Storms, Floods, and Debris Flows in Southern California and Arizona, 1978 and 1980: Proceedings of a Symposium, September 17-18,1980

Following the floods of 1978 and 1980 in southern California and Arizona a symposium was convened at the California Institute of Technology in September 1980 to document the significant events of these floods and to exchange information and evaluations. The symposium laid the groundwork for a volume of proceedings, which serves as a compact permanent source of information on these floods for not only local readers but national readers as well. Special attention is given in the proceedings to documenting problems--some engineering, some institutional--and to drawing conclusions and making recommendations for research. The papers included are not intended to be research papers or to replace the much more detailed reports of individual agencies. The emphasis was on preparing and presenting the papers soon after the event in such a way as to emphasize the regional nature of floods and flood control problems. The proceedings are organized into several sections, with 35 papers altogether. Following the overview and summary, Section 2, STORM METEOROLOGY, which consists of four papers, describes the long-range weather patterns that affect the southwestern United States; the relationship of these patterns to sea surface temperatures in the North Pacific Ocean; the short-term synoptic meteorology of the storms under consideration, showing the importance of multiple storm sequences; and statistical analyses of return periods, based on historical data, for precipitation at a point. Section 3, DOWNSTREAM RIVER FLOODING, consisting of nine papers, gives an overview of the floods on the larger rivers, how the flood control works responded, and what damages occurred. Section 4, UPLAND FLOODS AND SEDIMENT TRANSPORT (five papers), focuses on the unique aspects of sedimentation in regional floods. Section 5, LANDSLIDES, with four papers, explains the problems of landslides, both large and small, that were triggered by the prolonged periods of heavy rainfall. Section 6, CASE STUDIES OF ENGINEERING PROBLEMS (four papers), gives detailed analyses of three particular engineering problems: the failure of levees on the San Jacinto River, the uncontrolled filling of Lake Elsinore to damaging stages, and the severe streambed scour threatening to undermine the Interstate 10 highway bridge over the Salt River at Phoenix, Arizona. The experiences and analyses described in these papers should be useful to engineers who deal with similar structures and situations in the future. Section 7, EFFECTS ON THE SHORELINE, consisting of two papers, illustrates the damaging effects of the high storm waves and high tides that occurred in 1978 and 1980. Beach profiles shifted very rapidly, with sand being moved temporarily offshore, which exposed many shoreline structures to direct wave attack, causing severe damages. Section 8, POLICIES FOR FLOOD CONTROL AND HAZARD MITIGATION (six papers),focuses on institutional issues. Four of these papers advocate a strong new emphasis on hazard mitigation, better flood warning systems, and other nonstructural approaches as part of the mix of society's activities to deal with floods. About 300 people participated in the symposium, and many contributed to the questions and discussion. In the closing session there was a panel discussion by Russell Campbell, Engineering Geologist with the U.S. Geological Survey; John F. Kennedy, Director of the Iowa Institute on Hydraulic Research at the University of Iowa and member of the Committee on Natural Disasters of the National Research Council; Dale Peterson, Director of Community Services with the Federal Emergency Management Agency (FEMA) in San Francisco; and Richard Wainer, Los Angeles City Engineer's Office in Van Nuys. The writer served as moderator. Since it was not feasible to digest and record all of these discussions, I am attempting in this summary to capture the main conclusions and issues.* Nonetheless, the following conclusions and recommendations are solely the responsibility of the author and do not necessarily represent a consensus by the participants at the symposium. For the record it should be noted that the following papers included in the proceedings were not presented at the symposium: "Geotechnical Origin and Repair of the Bluebird Canyon Landslide, Laguna Beach, California" by Beach Leighton and "Levee Failures and Distress, San Jacinto River Levee and Bautista Creek Channel, Riverside County, Santa Ana River Basin, California" by Joe Sciandrone, Ted Albrecht, Jr., Richard Davidson, Jacob Douma, Dave Bamer, Charles Hooppaw, and A1 Robles, Jr. The latter paper is a shortened version of the official Corps of Engineers report on the San Jacinto River levee failure , which was not available in time for presentation at the conference. Numerous brief discussions at the symposium are gratefully acknowledged, although very few are included in the proceedings

Cost-effectiveness of ocriplasmin for the treatment of vitreomacular traction and macular hole

Background: If left untreated, vitreomacular traction (VMT) will infrequently improve through spontaneous resolution of vitreomacular adhesion (VMA), and patients remain at risk of further deterioration in vision. The mainstay of treatment for VMT is vitrectomy, an invasive procedure that carries the risk of rare but serious complications and further vision loss. As such, a ‘watch and wait’ approach is often adopted before this surgical intervention is performed. Ocriplasmin (microplasmin) is a potential alternative treatment for patients with symptomatic VMA/VMT that may remove the requirement for vitrectomy. Objective: The purpose of this study was to evaluate the cost-effectiveness of ocriplasmin for the treatment of VMT in comparison to standard of care. Study design: A cohort-based computer simulation model was developed, capturing three mutually exclusive subgroups: 1) VMT without epiretinal membrane (ERM) or full thickness macular hole (FTMH), 2) VMT with ERM but no FTMH, and 3) VMT with FTMH. Transition probabilities between health states, utilities, and resource utilisation were estimated based on clinical trial results, the literature, and expert opinion. The cost per quality-adjusted life year (QALY) gained was estimated over a lifetime, using UK unit costs and utilities associated with visual acuity, adverse events, metamorphopsia, and surgical interventions. Setting: Analyses were conducted from a UK payer perspective. Population: Transition probabilities for the model were primarily estimated from patient-level data from the combined Phase 3 MIVI-TRUST trials in patients with symptomatic VMA/VMT, including when associated with a FTMH ≤400 µm. Intervention: Ocriplasmin (microplasmin) is a one-time intravitreal injection designed specifically to release the abnormal traction between the macula and the vitreous and thereby treat VMT, as well as macular hole with persistent vitreous attachment. Main outcome measure: The main outcome measure of the economic evaluation was cost per QALY. Results: In all subgroups, ocriplasmin management generated more QALYs: 1) VMT without ERM or FTMH (0.105, (0.036, 0.191)); 2) VMT with ERM but no FTMH (0.041, (0.011, 0.131)); and 3) VMT with FTMH (0.053, (−0.002, 0.113)). The initial treatment costs were partially offset by later savings and net costs were estimated at £1,901 (£1,325, £2,474), £2,491 (£1,067, £2,511), and £1,912 (£1,233, £2,506), respectively. Costs per QALY were estimated at £18,056 (£8,241, £64,874), £61,059 (£8,269, £168,664), and £36,250 (−£144,788, £290,338), respectively. Short-term efficacy parameters were found to be key drivers of results. Conclusion: Ocriplasmin is most cost-effective in VMT patients without either ERM or FTMH

Storms, Floods, and Debris Flows in Southern California and Arizona, 1978 and 1980: Proceedings of a Symposium, September 17-18,1980

Following the floods of 1978 and 1980 in southern California and Arizona a symposium was convened at the California Institute of Technology in September 1980 to document the significant events of these floods and to exchange information and evaluations. The symposium laid the groundwork for a volume of proceedings, which serves as a compact permanent source of information on these floods for not only local readers but national readers as well. Special attention is given in the proceedings to documenting problems--some engineering, some institutional--and to drawing conclusions and making recommendations for research. The papers included are not intended to be research papers or to replace the much more detailed reports of individual agencies. The emphasis was on preparing and presenting the papers soon after the event in such a way as to emphasize the regional nature of floods and flood control problems. The proceedings are organized into several sections, with 35 papers altogether. Following the overview and summary, Section 2, STORM METEOROLOGY, which consists of four papers, describes the long-range weather patterns that affect the southwestern United States; the relationship of these patterns to sea surface temperatures in the North Pacific Ocean; the short-term synoptic meteorology of the storms under consideration, showing the importance of multiple storm sequences; and statistical analyses of return periods, based on historical data, for precipitation at a point. Section 3, DOWNSTREAM RIVER FLOODING, consisting of nine papers, gives an overview of the floods on the larger rivers, how the flood control works responded, and what damages occurred. Section 4, UPLAND FLOODS AND SEDIMENT TRANSPORT (five papers), focuses on the unique aspects of sedimentation in regional floods. Section 5, LANDSLIDES, with four papers, explains the problems of landslides, both large and small, that were triggered by the prolonged periods of heavy rainfall. Section 6, CASE STUDIES OF ENGINEERING PROBLEMS (four papers), gives detailed analyses of three particular engineering problems: the failure of levees on the San Jacinto River, the uncontrolled filling of Lake Elsinore to damaging stages, and the severe streambed scour threatening to undermine the Interstate 10 highway bridge over the Salt River at Phoenix, Arizona. The experiences and analyses described in these papers should be useful to engineers who deal with similar structures and situations in the future. Section 7, EFFECTS ON THE SHORELINE, consisting of two papers, illustrates the damaging effects of the high storm waves and high tides that occurred in 1978 and 1980. Beach profiles shifted very rapidly, with sand being moved temporarily offshore, which exposed many shoreline structures to direct wave attack, causing severe damages. Section 8, POLICIES FOR FLOOD CONTROL AND HAZARD MITIGATION (six papers),focuses on institutional issues. Four of these papers advocate a strong new emphasis on hazard mitigation, better flood warning systems, and other nonstructural approaches as part of the mix of society's activities to deal with floods. About 300 people participated in the symposium, and many contributed to the questions and discussion. In the closing session there was a panel discussion by Russell Campbell, Engineering Geologist with the U.S. Geological Survey; John F. Kennedy, Director of the Iowa Institute on Hydraulic Research at the University of Iowa and member of the Committee on Natural Disasters of the National Research Council; Dale Peterson, Director of Community Services with the Federal Emergency Management Agency (FEMA) in San Francisco; and Richard Wainer, Los Angeles City Engineer's Office in Van Nuys. The writer served as moderator. Since it was not feasible to digest and record all of these discussions, I am attempting in this summary to capture the main conclusions and issues.* Nonetheless, the following conclusions and recommendations are solely the responsibility of the author and do not necessarily represent a consensus by the participants at the symposium. For the record it should be noted that the following papers included in the proceedings were not presented at the symposium: "Geotechnical Origin and Repair of the Bluebird Canyon Landslide, Laguna Beach, California" by Beach Leighton and "Levee Failures and Distress, San Jacinto River Levee and Bautista Creek Channel, Riverside County, Santa Ana River Basin, California" by Joe Sciandrone, Ted Albrecht, Jr., Richard Davidson, Jacob Douma, Dave Bamer, Charles Hooppaw, and A1 Robles, Jr. The latter paper is a shortened version of the official Corps of Engineers report on the San Jacinto River levee failure , which was not available in time for presentation at the conference. Numerous brief discussions at the symposium are gratefully acknowledged, although very few are included in the proceedings

Prescribing opioid analgesics for chronic non-malignant pain in general practice - a survey of attitudes and practice

Background: This study replicates a previous postal survey of general practitioners (GPs) to explore whether attitudes to opioid prescribing have changed at a time when the number of opioid prescriptions issued in primary care has increased. Methods: With permission, a 57-item survey instrument previously utilised with GPs in the South-west of England was circulated to 214 GPs in city-centre practices in the East Midlands. The survey instrument included items relating to practice context, prescribing patterns and attitudes about analgesic medication, perceived prescribing frequency and reluctance to prescribe. Results: Responses were received from 94 GPs (45%). Almost three-quarters (72.7%) of GPs reported that they sometimes or frequently prescribed strong opioids for chronic non-cancer pain. Over two-thirds (67.8%) reported that they were sometimes or frequently reluctant to prescribe strong opioids for chronic non-cancer pain. No significant relationships were observed between perceived frequency of prescribing and a range of demographic factors; however, concerns about ‘physical dependence’, ‘long-term commitment to prescribing’ and ‘media reports’ were associated with less frequent reported prescribing of, and greater reluctance to prescribe, strong opioids. Discussion: Given the national trend for increased opioid prescriptions, it is unsurprising that more frequent self-reported prescribing is reported here; however, increased frequency does not translate into less reluctance about prescribing. The effectiveness of strong opioids for chronic pain is recognised, but concerns about addiction, dependence and misuse inform a reluctance to use strong opioids. These juxtapositions highlight a continued need for clearer understanding of GPs’ perceptions of strong opioids and point to the potential benefit of dedicated guidelines or specialist education and training to address their uncertainties

The quality of different types of child care at 10 and 18 months. A comparison between types and factors related to quality.

The quality of care offered in four different types of non-parental child care to 307 infants at 10 months old and 331 infants at 18 months old was compared and factors associated with higher quality were identified. Observed quality was lowest in nurseries at each age point, except that at 18 months they offered more learning activities. There were few differences in the observed quality of care by child-minders, grandparents and nannies, although grandparents had somewhat lower safety and health scores and offered children fewer activities. Cost was largely unrelated to quality of care except in child-minding, where higher cost was associated with higher quality. Observed ratios of children to adults had a significant impact on quality of nursery care; the more infants or toddlers each adult had to care for, the lower the quality of the care she gave them. Mothers' overall satisfaction with their child's care was positively associated with its quality for home-based care but not for nursery settings

Descriptive epidemiology of birth trauma in the United States in 2003

Sauber-Schatz EK, Markovic N, Weiss HB, Bodnar LM, Wilson JW, Pearlman MD. Descriptive epidemiology of birth trauma in the United States in 2003. Paediatric and Perinatal Epidemiology 2010; 24: 116–124.The rate of birth trauma in the US has been reported to range between 0.2 and 37 birth traumas per 1000 births. Because of the minimal number of population-based studies and the inconsistencies among the published birth trauma rates, the rate of birth trauma in the US remains unclear. This is a cross-sectional study that was conducted using 890 582 in-hospital birth discharges from the 2003 Healthcare Cost and Utilization Project Kids' Inpatient Database. A neonate was defined as having birth trauma if their hospital discharge record contained an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code from 767.0 to 767.9. Weighted data were used to calculate rates for all birth traumas and specific types of birth traumas, and rates and odds ratios by demographic, hospital and clinical variables. Weighted data represented a national estimate of 3 920 787 in-hospital births.Birth trauma was estimated to occur in 29 per 1000 births. The three most frequently diagnosed birth traumas were injuries to the scalp, other injuries to the skeleton and fracture of the clavicle. Significant univariable predictors for birth trauma included male gender, Asian or Pacific Islander race, living in urban or wealthy areas, being born in Western, urban and/or teaching hospital, a co-diagnosis of high birthweight, instrument delivery, malpresentation and other complications during labour and delivery. Birth trauma risk factors including those identified in this study may be useful to consider during labour and delivery. In conclusion, additional research is necessary to identify ways to reduce birth trauma and subsequent infant morbidity and mortality.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79198/1/j.1365-3016.2009.01077.x.pd

Women's experiences of coping with pain during childbirth: A critical review of qualitative research

Objective To identify and analyse qualitative literature exploring women׳s experiences of coping with pain during childbirth. Design Critical review of qualitative research. Findings Ten studies were included, conducted in Australia, England, Finland, Iceland, Indonesia, Iran and Sweden. Eight of the studies employed a phenomenological perspective with the remaining two without a specific qualitative methodological perspective. Thematic analysis was used as the approach for synthesising the data in this review. Two main themes emerged as the most significant influences upon a woman׳s ability to cope with pain: (i) the importance of individualised, continuous support and (ii) an acceptance of pain during childbirth. This review found that women felt vulnerable during childbirth and valued the relationships they had with health professionals. Many of the women perceived childbirth pain as challenging, however, they described the inherent paradox for the need for pain to birth their child. This allowed them to embrace the pain subsequently enhancing their coping ability. Key conclusions Women׳s experience of coping with pain during childbirth is complex and multifaceted. Many women felt the need for effective support throughout childbirth and described the potential implications where this support failed to be provided. Feeling safe through the concept of continuous support was a key element of care to enhance the coping ability and avoid feelings of loneliness and fear. A positive outlook and acceptance of pain was acknowledged by many of the women, demonstrating the beneficial implications for coping ability. These findings were consistent despite the socio-economic, cultural and contextual differences observed within the studies suggesting that experiences of coping with pain during childbirth are universal. Implications for practice The findings suggest there is a dissonance between what women want in order to enhance their ability to cope with pain and the reality of clinical practice. This review found women would like health professionals to maintain a continuous presence throughout childbirth and support a social model of care that promotes continuity of care and an increasing acceptance of pain as part of normal childbirth. It is suggested future research regarding the role of antenatal provision for instilling such a viewpoint in preparation of birth be undertaken to inform policy makers. The need for a shift in societal norms is also suggested to disseminate expectations and positive or negative views of what the role of pain during childbirth should be to empower women to cope with childbirth and embrace this transition to motherhood as part of a normal process

To identify the factors that influence the recognizing and responding to adult patient deterioration in acute hospitals

Aims. To identify factors that influence recognition and response to adult patient deterioration in acute hospitals. Design. A Mixed-Studies Systematic Review. Data sources. CINAHL, Medline and Web of Science were searched for relevant literature published between; 2007-2018. Review Methods. Studies were critically appraised, data extracted and thematically analyzed. Results. Thirteen papers met the inclusion criteria. Three main themes were identified: (1) Knowledge and understanding of clinical deterioration; (2) Organizational factors; managing deterioration and staffing levels; and (3) Communication; inter-professional relationships and professional-patient communication. Conclusion. Despite national guidelines, the review findings suggest that the recognition and response to adult patient deterioration in acute hospital settings is sub-optimal. A multitude of factors influencing the recognition and response to adult patient deterioration emerged from the findings. Impact. Patients are receiving sub-optimal care due to failure in recognizing and responding to patient deterioration in an appropriate and timely manner. Nurses lack knowledge and understanding of deterioration. Organizational factors contribute to inadequate care and communication among professionals was highlighted as challenging. The factors that influence the recognizing and responding to patient deterioration in acute hospitals are multi-faceted, however this review highlights immediate recommendations for professionals in the acute care setting

Process redesign for time-based emergency admission targets

Purpose: Hospitals have used process redesign to increase the efficiency of the emergency department (ED) to cope with increasing demand. While there are published studies suggesting a positive outcome, recent reviews have reported that it is difficult to conclude that these approaches are effective as a result of substandard research methodology. The purpose of this paper is to explore the perceptions of hospital staff on the impact of a process redesign initiative on quality of care. Design/methodology/approach: A retrospective qualitative case study examining a Lean Six Sigma (LSS) initiative in a large metropolitan hospital from 2009 to 2010. Non-probability sampling identified interview subjects who, through their participation in the redesign initiative, had a detailed understanding of the implementation and outcomes of the initiative. Between April 2012 and January 2013 26 in-depth semi-structured interviews were conducted and analysed with thematic content analysis. Findings: There were four important findings. First, when asked to comment on the impact of the LSS implementation, without prompting the staff spoke of quality of care. Second, there was little agreement among the participants as to whether the project had been successful. Third, despite the recognition of the need for a coordinated effort across the hospital to improve ED access, the redesign process was not successful in reducing existing divides among clinicians and among managers and clinicians. Finally, staff expressed tension between production processes to move patients more quickly and their duty of care to their patients as individuals. Originality/value: One of the first studies to explore the impact of process redesign through in-depth interviews with participating staff, this study adds further evidence that organisation implementing process redesign must ensure the supporting management practices are in place

Primary care challenges in diagnosing and referring patients with suspected rheumatoid arthritis: a national cross-sectional GP survey

Objective: National guidelines advocate referring patients with persistent synovitis to rheumatology within 3 working days of presentation to primary care. This occurs infrequently. We aimed to identify modifiable barriers to early referral of suspected RA patients among English general practitioners (GPs). Methods: We carried out a national cross-sectional survey of 1388 English GPs (RA Questionnaire for GPs [RA-QUEST] study). Questions addressed GPs’ confidence in diagnosing RA, clinical factors influencing RA diagnosis/referral, timeliness of referrals and secondary care access. Data were captured using 10-point visual analog scales, five-point Likert scales, yes/no questions or free text, and were analysed descriptively. Results: Small joint swelling and pain were most influential in diagnosing RA (91 and 84% rated the importance of these as 4 or 5 on a five-point Likert scale, respectively); investigations including RF (61% rating 4 or 5) and anti-CCP antibody (72% rating 4 or 5) were less influential. Patient history had the greatest impact on the decision to refer (92% rating this 4 or 5 on a 5-point Likert scale), with acute phase markers (74% rating 4 or 5) and serology (76% rating 4 or 5) less impactful. Despite the importance placed on history and examination, only 26% referred suspected RA immediately without investigations; 95% of GPs organizing further tests opted to test for RF. Conclusion: For suspected RA patients to be referred within 3 days of presentation to primary care there needs to be a paradigm shift in GPs’ approaches to making referral decisions, with a focus on clinical history and examination findings, and not the use of investigations such as RF