Category Archives: Preventative Medicine

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Global Alternative Medicine Market Proceeds To Witness Huge Upswing Over Assessment Period by 2025 - SpinazzolaLive

The researchers say the potential of the tactic used for years in tobacco control efforts is only just beginning to be understood in the beverage industry. They hope their findings could help inform public legislation in this area.

"The results of this study indicate that warning labels may be effective tools for reducing consumption of sugar-sweetened beverages, particularly beverages such as sweetened teas, pink lemonade and chocolate milk for which the sugar content is not immediately obvious or well known," said Cindy Leung, assistant professor of Nutritional Sciences at the University of Michigan School of Public Health and lead author of the study.

Reducing sugar in soft drinks particular hidden sugar that consumers are unaware of or that acts as empty calories in drinks has been a priority for public health initiatives and the beverage industry in recent years.

Legislation efforts from the public health side have focused on taxation: with jurisdictions such as Boulder, Albany, Berkeley, San Francisco, Seattle and Philadelphia all introducing sugar taxes (others, however, have rejected sugar taxes or brought in pre-emptive bans on such taxes).

The idea of warning labels, while not new, has received less attention. San Francisco passed the US first law mandating a warning label on soda ads in 2015, but last year the U.S. Court of Appeals for the 9th Circuit ruled the law was unconstitutional and infringed on brands right to commercial speech under the First Amendment.

The beverage industry, meanwhile, has always questioned the effectiveness of sugar taxes; while in 2015 it was the American Beverage Association which posed one of the first challenges to San Francisco's warning label law.

Other efforts to reduce sugar consumption from sugar-sweetened beverages include limiting or banning the availability of drinks and/or their advertising in schools or educational settings; and innovation from manufacturers in low or no sugar alternatives.

In the University of California, Davis, study published this month in The Journal of Nutrition and partly funded by the National Institutes of Health - researchers placed warning labels on beverage dispensers at a University of Michigan cafeteria for one semester in 2019. The bright yellow labels displayed a large triangle and exclamation mark, stating: "Warning: Drinking beverages with added sugar(s) contributes to type 2 diabetes, heart disease, and tooth decay."

Two other cafeterias in separate areas of the campus served as control sites, with no such warnings displayed on beverages.

Nearly 1,000 college students were contacted by email before and after the warning labels were implemented to ask them to participate in surveys with no specific mention of sugar-sweetened beverages. Participants were given a $10 gift card after completing each survey.

In total, 840 students across all cafeterias were included in the study. At the intervention site, consumption of sugar-sweetened drinks that had the warning label declined by 18.5% (compared to a decline of 4.7% at the control sites where no label was used). Students exposed to the warning labels also reduced their consumption of fruit juice by 21%, even though juices had not been labeled as sugar-sweetened beverages.

"Results of this intervention demonstrate that SSB warning labelsled to a 14.5% reduction in consumption of sugar-sweetened beverages amongcollege students, which was driven by significant declines inconsumption of fruit drinks, sweetened teas, and flavoredmilk,"write the researchers in the study.

Furthermore, the warning labels were considered acceptable by students.

"The vast majority of students at the intervention site also reportedpositive or neutral attitudes toward the sugar-sweetened warning labels.

"Together, these findings suggest that the warning labels are anacceptable and appropriate way to curb the consumption ofsugar-sweetened beverages, particularly where added sugars areless obvious, unlike regular sodas which have been the target ofpublic health programs and policies for years."

Consumption of diet soda did not change over the course of the study.

Eight US cities and states have proposed warning labels for sugar-sweetened beverages. San Francisco's Board of Supervisors is moving forward with amending its ordinance; while Baltimore, Washington, New York State, Vermont, Massachusetts, Hawaii and California have all proposed similar legislation (none of these have, as yet, moved forward in the legislative process).

The researchers suggest that data, such as from their study, could help inform strategies.

"Sugar-sweetened beverages remain ubiquitous in retail and cafeteria settings. As we explore avenues to promote healthy food and beverage choices, warning labels are a potential tool to reduce their consumption that should be tested in other populations and other settings, say the authors of the UC Davis study.

"These results provide evidence to inform future institutional strategies... and legislative efforts to use warning labels as a promising approach to sugar-sweetened beverage consumption.

Earlier this year, researchers at Brown School at Washington University in St. Louis carried out a systematic review and meta-analysis on the impact of sugar-sweetened beverage warning labels. They found that warnings on sugar-sweetened beverages were effective in dissuading consumers from choosing them: with labels using graphics having the most impact.

Meanwhile, an article published in the American Journal of Preventative Medicine in April evaluated warning policies in light of existing health and safety warnings on consumer products and the First Amendment; suggesting warnings on labels and at point of sale may pose fewer First Amendment concerns than on advertisements.

Source:Journal of Nutrition,'Warnings labels reduce sugar-sweetened beverage intake among college students'.https://doi.org/10.1093/jn/nxaa305

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Could warning labels on soda reduce consumption? - BeverageDaily.com

(TNS) - When cases of the novel coronavirus first emerged in the United States, concerns over whether the nation's health-care system had the capacity to care for mass quantities of sick individuals loomed large.

And as leaders grappled with how hospitals could treat a growing pool of COVID-19 patients, other facets of the health-care system were altered or paused.

At Kalispell Regional Medical Center in Montana, elective procedures ranging from cosmetic surgeries to routine cancer screenings were back-burnered in March, as they were at hospitals nationwide. Dr. Randall Zuckerman, chairman of Kalispell Regional's Department of Surgery and physician director of its surgical service line, said this was done primarily to conserve personal protective equipment (PPE).

"There are three major issues that impact our ability to deal with COVID and those are PPE, testing and hospital beds and the staff that manage them," Zuckerman said. "Upfront we were really worried about PPE because the global supply chain had run dry. When that happened all of the specialty societies, including the American College of Surgeons, came out with a very strong recommendation to stop elective surgery. So we stopped everything."

The decision also prompted Zuckerman and other surgeons within his unit to switch to what he called a "Team B approach." Instead of having the department's eight surgeons working at once, only two surgeons would work for a week at a time while the other six were sent home.

"There were still emergency surgeries that had to be performed. So what we were trying to avoid was all of us possibly coming down with COVID at the same time," Zuckerman explained. "At that point we didn't understand the magnitude of the virus. We didn't understand what would happen if you operated on someone who inadvertently got COVID."

The decision to halt elective procedures, which hospital leadership at the time said likely would cost Kalispell Regional millions, is just one example of how the pandemic has infiltrated nearly every arm of health care. And according to Zuckerman and other hospital leaders, one would be hard-pressed to find a piece of the industry that hasn't been impacted by the virus.

ZUCKERMAN IS one of three Kalispell Regional physicians recently interviewed by the Daily Inter Lake with the goal to better understand how COVID-19 has directly or indirectly affected day-to-day operations. Dr. Cory Short, a hospitalist trained in internal medicine and physician lead for the acute-care services line, and Dr. Adam Smith, a family medicine specialist and physician lead for the primary care service line, also were interviewed. All three physicians, who each oversee hundreds of employees within their respective service lines, said COVID-19 has been a nine-month learning curve, and it's one that has impacted each of their departments uniquely.

For example, Zuckerman said the ebb and flow of beds and PPE availability, as well as strain on staff, will be his deciding factors on whether non-emergency procedures are once again altered. He said PPE is no longer a concern at this point and his attention is now focused on hospital bed capacity and how many staff are quarantined due to symptoms or exposure.

"Just a little while ago we were running into bed troubles, and it was a function of both absolutely bed availability as well as staffing," Zuckerman said. "We were running at more than 100% capacity for a period of time and then we had a bunch of staff who were unavailable. So there was probably a three-week stretch where we thought seriously about canceling elective surgeries again."

The dedicated COVID unit at the hospital can comfortably fit around 30 patients. But for stretches in October and November, Flathead City-County Health Department data showed hospitalizations exceeded or hovered just below that number. Zuckerman added that aside from the COVID unit, he is watching emergency room capacity.

"The most unpredictable part is how many people will come through the emergency room, and that fluctuates daily. So then what we have is bodies sort of competing for the same beds." he said. " But honestly, the nurses, the CNAs and other folks over there are doing a fantastic job and are keeping the wheels spinning. To my knowledge, since starting services back up, we haven't had to cancel a surgery yet."

Zuckerman also noted there are certain routine screening procedures he would like to continue offering in-person. The reason for this is two-fold, with the first being to avoid an increase in patients exhibiting late-stage diseases something of which he and others experienced an influx after elective services started ramping back up in May.

Zuckerman pointed to colonoscopies as one example, which often allow doctors to spot small polyps and remove them before they become cancerous. He also said the cancellations prompted some delays in chemotherapy for those who had been diagnosed with cancer.

"If you stop all screening and treatments, there are downstream, detrimental effects to that," he pointed out. "And it may take awhile to see those effects, but this concern sort of runs true across a multitude of medical problems."

The second reason for Zuckerman wanting to maintain various in-person visits is the desire to maintain better relationships with his patients. He said in the past nine months the hospital's telehealth services have been used more frequently and while that technology has its benefits, he would rather report initial test results, namely cancer diagnoses, face-to-face.

"It's tough to deliver those results when you're not in the same room," Zuckerman said. "These conversations are usually complex and can be scary and it's hard for people to hear that information on the phone or via a computer."

Some of Zuckerman's concerns align with those expressed by Smith, who works as a primary care physician in Polson and Kalispell. Smith said not being able to closely monitor patients with chronic diseases is a major worry of his.

"There are a lot of preventative services that we offer in primary care that we certainly don't want to see delayed," Smith said. "That can be anything from colonoscopies to mammograms, which help us locate tumors before they become enlarged."

Smith also said he has lost some of his doctor-to-patient intimacy. As a primary care physician, he often has the opportunity to work with the same patients year after year, which allows him to bond with them and more deeply understand their needs. Smith said a few patients he has treated for more than a decade died from COVID-19-related complications.

"We care for people in all aspects of life, from birth to death," Smith said. "But it's certainly been hard to watch patients that you've cared for for so long be lost to this virus."

WHILE ASPECTS of the pandemic have challenged the world of primary care, a COVID-19-related shift in Smith's responsibilities has allowed him to witness health-care high points as well.

Smith has extensive experience working in rural settings and has functioned as a liaison between Kalispell Regional and critical-access hospitals in remote areas including Libby, Shelby, Polson and Ronan.

"We have really focused on how we can support these clinics, whether that's with education efforts, staffing or taking in critical patients," Smith said. "These small rural hospitals have less bench strength than we do, so situations like COVID tend to take a bigger toll on them. The teamwork I've seen has been incredible."

He highlighted one instance when a critical-access hospital had to send the vast majority of its staff home to quarantine, so Kalispell Regional helped organize and send over additional medical personnel. Smith said it has been fascinating to watch this level of teamwork play out not only at a local level, but on a global scale as well.

"The health-care industry typically has a competitive edge to it, but a lot of that has gone out the window with COVID," Smith said. "It's been interesting to watch hospitals collaborate on this and share what has worked for them and what hasn't."

Smith has also played an instrumental role in establishing Kalispell Regional's respiratory screening facilities. He said the pop-up resources, which prompted the hospital to bring on numerous additional staff members, have been vital in helping Flathead County understand its outbreak, especially after Kalispell Regional established in-house testing earlier this fall. Smith said the hospital has been regularly testing over 3,000 people per week since the testing platforms became fully operational in late October.

"Being able to identify this illness early so we can intervene sooner has really been helpful in testing and battling COVID here in Montana and it's a novelty that most of the state has not had," Smith said.

For Short, the quick turnaround in testing also has greatly benefited his emergency department's ability to organize and treat patients in a fast-moving environment. The in-house lab is able to provide results in about 48 hours, which helps Short and others not only have a better sense of how many patients are actually COVID-positive, but whether any staff members are infected as well.

WHILE SMITH and Zuckerman have dealt with various aspects of COVID-19, Short has been in the throes of treating positive patients directly since March.

He said the hospital's emergency department actually experienced a decline in patient activity at the start of the pandemic, as many other hospitals did. Short explained this was largely due to the public fearing exposure at the hospital.

"What we were seeing, for example, were patients who had actually experienced stroke symptoms several days prior to coming in and were then being admitted with advanced chest pain and heart complications after the fact," Short said. "So this started us down a major road of educating the public, telling people if they need emergency services, it's safe to come here, we have the necessary protocols in place."

Short said after the Flathead Valley experienced a dip in new cases around April and May, it didn't take long for emergency activity to pick back up. While the department typically sees around 50 to 60 patients per day, he estimated that number was closer to 70 to 80 visits over the summer and into the fall. The increase was due in part to the tourist season, but he also said the department was experiencing a noticeable bump in patients experiencing respiratory complications.

SHORT SAID the pandemic has been a marathon for both health-care workers and the community. And while he hopes the population is rounding into one of the final legs of that marathon with the upcoming shipment COVID-19 vaccine, he said it feels as though they still have a ways to go.

"We started off at a sprint and then transitioned into this marathon mode and that's really hard for everyone to sustain. The biggest challenge we face right now is endurance," Short said. "At the hospital level, we are tired. Fatigue is certainly settling in among staff. And at the community level, you know, we are all social creatures. We want to be with each other, we want to commune together and to continue having the discipline to not is really hard."

Smith and Zuckerman seconded this, saying they anticipate it will be difficult for others to continue practicing COVID-19 protocols in the coming months as Montana nears its one-year mark fighting the virus. All three physicians also agreed that they have never experienced anything like this pandemic in their lifetimes.

"I think many physicians, depending on what capacity they played in this response, would tell you this is perhaps the most challenging time of their career. I include myself in that," Short said. "It will be interesting to see how this virus has changed our society two, five or 10 years down the road. By then we will have known what worked, what didn't, and hopefully we will all come out stronger on the other side of that."

Reporter Kianna Gardner can be reached at 758-4407 or kgardner@dailyinterlake.com

(c)2020 the Daily Inter Lake (Kalispell, Mont.)

Visit the Daily Inter Lake (Kalispell, Mont.) at http://www.dailyinterlake.com

Distributed by Tribune Content Agency, LLC.

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The Impact of COVID on Hospital Operations: Physician Perspective - GovTech

You may be used to drizzling honey over oatmeal or in your tea. However, the trend today is to slather it on your face. Really.

People are searching for ways to use honey for face wash, and you can find how-to videos for honey face masks on TikTok and Instagram.

It may seem odd at first. You may be wondering why you would put something super sticky and full of sugar on your skin. Wouldnt that lead to breakouts (and a mess in your bathroom)?

Well, according to some, using honey on your face may lead to smooth, moisturized, blemish-free skin.

We dove into the research and talked to expert dermatologists to find out: Should everyone start using honey for face wash?

Whether its a tried-and-true skin care regimen, how often you wash your hair, or the cosmetics youre curious about, beauty is personal.

Thats why we rely on a diverse group of writers, educators, and other experts to share their tips on everything from the way product application varies to the best sheet mask for your individual needs.

We only recommend something we genuinely love, so if you see a shop link to a specific product or brand, know that its been thoroughly researched by our team.

Using honey as face wash isnt something beauty bloggers invented. People have used honey for its skin benefits for ages.

Legend has it, Cleopatra used a mask made of milk and honey on her face. Indigenous tribes in Burkina Faso also use honey to clean their skin.

Many other cultures use honey topically to treat wounds, eczema, and other skin conditions. This includes Ayurvedic medicine, Persian traditional medicine and Quranic medicine.

All of these people were and are on to something. Honey has many powerful properties, says New York City-based cosmetic dermatologist Michele Green, MD. According to research, honey has antibacterial, anti-inflammatory and humectant (moisturizing) properties.

The antibacterial properties make it good as both treatment and prevention for acne, Green explains. This is credited to the hydrogen peroxide in honey, although the amount varies among honey types.

Honeys anti-inflammatory powers come from antioxidants that help calm irritated skin, says Konstantin Vasyukevich, MD, a facial plastic surgeon and rejuvenation expert based in New York City.

And since honey has humectant effects, it may help keep skin looking younger, or at least smoother.

Lastly, honey contains natural enzymes that help remove dead skin cells and reduce redness, Green says.

Its important to note that most cosmetic products contain only up to 10 percent honey.

That doesnt seem like much, but it may still have an effect. As a natural remedy, honey is certainly not as effective in the treatment of medical skin conditions as a prescription medicine would be. However, it can be an effective remedy for someone with a mild skin condition or as a preventative treatment, Vasyukevich says.

It is generally safe to use honey on your skin, since it is great for people with acne [or] eczema. It is even safe for patients with sensitive skin, Green says.

However, consider testing the honey or product on a small area of your skin before applying it all over your face.

If you notice any redness, itching, or swelling when testing it, wash the honey or product off with soap and water. Then, Green recommends applying a topical hydrocortisone cream. Do not continue using the honey or product.

You may be having an irritant or allergic reaction to the honey itself or another ingredient. Consider contacting the manufacturer of the product to learn exactly what it contains. This can help you identify the culprit.

If you are curious about using honey on your face, you have options. Some users swear by applying raw honey directly to their skin and letting it sit for 510 minutes before washing it off.

Others prefer to create a face mask by mixing the honey with other ingredients, such as yogurt, matcha tea powder, or oats. Green shares this honey face mask recipe:

Finally, you can find a variety of skin care products (such as those below) that contain honey. The concentration of honey in these may be very low. So, it may be hard to tell if any benefits you experience are due to the honey or other ingredients.

If you wish to DIY your skin care, keep in mind that each variety of honey has different levels of antioxidants and other beneficial compounds. So, you may see different results depending on which honey youre using.

That said, many recommend Manuka honey, which has been shown to have higher antibacterial activity compared to other types of honey. Many brands add cane sugar or corn syrup to their honey. In a 2018 study of 118 honey samples, 27 percent were of questionable authenticity.

Consider buying local honey. Or use the True Source Honey tool to look up the UPC of a product and verify if its certified as pure.

Not interested in a DIY project? Consider these skin care products that contain honey. Each has at least a 4.5-star rating on Amazon.

Price: $

Appropriate for use on your face, chest, neck, and hands, this moisturizer with Manuka honey and beeswax is super silky not sticky. Its made to absorb well without leaving you greasy.

Buy the LOreal Age Perfect Hydra-Nutrition All-Over Honey Balm online.

Price: $

Peanuts and honey arent only good ingredients for making a sandwich. The two pack antioxidants and moisturizing benefits into this lotion.

Buy the Mario Badescu Honey Moisturizer online.

Price: $$

The charcoal in this mask is said to help relieve clogged pores while the honey moisturizes. The formula contains no parabens, phthalates, sodium lauryl sulfate, propylene glycol, mineral oil, DEA, petrolatum, paraffin, polyethylene beads, or formaldehyde.

Buy the Origins Clear Improvement Charcoal Honey Mask to Purify & Nourish online.

Price: $$

Farmacy uses a blend of honey, propolis, and royal jelly (all compounds made by bees) in this mask. However, if you have sensitive skin, the company warns that the warming sensation may cause irritation.

Buy the Farmacy Honey Potion Renewing Antioxidant Hydration Mask online.

Using honey for face wash or as a face mask is not only popular. It may also benefit your skin. Thanks to honeys antibacterial, anti-inflammatory, and humectant properties, it may help prevent acne, calm irritation, and maintain hydration.

If used properly, washing [your] face with honey can help keep the skin looking younger, improve radiance and smoothness, and mitigate irritation and acne flare-ups, Vasyukevich says.

However, be mindful to use pure honey if you are going to DIY a treatment.

As with any skin care regimen, if you notice irritation, stop using the product or honey. If your skin seems fine, be patient and try your honey routine for at least a week to see if you notice any difference.

Brittany Risher is a writer, editor, and digital strategist specializing in health and lifestyle content. Shes written for publications including Elemental, Mens Health, Womens Health, and Yoga Journal.

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Honey for Face Wash: Should You Use It? - Healthline

More than 200 people in Denmark have now been infected with a mutated version of the coronavirus.

Large areas of North Jutland, the country's northernmost region, have been placed under lockdown and prime minister Mette Frederiksen ordered a cull of all 15 million mink in the country's farms.

What is mink-related coronavirus?

Mink-related coronavirus refers to several mutated versions of Covid-19 that developed when mink caught the virus from humans working on Denmark's farms.

Mink have in turn infected humans with a mutant version of the virus.

Denmark's State Serum Institute said several mutant versions of the virus had been found in mink, some of which have mutations in the spike protein, which is significant in the bodys immune response and is a key target for vaccines.

Will the outbreak affect future vaccines?

Announcing the new lockdown measures, Ms Frederiksen said the mutated virus was a serious risk to public health and to the development of a vaccine.

Ms Frederiksen cited a report which said the mutated virus had been found the weaken the body's ability to form antibodies, potentially meaning current vaccines under development would not be able to provide immunity.

Some scientists outside Denmark however are sceptical about the impact the mutation could have on a possible future vaccine.

A single mutation, I would not expect to have that dramatic an effect, said Marion Koopmans, head of virology at Erasmus Medical Center in the Netherlands, where analysis of viruses from an earlier outbreak among mink was conducted.

Its almost never the case that its such a simple story of one mutation and all your vaccines stop working, Emma Hodcroft, a virus expert at the Institute of Social and Preventative Medicine in Bern, Switzerland, told Stat News.

The World health organisation's chief scientist also urged calm, saying researchers will need to wait before coming to a conclusion on whether the mutation will affect vaccines, adding that there was no indication it would.

What does this mean for Danish mink?

Denmark is the world's largest mink fur exporter, producing an estimated 17 million furs per year.

Kopenhagen Fur, a cooperative of 1,500 Danish breeders, alone accounts for 40 per cent of global mink production.

The Danish government has ordered a cull of all minks in the country's 1,139 farms.

Danish fur farmers said the cull may spell the end of the industry in the country.

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What is mink-related coronavirus? - The Independent

When the novel coronavirus began to spread across China, researchers at the Duke Human Vaccine Institute (DHVI) sprang into action and they havent slowed down since. They are collaborating with each other and with other institutions to unlock the secrets of the virus that causes COVID-19 and to develop tests, vaccines, and treatments.

Weve done more work faster than we have ever done before, making real progress on antibodies, tests, and a vaccine, says Barton Haynes, MD, the Frederic M. Hanes Professor of Medicine and the director of DHVI.

DHVI researchers are attacking the new virus by applying knowledge, experience, and technology gained from years of working with HIV, influenza, and other viruses.

All the work weve done has allowed us to transition on a dime, Haynes says. All the vaccine constructs weve developed were immediately repurposed for COVID-19.

And vaccine designs are only the tip of the iceberg. DHVI faculty are also developing and running assays and tests, accessioning and distributing blood and tissue samples for studies, and isolating antibodies from infected individuals. Using approaches from a number of different disciplines, they are putting together a holistic picture of how the immune system and the novel coronavirus interact.

Two long-running programs at DHVI set the stage for the swift response. One is the HIV vaccine research program funded by the National Institute for Allergy and Infectious Disease (NIAID). A series of three grants from NIAID have provided continuous funding since 2005 of the Duke Center for HIV/AIDS Vaccine Immunology (CHAVI), Duke Center for HIV/AIDS Vaccine Immunology and Immunogen Design, and Duke Consortia for HIV/AIDS Vaccine Development (CHAVD). The other is a pandemic preparedness program funded since 2017 by the Department of Defenses Advanced Research Projects Agency (DARPA).

All the work weve done has allowed us to transition on a dime, Haynes says. All the vaccine constructs weve developed were immediatelyrepurposedfor COVID-19.

The DARPA Pandemic Preparedness Platform (P3) seeks to develop strategies, technologies, supply chains, and expertise to make it possible to rapidly produce antibody-based treatments for any novel pathogen. These treatments, which can also be used for temporary prevention, are sometimes called passive vaccines or medical countermeasures.

Greg Sempowski, PhD, professor of medicine and pathology and leader of the P3 program, says, Im incredibly proud of how well our staff and scientists have stepped up. They have worked very long hours to quickly bring on all the systems needed to support this type of research. Its not easy. Having really high-quality people who are committed is an enormous asset.

DHVIs work on COVID-19 is being supported with emergency funding from the National Institutes of Health (NIH), supplements to existing grants, and $17million allocated to Duke by the North Carolina legislature.

Antibodies play a crucial role in the development of vaccines, treatments, and even some kinds of COVID-19 tests, so the first order of business was discovering antibodies capable of neutralizing the new virus, SARS-CoV-2.

Once we have the antibodies in hand, there are lots of different things we can do with them, says Michael Tony Moody, MD, associate professor of pediatrics. The key thing is getting the antibodies in hand. Moodys lab was one of several that collaborated to do just that.

DHVI researchers isolated more than 2,500 antibodies from individuals infected with COVID-19 in only ten weeksa remarkable feat.

Kevin Saunders, PhD, associate professor of surgery and director of research at DHVI, says, The antibody isolation technique that we use was developed under our HIV research programs over the last 15 years. Weve really learned how to do that quickly and in depth. Thats why we could get to 2,500 antibodies in a matter of weeks.

Of those antibodies, DHVI scientists have identified some with potent and complementary neutralizing powers against SARS-CoV-2. Together or individually, these antibodies could be a powerful treatment for people in the early stages of infection. They could also be used as a temporary preventative for people at high risk of exposure, such as healthcare workers.

One of these antibodies will be tested as a preventative in a Phase I trial in early 2021. Rather than manufacturing the antibodies, which is very time consuming, DHVI will manufacture mRNA molecules, the genetic blueprints that tell the body how to make the antibodies.

This effort is being supported by an additional $7.6 million grant from DARPA. Emmanuel Chip Walter, MD, professor of pediatrics, who directs the DHVI Clinical Trials Unit, will be running the trial. The manufacturing will happen onsite in DHVIs current Good Manufacturing Practice (cGMP) facility, directed by Matthew Johnson, PhD.

These potent antibodies are also being used to create a test for COVID-19. Because they bind so well to the virus, the antibodies will attract SARS-CoV-2 like a magnet. This type of test could be faster and less expensiveand therefore more widely availablethan polymerase chain reaction (PCR) tests.

A long-lasting vaccine, sometimes called an active vaccine to distinguish it from antibody treatments, is also a priority at DHVI.

An active vaccine spurs the body to create not only effective antibodies, but also memory cells that can churn out more of those antibodies in the future if needed.

Dozens of vaccine candidates are already being manufactured and tested around the world. This first wave of vaccines will doubtless slow down the spread of COVID-19, but its possible, even expected, that they will provide less than full protection.

DHVI is working on vaccines that will plug some of the holes. Were thinking about a second wave of vaccine with enhanced immunogenicity, Saunders says. DHVI vaccines may be able to provide a boost to some of the front runners if they turn out to have a low potency or not to be effective in a particular population, such as older adults.

A multidisciplinary understanding of SARS-CoV-2 antibodies is crucial to this effort. We really go deep, Saunders says. Weve looked at a more global picture of antibody response. That global picture is the necessary foundation for designing a highly effective vaccine.

The power of the DHVI is that we have people who think about the problem in a different way, but we all come together and use our skill sets to make the biggest impact on the same problem, Saunders says.

Kevin Wiehe, PhD, associate professor of medicine, studies the genetic sequences of antibodies using computational methods. He looks at how the antibody sequences from people with COVID-19 evolve as their infections progress. We normally do very deep sequencing so we can get hundreds of thousands of antibody sequences from an individual at any time point, he says. We can see the initial antibody response, which is potentially different than the [mature] antibody that occurs later.

Other DHVI scientists are looking at the other side of the equationthe virus. SARS-CoV-2 is covered with spike proteins that allow the virus to infect cells. These spikes are where antibodies attach.

Rory Henderson, PhD, assistant professor of medicine, uses computer simulations to identify mutations in the spike protein that alter its shape, or conformation. In an actual infection, spike proteins change conformation frequently. But in a vaccine, some of these conformations will do a better job than others at spurring the immune system to produce effective antibodies. Its been remarkable how quickly we were able to go from not knowing anything about the coronavirus to having these designs, Henderson says. If one of the shapes is preferred, we already have that particle ready for a vaccine.

This speed was made possible by previous HIV work. Henderson says, We repurposed all of the techniques and tools we used for HIV and applied those to the coronavirus spike.

Priyamvada Acharya, PhD, associate professor of surgery, puts it this way: We have been studying a very difficult virus for a long timeHIV 1. So we have gained some superpowers.

Acharya examines the engineered spike proteins at the atomic level in the Titan Krios cryo-electron microscope to make sure their shape is what was expected. Then the spikes can become ingredients in vaccines, either as mRNA or manufactured proteins. Indeed, some are already being evaluated in animal studies. Acharya uses the cyro-EM to take a look at samples from the studies to see if good antibodies are being produced and how they interact with the spike. So far, the results have been promising.

While DHVI researchers are working on new-and-improved vaccine designs, they are also participating in the nationwide effort to get the first wave of vaccine candidates evaluated as quickly as possible by serving as a clinical trial site. Phase 2 and 3 clinical trials require tens of thousands of volunteers at multiple sites across the country. DHVI enrolled more than 80 volunteers for the Phase 2/3 trial of the Pfizer vaccine candidate, and is now enrolling even more participants for a trial of AstraZenecas vaccine.

Walter, who is leading this effort as head of the DHVI Clinical Trials Unit, says, DHVI is pretty well positioned because of its experience with HIV, ranging from vaccine discovery to the ability to implement clinical trials. Shifting to COVID was challenging, but we had the resources to do it.

Walter also leads Dukes participation in the nationwide series of trials to test treatments for patients hospitalized with COVID-19. The first trial studied remdesivir alone, and subsequent trials tested it in combination with other medicines. The first study showed decreased time hospitalized for patients who got remdesivir, hence it became standard of care, Walter says.

Beyond vaccines, DHVI is also pursuing other avenues, including testing and diagnostics. Thomas Denny, DHVI chief operating officer, and his lab assisted with testing in the early days of the pandemic, when clinical labs were overwhelmed. Denny led a team at DHVIthat also designed and implemented the surveillance testing of students, staff, and faculty being used on campus this fall. As part of the campus testing program, DVHI has processed almost 100,000 tests since August 2.

Denny is also working on designing more sensitive assays that can determine not just whether the virus is present or not, but in what amounts. With a lot of viral infections, like HIV, weve learned over the years that being able to quantify the viral amount has been useful as a signal with respect to disease prognosis or response to therapy, he says. If the same is true for COVID-19, that information could be used to guide clinical decisions. Denny is analyzing samples from COVID-infected adults and children who are participating in observational studies at Duke. He will compare the results of his assays with notes on their clinical condition to look for correlations between viral load and disease progression.

Dennys lab also developed assays to look for antibodies to SARS-CoV-2 in the blood, which could, among other things, be used in seroprevalence studies to show how many people have recovered from COVID-19.

Christopher Woods, MD, MPH, professor of medicine, and his team are coming at diagnostics from a different directionlooking at the immune response. The idea is that samples from an infected person will contain not only the pathogen, but also biochemical signals of the immune response. In fact, the immune signals may be easier to detect in early stages of infection than the pathogen, which is only just beginning to multiply. Woods has a track record in this area: he and his team have been able to distinguish viral from bacterial infections based on the immune response, and to identify infections 36 to 48 hours before the onset of symptoms.

We have not had great success [in the past] being able to distinguish different types of viral respiratory infections, he says. Until COVID. He and his team have found a unique signature in blood samples that indicates the immune system is mounting a response to SARS-CoV-2 infection. The samples used in that study were from people who were past the early stages of infection, but Woods is planning future studies to see if the signature is present in the pre-symptomatic phase of COVID-19. If so, a diagnostic test for that signal could help curb the spread of the disease and allow earlier treatment.

Sallie Permar, MD, PhD, professor of pediatrics, molecular genetics & microbiology, immunology, and pathology, is working to understand the immune response to COVID-19 in children. Although children do get the disease, they are more likely to have no or few symptoms than adults. However, some children experience a severe inflammatory reaction to COVID-19, called Multisystem Inflammatory Syndrome in Children (MIS-C).

Not only do we want to understand what about infant or pediatric infections leads to the lack of disease during the acute infection, Permar says, but also what are the factors that lead to post-infection inflammatory syndrome?

To help answer some of these questions, Permar and Maria Blasi, PhD, assistant professor of medicine, are doing a study in non-human primates to track the immune response over the course of infection in adults and infants. They are also studying adult and infant lung cells in the lab to see how the cells respond to infection.

DHVI researchers are also studying children in several ongoing observational trials. These trials include infected children as well as children who are uninfected (at least initially) but living with someone who is. The children are being followed over time to learn more about immune activity and clinical symptoms during infection, recovery, and beyond. We dont yet know what a long-term response to the coronavirus is, Permar says. Well be studying them for at least a year.

While the Haynes, Saunders, and Sempowski labs were isolating antibodies from COVID-infected individuals, they also looked at a sample from a person who had been infected with another pandemic-causing coronavirusSevere Acute Respiratory Syndrome (SARS)in 2003. They discovered that some of the SARS antibodies from that individual also neutralized SARS-CoV-2.

That raised a tantalizing question: Might it be possible to design a vaccine that elicits cross-protective antibodies? Such a vaccinea pan-coronavirus vaccinewould protect against multiple coronaviruses, including Middle East Respiratory Syndrome (MERS), which emerged in 2012, as well as other as-yet-unknown coronaviruses.

SARS-CoV-2 is not a one-off event, Saunders says. There seems to be a coronavirus pandemic every eight to ten years. Were looking at the future pandemics and trying to predict what that will look like and to see if we can generate immunity for those types of viruses.

DHVI has already begun working with scientists at UNC-Chapel Hill on a pan-coronavirus vaccine.

Its only a matter of time before the next coronavirus outbreak, Haynes says, and we will be ready for it.

Top photo: Emmanuel "Chip" Walter, MD, head of the DHVI Clincal Trials Unit, gives a nasal swab to Kristin Weaver, a healthy participant in the Pfizer vaccine clinical trial.DHVIenrolled more than 80 volunteers for the Phase 2/3 trial of the Pfizer vaccine candidate. Photo by Lindsay Key.

Mary-Russell Roberson is a freelance writer in Durham. She covers the geriatrics and aging beat for the Department of Medicine in the Duke University School of Medicine.

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Years in the Making: Duke Human Vaccine Institute researchers attack COVID-19 - Duke Today

The need for healthcare in the U.S. is increasing, and many organizations are exploring alternative options to meet that demand. One possible solution could be EMS physician assistants (PAs).

PAs are medical professionals who can diagnose and treat patients, interpret laboratory data, and prescribe medications.1 In 2018 the PA field was the fifth-fastest-growing in the U.S.,2 and currently degrees are offered through 75 postgraduate PA programs with 25 specialties,3 with a third of those programs focusing on emergency medicine. However, despite the original PAs originating from military EMS in 1965,4 no program today concentrates specifically on EMS.5 To be able to deliver proficient EMS care, a provider must be well versed in the unique challenges, interventions, and situations posed by the EMS setting, all of which require education from specialized training programs.6

The purpose of this article is to propose such a program: a postgraduate EMS-focused PA program that would work to expand the current availability of PA education and prepare the EMS community to allow trained PAs to practice in the EMS setting.

In 2010 EMS was officially recognized as a subspecialty of emergency medicine,7 and the National Associated of EMS Physicians (NAEMSP) responded by accrediting EMS fellowships in 2012 to formally educate EM physicians to handle the unique situations EMS providers face.8 At this time 61 NAEMSP-accredited EMS fellowships are available to EM physicians in the United States.9

With the development of physician EMS fellowships also came physician response units, vehicles staffed by emergency medicine (preferably EMS) physicians and fellows dispatched directly as scene responders, usually alongside or in addition to the usual first responders. Physician response units have been shown to be efficient ways of delivering care beyond the scope of a regular ambulance.10

As PAs in the field would function as physician extenders, their most obvious entry into the world of EMS would be as an extension of current physician response units. Proposed functions would involve both prehospital care and administrative functions. As PAs can have vast differences in their scope of practice, this article primarily reflects the laws of Missouri. Consult and abide by relevant laws and regulations when adapting this information to your state.

With few exceptions, most PA programs graduate students with a focus on primary care medicine. Many PA programs provide only a single rotation in emergency medicine.

To assure new PA graduates can function in high-speed emergency medical situations, additional education in EM should be a requirement. This should be continued over the course of the PA EMS fellowship and, as in any realm of medicine, after graduation.

Specific emergency-based certification courses such as Advanced Cardiac Life Support, Pediatric Advanced Life Support, Basic Life Support, Advanced Trauma Life Support, the Incident Command Systems, and awareness-level hazardous-materials education should be considered mandatory and obtained within the initial month of training, prior to any scene response. It is essential for the initial month of training to focus on core emergency medicine topics, along with basic EMS scene safety, to provide some assurance the PA is proficient in EM and has a good foundation for the continued addition of EMS-specific knowledge.

For any EMS PA fellowship program to have credibility, it should have education goals aligned with the proven process of the physician EMS fellowship curriculum. Therefore, one major difference to consider is that EMS physicians seeking EMS fellowships already have had an intense EM residency, while PAs have general medicine experience. That makes EM education a necessity for the EMS PA candidates success.

Physician EMS fellowships are at present accredited by the Accreditation Council for Graduate Medical Education (ACGME),11 whose education goals are outlined in Section IV of the ACGME Program Requirements for Graduate Medical Education in Emergency Medical Services. A postgraduate program for PAs should strive to follow the example set forth in the EMS physician fellowship. PAs should be required to take similar coursework to the EMS physician, including courses in incident management, tactical medicine, emergency medical dispatch, and disaster management.

Proposed prehospital functions for EMS PAs would include critical care (trauma, cardiac arrest, mass-casualty/mass-gathering events); tactical operations; high-risk refusals; and mobile integrated healthcare, including high-use individuals and low-acuity patients.

Trauma and Critical Care

An EMS PA would be a prime candidate to deliver emergent critical care during complex traumas, cardiac arrests, and mass-casualty incidents (MCIs). Having a provider capable of bringing additional tools and skills to the prehospital response, such as point-of-care ultrasound (POCUS), has the potential to improve patient outcomes.12 Advanced intravenous access, including central venous catheterization in critically ill patients, is also improved with the use of POCUS.13 Advanced Trauma Life Support recommends early ultrasonography in trauma patients by utilizing expanded focused assessment using sonography in trauma (eFAST) exams.14 Completion of these exams with positive results has been shown to decrease time from injury to arrival in the operating suite.

Ultrasound can also be seen in confirmation of cardiac standstill during cardiac arrest events. In the event of cardiac standstill, the possibility of successful resuscitation drops extremely close to 0%.15

Another tool PAs could bring into field response is skilled video laryngoscopy. Video laryngoscopy has been shown to improve success rates in urgent intubations and decrease esophageal complications.16,17

In the event of an MCI or prolonged extrication, PAs can assume the important role of monitoring the critically ill patient. Interventions could include end-tidal carbon dioxide monitoring and pulse oximetry for evaluation of ventilation in both intubated and nonintubated patients.18 PAs can also insert arterial catheters for arterial blood pressure monitoring, rather than central venous catheters for central venous monitoring. Additional critical care monitoring skills would include placing a urinary catheter to monitor urine output (for severely prolonged extrication) and core temperature monitoring.

Mass-Gathering Events

During mass gatherings an influx of stable patients could present to a medical station. In these events a PA can provide online, on-scene medical control for prehospital providers. PAs have been able to decrease hospital lengths of stay when placed in triage, so it can be inferred they are capable of identifying the appropriate needs and dispositions for patients with acute presentations.19 Having a PA on scene may also help decrease the number of patients transported to a hospital or identify subtle presentations of more serious illnesses.

Tactical Operations

During law enforcement tactical operations, where situations demand deviation from established protocols, PAs can provide a higher level of care for officers and patients. All SWAT teams accredited by the National Tactical Officers Association require medical support, so having a PA on the team may prove beneficial not only for acute care of the ill and injured but for the preventative and long-term care of the team.20

High-Risk Refusals

Most EMS systems document that between 5%20% of their call volume results in patients refusal of medical treatment, with some systems indicating 30%.21 Many of these patients, especially those older than 65, will require some kind of follow-up care.22 These older patients are also more likely to die because of their illness within a week of their medical contact.23 Pediatric patients are also high-risk refusals due to the inclusion of parents and their requests. Psychiatric patients are also high-risk; therefore PAs may be able to bring additional medications not normally carried on ambulances for violent patients. They may also be able to provide a more thorough assessment, with the possibility of alternative dispositions to the ED.

High-Frequency Users

High-frequency users of EMS can also be reduced up to 30% through education and by providing the appropriate resources for alternative, more appropriate dispositions.24 In one example of a community paramedicine program in North Carolina, high-frequency user visits to the ED were cut by more than half under a program using paramedics with additional training.25 Utilizing PAs with prescriptive authority could reduce ED use even more.

Low-Acuity Patients

EMS providers are frequently dispatched to low-acuity, nonemergent patients, who often overlap with the high-frequency user subset. The Los Angeles Fire Department implemented a nurse practitioner-staffed ambulance that responded to many of these calls. In the first six months, their treat-and-release rate was 52% for the 329 patients to whom they were dispatched.26 One study noted that low-acuity ambulance users often had insurance and a primary care provider but lacked private transportation compared to those presenting via private transportation.27

These patients also believed enough ambulances were available for calls of all acuities and said they would continue to utilize ambulances for medical transportation.27 Another study demonstrated a reduction in ED visits through using other resources, such as telemedicine and urgent care centers.28 PAs could further reduce ED visits by appropriately triaging lower-acuity patients to these established resources.

ACEP suggests physicians with board certification in EMS are best prepared to fill the role of an EMS medical director.29 This role also includes dedication to continued EMS provider education, community evaluation, QI/QA, and EMS-focused research. The EMS PA can fulfill this role as an assistant medical director (though in Missouri EMS medical directors must be board-certified physicians).29,30

Administrative duties of the EMS PA can be subdivided into three categories: education (community and prehospital provider), QI/QA, and research.

Education

An EMS PA could provide medical education to two distinct audiences: the general community and EMS providers.

For community education, opportunities exist in settings such as community health fairs, specific targeted campaigns, and the promotion of celebration weeks (e.g., EMS Week, Health Literacy Week, etc.). These efforts should be focused on spreading health awareness, communicating the availability of resources, and assisting in the first steps toward health improvement.

For prehospital providers EMS PAs could teach initial education courses and provide continuing education on focused topics or skills with the appropriate simulation materials.

Quality Improvement

Since quality improvement is also among the responsibilities of the medical director, this task could be completed by a PA working as an assistant medical director. Responsibilities would include chart review, identification of common errors, and developing training courses and education materials to assist in continual improvement.

Research

Evidence-based practice has been shown to improve overall patient outcomes, and a commitment to research is another responsibility of the EMS medical director that could be executed by an EMS PA: seeking out new areas to investigate, completing or coordinating projects, and performing original research. Additionally, PAs could locate peer-reviewed, evidence-based best practices and develop new policies and protocols to incorporate them.

Several barriers likely exist to the immediate implementation of an EMS PA program such as the one described above. The first and foremost is obtaining funding. Most fellowship programs provide the student with a stipend, but there are also costs like liability insurance, vehicles, uniforms, training courses, and medical insurance. Ways to cover these costs include insurance reimbursement for patient care hours, grants, donations, and university input.

Furthermore, the emergency medical dispatch system must be assessed to ensure correct analysis of calls for the dispatch of appropriate resources. Studies have shown protocol-based EMD systems are consistently more accurate than those without EMD protocols.31

Because of a lack of current PA providers in the EMS setting, it is important that procedures, protocols, and policies be examined to ensure liability coverage.32 These policies should be set with the direct input of the division chief/medical director. They should specify who has ultimate on-scene authority for patients should a difference in opinion ever occur on the treatment plan.

As with all postgraduate academic programs, an EMS PA program must be affiliated with a university. Many existing physician response units are already aligned with major academic centers. This would also be beneficial toward future EMS research.

A prehospital-focused EMS PA postgraduate education program would be relatively easy to implement once these few small barriers are overcome. These providers would have the ability to improve the care and functioning of EMS, contributing to a more appropriate allocation of resources, reduced ED utilization, increased cost savings, and better overall health literacy.

1. American Academy of Physician Assistants. What is a PA? http://www.aapa.org/what-is-a-pa/.

2. Bureau of Labor Statistics. Fastest Growing Occupations, http://www.bls.gov/ooh/fastest-growing.htm.

3. Association of Postgraduate PA Programs. Postgraduate Pas Programs Listings, https://appap.org/programs/pa-programs-listing/.

4. American Academy of Physician Assistants. History of the PA Profession, http://www.aapa.org/about/history/.

5. Wright D. Physician Assistant Emergency Medicine Postgraduate Programs and Their Focus on EMS Education. Unpublished, 2019.

6. Widmeier K. Specialty Certifications in EMS. J Emerg Med Serv, 2015; http://www.jems.com/2015/09/08/specialty-certifications-in-ems/.

7. American College of Emergency Physicians. EMS the Newest Subspecialty of Emergency Medicine. ACEP Now, 2010 Nov 1; http://www.acepnow.com/article/ems-newest-subspecialty-emergency-medicine/.

8. National Association of EMS Physicians. EMS Subspecialty, https://naemsp.org/career-development/ems-subspecialty/.

9. National Association of EMS Physicians. Fellowship Programs, https://naemsp.org/career-development/fellowship-programs/.

10. Bell A, Lockey D, Coats T, Moore F, Davies G. Physician Response UnitA feasibility study of an initiative to enhance the delivery of pre-hospital emergency medical care. Resuscitation, 2006; 69 (3), 38993.

11. Accreditation Council for Graduate Medical Education. Emergency Medicine: Program Requirements and FAQs, http://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/7/EmergencyMedicalServices.

12. Btker MT, Jacobsen L, Rudolph SS, Knudsen L. The role of point of care ultrasound in prehospital critical care: a systematic review. Scand J Trauma, 2018; 26(1): 51.

13. Palepu GB, Deven J, Subrahmanyam M, Mohan S. Impact of ultrasonography oncentral venous catheter insertion in intensive care. Indian J Radiol Imaging, 2009; 19(3): 1918.

14. Bloom BA, Gibbons RC. Focused Assessment with Sonography for Trauma. StatPearls [Internet], http://www.ncbi.nlm.nih.gov/books/NBK470479/.

15. Cureton EL, Yeung LY, Kwan RO, et al. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma Acute Care Surg, 2012 Jul; 73(1): 10210.

16. Kory P, Guevarra K, Mathew JP, Hegde A, Mayo PH. The Impact of Video Laryngoscopy Use During Urgent Endotracheal Intubation in the Critically Ill. Anesthesia & Analgesia, 2013; 117(1): 1449.

17. Sakles JC, Mosier JM, Chiu S, Keim SM. Tracheal Intubation in the Emergency Department: A Comparison of GlideScope Video Laryngoscopy to Direct Laryngoscopy in 822 Intubations. J Emerg Med, 2012; 42(4): 4005.

18. Andrews FJ, Nolan JP. Critical care in the emergency department: monitoring the critically ill patient. Emerg Med J, 2006; 23(7): 5614.

19. Nestler DM. Effect of a physician assistant as triage liaison provider on patient throughput in an academic emergency department. Acad Emerg Med, 2012 Nov; 19(11): 1,23541.

20. National Tactical Officers Association. Tactical Response and Operations Standards for Law Enforcement Agencies, https://ntoa.org/pdf/swatstandards.pdf.

21. Hipskind JE, Gren J, Barr D. Patients Who Refuse Transportation by Ambulance: A Case Series. Prehosp Disaster Med, 1997; 12(4): 4550.

22. Vilke GM, Sardar Wm, Fisher R, Dunford JD, Chan TC. Follow-up of elderly patients who refuse transport after accessing 9-1-1. Prehosp Emerg Care, 2002 OctDec; 6(4): 3915.

23. Page D. Cancel with care. Which refusals can risk patient safetyand your career? J Emerg Med Serv, 2010 Dec; 35(12): 5661.

24. Pecci AW. Community-Based Program Cut ED Visits by Nearly 30%. Health Leaders, 2017 Oct 4; http://www.healthleadersmedia.com/clinical-care/community-based-program-cut-ed-visits-nearly-30.

25. Clarke JL, Bourn S, Skoufalos A, Beck EH, Castillo DJ. An innovative approach to health care delivery for patients with chronic conditions. Popul Health Manag, 2017 Feb; 20(1): 2330.

26. Eckstein M, Ito T, Guggenheim A, Sanko S. Nurse Practitioner Response Unit Launched in Los Angeles. J Emerg Med Serv, 2017; 42(2).

27. Pearson CP, Kim DS, Mika VH, et al. Emergency department visits in patients with low acuity conditions: Factors associated with resource utilization. Am J Emerg Med, 2018 Aug; 36(8): 1,32731.

28. Poon S, Schuur J, Mehrotra A. 172 Trends in Site of Care for Low-Acuity Conditions Among Those With Commercial Insurance, 20082015. Ann Emerg Med, 2017 Oct; http://www.annemergmed.com/article/S0196-0644(17)31099-5/fulltext.

29. American College of Emergency Physicians. The Role of the Physician Medical Director in Emergency Medical Services Leadership, http://www.acep.org/patient-care/policy-statements/the-role-of-the-physician-medical-director-in-emergency-medical-services-leadership.

30. Missouri Code of State Regulations. Rules of Department of Health and Senior Services, Division 30Division of Regulation and Licensure, Chapter 40Comprehensive Emergency Medical Services Systems Regulations; http://www.sos.mo.gov/CMSImages/AdRules/csr/current/19csr/19c30-40.pdf.

31. Clawson J, Olola CHO, Heward A, Scott G, Patterson B. Accuracy of emergency medical dispatchers subjective ability to identify when higher dispatch levels are warranted over a Medical Priority Dispatch System automated protocols recommended coding based on paramedic outcome data. Emerg Med J, 2007 Aug; 24(8): 5603.

32. National Association of EMS Physicians. EMS Physician-Performed Clinical Interventions in the Field Position Statement, https://naemsp.org/NAEMSP/media/NAEMSP-Documents/EMS-Physician-Performed-Clinical-Interventions-in-the-Field.pdf.

David Wright, MS, PA-C, NRP, is a physician assistant working in the Division of Pediatric Emergency Medicine at Washington University in St. Louis.

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The Benefits of an EMS PA Program - EMSWorld

Kathy Grant| What's Growing On

As the weather remains warm and our garden continues to surprise us with vigorous growth, you have probably also been plagued by the healthy insects and birds invading your tender greens.What to do is a challenge, especially if you are concerned about the residual effects of chemical sprays, either to yourself, or to your nearest waterway.

Theres hope!Hold back on heading to the store to buy what strikes your fancy, rather, spend a little time researching and reading about your options, then perhaps head to the store, or shop online, buying only what is safe and effective, or better yet, get to work to prevent problems prevent problems from happening in the first place.

Begin your fall gardening season with an IPM resolution to better garden housekeeping. Study the links below, and bookmark them below for easy reference.They also make a handy library if you have access to a printer.

This autumn, pest control in the landscape and veggie garden can include a little more than just a scarecrow and a garden shelf full of various sprays and pest control brews to keep your garden pest free.

So, what is Integrated Pest Control,(IPM), you ask?Check out the UCs IPM website for a fuller understanding: http://ipm.ucanr.edu/.But, basically, With IPM, you take actions to keep pests from becoming a problem, such as by growing a healthy crop that can withstand pest attacks, using disease-resistant plants, or caulking cracks to keep insects or rodents from entering a building. Rather than simply eliminating the pests you see right now, using IPM means you'll look at environmental factors that affect the pest and its ability to thrive. Armed with this information, you can create conditions that are unfavorable for the pest.

In other words, IPM acts at times like much like preventative medicine.

To properly adapt an integrated pest management (IPM) approach in your landscape gardening, it is best not to wait till you have problems in the garden.The University of California has created a wonderful regional checklist of monthly chores we should all be doing in the garden.

Start by going to the University of California Agriculture and Natural ResourcesIPM website, http://ipm.ucanr.edu/, and find the link to the Home, garden, turf, and landscape pests,then the Quick Link to the Seasonal Landscape IPM Checklist.

Choose the region and month you want to study, say San Joaquin,and November,then click to find a printable list of garden chores for you to work through for the month.Simple suggestions include pruning mistletoe from branches, or applying organic mulch below trees where soil is exposed, etc.

More long term goals are also stressed, which is key to IPMs effectiveness: Create an attractive landscape that reduces the need for pesticides and fertilizers, avoids runoff, and conserves water.An environmentally friendly landscape includes porous materials for walkways and other unplanted areas, good plant choices, proper site preparation, and smart irrigation equipment.A little study and small gardening changes can in the long run make your garden more sustainable.

To drill down to specific problems in certain plants, the UC IPM Plant Diagnostic Tool is a good resource to figure out solutions to specific pests in your garden.Find the tool athttps://www2.ipm.ucanr.edu/diagnostics/.

Subscribe to monthly blogs.https://ucanr.edu/blogs is a treasure trove of short, readable blog posts which keep you informed of the latest research and background to help you understand what are perceived as pests in the urban environment.

Finally, how do you control the birds, moths or squirrels in the garden, who love to nip at your veggie tender greens?The UC also has a series of Pest Notes, though a careful reading is required, since pests seasonal activities varies, as does their management. For the imported cabbage moths, Biological control and sprays of Bacillus thuringiensis and the Entrust formulation of spinosad are organically acceptable management tools,as reported in the UC ANR Publication 3442.As for the birds in the garden, a floating row cover is the simplest solution, or of course, a scarecrow, which is fun, and works for a while, until the birds figure out, its not you out there gardening!

For gardening-related questions, call the UC Master Gardener office at (209) 953-6112, or visit ourwebsite at ucanr.edu/sjmg.

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Beyond scarecrows and toxic brews: Using UC pest strategies in the autumnal garden - Stockton Record

In front of thousands who gathered to celebrate the countrys military parade on October 10, North Korean leader Kim Jong-un applauded his nations efforts in keeping out the novel coronavirus that has caused at least 1.2 million deaths around the world.

But behind the scenes, the number of citizens suspected of contracting the disease surged, according to data released by the World Health Organization.

Between October 1 and October 22, 3,373 North Korean nationals were added to the suspected patients lists, which likely occurred as the country was ramping up testing of attendees for the massive parade.

Just five days after the event, a total of 4,522 were suspected of being carriers of COVID-19. That figure quickly climbed to 5,368, including eight foreigners, by October 22. Many were quarantined but the data does not say whether anyone died from the virus.

Still, according to the WHO, no positive case was foundmeaning that North Korea has yet to report a single confirmed coronavirus case since the pandemic began roughly ten months ago. It is known that North Korea self-reports all coronavirus-related data to the WHO, so it is difficult to make a clear judgment on how factual the stated numbers are, according to experts.

Jean Lee, the director of the Korea Center at the Woodrow Wilson Center, told The National Interest that with the borders so tightly sealed, and so few foreigners on the ground in North Korea right now, its hard for us to gauge how accurate the claims are.

She added: Its hard to believe there were no cases, given the long border North Korea shares with China.

The exact number of attendees at the military parade is unknown, but it could be anywhere from thousands to tens of thousands. Video footage showed mask-less cheering citizens standing shoulder to shoulder with one another at Kim Il Sung Square, where a new ballistic missile was unveiled to the public.

Social distancing was obviously not being observed and along with the fact that the attendees werent wearing any face masks or coverings, this parade had the potential to be a super-spreader event.

But according to Korea Health Policy Project Director Dr. Kee B. Park, of Harvard Medical School, he believes that it is entirely possible that North Korea has been successful in keeping the coronavirus out of the country.

I am not aware of any request from the DPRK for external health teams to help monitor. They seem confident that their strategy has been successful so far, he told TNI.

The country is capable of implementing effective mitigation measure if there was to be an outbreak. Yes, many will get sick and some will die but I suspect it will be quickly contained.

Lee, however, was markedly less confident in North Koreas ability to battle any large-scale outbreak.

What we do know is that North Koreas fragile health-care system would be ill-equipped to deal with a full-blown outbreak of a virus that has taxed even the most sophisticated health-care systems in the world, she said.

Without adequate medicine or equipment, North Koreas doctors rely heavily on preventative medicine. Their strategy is to prevent the virus from spreading or, ideally, coming into the country, and their tactic is to impose strict lockdowns and travel restrictions.

Dr. J. Stephen Morrison, the senior vice president at the Center for Strategic and International Studies and director of its Global Health Policy Center, echoed similar sentiments.

Outside of few urban centers, health centers around the country are primitive, he told TNI, adding that many facilities dont even have running water or electricity. North Korea is very vulnerable.

Morrison also doesnt anticipate international health organizations will get access into the country anytime soon.

North Korea has a history of denying access and throwing up barriers and walls, he said. There is very minimal external presence to monitor.

However, according to Park, the continued effort to keep the virus outside North Koreas borders may come with steep economic and social costs.

The human cost of the continued isolation and mitigation will likely surpass the expected death toll of the virus itself as the pandemic rages on, he said. I would point out that most countries are wrestling with the same problem.

The U.S. Centers for Disease Control and Prevention states on its website that COVID-19 risk in North Korea is unknown. CDC recommends travelers avoid all nonessential international travel to North Korea.

The agency offers a final warning: If you get sick in North Korea and need medical care, it may be limited.

Ethen Kim Lieser is a Minneapolis-based Science and Tech Editor who has held posts at Google, The Korea Herald, Lincoln Journal Star, AsianWeek, and Arirang TV. Follow or contact him on LinkedIn.

Image: Soldiers attend a parade to mark the 75th anniversary of the founding of the ruling Workers' Party ofKorea, in this image released byNorthKorea's Central News Agency on October 10, 2020.

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Has Coronavirus Finally Arrived in North Korea? - The National Interest

Time and time again, youve probably heard me mention the rapid growth of the older adult population in the next few decades. Nonetheless, its a reality that everyone must face. Modern medicine, from preventative care to increased health literacy, along with social services the Administration of Aging and geriatric services are some of the many factors contributing to such development. Seeing that the election will play an important role in the future of older adult care and services, lets double down on the role that we can play as college students in the near future.

The world of aging does not limit itself to our discussions in academia or the skilled nursing communities that I referred to in my last column. Aging, in many ways, is a marketable and interdisciplinary field. Looking at the tech sector, theres a clear and immediate need for gerontologists to help critique and develop simple and reliable technology geared more toward older adults. For the public policy and politically oriented folks, theres room for advocacy on behalf of those diagnosed with Alzheimers or various forms of dementia. As mentioned above, knowing the fundamentals in the psychology of aging can open pathways to academia and research. For myself, I plan to head off to medical school Caribbean or not, but probably the former and pursue a fellowship in geriatric medicine soon after. In short, theres definitely a niche or space for you.

I havent even touched on the media and journalism side of aging. You might have seen initiatives to help preserve the stories of older adults through video interviews, university oral history archives or movies. One that often comes to mind is the StoryCorp program geared toward those diagnosed with some form of dementia, named the StoryCorp Memory Loss Initiative. Here, the stories of older adults can be shared to the StoryCorp project and are automatically uploaded to the Library of Congress collection in conjunction with the StoryCorp collection. Working in the Davis School of Gerontologys Communication Office, I know that we have a handful of opportunities where we try not only to increase our presence in the world of aging but also to showcase intergenerational interactions at the University.

But Lois, you, the inquisitive reader asks. Isnt gerontology and the field of aging as a whole really just one massive interdisciplinary field that is working to better orient itself to the care and assistance of older adults?

A weirdly specific question, but yes. The field of aging continues to be an incredibly complex and interdisciplinary field given its implications for almost every job sector. Even more, theres an 18% increase in the number of older adults in our current workforce since 2015, illustrating the need and care these individuals may require once they opt into retirement options.

However, I implore that you learn more about older adults before jumping into the field via trial by fire. Many can join the age bandwagon and dig out a niche in the field. Upon doing this, however, they might realize that working with the older adult population may not necessarily be their forte. So, here are a few classes offered by the School of Gerontology that could ease the transition or affirm your passion of helping older adults.

Administrative Problems in Aging provides some insight into the field of aging from an administrative standpoint. Currently taught by adjunct lecturer Tameka Brown, the class delves into topics such as working with and developing a human resources department, delegating responsibilities to coworkers and establishing a healthy work environment, all while taking older clients and employees into consideration.

Medical Issues of Older Persons: An Introduction to Geriatrics illustrates the changes in preventative care and treatment of age-related diseases throughout history while also providing insight on the current steps being taken to tackle issues among todays group of older adults. With Ed Schneider, professor of gerontology and Emeritus Dean of the Andrus Gerontology Center, its sure to be an exciting and fun class.

Neurobiology of Aging with John Walsh, associate professor of gerontology and assistant dean of education at the Davis School, is another exciting class geared more toward the science component of gerontology, looking more at cognitive function and the nervous system.

There are plenty more classes in the gerontology school as well that you should definitely give a look, particularly Maymesters and some of the smaller two-unit classes.

Outside of taking those fun gero classes, try and find some opportunities to work with older adults where youre able. At the moment, it might be incredibly difficult to find any in-person opportunities, or even hybrid volunteering, for that matter. That being said, many opportunities for getting involved or even just learning about possible careers in aging are being hosted by some clubs on campus.

From the Student Gerontology Association to GeroTech to the Medical Gerontology Association, there are places that allow for interaction with older adults, albeit through Zoom or other means. Many older adults are learning to adjust to these new and constantly changing circumstances as they continue to stay indoors and hope the pandemic clears soon. Internships at institutes such as SCAN or the Milken Foundation at its Center for the Future of Aging can certainly give you a better look into how aging is being transformed and better understood.

Bringing it all together, careers in aging are for any and all majors, and the opportunities in this promising field are endless and malleable to your personal and professional goals. Hopefully by the time were older maybe after retiring from a career in aging we look back at the progress weve made for the field of gerontology and reminisce, saying, Back in my day

Lois Angelo is a sophomore writing about the intersections of gerontology and social issues. He is also co-chief copy editor of the Daily Trojan. His column, Back In My Day, ran every other Tuesday.

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Back in My Day: Careers in aging are diverse and aplenty - Daily Trojan Online