Comparing Intubation Rates in Patients Receiving Parenteral Olanzapine With and Without a Parenteral Benzodiazepine in the Emergency Department.

STUDY OBJECTIVE: United States prescribing information recommends against coadministration of injectable olanzapine with injectable benzodiazepines due to a risk of cardiorespiratory depression, whereas European prescribing information recommends the 2 drugs not be administered within 60 minutes of each other. In contrast, a recently published American College of Emergency Physicians clinical policy recommends injectable olanzapine and benzodiazepines be coadministered for treating severe agitation. We sought to compare injectable olanzapine with and without injectable benzodiazepines for evidence of cardiorespiratory depression. METHODS: We performed a retrospective study of patients in an urban emergency department from January 2017 through November 2019 who received parenteral olanzapine with or without parenteral benzodiazepines. We included patients receiving 2 total medication doses, either olanzapine+benzodiazepine or 2 doses of olanzapine, coadministered within 60 minutes. The primary outcome was tracheal intubation in the emergency department. Secondary outcomes included hypotension (systolic blood pressure less than 90 mmHg) and hypoxemia (SpO2 less than 90%). RESULTS: We identified 693 patients (median [alcohol]=210 mg/dL, median age=37 years [IQR 29 to 49]). In total, 549 received 2 doses of olanzapine, and 144 patients received olanzapine and a benzodiazepine. We found no difference in intubation rates between the olanzapine-only group (21/549, 3.8%) and the olanzapine+benzodiazepine group (5/144, 3.5%; difference=0.3%, 95% confidence interval -3.0% to 3.7%). Rates of hypoxemia (2% olanzapine-only and 3% olanzapine+benzodiazepine) and hypotension (9% both groups) also were not different between groups. CONCLUSION: We found no difference in cardiorespiratory depression between patients receiving only olanzapine versus olanzapine plus a benzodiazepine.

Race, Ethnicity, and Cultural Identity Modify Postpartum Participation in the Minnesota WIC Program.

OBJECTIVE: To examine the racial, ethnic and cultural differences in postpartum participation of women who participated in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) during pregnancy by completing a retrospective analysis of observational data on 35,903 women who enrolled in Minnesota WIC during pregnancy, from April 2018 to March 2020. METHODS: Descriptive analyses were completed using chi-square tests of association to show differences in postpartum WIC participation by maternal demographics and health risk codes of the WIC participants. Binary logistic regression and multivariate logistic regression were used to obtain odds ratios to compare the likelihood of postpartum WIC participation across different races, ethnicities and cultural groups. RESULTS: Asian/Pacific Islander, East African, Hispanic, Hmong, Multigenerational Black, and Other Black pregnant participants were more likely than White participants to return to WIC postpartum (adjusted odds ratio (AOR) 2.54, 95% confidence interval (CI) 1.87-3.46; AOR 3.35, 95% CI 2.40-4.66; 1.30, 95% CI 1.10-1.54; AOR 6.76, 95% CI 4.39-10.42; AOR 1.40, 95% CI 1.11-1.77, AOR 1.52, 95% CI 1.26-1.83, respectively). American Indian pregnant participants were less likely than White participants to return to WIC postpartum (AOR 0.70, 95% CI 0.54-0.92). CONCLUSIONS FOR PRACTICE: These findings can help the Minnesota WIC program, as well as other WIC programs, better understand which cultural groups may need more specific outreach strategies to keep women participating in the program after giving birth. Further research is needed to understand why postpartum women choose to participate, or choose not to participate, in WIC.

Comparison of efficacy and frequency of akathisia and dystonia between olanzapine, metoclopramide and prochlorperazine in ED headache patients.

STUDY OBJECTIVE: To compare the efficacy and frequency of akathisia and dystonia between the dopamine antagonist headache medications olanzapine, metoclopramide and prochlorperazine. METHODS: This was a retrospective observational cohort study of patients presenting to a large urban level one trauma center between 2010 and 2018. Inclusion criteria was age ≥ 18 who presented to the emergency department with a chief complaint of headache who received either olanzapine, metoclopramide or prochlorperazine. The primary outcome was need for rescue medication. Secondary outcomes were receiving medication for either akathisia or dystonia. Logistic regression was used to identify differences between the three cohorts up to 72 h from initial presentation. RESULTS: There were 5643 patients who met inclusion criteria. Olanzapine was the most commonly used drug (n = 2994, 53%) followed by prochlorperazine (n = 2100, 37%) and metoclopramide (n = 549, 10%). After adjusting for age and gender, there were no differences in risk for receiving rescue therapy or developing akathisia or dystonia. CONCLUSION: During initial ED visit and up to 72 h after receiving olanzapine, metoclopramide or prochlorperazine, we found no difference in risk for requiring rescue medication or developing akathisia or dystonia.

Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study.

INTRODUCTION: Airway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. METHODS: The National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters. RESULTS: Of 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1-2.5, range 1-31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. CONCLUSIONS: EGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.

Bronchoscopy in the emergency department.

BACKGROUND: Flexible bronchoscopy has been safely used for decades in ambulatory and critical care settings to aid in the diagnosis and treatment of tracheobronchial tree disorders. Although emergency physicians have the requisite skills to operate and interpret flexible bronchoscopy, no reports exist on the use of bronchoscopy by emergency physicians apart from endotracheal tube placement and confirmation. OBJECTIVE: The primary goal of this study was to describe the indications, outcomes and complications of flexible bronchoscopy performed by emergency physicians in an urban academic emergency department. METHODS: This was a single-center retrospective cohort study involving chart and video review of 146 patients over a 10.5-year study period. Patients of any age were included if they had been tracheally intubated or mechanically ventilated and underwent flexible bronchoscopy in the emergency department. After patients were identified, manual chart and video review was used to collect data on patient demographics, indications for intubation, indications for bronchoscopy, details of the bronchoscopy procedure, procedural findings, outcomes of the procedure, complications, provider training levels, and additional bronchoscopies performed after admission. The data was analyzed using descriptive statistics. RESULTS: 146 patients were included in the study and all bronchoscopies were performed or supervised by attending emergency physicians. After bronchoscopy, 24% of patients displayed improvement in oxygenation or lobar collapse while most patients had no change in clinical status. One patient had temporary hypoxemia after bronchoscopy. When another physician performed a subsequent bronchoscopy during admission, the findings were in agreement with the ED bronchoscopy 86% of the time. CONCLUSION: At our institution, emergency physicians can safely and effectively use flexible bronchoscopy to diagnose and treat critically ill patients.

Identification of positive parenting practices among parents of young children living in low-income and racially, ethnically, and culturally diverse households.

Using the positive deviance approach, the purpose of this study was to identify parent feeding practices that might be protective against early childhood obesity among children with lower weight status (BMI percentile ≥5th-<85th) relative to higher weight status (BMI percentile ≥85th). Qualitative interviews were conducted with 71 parents of children aged 2-5 years old (48% girls) enrolled in the Minnesota Special Supplemental Nutrition Program for Women Infants and Children (WIC). Children were identified as having lower weight status (defined as 'positive deviants') (n = 36) or 'higher weight status' (n = 35), and were African American [n = 22], Hispanic [n = 23], or Hmong [n = 26]). Parents were asked about approaches to child feeding and health- and weight-related practices. Findings indicated that relative to caregivers of children with higher weight status, parents of children identified as positive deviant were more likely to report having a consistent routine for providing meals, using a guided choices approach, serving small portions of food during mealtimes, and trusting their child hunger and satiety cues. Moreover, parents of children identified as positive deviant were more likely to promote healthful eating and physical activity engagement and implement clear rules and limits for screen time than parents of children with higher weight status. Results suggest specific parent feeding behaviors and health-related practices that may influence child weight status among children living in low-income and racialized households. The findings of this study also provide research evidence and support the tenets of the Satter Division of Responsibility in Feeding framework. Parenting practices and strategies among parents of children identified as positive deviant are expected to be feasible and should be explored and communicated in future interventions to support age- and sex-recommended weight and health-related outcomes among young children to promote health equity.

Training the MCH workforce: the Time for Change is now.

INTRODUCTION: Maternal and child health (MCH) services are critical for vulnerable populations. Workforce shortages, poor retention, and gaps in necessary trainings impede the capacity of public health systems to address needs. This manuscript characterizes the current MCH workforce, MCH program applicants and graduates, and describe findings within a national context to devise elements of a recruitment and retention strategy. METHODS: Data were obtained for public health program applicants, first-destination employment outcomes, and worker perceptions and demographics. Data were stratified according to the MCH and total public health workforce and by local, state, and national totals. Data were characterized by degree type, discipline, demographics, and employment outcomes. RESULTS: MCH staff constitute 11% of the state and local governmental public health workforce. MCH staff are approximately as diverse, have higher educational attainment, and are more likely to hold nursing degrees than the rest of the public health workforce. Yet, just 14% of MCH staff hold any type of public health degree. The MCH pipeline from academia appears modestly sized, with approximately 5% of applicants between 2017 and 2021 applying to a MCH master's degree. DISCUSSION: The MCH workforce has a lower proportion of formal training or degrees in public health, though trends seem to indicate improvements. However, it is critical that a multi-faceted recruitment and retention strategy be coordinated by a broad range of stakeholders. These efforts will serve to improve the capability and capacity of the public health system to address critical needs of increasingly diverse MCH populations. SIGNIFICANCE: In order to modernize and reimagine the academic-public health pipeline, it is critical to better understand how many applicants and graduates exist within Maternal and Child Health programs across the US, and their characteristics. This manuscript connects that information with the most recently available public health workforce information on demographics, workplace perceptions, and intent to leave among staff at state and local health departments. Data presented in this paper allow the most comprehensive characterization of the MCH academia->practice pipeline to-date, identifies a fundamental disconnect in those career pathways, and offers options to repair that break.

Omega-3 Fatty Acid Dietary Supplements Consumed During Pregnancy and Lactation and Child Neurodevelopment: A Systematic Review.

BACKGROUND: Maternal nutrition during pregnancy and lactation has profound effects on the development and lifelong health of the child. Long-chain PUFAs are particularly important for myelination and the development of vision during the perinatal period. OBJECTIVES: We conducted a systematic review to examine the relationship between supplementation with omega-3 fatty acids during pregnancy and/or lactation and neurodevelopment in children, to inform the Scientific Report of the 2020 Dietary Guidelines Advisory Committee. METHODS: We identified articles on omega-3 fatty acid supplementation in pregnant and lactating women that included measures of neurodevelopment in their children (0-18 y) by searching PubMed, CENTRAL, Embase, and CINAHL Plus. After dual screening articles for inclusion, we qualitatively synthesized and graded the strength of evidence using pre-established criteria for assessing risk of bias, consistency, directness, precision, and generalizability. RESULTS: We included 33 articles from 15 randomized controlled trials (RCTs) and 1 prospective cohort study. Of the 8 RCTs that delivered omega-3 fatty acid dietary supplements during pregnancy alone (200-2200 mg/d DHA and 0-1100 mg/d EPA for approximately 20 wk), 5 studies reported ≥1 finding that supplementation improved measures of cognitive development in the infant or child by 6%-11% (P < 0.05), but all 8 studies also reported ≥1 nonsignificant (P > 0.05) result. There was inconsistent or insufficient evidence for other outcomes (language, social-emotional, physical, motor, or visual development; academic performance; risks of attention deficit disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, anxiety, or depression) and for supplementation during lactation or both pregnancy and lactation. Populations with a lower socioeconomic status and adolescents were underrepresented and studies lacked racial and ethnic diversity. CONCLUSIONS: Limited evidence suggests that omega-3 fatty acid supplementation during pregnancy may result in favorable cognitive development in the child. There was insufficient evidence to evaluate the effects of omega-3 fatty acid supplementation during pregnancy and/or lactation on other developmental outcomes.

Development of Food Pattern Recommendations for Infants and Toddlers 6-24 Months of Age to Support the Dietary Guidelines for Americans, 2020-2025.

BACKGROUND: Developing food-based dietary guidelines (FBDGs) for infants and toddlers is a complex task that few countries have attempted. OBJECTIVES: Our objectives are to describe the process of food pattern modeling (FPM) conducted to develop FBDGs for the Dietary Guidelines for Americans, 2020-2025 for infants 6 to <12 mo and toddlers 12 to <24 mo of age, as well as the implications of the results and areas needing further work. METHODS: The US 2020 Dietary Guidelines Advisory Committee, with the support of federal staff, conducted FPM analyses using 5 steps: 1) identified energy intake targets; 2) established nutritional goals; 3) identified food groupings and expected amounts, using 3 options for the amount of energy from human milk in each age interval; 4) estimated expected nutrient intakes for each scenario, based on nutrient-dense representative foods; and 5) evaluated expected nutrient intakes against nutritional goals. RESULTS: For human milk-fed infants (and toddlers), example combinations of complementary foods and beverages were developed that come close to meeting almost all nutrient recommendations if iron-fortified infant cereals are included at 6 to <12 mo of age. These combinations would also be suitable for formula-fed infants. For toddlers not fed human milk, 2 patterns were developed: the Healthy US-Style Pattern and the Healthy Vegetarian Pattern (a lacto-ovo vegetarian pattern). Achieving nutrient recommendations left virtually no remaining energy for added sugars. CONCLUSIONS: It is challenging to meet all nutrient needs during these age intervals. Added sugars should be avoided for infants and toddlers <2 y of age. Further work is needed to 1) establish a reference human milk composition profile, 2) update and strengthen the DRI values for these age groups, and 3) use optimization modeling, in combination with FPM, to identify combinations of foods that meet all nutritional goals.

A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages.

STUDY OBJECTIVE: Intramuscular medications are commonly used to treat agitation in the emergency department (ED). The purpose of this study is to compare intramuscular droperidol and olanzapine for treating agitation. METHODS: This was a prospective observational study of ED patients receiving intramuscular droperidol or olanzapine for acute agitation. The treating physician determined the medication and dose; however, over time drug shortages made either olanzapine (July to September 2019) or droperidol (November 2019 to March 2020) unavailable, creating a natural experiment. The primary outcome was time to adequate sedation, assessed by the Altered Mental Status Scale (AMSS), defined as time to AMSS score less than or equal to 0. RESULTS: We analyzed 1,257 patients (median age 42 years; 73% men); 538 received droperidol (median dose 5 mg) and 719 received olanzapine (median dose 10 mg). The majority of patients (1,086; 86%) had agitation owing to alcohol intoxication. Time to adequate sedation was 16 minutes (interquartile range 10 to 30 minutes) for droperidol and 17.5 minutes (interquartile range 10 to 30 minutes) for olanzapine (absolute difference -0.7 minutes; 95% confidence interval -2.1 to 0.5 minutes). Adjusted Cox proportional hazard model analysis revealed no difference between groups in time to sedation (hazard ratio for adequate sedation for droperidol compared with olanzapine 1.12; 95% confidence interval 1.00 to 1.25). Patients receiving olanzapine were more likely to receive additional medications for sedation (droperidol 17%; olanzapine 24%; absolute difference -8% [95% confidence interval -12% to -3%]). We observed no difference between drugs regarding adverse effects except for extrapyramidal adverse effects, which were more common with droperidol (n=6; 1%) than olanzapine (n=1; 0.1%). CONCLUSION: We found no difference in time to adequate sedation between intramuscular droperidol and olanzapine.

Medical needs of emergency department patients presenting with acute alcohol and drug intoxication.

STUDY OBJECTIVE: Some contend that patients with acute alcohol or illicit substance intoxication should be treated in outpatient detoxification centers rather than in the ED. However, these patients often have underlying acute medical needs. We sought to determine the frequency of medical interventions required by ED patients with alcohol or illicit substance intoxication. METHODS: This was a prospective observational study of consecutive ED patients presenting to an urban tertiary care ED with altered mental status due to alcohol or illicit substance use. We performed data collection for patients deemed to be low-risk for complications, as defined by receiving care in an intoxication observation unit. Trained staff observed and recorded all medical interventions, including medications administered, diagnostic testing, procedures performed, and airway interventions. The incidence of agitation was recorded using the Altered Mental Status Scale (AMSS, ordinal scale from -4 to +4, where +4 is most agitated). The data analysis is descriptive. RESULTS: This analysis included 2685 encounters (1645 unique patients; median age 39; 73% male) from January to May 2019. Average breath alcohol concentration was 0.20 g/dL (range 0.00-0.47). There were 89% encounters with alcohol intoxication, and in 17% encounters the patient was suspected or known to have drug intoxication (either alone or in conjunction with alcohol use). On arrival to the ED, 372 (14%) had agitation (AMSS +1 or higher) and 32 (1%) were profoundly agitated (AMSS +4). In total, 1526 (56%) received at least one intervention that could not be provided by a local detoxification or sobering facility. Of the study population, 955 (36%) received a sedating medication, 903 (34%) required physical restraints for patients or staff safety, 575 (21%) underwent imaging studies, 318 (12%) underwent laboratory testing, 367 (13%) received another intervention (IV access, EKG, splinting, wound care, etc). Additionally, 111 (4%) patients received an airway intervention (19 intubation, 23 nasal airway, 85 supplemental oxygen) and 275 (10%) required repositioning to protect the airway. There were 168 (6%) patients admitted to the hospital. CONCLUSION: In this population of relatively low-risk ED patients with drug and alcohol intoxication, a substantial proportion of patients received medical interventions.

Rapid Sequence Airway with the Intubating Laryngeal Mask in the Emergency Department.

BACKGROUND: The administration of sedation and neuromuscular blockade to facilitate extraglottic device (EGD) placement is known as rapid sequence airway (RSA). In the emergency department (ED), EGDs are used largely as rescue devices. In select patients, there may be significant advantages to using EGDs over laryngoscopy as the primary airway device in the ED. OBJECTIVE: Our study sought to describe the practice of RSA in the ED, including rates of successful oxygenation, ventilation, and complications from EGD use. METHODS: We identified patients in the ED between 2007 and 2017 who underwent RSA with the LMA® Fastrach™ (hereafter termed ILMA; Teleflex Medical Europe Ltd., Athlone, Ireland) placed as the first definitive airway management device. A trained abstractor performed chart and video review of the cases to determine patient characteristics, physician use of the ILMA, indication for ILMA placement, success of oxygenation and ventilation, success of intubation, and complications related to the device. RESULTS: During the study period, 94 patients underwent RSA with the ILMA. Of those, 93 (99%) were successfully oxygenated and ventilated, and when intubation was attempted, 89% were able to be intubated through the ILMA. The incidence of vomiting and aspiration was 1% and 3%, respectively. There were 30 different attending physicians who supervised RSA and the median number was 2 per physician in the 10-year study period. CONCLUSION: The practice of RSA with the ILMA in the ED is associated with a high rate of successful oxygenation, ventilation, and intubation with infrequent complications, even when performed by physicians with few experiences in the approach.

Non-invasive zero-heat-flux technology compared with traditional core temperature measurements in the emergency department.

INTRODUCTION: Core temperatures (Tcore) are often invasive, and can be underutilized. Peripheral temperatures are easier to obtain, but are often less accurate. A zero-heat-flux thermometer (ZHF) is a non-invasive method to obtain core temperatures (TZHF), and has been accurate when compared to Tcore in the operating room. We aimed to determine whether TZHF accurately and reliably measures Tcore in emergency department (ED) patients when compared to rectal, bladder or esophageal temperatures. METHODS: We conducted a prospective observational quality improvement project, with concurrent TZHF and Tcore measurements. The primary outcome was whether one device detected a fever (≥38.1 °C) when the other device did not. Unadjusted linear regression was used to determine the relationship between temperature differences between devices. RESULTS: 268 patients were included. Mean temperatures were 36.6 °C for Tcore and 36.3 °C for TZHF. 16 of 52 patients with fever identified by Tcore were not detected by TZHF, 13 with an infectious etiology. The mean temperature difference between Tcore and TZHF increased as the patient's temperature increased; the difference was 0.2 °C in afebrile patients, but 0.7 °C in febrile patients. CONCLUSION: While we found overall concordance between Tcore and TZHF, the ZHF did not detect fever in 25% of patients presenting with fever of infectious origin. Measurements between Tcore and TZHF varied more as temperatures increased, with TZHF consistently reporting lower values. Although more study is needed, these findings call into question the use of TZHF in the ED where detection of fever frequently guides patient evaluation and management.

Time to Loss of Preoxygenation in Emergency Department Patients.

BACKGROUND: In patients requiring emergency rapid sequence intubation (RSI), 100% oxygen is often delivered for preoxygenation to replace alveolar nitrogen with oxygen. Sometimes, however, preoxygenation devices are prematurely removed from the patient prior to the onset of apnea, which can lead to rapid loss of preoxygenation. OBJECTIVE: We sought to determine the elapsed time, on average, between removing the oxygen source and the loss of preoxygenation among non-critically ill patients in the emergency department (ED). METHODS: We conducted a prospective, crossover study of non-critically ill patients in the ED. Each patient received two identical preoxygenation trials for 4 min using a non-rebreather mask with oxygen flow at flush rate and a nasal cannula with oxygen flow at 10 L/min. After each preoxygenation trial, patients underwent two trials in random order while continuing spontaneous breathing: 1) removal of both oxygen sources and 2) removal of non-rebreather mask with nasal cannula left in place. We defined loss of preoxygenation as an end-tidal oxygen (exhaled oxygen percentage; EtO2) value < 70%. We measured EtO2 breath by breath until loss of preoxygenation occurred. RESULTS: We enrolled 42 patients, median age was 43 years (interquartile range [IQR] 30 to 54 years) and 72% were male. Median time to loss of preoxygenation was 20 s (IQR 17-25 s, 4.5 breaths) when all oxygen devices were removed, and 39 s (IQR 21-56 s, 8 breaths) when the nasal cannula was left in place. CONCLUSIONS: In this population of non-critically ill ED patients, most had loss of preoxygenation after 5 breaths if all oxygen devices were removed, and after 8 breaths if a nasal cannula was left in place. These data suggest that during ED RSI, preoxygenation devices should be left in place until the patient is completely apneic.

A comparative study of conducted electrical weapon incapacitation during a goal-directed task.

Conducted electrical weapons (CEW) are ubiquitous in law enforcement given their unique ability to physically incapacitate violently resisting subjects. Early use of animal models to study CEW incapacitation effectiveness (e.g. porcine model with 4-limb strain gauges) proved to be poorly predictive of human incapacitation effectiveness. In a previously published human study, we developed a methodology for the prospective assessment of the incapacitation effectiveness of CEWs in highly motivated human subjects. Here we use this methodology in Part 1 to compare the incapacitation effectiveness of the newly released Axon® (formerly TASER® International) T(ASER) 7 to the TASER X26E, the "gold standard", and the TASER X2, a current model. The T7 has a new "adaptive cross-connect" technology that may improve incapacitation effectiveness in the scenario of small spreads between probe pairs, a common cause of weapon "failure" in the field. In Part 2, we use our methodology to test the functionality of the T7 cross-connect technology by comparing different bay and probe configurations. This is the first published study in the literature comparing different CEW models using this human model. For Part 1, 29 subjects completed the study and had data available for analysis. For Part 2, 21 subjects completed the study and had data available for analysis. The subjects were motivated to complete the task of reaching a suspended martial arts dummy 3.4 m (11 ft) away while being exposed "under power" to the CEW. In Part 1, subjects were assigned to 1 of 6 groups with probe spreads of 10, 20, and 30 cm (4, 8, 12 in). Subjects were exposed to a "control" CEW (either the X2 or X26E) and the T7 on alternating sides. Exposures with the X2 and T7 included 2 bay-exposures. In Part 2, 21 subjects were assigned to 1 of 5 groups of different T7 bay and probe configurations all with a theoretical effective spread of 30 cm (12 in). Subjects were rated on their progress towards successfully reaching the dummy and on the extent of limb incapacitation using a quasi-blinded expert-observer scoring panel based on high-speed video review. In Part 1, all CEW models achieved maximal or near-maximal subject control with the 30 cm probe spread. With probe spreads of 10 and 20 cm the pooled data showed the T7 to be superior to the X2 for goal achievement (p < 0.001) and limb incapacitation (p = 0.002) mostly driven by differences seen with the 10 cm spread (2-bay exposures). The T7 was non-inferior to the X26E. In Part 2, there was no statistical significance between the limb capture scores, but there was a statistically significant difference in goal scores. The results overall validate that the T7 CEW cross-connect feature performed as expected. The T7 adaptive cross-connect feature with two simultaneous deployed probe pairs demonstrated a significant improvement in incapacitation effectiveness compared to the current X2 CEW with two simultaneously deployed probe pairs. Small probe spreads are a common reason for limited incapacitation effectiveness in the field and this study suggests the T7 may offer an improvement in this scenario. The T7, with single-bay exposures, was non-inferior to the single-bay X26E.

The physiologic effects of a new generation conducted electrical weapon on human volunteers at rest.

Axon Enterprise, Inc. (Axon) released its newest generation conducted electrical weapon (CEW), the T7, in October 2018. In order to compare the effects of this new CEW to prior generations, we used our previously described methodology to study the physiologic effects of CEWs on human volunteers at rest. This was a prospective, observational study of human subjects consisting of two parts. Part 1 was testing a single cartridge (2-probe) exposure. Subjects received a 10-s exposure from the T7 to the back with a 30 cm (12 in.) spread between the two probes. Part 2 was testing a simultaneous two-cartridge (4-probe) exposure. Subjects received a 10-s exposure from the T7 to the back with two cartridges with a 10 cm (4 in.) spread between each probe pair. The probe pairs were arranged cephalad to caudal such that the distance between the top probe of the first cartridge and the bottom probe of the second cartridge was 30 cm (12 in.). Vital signs were measured immediately before and after the exposure. Continuous spirometry was performed. ECG monitoring was performed immediately before and after the exposure. Venous pH, lactate, potassium, CK, catecholamines, and troponin were measured before and immediately after the exposure, at 1-h post-exposure, and again at 24 h. 11 subjects completed part 1 of the study. 9 subjects completed part 2 of the study. No subjects had a dysrhythmia or morphology change in the surface ECG. There were no statistical changes in vital signs pre- and post-exposure. While subjects did not have a statistical change in spirometry parameters pre-exposure to exposure except for a small drop in PETCO2, there was an increase in minute ventilation after the exposure that could have several explanations. A similar pattern was seen with prior generation weapons. No subject had elevated troponin levels. Other blood parameters including venous pH, lactate, potassium, CK, and catecholamines had changes similar to prior generation weapons. Comparison of the data for the single-cartridge exposures against the simultaneous two-cartridge exposures yielded no difference in vital signs, but the minute ventilation was higher for the two-cartridge exposures. The blood data, where there was a difference, was mixed. In our study, the physiologic effects of the Axon T7 are modest, consistent with the electrically-induced motor nerve-driven muscle contraction, and were similar to prior generation weapons.

Forgotten Fundamentals: A Review of State Legislation on Nutrition for Incarcerated Pregnant and Postpartum People.

Adequate nutritional intake during pregnancy is critical to infant health and development. People with the capacity for pregnancy who are incarcerated have limited control over their diets and rely on prisons and jails to meet their nutritional needs. This study examined state and federal statutes pertaining to nutrition care for pregnant people while incarcerated. Following a systematic search and review, we identified four qualitative codes relating to access to vitamins, supplemental food, additional hydration, and prenatal nutrition education. Summaries of state and federal statutes pertaining to nutrition were developed and compared with current prenatal nutrition recommendations. Less than a third of states had nutrition-related mandates and no states had statutes that included all key nutrition recommendations. No federal statutes addressed nutrition during pregnancy. Additionally, our review found no provisions for enforcement of the limited nutritional statutes that do exist. To mitigate adverse health consequences for pregnant people and their fetuses, policymakers should enact or amend legislation to align nutrition standards in all prisons and jails with national policy recommendations and provide mechanisms to oversee compliance.

Incorporating the life course model into MCH nutrition leadership education and training programs.

Life course perspective, social determinants of health, and health equity have been combined into one comprehensive model, the life course model (LCM), for strategic planning by US Health Resources and Services Administration's Maternal and Child Health Bureau. The purpose of this project was to describe a faculty development process; identify strategies for incorporation of the LCM into nutrition leadership education and training at the graduate and professional levels; and suggest broader implications for training, research, and practice. Nineteen representatives from 6 MCHB-funded nutrition leadership education and training programs and 10 federal partners participated in a one-day session that began with an overview of the models and concluded with guided small group discussions on how to incorporate them into maternal and child health (MCH) leadership training using obesity as an example. Written notes from group discussions were compiled and coded emergently. Content analysis determined the most salient themes about incorporating the models into training. Four major LCM-related themes emerged, three of which were about training: (1) incorporation by training grants through LCM-framed coursework and experiences for trainees, and similarly framed continuing education and skills development for professionals; (2) incorporation through collaboration with other training programs and state and community partners, and through advocacy; and (3) incorporation by others at the federal and local levels through policy, political, and prevention efforts. The fourth theme focused on anticipated challenges of incorporating the model in training. Multiple methods for incorporating the LCM into MCH training and practice are warranted. Challenges to incorporating include the need for research and related policy development.