Evaluating Risk Factors for Developing Hypoglycemia During Treatment of Hyperkalemia With Intravenous Regular Insulin.

Background: The conventional dose of 10 units of intravenous (IV) regular insulin to treat hyperkalemia has been associated with hypoglycemia. There have been retrospective studies evaluating weight-based dose vs conventional dose of IV regular insulin but the comparative efficacy and safety is not well established. Objective: Evaluate the difference in weight-based dosing of IV regular insulin between patients who experienced hypoglycemia vs. patients who did not experience hypoglycemia after the administration of IV regular insulin. Methods: This was a retrospective, electronic chart review at a single academic medical center which included patients ≥18 years of age with an emergency department or inpatient encounter who were administered IV regular insulin within 6 hours of a pre-treatment potassium of ≥5 mmol/L. Results: There was no significant difference in the weight-based insulin dose between patients who experienced a hypoglycemic event and patients who did not experience a hypoglycemic event (.14 vs .22 units/kg; P = .44). The potassium-lowering effect was similar between the two groups (1.02 vs .96 mmol/L; P = .56). A regression analysis revealed that female sex, low baseline blood glucose (glucose <140 mg/dL), and those who received a repeat dose of IV regular insulin were independent risk factors for development of hypoglycemia. Conclusion: This study found no difference in hypoglycemic events and potassium lowering based on IV weight-based regular insulin dosing, however other risk factors may predict hypoglycemia.

Perceived versus actual sedation practices in adult intensive care unit patients receiving mechanical ventilation.

BACKGROUND: With drug shortages, newer sedative medications, and updates in research, management of sedation and delirium in patients receiving mechanical ventilation continues to evolve. OBJECTIVE: To compare perceived and actual sedation practices for adults receiving mechanical ventilation in intensive care units (ICUs). METHODS: This was a multicenter, 2-part study conducted in adult ICUs in US hospitals. It included a sedation practice survey completed by ICU pharmacists and an observational study evaluating actual sedation practices over a 24-hour period. RESULTS: Surveys were completed for 85 ICUs; observational data for 496 patients were collected. Preferred sedatives from the survey data were propofol (short-term); propofol, midazolam, or lorazepam (intermediate); and lorazepam (long-term). Propofol was the most commonly used agent overall during the observational period (primarily for short-term and intermediate-length sedation); midazolam was the most commonly used for long-term sedation. Fentanyl was the preferred analgesic, and haloperidol and quetiapine were the preferred antipsychotics. Sedation treatment algorithms were used in only 50% of observed ICUs. Use of daily interruption of sedation was perceived to be 66% but was only observed in 36% of patients. Monitoring for delirium was reported among 25% of those surveyed but was observed in only 10% of patients. Targeted sedation goals were most frequently achieved when a treatment algorithm was used or when an opiate infusion was the single agent used for sedative management. CONCLUSIONS: These data suggest differences in perceived and actual sedation practice in the US, as well as underutilization of evidence-based interventions. Most notable was the limited use of sedation treatment algorithms, daily interruption of sedation, and monitoring for delirium. Individual sedation and delirium protocols should be evaluated and updated based on evidence-based recommendations.

Opportunities to Strengthen the National Disaster Medical System: The Military-Civilian NDMS Interoperability Study.

The definitive care component of the National Disaster Medical System (NDMS) may not be able to effectively manage tens of thousands of casualties resulting from a catastrophic disaster incident or overseas conflict. To address this potential national security threat, Congress authorized the US Secretary of Defense to conduct the NDMS Pilot Program to improve the interoperability, special capabilities, and patient capacity of the NDMS. The pilot's first phase was the Military-Civilian NDMS Interoperability Study, designed to identify broad themes to direct further NDMS research. Researchers conducted a series of facilitated discussions with 49 key NDMS federal and civilian (private sector) stakeholders to identify and assess weaknesses and opportunities for improving the NDMS. After qualitative analysis, 6 critical themes emerged: (1) coordination, collaboration, and communication between federal and private sector NDMS partners; (2) funding and incentives for improved surge capacity and preparedness for NDMS partners; (3) staffing capacity and competencies for government and private NDMS partners; (4) surge capacity, especially at private sector healthcare facilities; (5) training, education, and exercises and knowledge sharing between federal and private sector NDMS partners; and (6) metrics, benchmarks, and modeling for NDMS partners to track their NDMS-related capabilities and performance. These findings provide a roadmap for federal-level changes and additional operations research to strengthen the NDMS definitive care system, particularly in the areas of policy and legislation, operational coordination, and funding.

A disaster by any other name?: COVID-19 and support for an All-Hazards approach.

Disasters are among the crises that can test the decision making skill of elected and appointed public officials from planning through response and recovery. The COVID-19 crisis, a public health emergency rather than one with immediate damage to the built environment, has affected many aspects of community life. Experiences in responding to the pandemic will likely stimulate fresh planning initiatives for public health emergencies. How then should emergency planners approach planning and response tasks? The All-Hazards approach has been a mainstay of both research and policymaking for over 40 years, but it has come under recent criticism. In this paper, we consider if the All-Hazards approach to disaster management is still viable. Comparing the management needs that emerged in the pandemic with those of disasters from more familiar hazard agents, we conclude that the All-Hazards approach is valid and can continue to guide policymakers in their hazard and disaster management activities.

Los desastres se encuentran entre las crisis que pueden poner a prueba la capacidad de toma de decisiones de los funcionarios públicos electos y designados desde la planificación hasta la respuesta y la recuperación. La crisis de COVID­19, una emergencia de salud pública en lugar de una con daños inmediatos al entorno construido, ha afectado muchos aspectos de la vida comunitaria. Las experiencias en la respuesta a la pandemia probablemente estimularán nuevas iniciativas de planificación para emergencias de salud pública. Entonces, ¿cómo deben abordar los planificadores de emergencias las tareas de planificación y respuesta? El enfoque todos los peligros ha sido un pilar de la investigación y la formulación de políticas durante más de 40 años, pero ha sido objeto de críticas recientes. En este documento, consideramos si el enfoque de todos los peligros para la gestión de desastres sigue siendo viable. Al comparar las necesidades de gestión que surgieron en la pandemia con las de los desastres de agentes de peligro más familiares, llegamos a la conclusión de que el enfoque de todos los peligros es válido y puede seguir guiando a los responsables de la formulación de políticas en sus actividades de gestión de peligros y desastres.

Disaster mental health training programmes in New York City following September 11, 2001.

The need for mental health resources to provide care to the community following large-scale disasters is well documented. In the aftermath of the World Trade Center (WTC) disaster on September 11, 2001, many local agencies and organizations responded by providing informal mental health services, including disaster mental health training for practitioners. The quality of these programmes has not been assessed, however. The National Center for Disaster Preparedness at Columbia University's School of Public Health reviewed disaster mental health training programmes administered by community-based organizations, professional associations, hospitals, and government agencies after September 11. Results indicate that the quality and the effectiveness of programmes are difficult to assess. A wide range of curricula and a widespread lack of recordkeeping and credentialing of trainers were noted. Most of the training programmes provided are no longer available. Recommendations for improving the quality of disaster mental health training programmes are provided.

The COPEWELL Rubric: A Self-Assessment Toolkit to Strengthen Community Resilience to Disasters.

Measurement is a community endeavor that can enhance the ability to anticipate, withstand, and recover from a disaster, as well as foster learning and adaptation. This project's purpose was to develop a self-assessment toolkit-manifesting a bottom-up, participatory approach-that enables people to envision community resilience as a concrete, desirable, and obtainable goal; organize a cross-sector effort to evaluate and enhance factors that influence resilience; and spur adoption of interventions that, in a disaster, would lessen impacts, preserve community functioning, and prompt a more rapid recovery. In 2016-2018, we engaged in a process of literature review, instrument development, stakeholder engagement, and local field-testing, to produce a self-assessment toolkit (or "rubric") built on the Composite of Post-Event Well-being (COPEWELL) model that predicts post-disaster community functioning and resilience. Co-developing the rubric with community-based users, we generated self-assessment instruments and process guides that localities can more readily absorb and adapt. Applied in three field tests, the Social Capital and Cohesion materials equip users to assess this domain at different geo-scales. Chronicling the rubric's implementation, this account sheds further light on tensions between community resilience assessment research and practice, and potential reasons why few of the many current measurement systems have been applied.

Application of a Theoretical Model Toward Understanding Continued Food Insecurity Post Hurricane Katrina.

OBJECTIVE: Disaster recovery efforts focus on restoring basic needs to survivors, such as food, water, and shelter. However, long after the immediate recovery phase is over, some individuals will continue to experience unmet needs. Ongoing food insecurity has been identified as a post-disaster problem. There is a paucity of information regarding the factors that might place an individual at risk for continued food insecurity post disaster. METHODS: Using data from a sample (n=737) of households severely impacted by Hurricane Katrina, we estimated the associations between food insecurity and structural, physical and mental health, and psychosocial factors 5 years after Hurricane Katrina. Logistic regression models were fit and odds ratios (OR) and 95% CI estimated. RESULTS: Nearly one-quarter of respondents (23%) reported food insecurity 5 years post Katrina. Marital/partner status (OR: 0.7, CI: 0.42, 0.99), self-efficacy (OR: 0.56, CI: 0.37, 0.84), sense of community (OR: 0.7, CI: 0.44, 0.98), and social support (OR: 0.59, CI: 0.39, 0.89) lowered the odds of food insecurity and explained most of the effects of mental health distress on food insecurity. Social support, self-efficacy, and being partnered were protective against food insecurity. CONCLUSIONS: Recovery efforts should focus on fostering social-support networks and increased self-efficacy to improve food insecurity post disaster. (Disaster Med Public Health Preparedness. 2018;12:47-56).

Factors Associated with Continued Food Insecurity among Households Recovering from Hurricane Katrina.

In 2010, 14.5% of US households experienced food insecurity, which adversely impacts health. Some groups are at increased risk for food insecurity, such as female-headed households, and those same groups are often also at increased risk for disaster exposure and the negative consequences that come with exposure. Little research has been done on food insecurity post-disaster. The present study investigates long-term food insecurity among households heavily impacted by Hurricane Katrina. A sample of 683 households participating in the Gulf Coast Child and Family Health Study were examined using a generalized estimation model to determine protective and risk factors for food insecurity during long-term recovery. Higher income (Odds Ratio (OR) 0.84, 95% Confidence Interval (CI) 0.77, 0.91), having a partner (OR 0.93; 95% CI 0.89, 0.97), or "other" race were found to be protective against food insecurity over a five-year period following disaster exposure. Low social support (OR 1.14; 95% CI 1.08, 1.20), poor physical health (OR 1.08; 95% CI 1.03, 1.13) or mental health (OR 1.13; 95% CI 1.09, 1.18), and female sex (OR 1.05; 95% CI 1.01, 1.10) were risk factors. Policies and programs that increase access to food supplies among high-risk groups are needed to reduce the negative health impacts of disasters.

COPEWELL: A Conceptual Framework and System Dynamics Model for Predicting Community Functioning and Resilience After Disasters.

OBJECTIVE: Policy-makers and practitioners have a need to assess community resilience in disasters. Prior efforts conflated resilience with community functioning, combined resistance and recovery (the components of resilience), and relied on a static model for what is inherently a dynamic process. We sought to develop linked conceptual and computational models of community functioning and resilience after a disaster. METHODS: We developed a system dynamics computational model that predicts community functioning after a disaster. The computational model outputted the time course of community functioning before, during, and after a disaster, which was used to calculate resistance, recovery, and resilience for all US counties. RESULTS: The conceptual model explicitly separated resilience from community functioning and identified all key components for each, which were translated into a system dynamics computational model with connections and feedbacks. The components were represented by publicly available measures at the county level. Baseline community functioning, resistance, recovery, and resilience evidenced a range of values and geographic clustering, consistent with hypotheses based on the disaster literature. CONCLUSIONS: The work is transparent, motivates ongoing refinements, and identifies areas for improved measurements. After validation, such a model can be used to identify effective investments to enhance community resilience. (Disaster Med Public Health Preparedness. 2018;12:127-137).

Public health aspects of nuclear and radiological incidents.

Radiological and nuclear incidents are low probability but very high risk events. Measures can be, and have been, implemented to limit or prevent the impact on the public. Preparedness, however, remains the key to minimizing morbidity and mortality. Incidents may be related to hospital-based mis-administration of radiation in interventional radiology or nuclear medicine, industrial or nuclear power plant accidents. Safety and security measures are in place to prevent or mitigate such events. Despite efforts to prevent them, terrorist-perpetrated incidents with, for example, a radiological dispersal device (RDD) are also possible. Due to a misunderstanding of, or lack of, formal education regarding things in this realm, there can be considerable anxiety, even fear, about radiation-related incidents. Multiple studies evaluating healthcare provider willingness to report to work rank radiation as the hazard that will keep the largest number of workers at home. Even incidents that do not constitute a disaster can spiral out of control quite rapidly, placing considerable demands on community resources. Our communities will face these threats in the future and it is the responsibility of physicians and allied healthcare personnel to be trained and ready to care for those affected. The scope of resources needed to prepare for and respond to such incidents is indeed vast. It encompasses the coordinated effort of first responders and physicians, the preparedness of national agencies involved in responding to such events, and individual community cooperation and solidarity. This article reviews the approach to the short- and long-term effects of a radiological or nuclear incident on an affected population, with a specific focus on the medical and public health issues. It also summarizes the strengths and weaknesses of our current ability to respond effectively and makes recommendations to improve these capabilities.

Normative collective behavior in the Station building fire.

Objective. This article offers a test of the normative explanation of collective behavior by examining the fire at the Station nightclub in Rhode Island that killed 100 and injured nearly 200 persons.Methods. Information on all persons at the club comes from content analysis of documents from the Rhode Island Police Department, the Rhode Island Office of the Attorney General, and The Providence Journal. We use negative binomial regression to test hypotheses about the effects of group-level predictors of the counts of dead and injured in 179 groups at the nightclub.Results. Results indicate that group-level factors such as distance of group members at the start of the fire, the number of intimate relations among them, the extent to which they had visited the nightclub prior to the incident, and the average length of the evacuation route they used predict counts of injured and dead. The research also looks at what behavioral differences exist between survivors and victims, ascertains the existence of role extension among employees of the nightclub, and provides support for the affirmation that dangerous contexts negate the protective influence of intimate relations in groups.Conclusion. We argue for the abandonment of current emphasis on irrationality and herd-like imitative behavior in studies of evacuation from structural fires in buildings and for the inclusion of group-level processes in social psychological explanations of these incidents.

Nephrogenic diabetes insipidus induced by two amphotericin B liposomal formulations.

Immunocompromised patients are at risk for invasive molds and resistant fungal infections for which amphotericin B may be the only feasible treatment. Nephrogenic diabetes insipidus (DI) and renal tubular acidosis are known adverse effects of conventional amphotericin B; however, nephrogenic DI has been uncommonly associated with liposomal amphotericin B formulations. We describe an 18-year-old woman with aplastic anemia who developed invasive aspergillosis. She began treatment with high-dose (10 mg/kg/day) liposomal amphotericin B at home; however, her condition worsened, and she was hospitalized. Therapy with liposomal amphotericin B was continued until the patient began having symptoms consistent with nephrogenic DI. These symptoms resolved after discontinuation of liposomal amphotericin B; however, after rechallenge with lipid complex amphotericin B (5 mg/kg/day), the symptoms returned. The patient's nephrogenic DI was successfully treated with diuretics. Use of the Naranjo adverse drug reaction probability scale score indicated a probable relationship between liposomal amphotericin B and the development of nephrogenic DI. To our knowledge, this is the third report of nephrogenic DI induced by liposomal amphotericin B. This adverse effect is one of many severe adverse effects caused by all formulations of amphotericin B. A clear understanding of these adverse effects is vital for the clinician to successfully weigh the risks and benefits of antifungal therapy.