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Attrition did not change between pre-duty hour rules and post-duty hour rules time periods. Findings included improved well-being and an opportunity to learn about different approaches to patient care due to the increased number of residents involved in patient care. Many disadvantageous aspects of the duty hour rules were discussed including incomplete patient evaluations, delayed treatment decisions and discontinuity of care with missed information. With respect to education, residents perceived that there were fewer opportunities to follow patients longitudinally and less time for conference attendance. Overall, there was some frustration at the inflexibility of the rules, especially when it came to specific patient situations. The results included a negative perception of the duty hour rules on patient care and clinical experience. The residents felt more negatively than the interns about the impact of duty hour rules. There were high rates of reporting at least one episode of non-compliance with one of the duty hour rules during the last call month. Of note, the intervention schedule required an extra intern be allotted to the rotation. Attentional failures overnight were significantly more common in the traditionally scheduled interns. The findings included no change in global satisfaction, but statistically significant improvements in several aspects of education/training as well as improved satisfaction with amount of leisure time. They do not report much about their assessment methods, but do report a decrease in weekly hours from 86 to 76 and an approximately 99% compliance with the 24+6 rule since implementation. Life after 80 Hours: the Impact of Resident Work Hours Mandates on Trauma and Emergency Experience and Work Effort for Senior Residents and Faculty. They found that work hours were significantly reduced for residents but not faculty. Comparison of burnout among medical residents before and after the implementation of work hours limits. Burnout was statistically unchanged in the post-duty hour period overall (incidence of 41% compared to 49% before duty hours). Those who reported working more than 80 hours per week were more likely to experience burnout (69%) versus those who worked less than 80 hours (38. Implementing duty-hour restrictions without diminishing patient care or education: can it be done. Findings include a significant decrease in the number of patients admitted per call for the senior residents (from 8 to 6). Findings included significantly decreased continuity in well-child visits in the overall means, but not in the means for individual resident years. The nonrandomized observational study is what we focused on and is the comparison of operative experience in the programs that did and did not experiment with change in 2002-2003. According to the analyses conducted by the authors, there was no effect of experimenting with work hour rules on the operative experience of chief residents. When we conducted separate analyses, we found that university and university/community programs that experimented with change had a significant decrease in operative experience for the chief residents. The authors also found that adherence to an 80-hour rule did not relate to operative experience. Findings included that 41% of residents reported that duty hour rules were a moderate or considerable barrier to education. The senior residents were more likely to report the duty hour rules as a significant barrier. Impact of the 80-hour workweek on mortality and morbidity in trauma patients: an analysis of the National Trauma Data Bank. Findings included that the overall mortality for trauma patients decreased in the post-duty hour time period (4. When comparing time periods for university hospitals, the significant decrease persists, but when mortality rates for nonteaching hospitals were analyzed, there was a significant increase in the post-duty hour time period. Hospital wide adverse drug events before and after limiting weekly work hours of medical residents to 80.

This book received a distinguished book award from the Society for Military History. Satterfield is also the author of articles on several topics in military history, including irregular warfare and revolutions in military affairs. He joined the Strategy and Policy Department in 2012 as an Air Force colonel and became the Associate Dean in 2014 after retiring from active duty. His research interests include the transformative role of automation in warfare and the impact of technological change on institutions, society, and military strategy. He spent much of his military career in the high-altitude reconnaissance community as a U-2 pilot enjoying the view over interesting regions of the globe. Navy, is a Naval Aviator commissioned through Aviation Officer Candidate School in May 1989. Commander Sheehan holds degrees from the United States Naval Postgraduate School (Ph. He has logged over 3,500 flight hours and 750 arrested landings on 9 aircraft carriers. He subsequently served as engagement lead for South and East Africa at United States Naval Forces Africa in Naples, Italy. After earning his doctorate, he joined the faculty of the United States Naval War College in October 2013. Captain Soltero has completed multiple overseas deployments to the Mediterranean, Middle East, and Western Pacific and accumulated over 4,000 flight hours. He has taught at Hamilton College and at Kansas State University, where he served as director of the Institute for Military History. He has also been a fellow at the Center for Advanced Study in the Behavioral Sciences at Stanford University. His first book Hammer and Rifle: the Militarization of the Soviet Union, 19261933 (2000) won the Shulman Prize of the Association for Slavic, East European, and Eurasian Studies and the Best First Book Prize of the Historical Society. He has also published A Military History of Russia: From Ivan the Terrible to the War in Chechnya (2006), and the Russian Army in the Great War: the Eastern Front, 1914-1917 (2015). He is the author of several dozen articles and book chapters on Russian / Soviet military history and foreign policy. He holds a Masters in Aeronautical Science from Embry-Riddle University, is a 1998 graduate of the U. Professor Anand Toprani is a specialist in energy geopolitics and great power relations. He was also the recipient of the Smith Richardson Predoctoral Fellowship in International Security Studies from Yale University and the Ernest May Fellowship in History & Policy from Harvard University. His academic work has appeared or been accepted for publication in scholarly journals such as Diplomatic History, the Journal of Strategic Studies, and the Journal of Military History, and he is currently preparing a manuscript on oil and grand strategy for publication. Van Vleck, a 1981 graduate of the United States Merchant Marine Academy, Kings Point, New York. He has 27 years of commercial maritime and Military Sealift Command experience afloat and ashore. Prior to his assignment at the Naval War College, he was assigned as Military Sealift Command Pacific/Naval Fleet Auxiliary Force, West Deputy Director, later restructured as Deputy Commander, Commander Sealift Logistics. Professor Van Vleck reported to the Naval War College in 2005 to lead, manage, and field the Online Professional Military 36 Education continuum for junior officers and enlisted sailors. Before joining the War College faculty in 1998, he taught Chinese history at Harvard and at Wellesley College. He is a graduate of Marine Corps Amphibious Warfare School, Joint Forces Staff College and numerous specialized military skills schools and courses. His past assignments include service as a Rifle Platoon Commander, Rifle Company Executive Officer, and Battalion Liaison Officer with the 3rd Battalion, 3rd Marine Regiment; Series Commander and Company Commander with 2nd and 3rd Recruit Training Battalions, Marine Corps Recruit Depot, San Diego; Rifle Company Commander, Weapons Company Commander, Maritime Special Purpose Force Commander, and Battalion Operations Officer with the 3d Battalion, 5th Marine Regiment; G3 Future Operations Planner with the First Marine Expeditionary Force (Forward); Joint Assessments Branch Chief with U. Special Operations Command; Commanding Officer of the 1st Battalion, 1st Marine Regiment; Future Operations Officer and Special Operations Coordinator with the 1st Marine Division (Forward) / Task Force Leatherneck, Deputy for the Amphibious Warfare Branch, Expeditionary Warfare 37 Division, Office of the Chief of Naval Operations; and Commanding Officer of the Marine Corps Tactics and Operations Group. He has deployed overseas as part of two Unit Deployment Programs, two Marine Expeditionary Unit deployments, and for combat operations in Iraq (2003 and 2006-7) and Afghanistan (2012). Colonel Wonson also served as the first Marine Corps Fellow in the Yale International Security Studies Program.

Thus, uncertainties in emissions projections made 10 years or more in advance-for any hypothesized future achievement-can be considerable. But the process lacks accountability procedures to ensure and demonstrate the achievement of goals (such as tracking progress toward and attaining emissions reductions and achieving planned air quality improvements). Ambient Air Quality Monitoring Air monitoring networks are designed and deployed to address specific objectives. These include providing a database for (1) determining air quality in major metropolitan areas; (2) determining pollution trends; (3) assessing compliance with or progress toward meeting air quality objectives or standards; (4) implementing emergency control plans to prevent or mitigate air pollution episodes; and (5) determining physical changes in the atmosphere 41 Chapter 3: From Regulatory Action to Exposure and Dose (eg, visibility) and in chemical loading of ecosystems through atmospheric deposition. Despite this broad set of objectives, networks have mostly been used to measure air quality to determine (1) maximum concentrations within specified spatial areas, (2) representative concentrations for use in assessing exposures, (3) source-receptor relations (mainly pertaining to the impact of specific sources on local air quality), and (4) background concentrations and temporal trends. Most network monitoring stations for criteria pollutants are located in urban areas that have multiple sources of air pollution and high population densities. Consequently, these stations are useful for assessing population exposures in epidemiologic studies or risk assessments. Some sites (eg, those near roadways at ground level) may be affected by local sources, possibly limiting the spatial representativeness of their data, whereas others (eg, those on tops of buildings) characterize air quality on more regional scales. Continued operation of the extensive criteria pollutant network in the United States is essential for documenting long-term trends and spatial patterns in concentrations of pollutants known to have adverse human health effects. To the extent possible, discontinuities need to be avoided to minimize gaps in data. From an accountability perspective, a long-term trends database with sufficient spatial scope is essential to Table 3. Such speciation data also would play a critical role in future epidemiologic studies directed at component-specific or source-specific analyses of health impact. Data on a variety of these additional pollutant species are currently available from specialized monitoring networks. These networks are much more limited in both temporal and spatial scopes than the criteria pollutant network, which limits their current utility for studies to assess effectiveness of control strategies aimed at specific source types or mitigating secondary pollutant production. In recent years, the air quality management community has focused on the need for data to support the operation and evaluation of photochemical air quality simulation models (such as photochemical models). Typically, such intensive data sets were only available through special field measurement programs. Generally, 2 to 11 sampling sites are active in metropolitan areas with populations greater than 500,000. These samplers are required in each Metropolitan Statistical Area with a population of more than one million. Each site will be equipped with samplers using filters of multiple materials (Teflon, quartz, and nylon) to capture more representative samples of potentially volatile components and for their subsequent laboratory analysis. Specifically, 54 of the speciation sites will sample trends to support ongoing health studies; 44 will sample every three days and 10 will sample daily. All sites were operating as of January 2002 except those marked "Deploy in 2002" or "Deploy in 2003". These more sophisticated data facilitate rethinking the role that monitoring and analysis can play in the air quality management process and provides valuable new tools for accountability assessments. Some specific analyses of interest include (1) tracking ambient effects of changes in emissions for certain chemical species to judge the validity of modeled projections and the effectiveness of corresponding control programs; (2) corroboration of emission inventories; and (3) attributing source contributions to ambient levels of certain chemical species. Source apportionment involves applying multivariate statistical models to time-series records of ambient monitoring data to extract data signals that can be associated with specific sources. Because source apportionment can identify and quantify proportional contributions of specific source types to ambient air quality, it holds promise as a tool for accountability studies as well as source-oriented studies of health effects. To benefit public health, health-based air regulations must reduce not only ambient concentrations but also population exposures and doses. It has long been recognized that ambient air pollution concentrations do not necessarily represent the levels of air pollution to which people are actually exposed. Factors that influence this relation include the spatial and temporal patterns of ambient concentrations, the ways in which these patterns intersect with time-activity patterns of individuals, and sources of pollution in indoor environments where people spend time. Most people in developed western countries spend the majority of their time indoors, where ambient pollutants may penetrate incompletely and where numerous indoor pollution sources exist (Sexton and Ryan 1988). In addition, activity patterns may change in response to improving air quality, with more people going outdoors and engaging in physical activity. Furthermore, the concentration of a chemical biomarker found in an accessible biological sample (eg, blood) may not represent the dose to the critical target tissue (eg, lung epithelial cells) (Xu and Yu 1986; Bennett et al 1996, 1997; Kim and Hu 1998).

From these six cases he concluded that subdural hematomas, intraocular bleeding, and long bone injuries were "essential elements" in cases of identifying battered babies. In 1929, during his tenure at the Babies Hospital of Columbia University of Physicians and Surgeons, he became interested in radiology and developed a pediatric radiology department. Caffey was "perhaps the most eminent of the pioneers in pediatric radiology" and wrote several articles on infant injuries, cited within this article. His career became "increasingly distinguished with recognition in both pediatrics and radiology. A chronic condition is usually long-lasting and does not easily or quickly go away. Caffey hypothesized that subdural hematomas in infants were caused by parental abuse, other researchers recognized the possibility that the subdural hematomas were largely caused by birth trauma. One such study of subdural hematomas in infants found evidence of birth trauma in 25% of the infants. Birth trauma is a general term used to describe a difficult birth event in which an infant may sustain intracranial injury as a result of natural vaginal birth. Gulthkelch studied twenty-three cases of proven or "strongly suspected" cases of battered children under the age of three years. Guthkelch discovered subdural bleeding in thirteen children (57%) with ten of the children exhibiting bilateral bleeding in the brain and six (26%) exhibiting long bone fractures. He also discovered skull fractures in eight cases (33% of total children studied and 61% of those suffering from subdural hematomas) and six of those suffered a subdural hematoma. Caffey further explored the area of child abuse in young children when he released an article in the American Journal of Diseases of Children on whiplash shaking of an infant. Rather, he concluded that "there were several features of the subdural hematomas that indicated they were not caused by direct impact to the head, but caused by indirect accelerationdeceleration forces" as a result of the head whipping back and forth from the infant being shaken. Caffey based this conclusion on a lack of physical evidence of impact in the infants, such as bruises to the face or scalp and skull fractures. Caffey postured that "manual whiplash shaking of infants is a common primary type of trauma in the so-called `battered infant syndrome. The article never addressed the forum or manner in which these "admissions" were obtained nor did it address the exact substance of the alleged admission by the care-provider. From these twenty-seven cases, Caffey extrapolated that this small sample represented "an infinitesimal portion of the uncounted thousands of moderate and unadmitted, undetected and unrecorded whiplash-shakings which probably occur every day in the United States. Caffey proposed that routine eye examinations would provide a "superior screening method" for early detection of whiplash shakings. Caffey pointed out that his suggestion was not based on any type of scientific study. Caffey noted in his article that two of the first six battered babies he studied in 1946 suffered from retinal hemorrhages and subdural hematomas. He also relied on the fact that similar intraocular lesions were reported in two cases by Guthkelch. Caffey further relied on a study by Mushin, who found ocular changes in ten of twelve battered infants. Ommaya was called as a defense expert witness in the highly publicized trial of Louise Woodward, a British au pair accused of killing an 8-month-old baby in her care. This study concluded that: [e]xperimental whiplash injury in rhesus monkeys has demonstrated that experimental cerebral concussion, as well as gross hemorrhages and contusions over the surface of the brain and upper cervical cord, can be produced by rotational displacement of the head on the neck alone, without significant direct head impact. These experimental observations have been studied in the light of published reports of cerebral concussion and other evidence for central nervous system involvement after whiplash injury in man. First, researchers assumed that by extending the impact curve they could accurately predict what threshold level of injury was necessary to produce injury to infant human brains. Second, researchers failed to recognize that some of the monkeys hit their heads on the back of the seat during the acceleration process, potentially causing impact injuries. Caffey admitted that he did not base his assumptions regarding the "battered infant syndrome" upon any actual direct evidence or science. These assumptions underlying the diagnosis make it unreliable, and potentially dangerous, courtroom evidence.