Up and over: Consequences of raising the United States-Mexico border wall height.

OBJECTIVES: San Diego County's geographic location lends a unique demographic of migrant patients injured by falls at the United States-Mexico border. To prevent migrant crossings, a 2017 Executive Order allocated funds to increase the southern California border wall height from 10 ft to 30 ft, which was completed in December 2019. We hypothesized that the elevated border wall height is associated with increased major trauma, resource utilization, and health care costs. METHODS: Retrospective trauma registry review of border wall falls was performed by the two Level I trauma centers that admit border fall patients from the southern California border from January 2016 to June 2022. Patients were assigned to either "pre-2020" or "post-2020" subgroups based upon timing of completion of the heightened border wall. Total number of admissions, operating room utilization, hospital charges, and hospital costs were compared. RESULTS: Injuries from border wall falls grew 967% from 2016 to 2021 (39 vs. 377 admissions); this percentage is expected to be supplanted in 2022. When comparing the two subgroups, operating room utilization (175 vs. 734 total operations) and median hospital charges per patient ($95,229 vs. $168,795) have risen dramatically over the same time period. Hospital costs increased 636% in the post-2020 subgroup ($11,351,216 versus $72,172,123). The majority (97%) of these patients are uninsured at admission, with costs largely subsidized by federal government entities (57%) or through state Medicaid enrollment postadmission (31%). CONCLUSION: The increased height of the United States-Mexico border wall has resulted in record numbers of injured migrant patients, placing novel financial and resource burdens on already stressed trauma systems. To address this public health crisis, legislators and health care providers must conduct collaborative, apolitical discussions regarding the border wall's efficacy as a means of deterrence and its impact on traumatic injury and disability. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Use of simulation as a needs assessment to develop a focused team leader training curriculum for resuscitation teams.

BACKGROUND: Many inpatients experience cardiac arrest and mortality in this population is extremely high. Simulation is frequently used to train code teams with the goal of improving these outcomes. A key step in designing such a training curriculum is to perform a needs assessment. We report on the effectiveness of a simulation-based training program for residents designed using unannounced in-situ simulation cardiac arrest data as a needs assessment. METHODS: In order to develop the curriculum for training, a needs assessment was done using in-situ simulation. Prior to instruction, residents were assessed in their ability to lead a simulated resuscitation using a standardized checklist. During the intervention phase, residents participated in didactic and team training. The didactic training consisted of pharmacology review, ACLS update and TeamSTEPPS training. Residents took turns as code team leader in three simulation sessions. Rapid cycle deliberate practice (RCDP) was employed as part of simulation sessions. All residents returned, for post-intervention assessment. Mean pre-post test scores were analyzed to determine if there was a significant difference. RESULTS: Twenty-seven residents participated. Mean pre-training assessment score was 47.6 (95% CI 37.5-57.9). The mean post-training assessment score was 84.4 (95% CI 79.0-89.5). The mean time to defibrillation after pads were placed in scenario with shockable rhythm decreased from 102.2 seconds (95% CI 74.0-130.5) to 56.3 (95% CI 32.7-79.8). CONCLUSION: Using unannounced in-situ cardiac arrest simulations as a needs assessment, a simulation-based training program was developed that significantly improved resident performance as team leader. Future work is needed to determine if this improvement translates into patient benefits and is sustainable. However, in-situ simulation is a promising tool for curriculum development.

Assessment of Drug Interaction Potential Between the Hepatitis C Virus Direct-Acting Antiviral Agents Elbasvir/Grazoprevir and the Nucleotide Analog Reverse-Transcriptase Inhibitor Tenofovir Disoproxil Fumarate.

Treatment of individuals coinfected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) requires careful consideration of potential drug-drug interactions. We evaluated the pharmacokinetic interaction of the direct-acting antiviral agents elbasvir and grazoprevir coadministered with the nucleotide reverse transcriptase inhibitor tenofovir disoproxil fumarate (TDF). Three open-label, multidose studies in healthy adults were conducted. In the first study (N = 10), participants received TDF 300 mg once daily, elbasvir 50 mg once daily, and elbasvir coadministered with TDF. In the second study (N = 12), participants received TDF 300 mg once daily, grazoprevir 200 mg once daily, and grazoprevir coadministered with TDF. In the third study (N = 14), participants received TDF 300 mg once daily and TDF 300 mg coadministered with coformulated elbasvir/grazoprevir 50 mg/100 mg once daily. Pharmacokinetics and safety were evaluated. Following coadministration, the tenofovir area under the plasma concentration-time curve to 24 hours and maximum plasma concentration geometric mean ratios (90% confidence intervals) for tenofovir and coadministered drug(s) versus tenofovir were 1.3 (1.2, 1.5) and 1.5 (1.3, 1.6), respectively, when coadministered with elbasvir; 1.2 (1.1, 1.3) and 1.1 (1.0, 1.2), respectively, when coadministered with grazoprevir; and 1.3 (1.2, 1.4) and 1.1 (1.0, 1.4), respectively, when coadministered with the elbasvir/grazoprevir coformulation. TDF had minimal effect on elbasvir and grazoprevir pharmacokinetics. Elbasvir and/or grazoprevir coadministered with TDF resulted in no clinically meaningful tenofovir exposure increases and was generally well tolerated, with no deaths, serious adverse events (AEs), discontinuations due to AEs, or laboratory AEs reported. No dose adjustments for elbasvir/grazoprevir or TDF are needed for coadministration in HCV/HIV-coinfected people.

Assessment of drug interaction potential between the HCV direct-acting antiviral agents elbasvir/grazoprevir and the HIV integrase inhibitors raltegravir and dolutegravir.

BACKGROUND: Elbasvir/grazoprevir is a once-daily fixed-dose combination therapy for the treatment of chronic HCV infection, including HCV/HIV coinfection. OBJECTIVES: To evaluate the pharmacokinetic interaction of elbasvir and grazoprevir with raltegravir or dolutegravir. METHODS: Three open-label trials in healthy adult participants were conducted. In the raltegravir trials, participants received a single dose of raltegravir 400 mg, a single dose of elbasvir 50 mg or grazoprevir 200 mg, and raltegravir with either elbasvir or grazoprevir. In the dolutegravir trial, participants received a single dose of dolutegravir 50 mg alone or co-administered with once-daily elbasvir 50 mg and grazoprevir 200 mg. RESULTS: The raltegravir AUC0-∞ geometric mean ratio (GMR) (90% CI) was 1.02 (0.81-1.27) with elbasvir and 1.43 (0.89-2.30) with grazoprevir. Dolutegravir AUC0-∞ GMR (90% CI) was 1.16 (1.00-1.34) with elbasvir and grazoprevir. The elbasvir AUC0-∞ GMR (90% CI) was 0.81 (0.57-1.17) with raltegravir and 0.98 (0.93-1.04) with dolutegravir. The grazoprevir AUC0-24 GMR (90% CI) was 0.89 (0.72-1.09) with raltegravir and 0.81 (0.67-0.97) with dolutegravir. CONCLUSIONS: Elbasvir or grazoprevir co-administered with raltegravir or dolutegravir resulted in no clinically meaningful drug-drug interactions and was generally well tolerated. These results support the assertion that no dose adjustments for elbasvir, grazoprevir, raltegravir or dolutegravir are needed for co-administration in HCV/HIV-coinfected people.

PyPhi: A toolbox for integrated information theory.

Integrated information theory provides a mathematical framework to fully characterize the cause-effect structure of a physical system. Here, we introduce PyPhi, a Python software package that implements this framework for causal analysis and unfolds the full cause-effect structure of discrete dynamical systems of binary elements. The software allows users to easily study these structures, serves as an up-to-date reference implementation of the formalisms of integrated information theory, and has been applied in research on complexity, emergence, and certain biological questions. We first provide an overview of the main algorithm and demonstrate PyPhi's functionality in the course of analyzing an example system, and then describe details of the algorithm's design and implementation. PyPhi can be installed with Python's package manager via the command 'pip install pyphi' on Linux and macOS systems equipped with Python 3.4 or higher. PyPhi is open-source and licensed under the GPLv3; the source code is hosted on GitHub at https://github.com/wmayner/pyphi. Comprehensive and continually-updated documentation is available at https://pyphi.readthedocs.io. The pyphi-users mailing list can be joined at https://groups.google.com/forum/#!forum/pyphi-users. A web-based graphical interface to the software is available at http://integratedinformationtheory.org/calculate.html.

Scaling up a treatment to simultaneously remove persistent organic pollutants and heavy metals from contaminated soils.

Soil washing is a treatment process that can be used to remediate both organic and inorganic pollutants from contaminated soils, sludges, and sediments. A soil washing procedure was evaluated utilizing about 100g samples of soil that had been field-contaminated with arsenic, chromium, copper, pentachlorophenol (PCP), polychlorinated dibenzo-p-dioxins (PCDDs) and polychlorinated dibenzofurans (PCDFs). The highest level of mobilization/detoxification was achieved in three soil washes with a mixture of 0.1M [S,S]-ethyelnediaminedisuccinate ([S,S]-EDDS) and 2% Brij 98 at pH 9 with 20 min of ultrasonication treatment at room temperature. This combination mobilized 70% of arsenic, 75% of chromium, 80% of copper, 90% of PCP, and 79% of PCDDs and PCDFs, so that the decontaminated soil met the maximum acceptable concentrations of the generic C-level criteria regulated by the Ministère du Développement Durable, de l'Environnement et des Parcs for the Province of Québec, Canada. The organic pollutants were back-extracted from the aqueous suspension with hexane. Heavy metals were virtually completely precipitated from the aqueous washing suspension with Mg(0) particles at room temperature. The PCP was detoxified by catalytic hydrodechlorination with a stream of 5% (v/v) H(2)-supercritical CO(2) that transported the organosoluble fraction through a reaction chamber containing 2% Pd/γ-Al(2)O(3). In toto, this soil washing procedure demonstrates that persistent organic pollutants and selected heavy metals can be co-extracted efficiently from a field-contaminated soil with three successive washes with the same soil washing solution containing [S,S]-EDDS and a non-ionic surfactant (Brij 98) in admixture. An industrial-scale ex situ soil washing procedure with a combination of a non-ionic surfactant and a complexing reagent seems to be a plausible remediation technique for this former wooden utility pole storage facility.

Reduction of hexavalent chromium mediated by micro- and nano-sized mixed metallic particles.

A variety of micron-scale mixed metallic particles (Pd/Fe, Ag/Fe, Cu/Fe, Zn/Fe, Co/Fe, Mg/Fe, Ni/Fe, Al/Fe, Si/Fe, Pd/Cu and Pd/Zn; and Pd/Cu/Fe, Pd/Zn/Fe and Zn/Cu/Fe) and selected nano-sized bimetallic analogs (Pd/Fe, Cu/Fe and Pd/Cu) were evaluated for reducting activity with Cr(VI) in a surfactant preparation (Tween 20) under a variety of reaction conditions. Relative to the reactivity of the zero-valent iron, the tested bimetallic mixtures (Pd/Fe>Pd/Zn>Ag/Fe>Ni/Fe>Zn/Fe>Pd/Cu>Cu/Fe) appreciably increased the pseudo-first-order rate constant. The Zn/Cu/Fe represented a cost-effective preparation providing comparable or improved kinetic parameters relative to the more expensive palladized bimetallic mixtures. The Pd/Fe, Cu/Fe and Pd/Cu nano-sized particles proved to be more reactive (up to 100-fold) for the reductive remediation of Cr(VI). The results were comparable when working with nano-sized Cu and Fe particles, suggesting that the cementation of a noble metal serves not only as a reaction catalyst but also provides protection to the metallic surface, impeding its rapid inactivation.

Simultaneous mobilization of heavy metals and polychlorinated biphenyl (PCB) compounds from soil with cyclodextrin and EDTA in admixture.

This study evaluated the efficacy of a washing process with cyclodextrin in combination with ethylenediaminetetraacetate (EDTA) for the simultaneous mobilization of heavy metals and PCBs from a field contaminated soil. Ultrasonically aided mixing of the field contaminated soil with a combination of cyclodextrin solution (10%, w/v) and a sparing quantity (2 mmol) of EDTA, simultaneously mobilized appreciable quantities of PCBs and much of the analyte metal (Cd, Cr, Cu, Mn, Ni, Pb, Zn) burdens. Relative to the action of individual reagents, a combination of randomly methylated (RAMEB) or hydroxypropyl beta-cyclodextrin (HPCD) with EDTA did not alter the PCB extraction efficiency nor did the presence of cyclodextrin change the efficiency of mobilization of most heavy metals (Al, Cd, Cr, Fe, Mn, Ni, and Zn) but did increase the recovery of Cu and Pb modestly. Three sonication-washes with the same charge of reagents mobilized appreciable quantities of PCBs (40-76%) and quantitatively extracted the labile fraction of Cd, Cu, Mn, and Pb. RAMEB proved to be more efficient than HPCD for PCB extractions. Three successive extractions with a single charge of cyclodextrin mobilized almost as much PCB (RAMEB, 76%; HPCD, 40%) as did the companion extractions that used fresh reagents each time (RAMEB, 78%; HPCD, 42%). Collectively, these studies demonstrated that PCB compounds and selected heavy metals can be co-extracted efficiently from soil with three successive washes with the same washing suspension containing EDTA and cyclodextrin.

A washing procedure to mobilize mixed contaminants from soil: II. Heavy metals.

We conducted a laboratory study to assess the efficiency of nonionic and anionic surfactants in combination with a sparing quantity of ethylenediaminetetraacetate (EDTA) to simultaneously extract heavy metals (HMs) and polychlorinated biphenyl (PCB) compounds from a field-contaminated soil. A soil wash that mobilized both HMs and PCBs was combined with back-extraction with hexane to remove PCBs from the aqueous wash. The aqueous washing suspension was then regenerated by precipitation of the HMs induced by corrosion and hydrolysis of zero-valent Mg to provide a cleaned soil and innocuous extract. Finally, the washing suspension was recycled twice to mobilize more contaminants from the soil particulate fraction. After ultrasonic equilibration, EDTA in admixture with a nonionic surfactant did not appreciably change the efficiency of mobilization of most heavy metals (Al, Cd, Cr, Fe Mn, Ni, and Zn), but did increase the recovery of Cu and Pb. The release of EDTA from HM complexes was efficient for most metals (99%) but was influenced by the chemical characteristics of the surfactant. The EDTA recovery (62-65%) after three cycles of soil washing, hexane back-extraction, and Mg(0) treatment was similar for all reagent combinations. In toto, these studies demonstrate that after treatment with ultrasound, selected heavy metals can be coextracted efficiently from soil with a single washing suspension containing EDTA and a nonionic surfactant.

A washing procedure to mobilize mixed contaminants from soil: I. Polychlorinated biphenyl compounds.

We conducted a laboratory study to assess the feasibility of a washing process with nonionic and anionic surfactants in combination with ethylenediaminetetraacetate (EDTA) for the simultaneous mobilization of heavy metals and polychlorinated biphenyls (PCBs) from a field-contaminated soil. Unit processes consisting of complexometric extraction and surfactant-assisted mobilization were combined with reagent regeneration and detoxification steps to generate innocuous products. Ten minutes of ultrasonic mixing of the soil with a combination of 30 mL L(-1) surfactant suspension and a sparing quantity (2 mmol) of EDTA mobilized appreciable quantities of PCBs, virtually all of the available Cd, Cu, Mn, and Pb, and lesser amounts of the Zn, Ni, and Cr but only small quantities of Al and Fe. Relative to individual reagents, combinations of surfactant (Brij 98, Triton X-301, or Triton XQS-20) with EDTA did not influence PCB extraction efficiencies perceptibly. Of the three surfactants, the Brij 98 proved to be the most efficient for three successive extractions with a single charge, mobilizing 83% of the PCBs, whereas companion extractions that used fresh reagent each time mobilized 87% of the soil PCB content. The decreased PCB mobilization with the same quantity of anionic surfactant (71 or 68%) resulted from losses during the EDTA regeneration process with zero-valent Mg. In toto, these studies demonstrate that PCB compounds and selected heavy metals can be coextracted efficiently from soil with three successive washes with the same washing suspension containing EDTA and a nonionic surfactant.