Transfer Guidelines Research Articles

Association of emergency department characteristics with presence of recommended pediatric-specific behavioral health policies.

In the United States, pediatric emergency department (ED) visits for behavioral health (BH) are increasing. We sought to determine ED-level characteristics associated with having recommended BH-related policies. We conducted a retrospective serial cross-sectional study of National Pediatric Readiness Project assessments administered to US EDs in 2013 and 2021. Changes in responses related to BH items over time were examined. Multivariable logistic regression models examined ED characteristics associated with the presence of specific BH-related policies in 2021. Of 3554 EDs that completed assessments in 2021, 73.0% had BH-related policies, 66.5% had transfer guidelines for children with BH issues, and 38.6% had access to BH resources in a disaster. Of 2570 EDs that completed assessments in both 2013 and 2021, presence of specific BH-related policies increased from 48.6% to 72.0% and presence of appropriate transfer guidelines increased from 56.2% to 64.9%. The adjusted odd ratios (aORs) of having specific BH-related policies were lower in rural (aOR 0.73; 95% confidence interval [CI] 0.57, 0.92) and remote EDs (aOR 0.65; 95% CI 0.48, 0.88) compared to urban EDs; lower among EDs with versus without trauma center designation (aOR 0.80; 95% CI 0.67, 0.95); and higher among EDs with a nurse and physician pediatric emergency care coordinator (PECC) (aOR 1.89; 95% CI 1.54, 2.33) versus those without a PECC. Although pediatric readiness for BH conditions increased from 2013 to 2021, gaps remain, particularly among rural EDs and designated trauma centers. Having nurse and physician PECCs is a modifiable strategy to increase ED pediatric readiness pertaining to BH.

Outcomes of Patients With Traumatic Brain Injury Transferred to Trauma Centers

Wide variations exist in traumatic brain injury (TBI) management strategies and transfer guidelines across the country. To assess the outcomes of patients with TBI transferred to the American College of Surgeons (ACS) level I (LI) or level II (LII) trauma centers (TCs) on a nationwide scale. In this secondary analysis of the ACS Trauma Quality Improvement Program database (2017 to 2020), adult patients with isolated TBI (nonhead abbreviated injury scale = 0) with intracranial hemorrhage (ICH) who were transferred to LI/LII TCs we re included. Data were analyzed from January 1, 2017, through December 31, 2020. Outcomes were rates of head computed tomography scans, neurosurgical interventions (cerebral monitors, craniotomy/craniectomy), hospital length of stay, and mortality. Descriptive statistics and hierarchical mixed-model regression analyses were performed. Of 117 651 patients with TBI with ICH managed at LI/LII TCs 53 108; (45.1%; 95% CI, 44.8%-45.4%) transferred from other centers were identified. The mean (SD) age was 61 (22) years and 30 692 were male (58%). The median (IQR) Glasgow Coma Scale score on arrival was 15 (14-15); 5272 patients had a Glasgow Coma Scale score of 8 or less on arrival at the receiving trauma center (10%). A total of 30 973 patients underwent head CT scans (58%) and 2144 underwent repeat head CT scans at the receiving TC (4%). There were 2124 patients who received cerebral monitors (4%), 6862 underwent craniotomy/craniectomy (13%), and 7487 received mechanical ventilation (14%). The median (IQR) hospital length of stay was 2 (1-5) days and the mortality rate was 6.5%. There were 9005 patients (17%) who were discharged within 24 hours and 19 421 (37%) who were discharged within 48 hours of admission without undergoing any neurosurgical intervention. Wide variations between and within trauma centers in terms of outcomes were observed in mixed-model analysis. In this study, nearly half of the patients with TBI managed at LI/LII TCs were transferred from lower-level hospitals. Over one-third of these transferred patients were discharged within 48 hours without any interventions. These findings indicate the need for systemwide guidelines to improve health care resource use and guide triage of patients with TBI.

Defining futile and potentially avoidable interhospital trauma transfers

PurposeInterhospital transfer of critically injured patients to a major trauma service reduces preventable death in major trauma. Yet some of those transferred die without intervention. These ‘futile’ interhospital trauma transfers (IHTs), and other potentially avoidable IHTs place enormous stress on families of trauma victims, can delay care, and incur great cost to public health resources. This study sought to characterise these IHTs using current state guidelines for interhospital transfer. MethodsA retrospective cohort study was conducted using our institution's trauma registry from January 2016–December 2020. All adult patients transferred to our major trauma service were analysed. Futile IHTs were defined as death or transfer to hospice care without surgical, endoscopic, or radiological intervention, and without ICU admission, within 72 h of admission. Potentially avoidable IHTs were defined as all patients discharged alive without intervention or ICU care, and secondary over-triage patients are a subset of these patients who were discharged within 72 h of admission. Patient demographics, injuries, and treatments were categorised from electronic records and analysed. ResultsOf 2,837 IHTs, seven (0.2 %) met criteria for futility. The majority were female, median age of 80 (IQR 85–75) and had a median Injury Severity Score (ISS) of 16 (IQR 25.5–11.5). By contrast, 1391 patients (49 %) were classified as potentially avoidable and 513 (18 %) were considered secondary over-triage. The majority were male, median age of 43 (IQR 62–28), and had a median ISS of 9 (IQR 13–4). Of these potentially avoidable IHTs, 984 (70.7 %) were discharged directly home. ConclusionFutile IHTs were infrequent, however over half of all trauma patients transferred from other hospitals were discharged without tertiary-level intervention. Trauma services should consider developing systems such as telehealth to support regional general and orthopaedic surgeons to co-manage lower risk trauma, particularly minor head and minor spinal trauma patients. This could be an integral part of safely reducing potentially avoidable IHTs and their associated costs while maintaining a low rate of preventable mortality in trauma.

The current state of intensive care unit discharge practices - Results of an international survey study.

Increasing pressure on limited intensive care capacities often requires a subjective assessment of a patient's discharge readiness in the absence of established Admission, Discharge, and Transfer (ADT) guidelines. To avoid suboptimal care transitions, it is important to define clear guidelines for the admission and discharge of intensive care patients and to optimize transfer processes between the intensive care unit (ICU) and lower care levels. To achieve these goals, structured insights into usual ICU discharge and transfer practices are essential. This study aimed to generate these insights by focusing on involved stakeholders, established processes, discharge criteria and tools, relevant performance metrics, and current barriers to a timely and safe discharge. In 2022, a structured, web-based, anonymous cross-sectional survey was conducted, aimed at practicing ICU physicians, nurses, and bed coordinators. The survey consisted of 29 questions (open, closed, multiple choice, and scales) that were divided into thematic blocks. The study was supported by several national and international societies for intensive care medicine and nursing. A total of 219 participants from 40 countries (105 from Germany) participated in the survey. An overload of acute care resources with ~90% capacity utilization in the ICU and the general ward (GW) leads to not only premature but also delayed patient transfers due to a lack of available ward and intermediate care (IMC) beds. After multidisciplinary rounds within the intensive care team, the ICU clinician on duty usually makes the final transfer decision, while one-third of the panel coordinates discharge decisions across departmental boundaries. By the end of the COVID-19 pandemic, half of the hospitals had implemented ADT policies. Among these hospitals, nearly one-third of the hospitals had specific transfer criteria established, consisting primarily of vital signs and laboratory data, patient status and autonomy, and organization-specific criteria. Liaison nurses were less common but were ranked right after the required IMC capacities to bridge the care gap between the ICU and normal wards. In this study, 80% of the participants suggested that transfer planning would be easier if there was good transparency regarding the capacity utilization of lower care levels, a standardized transfer process, and improved interdisciplinary communication. To improve care transitions, transfer processes should be managed proactively across departments, and efforts should be made to identify and address care gaps.

CLINICIANS' PERCEPTIONS OF MANUAL HANDLING POLICIES IN STROKE REHABILITATION: A QUALITATIVE FOCUS GROUP STUDY.

The professional literature guides manual handling in numerous health care settings. The effects of these guidelines on stroke rehabilitation and the clinical communication of health care professionals are unknown. This paper aims to investigate the perspectives of nurses and physiotherapists on handling guidelines in their professions to identify conflicts in opinions to provide optimum care to people with stroke. A qualitative focus group study. Three focus groups were conducted. The participants were physiotherapists or nurses with 1 year of stroke care experience. The data were thematically analysed. Nineteen participants (12 physiotherapists and 7 nurses) were interviewed. The data analysis revealed 3 themes. First, "The application of handling in stroke rehabilitation" includes clinical reasoning and real-world handling practices. The second theme, "Physical Effects on Therapists," examines the long-term effects of manual handling on therapists, including work-related musculoskeletal disorders. The final theme, "Conflicts among health care professionals," investigates stroke rehabilitation equipment conflicts between nurses and physiotherapists. The study concludes that stroke transfer guidelines in the specialised literature may impact health care professionals' perspectives. Conflicts among health care professionals can impair teamwork. Thus, health care professionals should work together as stroke rehabilitation teams to develop unified transfer guidelines that aid rehabilitation and avoid work-related musculoskeletal disorders.

Interfacility Transfer Guidelines for Patients With Isolated Facial Trauma—From Problem to Solution

This Viewpoint discusses the need to implement proposed guidelines for facial trauma assessment to prevent unnecessary interfacility transfer of patients with facial trauma despite most such patients having injuries that do not require surgical intervention.

249 Interprofessional Consultation to Reduce Unnecessary Transfers of Complicated Mild TBI to Tertiary Referral Centers

INTRODUCTION: The neurosurgical intervention rate for complicated mild traumatic brain injury (cmTBI) is less than 1%. However, the absence of transfer guidelines and fear of malpractice results in unnecessary transfers of cmTBI patients to tertiary referral centers. METHODS: Between April 2021 and March 2023, we implemented a Tele-TBI at three community hospitals for cmTBI patients seen in the emergency department (ED). An interprofessional telehealth-based consultation between emergency medicine and neurosurgery determined if a patient needed to be transferred to the Level-1Trauma Center or could be cared for at the community hospital. A retrospectively chart review was used to determine if transfers were unnecessary. Transfer rates were compared for patients from hospitals with and without the Tele-TBI protocol. RESULTS: Out of 822 cmTBI patients seen in our ED, 73% (n = 602) were transferred from other hospitals. The mean age of transferred patients was 67.5 (±19.9) and median GCS was 15. During this time, 128 Tele-TBI consultations were performed. The mean age was 75.7 (±16.2), and median GCS was 15. The overall transfer rate was decreased by 89% (n = 15/128) when Tele-TBI consultations were initiated. Tele-TBI-enabled hospitals had significantly fewer (p < 0.001) unindicated transfers (28.7%, n = 66 versus 71.3% n = 164) and led to fewer (p = 0.003) transferred patients discharged directly from the Level-1Trauma Center ED (28.6%, n = 66 versus 72.3%, n = 173). ICU admissions and frequency of neurosurgical intervention did not differ between hospitals with or without tele-TBI implementation. CONCLUSIONS: Interprofessional telehealth-based consultation can effectively triage patients with cmTBI presenting to community hospitals, leading to fewer unnecessary transfers with similar rates of ICU admissions and neurosurgical interventions.

Legal Issues Concerning of Data Security and Privacy in Automated Income Tax Systems in Nigeria

The adoption of automated income tax systems in Nigeria has ushered in a new era of efficiency and transparency, offering promising prospects for streamlined tax administration. However, the absence of comprehensive data protection legislation and potential cybersecurity threats pose significant challenges. The legal landscape surrounding data security and privacy in the context of automated tax systems necessitating an in-depth exploration of this study. This study aims to analyze the prospects and legal challenges associated with data security and privacy in the implementation of automated income tax systems in Nigeria. The study employs a multi-faceted methodology, combining a thorough review of existing literature and an analysis of relevant legal frameworks. Additionally, 303 questionnaires were distributed to respondents to ascertain insights concerning the prospect of automated income tax and cybersecurity measures in place concerning data security and privacy. The study found that there are several prospects associated with automated income tax systems, including increased efficiency, transparency, and enhanced revenue collection. However, legal challenges are identified, such as the lack of comprehensive data privacy legislation, cybersecurity threats, and control. The study therefore concludes that, while automated income tax systems offer significant benefits, addressing the legal challenges is paramount for their successful implementation. The study recommends the urgent enactment of comprehensive data protection legislation, the implementation of robust cybersecurity measures, and increased public awareness programs. Additionally, guidelines for international data transfer should be established to ensure the privacy and security of taxpayer information.

Intraspecific variability in cold hardiness of Taurus cedar (Cedruslibani A. Rich.) in Türkiye

To better guide Cedruslibani provenances movement to northerly and higher-altitude sites for afforestation, the limits of hardiness to cold should be better known. In this study, we quantified the cold hardiness of seven C.libani provenances sampled from a provenance trial in Ankara, Türkiye, a site located outside the natural range of distribution of the species. Visual damage observation and chlorophyll fluorometry screening methods were used to assess variation in cold hardiness (LT50, the temperature estimated at which 50% of the needle tissue is damaged) among populations. Overall, C.libani can tolerate winter temperatures down to − 21.5 °C. Even though there were significant differences in cold hardiness among populations, the maximum difference was only 1.9 °C between the most and the least cold-resistant provenances. Cold tolerance was generally greater for provenances that experienced colder temperatures in March and lower levels of total precipitation in their native ranges. We also conclude that the fluorometry method provides a more efficient and stable comparison of cold hardiness than visual observation for C.libani. The results of this study may be useful for assisted migration and breeding programs, as well as for developing guidelines for genetic materials transfer, to increase productivity or adaptability of C.libani.

Numerical investigation of a novel concrete-to-steel column splice in mixed structures in height

Buildings in which the type of structural material changes between their stories are referred to as mixed-in-height structures. Typically, these buildings have concrete structures in lower stories and steel structures in upper stories. Valuable investigations have been conducted on mixed-in-height structures to explore their seismic response and changes in structural natural period due to the sudden change in the lateral stiffness at transition level and mass irregularity, but scant attention has been given to the connection between steel and concrete structures at varying heights. Given the geometrical limitations of existing concrete structures, the dimensions of steel columns in supplementary stories must align with those of reinforced concrete columns. Consequently, building codes have not yet provided guidelines for proper connection details and effective load transfer from upper steel to lower concrete structures which is crucial due to the abrupt changes in stiffness and force transfer mechanisms in such splice connections. Thus, this study considers Numerical investigation on two full-scale laboratory tested specimens, with similar details but different axial loads, and numerical analysis of a new connection between a concrete and a steel column at the transition level. This research examines the aforementioned connection under two boundary conditions. Furthermore, after validating the numerical models with experimental specimens, axial load parameters, relative percentage of reinforcement to concrete area, and the force–displacement diagrams are presented. Finally, a numerical model of a three-story column in a frame is analyzed using finite element analysis under lateral load, and the sequence of plastic hinge formation is studied. The practicality and effectiveness of the proposed splice was verified herein. Furthermore, the average value of ductility (µ) was calculated to be 5.5, while exhibiting negligible overstrength factor (Ω). Similar response parameters were calculated for F-AL-R2 (43.2 kN/mm, 21.1 kN/mm) and F-AL-R3 (43.8 kN/mm, 22 kN/mm), indicating that the influence of increased rebar percentage diminishes at higher values. The analysis demonstrates that column connection failure did not occur, and the sequence of hinge formation was from top to bottom, validating the suitable performance of the proposed connection.

Mitigating the socioeconomic impacts of the mining industry through Social Technologies: Guidelines for technology transfer between universities and communities

AbstractThe mineral sector causes socioeconomic and environmental impacts on the surrounding communities. Thus, Social Technologies (STs) developed by universities are an alternative for improving the quality of life of the people affected by mining activities. STs are a Latin American practice comprising solutions for social inclusion and economic development. Thus, this article critically investigates the impacts of mining and STs, reinforcing the potential applications of STs in this field. Additionally, the work discusses the possibilities of technology transfer from the university to society through a comprehensive literature review, and the authors developed guidelines to mitigate the impacts of mining activities using STs implementation with technology transfer as a tool. The literature review showed that, although multiple STs aim at social inclusion, the success of the ST depends on the socio‐technical suitability of each community, an efficient training process, and the capacity for self‐management by the social actors. The guideline created includes aspects of: approach and scenario reconstruction, mapping, identification of vocations, training, and technical support for affected communities. Additionally, the mining sector can use these guidelines as a Corporate Social Responsibility tool.

Best Practices and Guidelines (2022) for Scale-up and Technology Transfer in Freeze Drying Based on Case Studies. Part 2: Past Practices, Current Best Practices, and Recommendations

Scale-up and transfer of lyophilization processes remain very challenging tasks considering the technical challenges and the high cost of the process itself. The challenges in scale-up and transfer were discussed in the first part of this paper and include vial breakage during freezing at commercial scale, cake resistance differences between scales, impact of differences in refrigeration capacities, and geometry on the performance of dryers. The second part of this work discusses successful and unsuccessful practices in scale-up and transfer based on the experience of the authors. Regulatory aspects of scale-up and transfer of lyophilization processes were also outlined including a topic on the equivalency of dryers. Based on an analysis of challenges and a summary of best practices, recommendations on scale-up and transfer of lyophilization processes are given including projections on future directions in this area of the freeze drying field. Recommendations on the choice of residual vacuum in the vials were also provided for a wide range of vial capacities.Graphical

Multi-Trait Selection and Stability in Norway Spruce (Picea abies) Provenance Trials in Romania

Provenance trials replicated in multiple environments allow the selection of populations with high and stable performances. In this study, two methods have been applied to select stable Norway spruce provenances with high performances in three provenance trials established in Romania in 1972, where 81 provenances have been tested. Four traits were assessed: total and pruned height, diameter at breast height and survival rate. Two multi-trait indices have been used: multi-trait genotype-ideotype distance index (MGIDI) for each provenance trial and multi-trait stability index (MTSI) across provenance trials. The selection differential was between 0.2 and 17.8% better than each site means. Several Norway spruce provenances showed stability and high performances, as confirmed by both selection indices. Our results provide valuable information for the genetic improvement program and seed transfer guidelines based on assisted migration in this ecologically and economically important forest tree species.

Prevalence of low back pain among Irish radiographers

BACKGROUNDAccording to the literature, low back pain (LBP) is one of the top ten diseases and injuries contributing to disability-adjusted life years worldwide. To the best of the authors’ knowledge there are no studies investigating the prevalence of LBP among radiographers working in Ireland or have compared prevalence rates with the national population or other cohorts of radiographers or healthcare professionals. This study aimed to determine the prevalence of LBP among radiographers working or who have previously worked in Ireland and to identify any causative factors. METHODSA cross-sectional study in the form of an online questionnaire was developed. Participation was advertised online via social media platforms. Inclusion criteria included qualified radiographers working in Ireland or who had recently worked in Ireland. Section A of the questionnaire focussed on acquiring demographic data. Section B comprised eight questions relating to LBP, including current and previous experiences, causative factors and consequences.Further details on any episodes of LBP in the previous year, whether work and leisure activities had been affected, whether any extracurricular activities caused LBP, and whether a participant sought professional advice. Section C (six questions) used a 5-point ordinal scale to collect information on the frequency of specific tasks performed by radiographers in their daily roles. Section D involved exploratory questions, including whether LBP has forced a career change if they knew anyone who has changed their career as a result of LBP, reaction to the amount of manual handling required for radiographers, whether they thought manual handling training was sufficient, thoughts on the availability of assistive transfer devices, reasons for not following correct patient transfer guidelines, and finally whether they were concerned about LBP affecting their future. RESULTS151 radiographers participated in this study, and the point prevalence rate of LBP was 50%, with 12 months prevalence rate of 75%. Regarding activity levels, 25% (n=37) reported reduced work activity, and a further 43%(n=65) reduced leisure activities due to LBP. 37% (n=56) have sought medical advice from a doctor, physiotherapist, or other HCP concerning their LBP in the last year. 68% (n=104) of respondents who have LBP confirmed it was not a result of any extracurricular activities. CONCLUSIONThe prevalence of LBP among radiographers in Ireland was high and 4.7 times higher than the period prevalence rate recorded in the general population. LBP rates were similar to radiographers working in other jurisdictions. Data from this study may help manage LBP and monitor any interventions' effectiveness.

Best Practices and Guidelines (2022) for Scale-Up and Tech Transfer in Freeze-Drying Based on Case Studies. Part 1: Challenges during Scale Up and Transfer

The freeze-drying process scale-up and transfer remain a complicated and non-uniform practice. We summarized inefficient and good practices in these papers and provided some practical advice. It was demonstrated that using the same process set points/times in laboratory and commercial scale dryers may lead to loss of product quality (collapse or vial breakage). The emerging modeling approach demonstrated practical advantages. However, the upfront generation of some input parameters (vial heat transfer coefficient, minimum controllable pressure, and maximum sublimation rate) is essential for model utilization. While the primary drying step can be transferred with a high degree of confidence (e.g., using modeling), and secondary drying is usually fairly straightforward, predicting potential changes in product behavior during freezing remains challenging.Graphical

Designing Teaching for Transfer in English for Academic Purposes

Transfer of learning is an important goal of English for Academic Purposes (EAP) education where multilingual students learn knowledge and skills of academic literacy to use in other contexts of writing. Despite the importance of learning transfer in EAP, it does not often take place without mindful teaching for transfer. EAP teachers should make active efforts to help students shape the habit of transfer thinking and experience successful transfer while taking EAP courses. This action research aims at promoting learning transfer by designing and implementing pedagogical tools guided by the notion of high road transfer: (a) transfer guideline, (b) transfer feedback, (c) transfer journals, and (d) transfer imagination activity. The teaching for transfer innovation lasted over the 16-week semester in the target course where multilingual students, who use English as a second/foreign language, learned skills (e.g., how to design PowerPoint slides using different modes of communication, critical reading, source-use skills, synthesizing, finding sources, revising, editing, and reference style) and knowledge of writing (e.g., multimodality and rhetorical situation). Each pedagogical tool was implemented in the classroom so that students maintain their awareness of the importance of learning transfer while taking the target course. Overall, the teaching for the transfer project had positive impacts on articulating what students learn from the target course, leading to actual transfer of learning to other contexts of writing. Future pedagogical directions for promoting learning transfer in EAP are discussed.

Smooth Transitions: Enhancing Interprofessional Collaboration when Planned Community Births Transfer to Hospital Care.

In Washington state, planned community births are attended by direct entry licensed midwives (LMs) and certified nurse-midwives (CNMs). The most recently published vital statistics data from 2018 reported that 3.6% of the 84,648 births in Washington occurred at home or in freestanding birthing centers. Approximately 16.2% of planned home birth and birth center clients experience intrapartum or early postpartum transfer to the hospital, while 1.8% of their newborns do. The safety of and satisfaction with these types of referrals depends on multisystem processes performed by a variety of health care professionals. Smooth Transitions is a quality improvement (QI) initiative in Washington state that was developed to enhance interprofessional collaboration between community-based midwives, emergency medical services (EMS), and hospital personnel to improve the quality of hospital transfers from planned community settings. Key interventions to date have included (1) information sharing to dispel misconceptions and provide context regarding community births and midwives; (2) co-creation of transfer guidelines; (3) regularly held interprofessional meetings to review transfers and build relationships; and (4) ongoing review of qualitative feedback that captures the perspectives of all involved. Responses on questionnaires and audits indicate that Smooth Transitions has had a positive impact on provider, staff, and patient experiences with hospital transfers. Future endeavors will include strengthening quantitative data collection processes to measure safety indicators, expanding relationships with EMS, and building a case review process that is legally protected. By engaging representatives of all stakeholder groups and addressing community-to-hospital transfers as a multisystems issue, replication of the Smooth Transitions QI Program nationally could promote increased community midwifery integration by enhancing the referral experience for both patients and caregivers.

Coherence and Efficient Energy Transfer in Molecular Wires: Insights from Surface Hopping Simulations.

Understanding the dynamics of electronic energy transfer through a molecular wire is essential to understand the working of natural processes like photosynthesis. We investigate simpler 2 and 3-site model Hamiltonians in this work to understand the importance of coherence to efficient energy transfer. We compare the results of surface hopping simulation with that of numerically exact results and rate theories. Different parameters are analyzed, motivated by a photosynthetic molecular wire - the FMO complex. A comparison of results from different theories shows that coherence can play an important role towards efficient energy transfer for certain parameters. When these coherences are important, even small couplings (of the order of 5 cm-1 ) in the Hamiltonian can significantly affect rates. Surface hopping simulations capture all the results correctly qualitatively. Rate theories, on the other hand, can differ significantly from numerically exact results when coherences become important. The results of this work should provide design guidelines for efficient energy transfer in molecular wires.

Whitebark pine genecology field trials in British Columbia: Age 5 results

Whitebark pine (Pinus albicaulis Engelm.) is listed as endangered in Canada, chiefly due to decimation by white pine blister rust (WPBR), (caused by the non-native, invasive fungal pathogen Cronartium ribicola J. C. Fisch.), mountain pine beetle (Dendroctonus ponderosae Hopkins) and a shifting climatic niche. In response to the federal listing of the species, it is incumbent on the Province of British Columbia (BC) to take steps towards its restoration. To this end the development of populations of well-adapted parent trees with genetic resistance to WPBR that can provide seed, will be key to BC’s successful regeneration efforts. To select such parental genotypes for the future seedlots that will be needed, multi-environment common garden tests were established in most of the climate types where whitebark pine grows in BC and several farm field settings. Seed sources from across much of the range in Canada and U.S. have been utilized. Age five-years results are reported for blister rust resistance, survival and height growth. Rust incidence at this stage was generally low (0.1–24 %), except for one trial with 95 % of the seedlings infected. Genetic correlation of rust resistance scores across several of the sites were generally non-significant or weak except two northern trials (r = 0.353, p < 0.001). Genetic effects for height growth were uniformly strong for populations, but less so for families within seed source. Population climate was significantly correlated to field performance, particularly on harsher test sites. For example, at McBride Peak correlation of mean annual temperature with height growth was r = −0.514, p = 0.0007. As rust infection increases over time, and test plants grow above the snow, long-term objectives of reliable identification of WPBR resistance parent trees, establishment of climate-based seed transfer guidelines, assessment of variation in rust hazard and trait durability of rust resistance should become evident. Implications for management using rust resistant planting stock in BC are considered.

Interfacility Transfer Guidelines for Isolated Facial Trauma: A Multidisciplinary Expert Consensus.

The objective of this study was to develop guidelines for the transfer of patients with isolated craniomaxillofacial trauma. A national, multidisciplinary expert panel was assembled from leadership in national organizations and contributors to published literature on facial reconstruction. The final panel consisted of five plastic surgeons, four otolaryngologist-head and neck surgeons, and four oral and maxillofacial surgeons. The expert panelists' opinions on transfer guidelines were collected using the modified Delphi process. Consensus was predefined as 90 percent or greater agreement per statement. After four Delphi consensus building rounds, 13 transfer guidelines were established, including statements on fractures of the frontal sinus, orbit, midface, and mandible, as well as soft-tissue injuries. Twelve guidelines reached consensus. The decision to transfer a patient with craniomaxillofacial trauma to another facility is complex and multifactorial. While a percentage of overtriage is acceptable to promote safe disposition of trauma patients, unnecessarily high rates of secondary overtriage divert emergency medical services, increase costs, delay care, overload tertiary trauma centers, and result in tertiary hospital staff providing primary emergency coverage for referring hospitals. These craniomaxillofacial transfer guidelines were designed to serve as a tool to improve and streamline the care of facial trauma patients. Such efforts may decrease the additional health care expenditures associated with secondary overtriage while decompressing emergency medical systems and tertiary emergency departments.