% [31-49] PI). Few residents felt that their residency program provided them with adequate preparation and training (22% [14-33] ND, 16% [8-27] RE, and 17% [9-29] PI). Greater than 85% of attendings (89% [84-94] ND, 88% [81-92] RE, and 87% [80-92] PI) and 70% of residents (81% [71-89] ND, 71% [58-81] RE, and 82% [70-90] PI) believe that their hospital or residency program, respectively, should provide them with preparation and training. Approximately one-half of attendings and residents are confident that they would be safe at work during response to a ND or PI (55% [47-64] and 58% [49-67] of attendings; 59% [48-70] and 48% [35-61] of residents, respectively), whereas approximately one-third responded the same regarding a RE (31% [24-40] of attendings and 28% [18-41] of residents). Fewer than 40% of attendings (34% [26-43]) and residents (38% [27-51]) designated who would take care of their family obligations in the event they were called into work during a disaster. Regardless of severity, 79% (71-85) of attendings and 73% (62-82) of residents indicated WTR to a ND, whereas 81% (73-87) of attendings and 70% (58-81) of residents indicated WTR to PI. Fewer were willing to respond to a RE (63% [55-71] of attendings and 52% [39-64] of residents). In adjusted logistic regression analyses, those anesthesiologists who reported knowing one's role in response to a ND (OR, 15.8 [4.5-55.3]) or feeling psychologically prepared to respond to a ND (OR, 6.9 [2.5-19.0]) were found to be more willing to respond. Similar results were found for RE and PI constructs. Both attendings and residents were willing to respond in whatever capacity needed, not specifically to provide anesthesia. CONCLUSIONS: Few anesthesiologists reported receiving sufficient education and training in disaster medicine and public health preparedness. Providing education and training and enhancing related employee services may further bolster WTR and help to build a more capable and effective medical workforce for disaster response.

Perceived Facilitators and Barriers to Local Health Department Workers' Participation in Infectious Disease Emergency Responses.

CONTEXT: Local health departments play a key role in emergency preparedness and respond to a wide range of threats including infectious diseases such as seasonal influenza, tuberculosis, H1N1, Ebola virus disease, and Zika virus disease. To successfully respond to an infectious disease outbreak, local health departments depend upon the participation of their workforce; yet, studies indicate that sizable numbers of workers would not participate in such a response. The reasons why local health department workers participate, or fail to participate, in infectious disease responses are not well understood. OBJECTIVE: To understand why local health department workers are willing, or not willing, to report to work during an infectious disease response. DESIGN: From April 2015 to January 2016, we conducted 28 semistructured interviews with local health department directors, preparedness staff, and nonpreparedness staff. SETTING: Interviews were conducted with individuals throughout the United States. PARTICIPANTS: We interviewed 28 individuals across 3 groups: local health department directors (n = 8), preparedness staff (n = 10), and nonpreparedness staff (n = 10). MAIN OUTCOME MEASURES: Individuals' descriptions of why local health department workers are willing, or not willing, to report to work during an infectious disease response. RESULTS: Factors that facilitate willingness to respond to an infectious disease emergency included availability of vaccines and personal protective equipment; flexible work schedule and childcare arrangements; information sharing via local health department trainings; and perceived commitments to one's job and community. Factors that hinder willingness to respond to an infectious disease emergency included potential disease exposure for oneself and one's family; logistical considerations for care of children, the elderly, and pets; and perceptions about one's role during an infectious disease response. CONCLUSION: Our findings highlight opportunities for local health departments to revisit their internal policies and engage in strategies likely to promote willingness to respond among their staff. As LHDs face the persistent threat of infectious diseases, they must account for response willingness when planning for and fielding emergency responses. Our findings highlight opportunities for local health departments to revisit their internal policies and engage in strategies likely to promote response willingness to infectious disease emergencies among their staff.

Decision Processes and Determinants of Hospital Evacuation and Shelter-in-Place During Hurricane Sandy.

CONTEXT: Evacuation and shelter-in-place decision making for hospitals is complex, and existing literature contains little information about how these decisions are made in practice. OBJECTIVE: To describe decision-making processes and identify determinants of acute care hospital evacuation and shelter-in-place during Hurricane Sandy. DESIGN: Semistructured interviews were conducted from March 2014 to February 2015 with key informants who had authority and responsibility for evacuation and shelter-in-place decisions for hospitals during Hurricane Sandy in 2012. Interviews were recorded, transcribed, and thematically analyzed. SETTING AND PARTICIPANTS: Interviewees included hospital executives and state and local public health, emergency management, and emergency medical service officials from Delaware, Maryland, New Jersey, and New York. MAIN OUTCOME MEASURE(S): Interviewees identified decision processes and determinants of acute care hospital evacuation and shelter-in-place during Hurricane Sandy. RESULTS: We interviewed 42 individuals from 32 organizations. Decisions makers reported relying on their instincts rather than employing guides or tools to make evacuation and shelter-in-place decisions during Hurricane Sandy. Risk to patient health from evacuation, prior experience, cost, and ability to maintain continuity of operations were the most influential factors in decision making. Flooding and utility outages, which were predicted to or actually impacted continuity of operations, were the primary determinants of evacuation. CONCLUSION: Evacuation and shelter-in-place decision making for hospitals can be improved by ensuring hospital emergency plans address flooding and include explicit thresholds that, if exceeded, would trigger evacuation. Comparative risk assessments that inform decision making would be enhanced by improved collection, analysis, and communication of data on morbidity and mortality associated with evacuation versus sheltering-in-place of hospitals. In addition, administrators and public officials can improve their preparedness to make evacuation and shelter-in-place decisions by practicing the use of decision-making tools during training and exercises.

Hospital Administration and Nursing Leadership in Disasters: An Exploratory Study Using Concept Mapping.

Strong leadership is critical in disaster situations when "patient surge" challenges a hospital's capacity to respond and normally acceptable patterns of care are disrupted. Activation of the emergency operations plan triggers an incident command system structure for leadership decision making. Yet, implementation of the emergency operations plan and incident command system protocols is ultimately subject to nursing and hospital leadership at the service- and unit level. The results of these service-/unit-based leadership decisions have the potential to directly impact staff and patient safety, quality of care, and ultimately, patient outcomes. Despite the critical nature of these events, nurse leaders and administrators receive little education regarding leadership and decision making during disaster events. The purpose of this study is to identify essential competencies of nursing and hospital administrators' leadership during disaster events. An integrative mixed-methods design combining qualitative and quantitative approaches to data collection and analysis was used. Five focus groups were conducted with nurse leaders and hospital administrators at a large urban hospital in the Northeastern United States in a collaborative group process to generate relevant leadership competencies. Concept Systems Incorporated was used to sort, prioritize, and analyze the data (http://conceptsystemsinc.com/). The results suggest that participants' institutional knowledge (of existing resources, communications, processes) and prior disaster experience increase leadership competence.

EPPM and willingness to respond: the role of risk and efficacy communication in strengthening public health emergency response systems.

This study examines the attitudinal impact of an Extended Parallel Process Model (EPPM)-based training curriculum on local public health department (LHD) workers' willingness to respond to representative public health emergency scenarios. Data are from 71 U.S. LHDs in urban and rural settings across nine states. The study explores changes in response willingness and EPPM threat and efficacy appraisals between randomly assigned control versus intervention health departments, at baseline and 1 week post curriculum, through an EPPM-based survey/resurvey design. Levels of response willingness and emergency response-related attitudes/beliefs are measured. Analyses focus on two scenario categories that have appeared on a U.S. government list of scenarios of significant concern: a weather-related emergency and a radiological "dirty" bomb event (U.S. Department of Homeland Security, 2007). The greatest impact from the training intervention on response willingness was observed among LHD workers who had low levels of EPPM-related threat and efficacy perceptions at baseline. Self-efficacy and response efficacy and response willingness increased in intervention LHDs for both scenarios, with greater response willingness increases observed for the radiological "dirty" bomb terrorism scenario. Findings indicate the importance of building efficacy versus enhancing threat perceptions as a path toward greater response willingness, and suggest the potential applicability of such curricular interventions for boosting emergency response willingness among other cadres of health providers.

Emergency preparedness law and willingness to respond in the EMS workforce.

INTRODUCTION: For effective responses to emergencies, individuals must have the ability to respond and also be willing to participate in the response. A growing body of research points to gaps in response willingness among several occupational cohorts with response duties, including the Emergency Medical Services (EMS) workforce. Willingness to respond is particularly important during an influenza or other pandemic, due to increased demands on EMS workers and the potential for workforces to be depleted if responders contract influenza or stay home to care for sick dependents. State emergency preparedness laws are one possible avenue to improve willingness to respond. Hypothesis Presence of certain state-level emergency preparedness laws (ie, ability to declare a public health emergency; requirement to create a public health emergency plan; priority access to health resources for responders) is associated with willingness to respond among EMS workers. METHODS: Four hundred twenty-one EMS workers from the National Registry of Emergency Medical Technicians' (NREMT's) mid-year Longitudinal EMT Attributes and Demographics Study (LEADS) were studied. The survey, which included questions about willingness to respond during an influenza pandemic, was fielded from May through June 2009. Survey data were merged with data about the presence or absence of the three emergency preparedness laws of interest in each of the 50 US states. Unadjusted logistic regression analyses were performed with the presence/absence of each law and were adjusted for respondents' demographic/locale characteristics. RESULTS: Compared to EMS workers in states that did not allow the government to declare a public health emergency, those in states that permitted such declarations were more likely to report that they were willing to respond during an influenza pandemic. In adjusted and unadjusted analyses, this difference was not statistically significant. Similar results were found for the other state-level emergency preparedness laws of interest. CONCLUSION: While state-level emergency preparedness laws are not associated with willingness to respond, recent research suggests that inconsistencies between the perceived and objective legal environments for EMS workers could be an alternative explanation for this study's findings. Educational efforts within the EMS workforce and more prominent state-level implementation of emergency preparedness laws should be considered as a means to raise awareness of these laws. These types of actions are important steps toward determining whether state-level emergency preparedness laws have the potential to promote response willingness among EMS workers.

Embedding Equity into the Hospital Incident Command System: A Narrative Review.

BACKGROUND: Disasters exacerbate health inequities, with historically marginalized populations experiencing unjust differences in health care access and outcomes. Health systems plan and respond to disasters using the Hospital Incident Command System (HICS), an organizational structure that centralizes communication and decision-making. The HICS does not have an equity role or considerations built into its standard structure. The authors conducted a narrative review to identify and summarize approaches to embedding equity into the HICS. METHODS: The peer-reviewed (PubMed, SCOPUS) and gray literature was searched for articles from high-income countries that referenced the HICS or Incident Command System (ICS) and equity, disparities, or populations that experience inequities in disasters. The primary focus of the search strategy was health care, but the research also included governmental and public health system articles. Two authors used inductive thematic analysis to assess commonalities and refined the themes based on feedback from all authors. RESULTS: The database search identified 479 unique abstracts; 76 articles underwent full-text review, and 11 were included in the final analysis. The authors found 5 articles through cited reference searching and 13 from the gray literature search, which included websites, organizations, and non-indexed journal articles. Three themes from the articles were identified: including equity specialists in the HICS, modifying systems to promote equity, and sensitivity to the local community. CONCLUSION: Several efforts to embed equity into the HICS and disaster preparedness and response were discovered. This review provides practical strategies health system leaders can include in their HICS and emergency preparedness plans to promote equity in their disaster response.

Centering Health Equity in the Implementation of the Hospital Incident Command System: A Qualitative Case Comparison Study.

OBJECTIVE: Disasters exacerbate inequities in health care. Health systems use the Hospital Incident Command System (HICS) to plan and coordinate their disaster response. This study examines how 2 health systems prioritized equity in implementing the Hospital Incident Command System (HICS) during the coronavirus disease 2019 (COVID-19) pandemic and identifies factors that influenced implementation. METHODS: This is a qualitative case comparison study, involving semi-structured interviews with 29 individuals from 2 US academic health systems. Strategies for promoting health equity were categorized by social determinants of health. The Consolidated Framework for Implementation Research (CFIR) guided analysis using a hybrid inductive-deductive approach. RESULTS: The health systems used various strategies to incorporate health equity throughout implementation, addressing all 5 social determinants of health domains. Facilitators included HICS principles, external partnerships, community relationships, senior leadership, health equity experts and networks, champions, equity-stratified data, teaming, and a culture of health equity. Barriers encompassed clarity of the equity representative role, role ambiguity for equity representatives, tokenism, competing priorities, insufficient resource allocation, and lack of preparedness. CONCLUSIONS: These findings elucidate how health systems centered equity during HICS implementation. Health systems and regulatory bodies can use these findings as a foundation to revise the HICS and move toward a more equitable disaster response.