Variations in the California Emergency Medical Services Response to Opioid Use Disorder

Introduction: Opioids contributed to over 300,000 deaths in the United States in the past 10 years. Most research on drug use occurs in clinics or hospitals; few studies have evaluated the impact of opioid use on emergency medical services (EMS) or the EMS response to opioid use disorder (OUD). This study describes the perceived burden of disease, data collection, and interventions in California local EMS agencies (LEMSA). Methods: We surveyed medical directors of all 33 California LEMSAs with 25 multiple-choice and free-answer questions. Results were collected in RedCap and downloaded into Excel (Microsoft Corporation, Redmond WA). This study was exempt from review by the Alameda Health System - Highland Hospital Institutional Review Board. Results: Of the 33 California LEMSAs, 100% responded, all indicating that OUD significantly affects their patients. Most (91%) had specific protocols directing care of those patients and repeat naloxone dosing. After naloxone administration, none permitted release to law enforcement custody, 6% permitted patient refusal of care, and 45% directed base hospital contact for refusal of care. Few protocols directed screening or treatment of OUD or withdrawal symptoms. Regular data collection occurred in 76% of LEMSAs, with only 48% linking EMS data with hospital or coroner outcomes. In only 30% did the medical director oversee regular quality improvement meetings. Of respondents, 64% were aware of public health agency-based outreach programs and 42% were aware of emergency department BRIDGE programs (Medication Assisted Treatment and immediate referral). Only 9% oversaw naloxone kit distribution (all under the medical director), and 6% had EMS-based outreach programs. In almost all (94%), law enforcement officers carried naloxone and administered it anywhere from a few times a year to greater than 200 in one LEMSA. Conclusion: This study represents an important description of EMS medical directors' approaches to the impact of OUD as well as trends in protocols and interventions to treat and prevent overdoses. Through this study, we can better understand the variable response to patients with OUD across California

Manufacture of Gowdy spacetimes with spikes

In numerical studies of Gowdy spacetimes evidence has been found for the development of localized features (spikes) involving large gradients near the singularity. The rigorous mathematical results available up to now did not cover this kind of situation. In this work we show the existence of large classes of Gowdy spacetimes exhibiting features of the kind discovered numerically. These spacetimes are constructed by applying certain transformations to previously known spacetimes without spikes. It is possible to control the behaviour of the Kretschmann scalar near the singularity in detail. This curvature invariant is found to blow up in a way which is non-uniform near the spike in some cases. When this happens it demonstrates that the spike is a geometrically invariant feature and not an artefact of the choice of variables used to parametrize the metric. We also identify another class of spikes which are artefacts. The spikes produced by our method are compared with the results of numerical and heuristic analyses of the same situation.Comment: 25 page

Initial Hypersurface Formulation: Hamilton-Jacobi Theory for Strongly Coupled Gravitational Systems

Strongly coupled gravitational systems describe Einstein gravity and matter in the limit that Newton's constant G is assumed to be very large. The nonlinear evolution of these systems may be solved analytically in the classical and semiclassical limits by employing a Green function analysis. Using functional methods in a Hamilton-Jacobi setting, one may compute the generating functional (`the phase of the wavefunctional') which satisfies both the energy constraint and the momentum constraint. Previous results are extended to encompass the imposition of an arbitrary initial hypersurface. A Lagrange multiplier in the generating functional restricts the initial fields, and also allows one to formulate the energy constraint on the initial hypersurface. Classical evolution follows as a result of minimizing the generating functional with respect to the initial fields. Examples are given describing Einstein gravity interacting with either a dust field and/or a scalar field. Green functions are explicitly determined for (1) gravity, dust, a scalar field and a cosmological constant and (2) gravity and a scalar field interacting with an exponential potential. This formalism is useful in solving problems of cosmology and of gravitational collapse.Comment: 30 pages Latex (IOP) file with 2 IOP style files, to be published in Classical and Quantum Gravity (1998

Locally U(1)*U(1) Symmetric Cosmological Models: Topology and Dynamics

We show examples which reveal influences of spatial topologies to dynamics, using a class of spatially {\it closed} inhomogeneous cosmological models. The models, called the {\it locally U(1)$\times$U(1) symmetric models} (or the {\it generalized Gowdy models}), are characterized by the existence of two commuting spatial {\it local} Killing vectors. For systematic investigations we first present a classification of possible spatial topologies in this class. We stress the significance of the locally homogeneous limits (i.e., the Bianchi types or the `geometric structures') of the models. In particular, we show a method of reduction to the natural reduced manifold, and analyze the equivalences at the reduced level of the models as dynamical models. Based on these fundamentals, we examine the influence of spatial topologies on dynamics by obtaining translation and reflection operators which commute with the dynamical flow in the phase space.Comment: 32 pages, 1 figure, LaTeX2e, revised Introduction slightly. To appear in CQ

The Gowdy T3 Cosmologies revisited

We have examined, repeated and extended earlier numerical calculations of Berger and Moncrief for the evolution of unpolarized Gowdy T3 cosmological models. Our results are consistent with theirs and we support their claim that the models exhibit AVTD behaviour, even though spatial derivatives cannot be neglected. The behaviour of the curvature invariants and the formation of structure through evolution both backwards and forwards in time is discussed.Comment: 11 pages, LaTeX, 6 figures, results and conclusions revised and (considerably) expande

Adjusted ADM systems and their expected stability properties: constraint propagation analysis in Schwarzschild spacetime

In order to find a way to have a better formulation for numerical evolution of the Einstein equations, we study the propagation equations of the constraints based on the Arnowitt-Deser-Misner formulation. By adjusting constraint terms in the evolution equations, we try to construct an "asymptotically constrained system" which is expected to be robust against violation of the constraints, and to enable a long-term stable and accurate numerical simulation. We first provide useful expressions for analyzing constraint propagation in a general spacetime, then apply it to Schwarzschild spacetime. We search when and where the negative real or non-zero imaginary eigenvalues of the homogenized constraint propagation matrix appear, and how they depend on the choice of coordinate system and adjustments. Our analysis includes the proposal of Detweiler (1987), which is still the best one according to our conjecture but has a growing mode of error near the horizon. Some examples are snapshots of a maximally sliced Schwarzschild black hole. The predictions here may help the community to make further improvements.Comment: 23 pages, RevTeX4, many figures. Revised version. Added subtitle, reduced figures, rephrased introduction, and a native checked. :-

Influence of electron correlations on ground-state properties of III-V semiconductors

Lattice constants and bulk moduli of eleven cubic III-V semiconductors are calculated using an ab initio scheme. Correlation contributions of the valence electrons, in particular, are determined using increments for localized bonds and for pairs and triples of such bonds; individual increments, in turn, are evaluated using the coupled cluster approach with single and double excitations. Core-valence correlation is taken into account by means of a core polarization potential. Combining the results at the correlated level with corresponding Hartree-Fock data, we obtain lattice constants which agree with experiment within an average error of -0.2%; bulk moduli are accurate to +4%. We discuss in detail the influence of the various correlation contributions on lattice constants and bulk moduli.Comment: 4 pages, Latex, no figures, Phys. Rev. B, accepte

Isolation and study of a ubiquitously expressed tomato pectin methylesterase regulatory region

Pectin methylesterase (PME) is an enzyme located in the plant cell wall of higher plants whose physiological role is largely unknown. We had isolated a PME gene from a tomato genomic library, including 2.59 kb of 5' flanking region and the coding region. Both coding and promoter region were sequenced and computer analyzed. Tobacco transgenic plants were created harboring constructs in which 2.596 Kb, 1.306 Kb and 0.267 Kb sizes of the promoter were driving the expression of \u3b2-Glucuronidase gene (GUS). GUS activity was studied by histochemical and fluorometric assays. Two introns of 106 and 1039 bp were found in the coding region and phylogenetic analysis placed this PME gene closer to genes from Citrus sinensis and Arabidopsis thaliana than tomato fruit-specific PME genes. In the promoter, it was found direct repeats, perfect inverted repeats and light responsive elements. GUS histochemical analysis showed activity in all plant tissues with the exception of pollen. The reduction in the promoter size induced a reduction in GUS activity in root, stem and leaf. Furthermore, root and leaf showed the highest and lowest activity, respectively. We had isolated a tomato PME gene with novel characteristics as compared with other known PME genes from tomato