The Need for Effective Licensure Laws for Mid-Level Health Care Providers in Countries Facing Chronic Physician Shortages: A Case Study of the Marshall Islands\u27 Health Assistants

Facing a global physician shortage and high international emigration rates, developing countries are increasingly looking to mid-level health care providers to provide critical primary health care services. Mid-level providers have more training than nurses but less than full physicians and are typically authorized to prescribe medications and perform simple medical procedures. As the demand for health care providers continues to grow, mid-level providers are increasingly being asked to provide a broader array of clinical services. In response to this growing need, mid-level providers are increasingly practicing outside of their licensed scope of practice, which may both compromise patient safety and expose providers to legal liability. To ensure that countries are striking an appropriate balance between the increasing need for health care providers and the need to protect patient safety, the World Health Organization (“WHO”) has called on countries to review their medical licensure laws to ensure that they clearly and appropriately define mid-level providers’ scope of practice, degree of autonomy, initial and continuing educational requirements, and disciplinary mechanisms. One developing country that is utilizing mid-level providers to address its chronic physician shortage and whose licensure laws fail to satisfy the WHO recommendations is the Republic of the Marshall Islands (“Marshall Islands”). The Marshall Islands’ health assistants provide critical primary health care services to the country’s outer island communities. However, the licensure law applying to health assistants does not clearly define their scope of practice, degree of autonomy, or continuing education requirements. As international aid from the United States decreases in the coming years and the outer island health care system likely deteriorates, these health assistants will be faced with increasingly difficult treatment scenarios. To ensure that these providers are adequately trained for these situations, the Marshall Islands should enact a comprehensive health assistant licensure scheme consistent with the WHO recommendations. After analyzing existing medical licensure laws in the Marshall Islands, this Comment will propose a comprehensive health assistant licensure scheme that is consistent with WHO recommendations and modeled on the Marshall Islands’ Nursing Practice Act

Mathematical Foundations of Complex Tonality

Equal temperament, in which semitones are tuned in the irrational ratio of $2^{1/12} : 1$, is best seen as a serviceable compromise, sacrificing purity for flexibility. Just intonation, in which intervals given by products of powers of $2$, $3$, and $5$, is more natural, but of limited flexibility. We propose a new scheme in which ratios of Gaussian integers form the basis of an abstract tonal system. The tritone, so problematic in just temperament, given ambiguously by the ratios $\tfrac{45}{32}$, $\tfrac{64}{45}$, $\tfrac{36}{25}$, $\tfrac{25}{18}$, none satisfactory, is in our scheme represented by the complex ratio $1 + \rm{i} : 1$. The major and minor whole tones, given by intervals of $\tfrac{9}{8}$ and $\tfrac{10}{9}$, can each be factorized into products of complex semitones, giving us a major complex semitone $\tfrac{3}{4}(1 + \rm{i})$ and a minor complex semitone $\tfrac{1}{3}(3 + \rm{i})$. The perfect third, given by the interval $\tfrac{5}{4}$, factorizes into the product of a complex whole tone $\tfrac{1}{2}(1 + 2\rm{i})$ and its complex conjugate. Augmented with these supplementary tones, the resulting scheme of complex intervals based on products of powers of Gaussian primes leads very naturally to the construction of a complete system of major and minor scales in all keys.Comment: 35 pages, revise

Assessing sedimentary records of paleohurricane activity using modeled hurricane climatology

Author Posting. © American Geophysical Union, 2008. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Geochemistry Geophysics Geosystems 9 (2008): Q09V10, doi:10.1029/2008GC002043.Patterns of overwash deposition observed within back-barrier sediment archives can indicate past changes in tropical cyclone activity; however, it is necessary to evaluate the significance of observed trends in the context of the full range of variability under modern climate conditions. Here we present a method for assessing the statistical significance of patterns observed within a sedimentary hurricane-overwash reconstruction. To alleviate restrictions associated with the limited number of historical hurricanes affecting a specific site, we apply a recently published technique for generating a large number of synthetic storms using a coupled ocean-atmosphere hurricane model set to simulate modern climatology. Thousands of overwash records are generated for a site using a random draw of these synthetic hurricanes, a prescribed threshold for overwash, and a specified temporal resolution based on sedimentation rates observed at a particular site. As a test case we apply this Monte Carlo technique to a hurricane-induced overwash reconstruction developed from Laguna Playa Grande (LPG), a coastal lagoon located on the island of Vieques, Puerto Rico in the northeastern Caribbean. Apparent overwash rates in the LPG overwash record are observed to be four times lower between 2500 and 1000 years B.P. when compared to apparent overwash rates during the last 300 years. However, probability distributions based on Monte Carlo simulations indicate that as much as 65% of this drop can be explained by a reduction in the temporal resolution for older sediments due to a decrease in sedimentation rates. Periods of no apparent overwash activity at LPG between 2500 and 3600 years B.P. and 500–1000 years B.P. are exceptionally long and are unlikely to occur (above 99% confidence) under the current climate conditions. In addition, breaks in activity are difficult to produce even when the hurricane model is forced to a constant El Niño state. Results from this study continue to support the interpretation that the western North Atlantic has exhibited significant changes in hurricane climatology over the last 5500 years.Funding for this research was provided by the Earth Systems History Program of the National Science Foundation, Risk Prediction Initiative, National Geographic Society, Coastal Ocean Institute at WHOI, and the Andrew W. Mellon Foundation Endowed Fund for Innovative Research

Tropical cyclone wind speed constraints from resultant storm surge deposition : a 2500 year reconstruction of hurricane activity from St. Marks, FL

Author Posting. © American Geophysical Union, 2013. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Geochemistry, Geophysics, Geosystems 14 (2013): 2993–3008, doi:10.1002/ggge.20217.Recent work suggests that the patterns of intense (≥category 3 on the Saffir-Simpson scale) hurricane strikes over the last few millennia might differ from that of overall hurricane activity during this period. Prior studies typically rely on assigning a threshold storm intensity required to produce a sedimentological overwash signal at a particular coastal site based on historical analogs. Here, we improve on this approach by presenting a new inverse-model technique that constrains the most likely wind speeds required to transport the maximum grain size within resultant storm deposits. As a case study, the technique is applied to event layers observed in sediments collected from a coastal sinkhole in northwestern Florida. We find that (1) simulated wind speeds for modern deposits are consistent with the intensities for historical hurricanes affecting the site, (2) all deposits throughout the ∼2500 year record are capable of being produced by hurricanes, and (3) a period of increased intense hurricane frequency is observed between ∼1700 and ∼600 years B.P. and decreased intense storm frequency is observed from ∼2500 to ∼1700 and ∼600 years B.P. to the present. This is consistent with prior reconstructions from nearby sites. Changes in the frequency of intense hurricane strikes may be related to the degree of penetration of the Loop Current in the Gulf of Mexico.This work was supported by the National Science Foundation.2014-02-2

A decadally-resolved paleohurricane record archived in the late Holocene sediments of a Florida sinkhole

Author Posting. © The Author(s), 2011. This is the author's version of the work. It is posted here by permission of Elsevier B.V. for personal use, not for redistribution. The definitive version was published in Marine Geology 287 (2011): 14-30, doi:10.1016/j.margeo.2011.07.001.A 4500-year record of hurricane-induced storm surges is developed from sediment cores collected from a coastal sinkhole near Apalachee Bay, Florida. Recent deposition of sand layers in the upper sediments of the pond was found to be contemporaneous with significant, historic storm surges at the site modeled using SLOSH and the Best Track, post-1851 A.D. dataset. Using the historic portion of the record for calibration, paleohurricane deposits were identified by sand content and dated using radiocarbon-based age models. Marine-indicative foraminifera, some originating at least 5 km offshore, were present in several modern and ancient storm deposits. The presence and long-term preservation of offshore foraminifera suggest that this site and others like it may yield promising microfossil-based paleohurricane reconstructions in the future. Due to the sub-decadal (~ 7 year) resolution of the record and the site’s high susceptibility to hurricane-generated storm surges, the average, local frequency of recorded events, approximately 3.9 storms per century, is greater than that of previously published paleohurricane records from the region. The high incidence of recorded events permitted a time series of local hurricane frequency during the last five millennia to be constructed. Variability in the frequency of the largest storm layers was found to be greater than what would likely occur by chance alone, with intervals of both anomalously high and low storm frequency identified. However, the rate at which smaller layers were deposited was relatively constant over the last five millennia. This may suggest that significant variability in hurricane frequency has occurred only in the highest magnitude events. The frequency of high magnitude events peaked near 6 storms per century between 2800 and 2300 years ago. High magnitude events were relatively rare with about 0-3 storms per century occurring between 1900 to 1600 years ago and between 400 to 150 years ago. A marked decline in the number of large storm deposits, which began around 600 years ago, has persisted through present with below average frequency over the last 150 years when compared to the preceding five millennia.Funding for this research was supported by the National Science Foundation and the Coastal Ocean Institute. the model. The Florida State University Marine Laboratory provided lodging during fieldwork. This research was completed during an American Meteorological Society Graduate Fellowship, National Science Foundation Graduate Fellowship and Coastal Ocean Institute Fellowship. This work was further supported by National Science Foundation award #OCE-0903020

Influence of providers and nurses on completion of non-targeted HIV screening in an urgent care setting

Introduction: Despite recommendations by the Centers for Disease Control (CDC) that all adults be offered non-targeted HIV screening in all care settings, screening in acute-care settings remains unacceptably low. We performed an observational study to evaluate an HIV screening pilot in an academic-community partnership health center urgent care clinic. Methods: We collected visit data via encounter forms and demographic and laboratory data from electronic medical records. A post-pilot survey of perceptions of HIV screening was administered to providers and nurses. Multivariable analysis was used to identify factors associated with completion of testing. Results: Visit provider and triage nurse were highly associated with both acceptance of screening and completion of testing, as were younger age, male gender, and race/ethnicity. 23.5% of patients completed tests, although 36.0% requested screening; time constraints as well as risk perceptions by both the provider and patient were cited as limiting completion of screening. Post-pilot surveys showed mixed support for ongoing HIV screening in this setting by providers and little support by nurses. Conclusions: Visit provider and triage nurse were strongly associated with acceptance of testing, which may reflect variable opinions of HIV screening in this setting by clinical staff. Among patients accepting screening, visit provider remained strongly associated with completion of testing. Despite longstanding recommendations for non-targeted HIV screening, further changes to improve the testing and results process, as well as provider education and buy-in, are needed to improve screening rates

Perceptions and behaviours of infectious diseases physicians when managing urinary tract infections due to MDR organisms

Objectives The objective of this study was to attain a better understanding of infectious diseases (ID) physicians' experience with MDR organism (MDRO) urinary tract infections (UTIs) by means of a survey on disease perception, diagnostic management and treatment preferences. Methods A nine-question survey was developed and distributed to members of the North American Emerging Infections Network (EIN) in September 2013. Results Seven hundred and fourteen out of 1461 EIN members responded to the survey (49%). The responses of 603 responders were studied. Most providers perceived an increase in the incidence of MDRO UTIs over the past 3 years (75% of adult ID responders and 63% of paediatric ID responders). One hundred and thirty-four (22%) responders prefer intravenous over oral administration of antimicrobials when both are available, 171 (28%) prefer longer durations of therapy when comparing an MDRO with a susceptible isolate of the same species and 142 (24%) order a repeat urine culture as ‘proof of cure' after treating an MDRO UTI. Nevertheless, 530 (88%) responders perceived MDRO UTIs to be of similar severity as non-MDRO UTIs. Fifty-five percent of providers prescribed fosfomycin for MDRO UTI at least once; the most common prescribing pattern (among a wide spectrum of approaches) was a single dose (16%). Conclusions Future studies on MDRO UTIs should clarify the role of resistance in patient outcomes and the comparative efficacy of different antimicrobials. Of particular interest is fosfomycin, which is unrelated to other antibiotic classes and may take a more prominent role in treating MDRO cystiti

Climate forcing of unprecedented intense-hurricane activity in the last 2000 years

© The Author(s), 2015. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Earth's Future 3 (2015): 49–65, doi:10.1002/2014EF000274.How climate controls hurricane variability has critical implications for society is not well understood. In part, our understanding is hampered by the short and incomplete observational hurricane record. Here we present a synthesis of intense-hurricane activity from the western North Atlantic over the past two millennia, which is supported by a new, exceptionally well-resolved record from Salt Pond, Massachusetts (USA). At Salt Pond, three coarse grained event beds deposited in the historical interval are consistent with severe hurricanes in 1991 (Bob), 1675, and 1635 C.E., and provide modern analogs for 32 other prehistoric event beds. Two intervals of heightened frequency of event bed deposition between 1400 and 1675 C.E. (10 events) and 150 and 1150 C.E. (23 events), represent the local expression of coherent regional patterns in intense-hurricane–induced event beds. Our synthesis indicates that much of the western North Atlantic appears to have been active between 250 and 1150 C.E., with high levels of activity persisting in the Caribbean and Gulf of Mexico until 1400 C.E. This interval was one with relatively warm sea surface temperatures (SSTs) in the main development region (MDR). A shift in activity to the North American east coast occurred ca. 1400 C.E., with more frequent severe hurricane strikes recorded from The Bahamas to New England between 1400 and 1675 C.E. A warm SST anomaly along the western North Atlantic, rather than within the MDR, likely contributed to the later active interval being restricted to the east coast.Funding was provided by US National Science Foundation (awards 0903020 and 1356708), the Risk Prediction Initiative at the Bermuda Institute for Ocean Sciences (BIOS), US Department of Energy National Institute for Climate Change Research, National Oceanic and Atmospheric Administration (award NA11OAR431010), and the Dalio Explore Fund

Pattern Transfer of Sub-10 nm Features via Tin-Containing Block Copolymers

Tin-containing block copolymers were investigated as materials for nanolithographic applications. Poly(4-trimethylstannylstyrene-block-styrene) (PSnS-PS) and poly(4-trimethylstannylstyrene-block-4-methoxystyrene) (PSnS-PMOST) synthesized by reversible addition–fragmentation chain transfer polymerization form lamellar domains with periodicities ranging from 18 to 34 nm. Thin film orientation control was achieved by thermal annealing between a neutral surface treatment and a top coat. Incorporation of tin into one block facilitates pattern transfer into SiO_2 via a two-step etch process utilizing oxidative and fluorine-based etch chemistries

Historically unprecedented Northern Gulf of Mexico hurricane activity from 650 to 1250 CE

© The Author(s), 2020. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Rodysill, J. R., Donnelly, J. P., Sullivan, R., Lane, P. D., Toomey, M., Woodruff, J. D., Hawkes, A. D., MacDonald, D., d'Entremont, N., McKeon, K., Wallace, E., & van Hengstum, P. J. Historically unprecedented Northern Gulf of Mexico hurricane activity from 650 to 1250 CE. Scientific Reports, 10(1), (2020): 19092. doi:10.1038/s41598-020-75874-0.Hurricane Michael (2018) was the first Category 5 storm on record to make landfall on the Florida panhandle since at least 1851 CE (Common Era), and it resulted in the loss of 59 lives and $25 billion in damages across the southeastern U.S. This event placed a spotlight on recent intense (exceeding Category 4 or 5 on the Saffir-Simpson Hurricane Wind Scale) hurricane landfalls, prompting questions about the natural range in variability of hurricane activity that the instrumental record is too short to address. Of particular interest is determining whether the frequency of recent intense hurricane landfalls in the northern Gulf of Mexico (GOM) is within or outside the natural range of intense hurricane activity prior to 1851 CE. In this study, we identify intense hurricane landfalls in northwest Florida during the past 2000 years based on coarse anomaly event detection from two coastal lacustrine sediment archives. We identified a historically unprecedented period of heightened storm activity common to four Florida panhandle localities from 650 to 1250 CE and a shift to a relatively quiescent storm climate in the GOM spanning the past six centuries. Our study provides long-term context for events like Hurricane Michael and suggests that the observational period 1851 CE to present may underrepresent the natural range in landfalling hurricane activity.Funding for this project was provided by the Strategic Environmental Research and Development Program (SERDP) grant and NSF awards 0903020, 1902463, and 1854980 awarded to Jeffrey Donnelly, and the USGS Land Change Science Program