No description available.

A major tropical storm will strike in the area of West Central Florida. In anticipation of this storm, this study seeks to predict the specific areas within the Baker Canal drainage basin that will be inundated as a result of this expected event. There are few references concerning extreme flooding in small drainage basins within existing literature. For the purposes of this study this event was considered to be a Probable Maximum Flood (PMF) as defined by Crippen and Bue (1977). The Hydrologic Engineering Centers' Geographic River Analysis System was used to develop water surface elevations and flow rates. Maps depicting this potential flooding at various flood stages were produced using the Environmental Survey Research Institute's geographic Information mapping program ArcView3.3. This investigation produced estimates of the surface area of a Probable Maximum Flood and the estimated flood inundated 23.7% of the study area. The estimated extent of Probable Maximum Flood indicates that the flood will affect one thousand and seventy six (1,076) homes and other structures. The study found that eight hundred and sixty three (863) acres or 27% of the land within the PMF flood zone is listed for future development by the County Planning Commission. When this projected development area is added to existing developed land area a total of 85% of all developed land within the estimated flood area will be submerged and subject to damage. An extreme flood study on a small drainage basin prior to the event can be a viable tool for mitigation planning if it is recognized that there are variables that can produce a relatively large range of error. The potential for this type of study is in its' comparison with an actual event affecting the same area. If the predicted study and the real event study agree within reasonable limits then, maximum flood investigations on small basins could be considered a useful tool in hazard reduction.

This study explored the perspectives on place of eight people with severe mental illness living, for one year or longer, in an urban psychiatric hospital. The research questions were: how do people with severe mental illness view the psychiatric hospital as place?; and how do they make meaning of the experience of living in hospital. The research employed a phenomenological approach, as described by Giorgi (1985). Using purposive sampling, one time, semi-structured, individual interviews were conducted. The audio recorded interviews were transcribed and thematically coded using Giorgi’s (2005) method. The meanings of the participants’ experiences are captured by the meta-theme: this is not a home; it’s a hospital. Four additional major themes emerged; and each of the major themes also had sub-themes The findings of this study challenged commonly held assumptions on how people living long term in a psychiatric hospital view the hospital as place and on institutionalization.

This study explored the perspectives on place of eight people with severe mental illness living, for one year or longer, in an urban psychiatric hospital. The research questions were: how do people with severe mental illness view the psychiatric hospital as place?; and how do they make meaning of the experience of living in hospital. The research employed a phenomenological approach, as described by Giorgi (1985). Using purposive sampling, one time, semi-structured, individual interviews were conducted. The audio recorded interviews were transcribed and thematically coded using Giorgi’s (2005) method. The meanings of the participants’ experiences are captured by the meta-theme: this is not a home; it’s a hospital. Four additional major themes emerged; and each of the major themes also had sub-themes The findings of this study challenged commonly held assumptions on how people living long term in a psychiatric hospital view the hospital as place and on institutionalization.

Severe sepsis kills an estimated 1,400 people worldwide every day. This often fatal infectious process accounts for an estimated 215,000 deaths in the United States (US) annually. The main goal of this project was to evaluate the impact of the Emergency Department Severe Sepsis Alert and Practice Protocol (EDSSAPP) post implementation, on time to first antibiotic administration, length of stay, and mortality in patients admitted via the ORMC ED with severe sepsis. This study evaluated the time to first antibiotic administration, total ED and hospital length of stay (LOS) and mortality of severe sepsis patients either with a severe sepsis alert (SSA) activated or no alert activated that were admitted to the hospital through the ED. A retrospective review of the electronic medical record (EMR) was conducted to gather the required data across three time cohorts: base line/time zero (T0), six months prior to the implementation of EDSSAPP; Time one (T1) the first six months following initial EDSSAPP implementation; and Time two (T2), six months following reinstatement of the corporate sepsis committee. The most significant finding of this study was the increased number of Severe Sepsis Alerts activated in time cohort T2 (n=113) compared to T1 (n=19). Another important finding was the decreased mortality in T2 (16.4%) compared to T0 (22.7%) and T1 (33%). Overall, the number of ED patients with severe sepsis who received antibiotics within the EDSSAPP required 60 minutes did not consistently improve across the three time cohorts, T0 (81.8%), T1 (71.7%) and T2 (80.6%). The hospital LOS of stay was increased by almost 1.5 days between those patients with a severe sepsis alert activated in T1 (9.00 days) compared to time T2 (10.48 days). There was no significant decrease in the ED LOS across time cohorts and between groups of patients who had a SSA activated versus no alert activated. However, there was a 1 hour and 28 minute decrease in ED LOS in patients who had a severe sepsis alert activated in T1 compared to T0. In addition, there was a 1 hour and 52 minutes decrease in ED LOS between patients who had a SSA activated compared to those who had no alert activated in T2. While EDSSAPP data does not demonstrate the statistically significant results that was expected, the challenges related to adherence by providers to EDSSAPP is as it is seen in the literature. Increased awareness via consistent communication of on-going audit results to ED personnel will heighten their awareness for severe sepsis and EDSSAPP. Improved collaborative efforts with the interdisciplinary team are needed to refocus everyone's efforts to increase early recognition that is followed by appropriate treatment interventions and documentation is essential. Lastly, the development of a formal process to follow up with individual providers as close to real time as possible following a SSA that includes accountability for care provided and related documentation would also contribute to both awareness and adherence.

No description available.

Traumatic brain injury (TBI) constitutes a major health problem and is a leading cause of long-term disability and death. Patients with severe traumatic brain injury, S-TBI, comprise a heterogeneous group with varying complexity and prognosis. The primary aim of this thesis was to increase knowledge about clinical course and outcome with regard to prognostic factors. Papers I, II and III were based on data from a prospective multicentre observational study from six neurotrauma centers (NCs) in Sweden and Iceland of patients (n=103-114), 18-65 years with S-TBI requiring neurosurgical intensive care or collaborative care with a neurosurgeon (the “PROBRAIN” study).  Paper IV and V were performed on a regional subset (n=37). In Paper I, patients with posttraumatic disorders of consciousness (DOC) were assessed as regards relationship between conscious state at 3 weeks and outcomes at 1 year. The number of patients who emerged from minimally conscious state (EMCS) 1 year after injury according to status at 3 weeks were: coma (0/6), unresponsive wakeful syndrome (UWS) (9/17), minimally conscious state (MCS) (13/13), anaesthetized (9/11). Outcome at 1 year was good (Glasgow Outcome Scale Extended (GOSE>4) in half of the patients in MCS (or anaesthetized) at 3 weeks, but not for any of the patients in coma or UWS.    In Paper II, the relationships between clinical care descriptors and outcome at 1 year were assessed. A longer length of stay in intensive care, and longer time between discharge from intensive care and admission to inpatient rehabilitation, were both associated with a worse outcome on the GOSE. The number of intervening care units between intensive care and rehabilitation, was not significantly associated with outcome at 1 year.  In Paper III, the clinical course of cognitive and emotional impairments as reflected in the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and the Hospital Anxiety and Depression Scale (HADS) were assessed from 3 weeks to 1 year together with associations with outcomes GOSE and Rancho Los Amigos Cognitive Scale-Revised (RLAS-R) at 1 year. Cognition improved over time and appeared to be stable from 3 months to 1 year.  In Paper IV, clinical parameters, the clinical pathways from injury to 3 months after discharge from the NC in relation to outcomes 3 months post-injury. Ratings on the RLAS-R improved significantly over time. Eight patients had both “superior cognitive functioning” on the RLAS-R and “favourable outcome” on the GOSE. Acute transfers to the one regional NC was direct and swift, transfers for postacute rehabilitation scattered patients to many hospitals/hospital departments, not seldom by several transitional stages.  In Paper V, an initial computerized tomography of the brain (CTi) and a further posttraumatic brain CT after 24 hours (CT24) were evaluated according to protocols for standardized assessment, the Marshall and Rotterdam classifications. The CT scores only correlated with clinical outcome measures (GOSE and RLAS-R) at 3 months, but failed to yield prognostic information regarding outcome at 1 year. A prognostic model was also implemented, based on acute data (CRASH model). This model predicted unfavourable outcomes for 81% of patients with bad outcome and for 85% of patients with favourable outcome according to GOSE at 1 year. When assessing outcomes per se, both GOSE and RLAS-R improved significantly from 3 months to 1 year.  The papers in this study point both to the generally favourable outcomes that result from active and aggressive management of S-TBI, while also underscore our current lack of reliable instruments for outcome prediction. In the absence of an ability to select patients based on prognostication, the overall favourable prognosis lends support for providing active rehabilitation to all patients with S-TBI. The results of these studies should be considered in conjunction with the prognosis of long-term outcomes and the planning of rehabilitation and care pathways. The results demonstrate the importance of a combination of active, acute neurotrauma care and intensive specialized neurorehabilitation with follow-up for these severely injured patients.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Science in Epidemiology (Epidemiology and Biostatistics). 2016 / Background Reducing severe acute respiratory illness (SARI)-associated mortality in African children remains a public health priority and an immense challenge. The pneumococcal conjugate vaccine (PCV) was introduced into the South African routine immunization programme in 2009. The objectives of this study were: I. To describe the demographic characteristics, clinical presentation, respiratory pathogens of children aged <5 years hospitalized with SARI in an urban (Chris Hani-Baragwanath Hospital, Soweto) and a rural (Matikwana and Mapuleng Hospitals, Mpumalanga) setting in South Africa from 2009-2013 and II. To compare the factors associated with mortality among children aged <5 years hospitalized with SARI in these two sites separately. Methods Hospitalized children with SARI were enrolled into an active, prospective sentinel surveillance program. Clinical and epidemiologic data were collected until discharge. Nasopharyngeal aspirates were tested for influenza (A and B) and eight other respiratory viruses. In-hospital case-fatality proportion (CFP) and risk factors for mortality were determined for each hospital site separately using unconditional logistic regression. Results The in-hospital CFP was significantly higher in the rural (6.9%, 103/1486) than the urban (1.3%, 51/3811) site (p<0.001). This was observed among both HIV-infected (urban: 6.6%, 17/257) vs. (rural: 12.9%, 30/233) (p=0.019) and HIV-uninfected children (urban: 0.6%, 13/2236) vs. (rural: 4.2% 36/857) (p<0.001). In the urban site the only factor that is independently associated with death on multivariate analysis was HIV infection (odds ratio (OR) 12.1, 95% confidence interval (CI) 5.8-25.2). In the rural site HIV infection (OR 3.5, 95% CI 1.7-6.9), age <1 year (OR 3.5, 95% CI 2.0-6.1) vs. 1-4 years, any respiratory virus detected (OR 0.4, 95% CI 0.2-0.6), pneumococcal infection(OR 4.5, 95% CI 1.8-10.8) and malnutrition (OR 12.8, 95%CI 1.2-134.6) were independently associated with mortality. Conclusion SARI mortality was higher in the rural setting. Even in the era of PCV availability pneumococcus is still associated with mortality in rural areas. Efforts to prevent and treat HIV infections in children and reduce malnutrition may reduce SARI deaths. / MT2017

Tornadoes cause numerous deaths and significant property damage each year, yet how tornado activity varies across climate states, particularly under global warming, remains poorly understood. Importantly, severe weather events arise during transient periods of extreme thermodynamic environments whose variability may differ from that of the environmental mean state. This study analyzes the climatological relationships between commonly-used severe weather environmental proxies (the product of convective available potential energy and bulk vertical wind shear, energy-helicity index, and the significant tornado parameter) and tornado density on three dominant timescales of climate forcing: diurnal, seasonal, and interannual. We utilize reanalysis data to calculate the spatial distributions of the mean, median, and a range of extreme percentiles of these proxies across each timescale as well as for the full climatology. We then test the extent to which each measure captures the spatiotemporal variability of tornado density over the continental United States. Results indicate that the mean is a suitable statistic when used with the full climatology of the energy-helicity index and the significant tornado parameter without using convective inhibition in calculations, the diurnal cycle for convective available potential energy and the product of convective available potential energy and bulk vertical wind shear, and the interannual variations for all proxies except convective available potential energy. The mean is outperformed by extreme percentiles otherwise. This understanding of climatological relationships between tornadoes and the large scale environments can improve prediction of tornado frequency and provides a foundation for understanding how changes in the statistics of large-scale environments may affect tornado activity in a future warmer climate state.

Paper one is a systematic literature review of qualitative studies examining psychosis in women using a metasynthesis approach. The review involved three stages: a systematic search of qualitative studies reporting the experiences of women with psychosis, critical appraisal of these studies, and the metasynthesis. Thirteen studies met the inclusion criteria, yielding data from 220 women in total. The synthesis of the studies demonstrated three overarching themes: (a) women's beliefs about their illness, (b) perceived consequences of illness, and (c) strategies to cope with illness. Important barriers to strategy use were identified and recommendations made for addressing them. In the second paper grounded theory methodology was used to explore recovery in women who had experienced psychosis following childbirth. Semi-structured interviews were conducted with 12 participants and data were analysed using grounded theory methodology. A theory of four superordinate themes was developed from the data, including: (a) the process of recovery; (b) evolving an understanding; (c) strategies for recovery; and (d) sociocultual context. It was concluded that women experienced a complex process of recovery which was ongoing. The role of other people, including professionals in the recovery process was central. Recommendations were made for professionals to assess women's position in terms of their recovery in order to offer timely, appropriate interventions. The final paper is a critical reflection of the work reported in the previous two papers. I reflected upon how my previous experiences influenced my decision to undertake this research and other aspects of the research process. I explored the rationale for my choice of research methodology and discussed the debates which exist around the use of these methods. Finally, my personal reflections upon the entire research process are included.