Helping the Helpers: Assisting Staff and Volunteer Workers Before, During, and After Disaster Relief Operations.

Self-care strategies and system supports employed in preparation for, during, and after disaster relief operations (DROs) are crucial to relief worker well-being and the overall effectiveness of relief efforts. Relief organizations and management must structure DROs in a manner that promotes self-care and workers must implement proper self-care strategies. Proper self-care before, during, and after a DRO can reduce negative reactions to stressful emergency work and promote growth, mastery, and self-efficacy after the experience. Therefore, the purpose of this article is to discuss the importance of organizational supports and self-care strategies in disaster relief settings. This article emphasizes the role of both individual and management participation and commitment to relief worker support and positive experience in DROs and provides suggestions for doing so. These suggestions are derived from the empirical and experiential literature and extensions from the theoretical background, and from our experience as managers in DROs.

Disaster Mental Health and Community-Based Psychological First Aid: Concepts and Education/Training.

Any community can experience a disaster, and many traumatic events occur without warning. Psychologists can be an important resource assisting in psychological support for individuals and communities, in preparation for and in response to traumatic events. Disaster mental health and the community-based model of psychological first aid are described. The National Preparedness and Response Science Board has recommended that all mental health professionals be trained in disaster mental health, and that first responders, civic officials, emergency managers, and the general public be trained in community-based psychological first aid. Education and training resources in these two fields are described to assist psychologists and others in preparing themselves to assist their communities in difficult times and to help their communities learn to support one another.

Examination of the diurnal assumptions of the test of variables of attention for elementary students.

OBJECTIVE: To examine the diurnal assumptions of the test of variables of attention (TOVA). METHOD: The present study assessed 122 elementary students aged 5.5 to 10.0 years who were randomly assigned to one of four different groups based on time of administration (M-M: morning-morning, M-A: morning-afternoon, A-M: afternoon-morning, and A-A: afternoon-afternoon). Morning administration occurred between 8:00 and 10:00 a.m., and afternoon administration occurred between 1:00 and 3:00 p.m. RESULTS: Reliability was consistent across groups, and there were no significant differences between groups. Classification of the students into ADHD or non-ADHD groups was similar across groups, and the children who were identified as ADHD with the Vanderbilt ADHD diagnostic teacher rating scale were consistently classified as ADHD on the TOVA regardless of time of day. CONCLUSION: The results of the present study indicate that the psychometric values of the TOVA remain intact whether its administration was in the morning or afternoon.

Trends in the incidence of noncardiogenic acute respiratory failure: the role of race.

OBJECTIVE: We sought to examine trends in the race-specific incidence of acute respiratory failure in the United States. DESIGN: Retrospective cohort study. SETTING: We used the National Hospital Discharge Survey database (1992-2007), an annual survey of approximately 500 hospitals weighted to provide national hospitalization estimates. PATIENTS: All incident cases of noncardiogenic acute respiratory failure hospitalized in the United States. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified noncardiogenic acute respiratory failure by the presence of International Classification of Diseases, Ninth Revision, codes for respiratory failure or pulmonary edema (518.4, 518.5, 518.81, and 518.82) and mechanical ventilation (96.7×), excluding congestive heart failure. Incidence rates were calculated using yearly census estimates standardized to the age and sex distribution of the 2000 census population. Annual cases of noncardiogenic acute respiratory failure increased from 86,755 in 1992 to 323,474 in 2007. Noncardiogenic acute respiratory failure among black Americans increased from 56.4 (95% confidence interval 39.7-73.1) to 143.8 (95% confidence interval 123.8-163.8) cases per 100,000 in 1992 and 2007, respectively. Among white Americans, the incidence of noncardiogenic acute respiratory failure increased from 31.2 (95% confidence interval 26.2-36.5) to 94.0 (95% confidence interval 86.7-101.2) cases per 100,000 in 1992 and 2007, respectively. The average annual incidence of noncardiogenic acute respiratory failure over the entire study period was 95.1 (95% confidence interval 93.9-96.4) cases per 100,000 for black Americans compared to 66.5 (95% confidence interval 65.8-67.2) cases per 100,000 for white Americans (rate ratio 1.43, 95% confidence interval 1.42-1.44). Overall in-hospital mortality was greater for other-race Americans, but only among patients with two or more organ failures (57% [95% confidence interval 56%-59%] for other race, 51% [95% confidence interval 50%-52%] for white, 50% [95% confidence interval 49%-51%] for black). CONCLUSIONS: The incidence of noncardiogenic acute respiratory failure in the United States increased between 1992 and 2007. Black and other-race Americans are at greater risk of developing noncardiogenic acute respiratory failure compared to white Americans.

The effect of race and ethnicity on outcomes among patients in the intensive care unit: a comprehensive study involving socioeconomic status and resuscitation preferences.

OBJECTIVE: We sought to determine whether race or ethnicity is independently associated with mortality or intensive care unit length of stay among critically ill patients after accounting for patients' clinical and demographic characteristics including socioeconomic status and resuscitation preferences. DESIGN: Historical cohort study of patients hospitalized in intensive care units. SETTING: Adult intensive care units in 35 California hospitals during the years 2001-2004. PATIENTS: A total of 9,518 intensive care unit patients (6,334 white, 655 black, 1,917 Hispanic, and 612 Asian/Pacific Islander patients). MEASUREMENTS AND MAIN RESULTS: The primary outcome was risk-adjusted mortality and a secondary outcome was risk-adjusted intensive care unit length of stay. Crude hospital mortality was 15.9% among the entire cohort. Asian patients had the highest crude hospital mortality at 18.6% and black patients had the lowest at 15.0%. After adjusting for age and gender, Hispanic and Asian patients had a higher risk of death compared to white patients, but these differences were not significant after additional adjustment for severity of illness. Black patients had more acute physiologic derangements at intensive care unit admission and longer unadjusted intensive care unit lengths of stay. Intensive care unit length of stay was not significantly different among racial/ethnic groups after adjustment for demographic, clinical, and socioeconomic factors and do-not-resuscitate status. In an analysis restricted only to those who died, decedent black patients averaged 1.1 additional days in the intensive care unit (95% confidence interval, 0.26-2.6) compared to white patients who died, although this was not statistically significant. CONCLUSIONS: Hospital mortality and intensive care unit length of stay did not differ by race or ethnicity among this diverse cohort of critically ill patients after adjustment for severity of illness, resuscitation status, socioeconomic status, insurance status, and admission type. Black patients had more acute physiologic derangements at intensive care unit admission and were less likely to have a do-not-resuscitate order. These results suggest that among intensive care unit patients, there are no racial or ethnic differences in mortality within individual hospitals. If disparities in intensive care unit care exist, they may be explained by differences in the quality of care provided by hospitals that serve high proportions of minority patients.

Age-, sex-, and race-based differences among patients enrolled versus not enrolled in acute lung injury clinical trials.

OBJECTIVE: Little is known about the participation of racial/ethnic minorities, women, and the elderly into critical care clinical trials. We sought to characterize the representation of racial and ethnic minorities, women, and older patients in clinical trials of patients with acute lung injury and to determine the reasons for nonenrollment. DESIGN, SETTING, AND PATIENTS: We performed a cross-sectional analysis of pooled screening logs from 44 academic hospitals participating in three multicentered, randomized, controlled trials conducted by the Acute Respiratory Distress Syndrome Network from 1996 to 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We calculated odds ratios of enrollment for age, sex, racial groups, and the odds ratio for the presence of each exclusion criterion by age, sex, and race adjusted for demographics, acute lung injury risk factor, study, and study center. A total of 10.4% of 17,459 screened patients with acute lung injury were enrolled. The median (range) enrollment by center was 15% (2% to 88%). Older patients of both sexes were less likely to be enrolled, but older women were more likely to be enrolled than older men. The adjusted odds ratio (95% confidence interval) for enrollment among men > or =75 yrs of age was 0.59 (0.45 to 0.77) and for women > or =75 yrs of age was 0.45 (0.32 to 0.62) compared with men <35 yrs of age. There were no differences in the likelihood of enrollment among all racial/ethnic groups. Older patients and men were less likely to be enrolled because of medical comorbidity. Among all patients who were not enrolled, black patients and their families refused participation more often than white patients. CONCLUSIONS: Older patients are less likely to be enrolled in acute lung injury clinical trials. There is no evidence that women or racial/ethnic minorities are underrepresented in acute lung injury clinical trials.

Long-range shielding effects in the (1)H NMR spectra of Mosher-like ester derivatives.

The relative magnitudes of the chemical shift differences (Deltadeltas) in the two diastereomers of menthyl esters of known chiral derivatizing agents (CDAs) were compared to those of the alpha-methoxy-alpha-trifluoromethyl-1-naphthylacetyl (MTN((1))A) analogues I. Discrimination of the terminal diastereotopic methyl resonances in esters of the homologous, symmetrical carbinols II was evaluated. Remarkably, the methyls differed in the MTN((1))A esters III even when n = 15; an unexpected crossover in the sign of the Deltadelta values was also observed.

Recent trends in acute lung injury mortality: 1996-2005.

OBJECTIVE: Studies from single centers have suggested that mortality from acute lung injury (ALI) has declined over time. However, recent trends in ALI mortality from centers across the United States are unknown. We sought to determine whether recent advances in the treatment of ALI and related critical illnesses have resulted in decreased mortality from ALI. DESIGN: Retrospective cohort study of patients enrolled in the Acute Respiratory Distress Syndrome (ARDS) Network randomized controlled trials. SETTING: Adult intensive care units participating in the ARDS Network trials. PATIENTS: 2,451 mechanically ventilated patients with ALI enrolled in the ARDS Network randomized controlled trials between 1996 and 2005. MEASUREMENTS AND MAIN RESULTS: Crude mortality was 35% in 1996-1997 and declined during each subsequent time period to a low of 26% in 2004-2005 (test for trend p < 0.0005). After adjusting for demographic and clinical covariates, including receipt of lower tidal volume ventilation and severity of illness, the temporal trend persisted (test for trend p = 0.002). When analyzed by individual causes of lung injury, there were not any statistically significant temporal trends in 60-day mortality for the most common causes of lung injury (pneumonia, sepsis, aspiration, and trauma). CONCLUSIONS: Over the past decade, there seems to be a clear temporal improvement in survival among patients with ALI treated at ARDS Network centers. Our findings strongly suggest that other advancements in critical care, aside from lower tidal volume ventilation, accounted for this improvement in mortality.

Racial and ethnic disparities in mortality from acute lung injury.

OBJECTIVE: Little is known about the influence of race and ethnicity on mortality from acute lung injury (ALI). We sought to determine whether black race or Hispanic ethnicity is independently associated with mortality among patients with ALI. DESIGN: Retrospective cohort study of patients enrolled in the Acute Respiratory Distress Syndrome Network randomized controlled trials. SETTING: Adult intensive care units participating in the Acute Respiratory Distress Syndrome Network trials. PATIENTS: A total of 2362 mechanically ventilated patients (1715 white, 449 black, and 198 Hispanic) with ALI. MEASUREMENTS AND MAIN RESULTS: The primary outcome was 60-day mortality. A secondary outcome was number of ventilator-free days. Crude mortality was 33% for both blacks and Hispanics compared with 27% for whites (p = 0.02). After adjusting for demographic and clinical covariates, the association between race/ethnicity and mortality persisted (odds ratio [OR] = 1.42; 95% confidence interval [CI] 1.10-1.84 for blacks; OR = 1.94; 95% CI, 1.36-2.77 for Hispanics; OR = 1.00 for whites). After adjustment for severity of illness (Acute Physiology Score), black race was no longer significantly associated with mortality (OR = 1.25; 95% CI, 0.95-1.66), whereas the association with Hispanic ethnicity persisted (OR = 2.00; 95% CI, 1.37-2.90). Hispanics had significantly fewer ventilator-free days compared with whites after adjustment for demographic and clinical covariates (mean difference in days = -2.3; 95% CI -3.90 to -0.70). CONCLUSIONS: Black and Hispanic patients with ALI have a significantly higher risk of death compared with white patients. This increased risk seemed to be mediated by increased severity of illness at presentation for blacks, but was unexplained among Hispanics.

Effect of sepsis therapies on health-related quality of life.

Sepsis is one of the most common conditions encountered in the intensive care unit and is the 10th leading cause of death overall in the United States. Both long-term survival and health-related quality of life are reduced in survivors of sepsis, yet there is little knowledge of the effect of sepsis-specific interventions on either long-term survival or health-related quality of life. The present article discusses the importance of studying health-related quality of life as it relates to sepsis management strategies, particularly in the context of pharmacologic therapy with recombinant human activated protein C.

Effect of race on asthma management and outcomes in a large, integrated managed care organization.

BACKGROUND: Morbidity from asthma disproportionately affects black people. Whether this excess morbidity is fully explained by differences in asthma severity, access to care, or socioeconomic status (SES) is unknown. METHODS: We assessed whether there were racial disparities in asthma management and outcomes in a managed care organization that provides uniform access to health care and then determined to what degree these disparities were explained by differences in SES, asthma severity, and asthma management. We prospectively studied 678 patients from a large, integrated health care delivery system. Patients who had been hospitalized for asthma were interviewed after discharge to ascertain information about asthma history, health status, and SES. Small-area socioeconomic data were ascertained by means of geocoding and linkage to the US Census 2000. Patients were followed up for subsequent emergency department (ED) visits or hospitalizations (median follow-up, 1.9 years). RESULTS: Black race was associated with a higher risk of ED visits (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.39-2.66) and hospitalizations (HR, 1.89; 95% CI, 1.30-2.76). This finding persisted after adjusting for SES and differences in asthma therapy (adjusted HR for ED visits, 1.73; 95% CI, 1.07-2.81; and adjusted HR for hospitalizations, 2.01; 95% CI, 1.33-3.02). CONCLUSIONS: Even in a health care setting that provides uniform access to care, black race was associated with worse asthma outcomes, including a greater risk of ED visits and hospitalizations. This association was not explained by differences in SES, asthma severity, or asthma therapy. These findings suggest that genetic differences may underlie these racial disparities.

The effect of inpatient hospice units on hospice use post-admission.

The objective of this study was to determine whether having a hospice unit within the hospital increases the proportion of terminally ill patients who use hospice services (including home, nursing home, or inpatient hospice) post-admission. Using medical record data abstracted for 232 randomly selected patients with terminal cancer admitted to six community hospitals in Connecticut, we found that patients admitted to a hospital with a hospice unit were more likely to use hospice services (i.e., home hospice, nursing home hospice, or inpatient hospice) post-admission than patients admitted to a hospital without a hospice unit (unadjusted OR 5.7, 95% CI 3.1, 10.6). This effect persisted after adjusting for patient age, gender, marital status, documented discussions of prognosis, prior hospice use, and type of cancer.