Pseudomonas frederiksbergensis strain SI8 is a psychrotrophic bacterium capable of efficient aerobic degradation of aromatic hydrocarbons. The draft genome of P. frederiksbergensis SI8 is 6.57 Mb in size, with 5,904 coding sequences and 60.5% G+C content. The isopropylbenzene (cumene) degradation pathway is predicted to be present in P. frederiksbergensis SI8.
Previously, extracellular vesicle production in Gram-positive bacteria
was dismissed due to the absence of an outer membrane, where Gram-negative
vesicles originate, and the difficulty in envisioning how such a process could
occur through the cell wall. However, recent work has shown that Gram-positive
bacteria produce extracellular vesicles and that the vesicles are biologically
active. In this study, we show that Bacillus subtilis produces
extracellular vesicles similar in size and morphology to other bacteria,
characterized vesicles using a variety of techniques, provide evidence that
these vesicles are actively produced by cells, show differences in vesicle
production between strains, and identified a mechanism for such differences
based on vesicle disruption. We found that in wild strains of B.
subtilis, surfactin disrupted vesicles while in laboratory strains
harboring a mutation in the gene sfp, vesicles accumulated in
the culture supernatant. Surfactin not only lysed B. subtilis
vesicles, but also vesicles from Bacillus anthracis, indicating
a mechanism that crossed species boundaries. To our knowledge, this is the first
time a gene and a mechanism has been identified in the active disruption of
extracellular vesicles and subsequent release of vesicular cargo in
Gram-positive bacteria. We also identify a new mechanism of action for
To describe the development and evaluation of an observation system to assess the process of mother-infant feeding interaction relevant to infant neuro-behavioral regulation: the Mother-Infant Feeding Tool.
Special care nursery just before discharge and in the home at 1 and 4 months postterm age.
Forty-three mother-infant dyads.
Videotaped feeding interactions were examined to assess regulatory processes of mother-infant interaction. Data were collected at three times over the infant’s first 4 postterm months: before the infant’s discharge from the special care nursery and at 1 and 4 months postterm age in the home.
Across all three data points mothers rarely talked to their infants.
Further testing is needed, but the Mother-Infant Feeding Tool shows promise in assessing very early mother-infant feeding interactions.
preterm infant feeding; mother-infant interaction; preterm infants
To describe maternal behaviors occurring before infant regulated or dysregulated behavior at three times in early infancy and examine behavioral patterns over time with their prematurely born infants.
Method & Design
Video-recordings of 37 dyads were coded on infant regulated and dysregulated behaviors following maternal soothing and stimulating behaviors.
At each time, infants showed more regulation after maternal soothing than after maternal stimulating. Further study is merited.
Knowing infant regulation and dysregulation following categories of maternal behavior could help mothers anticipate infant regulatory or dysregulatory behavior in response to their own behavior and identify supportive caregiving strategies.
Feeding Behaviors; Lag Analysis; Sequential Analysis
Coagulopathy is present in 25-38% of trauma patients upon arrival to the hospital and these patients are four times more likely to die than trauma patients without coagulopathy. Recently, a high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBCs) has been shown to decrease mortality in massively transfused trauma patients. Therefore, we hypothesized that patients with elevated INR on arrival to the hospital may benefit more from transfusion with a high ratio of FFP:PRBC than those with a lower INR.
Retrospective multicenter cohort study of 437 massively transfused trauma patients. To determine if the effect of the ratio of FFP:PRBC on death at 24 hours is modified by a patient’s admission INR on arrival to the hospital we used contingency tables and logistic regression.
Trauma patients who arrived to the hospital with an elevated INR had a greater risk of death than those with a lower INR. However, as the ratio of FFP:PRBC transfused increased, mortality decreased similarly between the INR quartiles.
The mortality benefit from a high FFP:PRBC ratio is similar for all massively transfused trauma patients. This is contrary to the current belief that only coagulopathic trauma patients benefit from a high FFP:PRBC ratio. Furthermore, it is unnecessary to determine whether INR is elevated before transfusing a high FFP:PRBC ratio. Future studies are needed to determine the mechanism by which a high FFP:PRBC ratio decreases mortality in all massively transfused trauma patients.
Platelets play a central role in hemostasis after trauma. However, the platelet count of most trauma patients does not fall below the normal range (100-450 ×109/L), and as a result, admission platelet count has not been adequately investigated as a predictor of outcome. The purpose of this study was to examine the relationship between admission platelet count and outcomes after trauma.
Retrospective cohort study of 389 massively transfused trauma patients. Regression methods and the Kruskal-Wallis test were used to test the association between admission platelet count and 24 hour mortality and units of PRBCs transfused.
For every 50 × 109/L increase in admission platelet count, the odds of death decreased 17% at 6 hours (p=0.03, 95% CI 0.70-0.99) and 14% at 24 hours (p=0.02, 95% CI 0.75-0.98). The probability of death at 24 hours decreased with increasing platelet count. For every 50 × 109/L increase in platelet count, patients received 0.7 fewer units of blood within the first 6 hours (p=0.01, 95% CI -1.3- -0.14) and one less unit of blood within the first 24 hours (p=0.002, 95% CI -1.6 - -0.36). The mean number of units of PRBCs transfused within the first 6 and 24 hours decreased with increasing platelet count.
Admission platelet count was inversely correlated with 24 hour mortality and transfusion of PRBCs. A normal platelet count may be insufficient after severe trauma, and as a result, these patients may benefit from a lower platelet transfusion threshold. Future studies of platelet number and function after injury are needed.
The green bottle fly maggot, Lucilia sericata, is a species with importance in medicine, agriculture and forensics. Improved understanding of this species’ biology is of great potential benefit to many research communities. MicroRNAs (miRNA) are a short non-protein coding regulatory RNA, which directly regulate a host of protein coding genes at the translational level. They have been shown to have developmental and tissue specific distributions where they impact directly on gene regulation. In order to improve understanding of the biology of L. sericata maggots we have performed small RNA-sequencing of their secretions and tissue at different developmental stages.
We have successfully isolated RNA from the secretions of L. sericata maggots. Illumina small RNA-sequencing of these secretions and the three tissues (crop, salivary gland, gut) revealed that the most common small RNA fragments were derived from ribosomal RNA and transfer RNAs of both insect and bacterial origins. These RNA fragments were highly specific, with the most common tRNAs, such as GlyGCC, predominantly represented by reads derived from the 5’ end of the mature maggot tRNA. Each library also had a unique profile of miRNAs with a high abundance of miR-10-5p in the maggot secretions and gut and miR-8 in the food storage organ the crop and salivary glands. The pattern of small RNAs in the bioactive maggot secretions suggests they originate from a combination of saliva, foregut and hindgut tissues. Droplet digital RT-PCR validation of the RNA-sequencing data shows that not only are there differences in the tissue profiles for miRNAs and small RNA fragments but that these are also modulated through developmental stages of the insect.
We have identified the small-RNAome of the medicinal maggots L. sericata and shown that there are distinct subsets of miRNAs expressed in specific tissues that also alter during the development of the insect. Furthermore there are very specific RNA fragments derived from other non-coding RNAs present in tissues and in the secretions. This new knowledge has applicability in diverse research fields including wound healing, agriculture and forensics.
Rhodovulum sp. strain NI22 is a hydrocarbon-degrading member of the genus Rhodovulum. The draft genome of Rhodovulum sp. NI22 is 3.8 Mb in size, with 3,756 coding sequences and 64.4% G+C content. The catechol and gentisate pathways for naphthalene degradation are predicted to be present in Rhodovulum sp. NI22.
We report a magneto-fluorescent theranostic nanocomplex targeted to neutrophil gelatinase associated lipocalin (NGAL) for imaging and therapy of pancreatic cancer.
Materials and Methods
Gold nanoshells resonant at 810 nm were encapsulated in silica epilayers doped with iron oxide and the NIR dye ICG, resulting in theranostic gold nanoshells (TGNS), which were subsequently conjugated with antibodies targeting NGAL in AsPC-1-derived xenografts in nude mice.
AntiNGAL-conjugated TGNS specifically targeted pancreatic cancer cells in vitro and in vivo providing contrast for both NIR fluorescence and T2 weighted MR imaging with higher tumor contrast than can be obtained using long-circulating but non-targeted PEGylated nanoparticles. The nanocomplexes also enabled highly specific cancer cell death via NIR photothermal therapy in vitro.
Theranostic gold nanoshells with embedded NIR and MR contrasts can be specifically targeted to pancreatic cancer cells with expression of early disease marker NGAL, and enable molecularly targeted imaging and photothermal therapy.
nanoshells; optical imaging; photothermal; pancreatic cancer; noninvasive imaging; MRI
Pseudomonas aeruginosa ATCC 33988 is highly adapted to grow in jet and diesel fuel, with a defined regulation of adaptive genes and metabolization of n-alkanes. The draft genome of strain ATCC 33988 is 6.4 Mb in size, with 5,975 coding sequences and 66.3% G+C content, and it is highly similar to that of the clinical strain P. aeruginosa PAO1.
Suboptimal management of Parkinson's disease (PD) medication in hospital may lead to avoidable complications. We introduced an in-patient PD unit for those admitted urgently with general medical problems. We explored the effect of the unit on medication management, length of stay and patient experience.
We conducted a single-center prospective feasibility study. The unit's core features were defined following consultation with patients and professionals: specially trained staff, ready availability of PD drugs, guidelines, and care led by a geriatrician with specialty PD training. Mandatory staff training comprised four 1 h sessions: PD symptoms; medications; therapy; communication and swallowing. Most medication was prescribed using an electronic Prescribing and Administration system (iSOFT) which provided accurate data on time of administration. We compared patient outcomes before and after introduction of the unit.
The general ward care (n = 20) and the Specialist Parkinson's Unit care (n = 24) groups had similar baseline characteristics. On the specialist unit: less Parkinson's medication was omitted (13% vs 20%, p < 0.001); of the medication that was given, more was given on time (64% vs 50%, p < 0.001); median length of stay was shorter (9 days vs 13 days, p = 0.043) and patients' experience of care was better (p = 0.01).
If replicated and generalizable to other hospitals, reductions in length of stay would lead to significant cost savings. The apparent improved outcomes with Parkinson's unit care merit further investigation. We hope to test the hypothesis that specialized units are cost-effective and improve patient care using a randomized controlled trial design.
•We prospectively evaluated a specialist Parkinson's unit for in-patients.•Patients who received Parkinson's unit care had shorter length of stay.•Patients who received Parkinson's unit care had better experience of care.•More Parkinson's medication was given on time.•Less Parkinson's medication was omitted.
Parkinson's disease; Hospitalization; Errors; Medication; Length of stay; Specialist unit
Many intracellular bacterial pathogens naturally release membrane vesicles (MVs) under a variety of growth environments. For pathogenic bacteria there are strong evidences that released MVs are a delivery mechanism for the release of immunologically active molecules that contribute to virulence. Identification of membrane vesicle-associated proteins that can act as immunological modulators is crucial for opening up new horizons for understanding the pathogenesis of certain bacteria and for developing novel vaccines. In this protocol, we provide all the details for isolating MVs secreted by either mycobacteria or Gram-positive bacteria and for the subsequent identification of the protein content of the MVs by mass spectrometry. The protocol is adapted from Gram-negative bacteria and involves four main steps: (1) isolation of MVs from the culture media; (2) purification of MVs by density gradient ultrucentrifugation; (3) acetone precipitation of the MVs protein content and in-solution trypsin digestion and (4) mass spectrometry analysis of the generated peptides and protein identification. Our modifications are:•Growing Mycobacteria in a chemically defined media to reduce the number of unrelated bacterial components in the supernatant.•The use of an ultrafiltration system, which allows concentrating larger volumes.•In solution digestion of proteins followed by peptides purification by ziptip.
Gram positive bacteria; Membrane vesicles; Protein content; Vesicles isolation
Plasmon-resonant nanoparticle complexes show highly promising potential for light-triggered, remote-controlled delivery of oligonucleotides on demand, for research and therapeutic purposes. Here we investigate the light-triggered release of DNA from two types of nanoparticle substrates: Au nanoshells and Au nanorods. Both light-triggered and thermally induced release are distinctly observable from nanoshell-based complexes, with light-triggered release occurring at an ambient solution temperature well below the DNA melting temperature. Surprisingly, no analogous measureable release was observable from nanorod-based complexes below the DNA melting temperature. These results suggest that a nonthermal mechanism may play a role in plasmon resonant, light-triggered DNA release.
Plasmon; nanoshell; nanorod; hot electron; photoinduced electron transfer; enhanced local field; photothermal; DNA
Adaptive maternal feeding behaviors are sensitive and responsive to the infant and support the infant’s participation in feeding. Adaptive infant behaviors help the infant to participate in the feeding within developmental capacities and to interact in a positive manner with the mother. Therefore, the purpose of this study was to explore the contribution of the adaptiveness of early maternal feeding behavior to the adaptiveness of later infant feeding behavior, accounting for maternal depressive symptoms and neonatal health. Thirty-seven premature infants and their mothers were assessed in the special care nursery just before discharge and in their homes at 4 months postterm age. The adaptive quality of maternal and infant behavior was assessed using the Parent-Child Early Relational Assessment. Maternal depressive symptoms were assessed using the Center for Epidemiological Study–Depression Scale. Infant health was assessed using the Neonatal Health Index. Linear regression analyses revealed that the adaptiveness of maternal feeding behavior before special care nursery discharge contributed significantly to the adaptiveness of infant feeding behavior at 4 months postterm age, accounting for neonatal health and maternal depressive symptoms. Although further study of the relationship is needed, findings support development of interventions to enhance the adaptiveness of mothers’ early feeding behaviors.
Mother-infant interaction; Infant feeding; Infant behavior; Mother behavior; Infant; Premature
Diet and lifestyle play a significant role in the development of colorectal cancer, but the full complexity of the association is not yet understood. Dietary pattern analysis is an important new technique that may help to elucidate the relationship. This review examines the most common techniques for extrapolating dietary patterns and reviews dietary pattern/colorectal cancer studies published between September 2011 and August 2012. The studies reviewed are consistent with prior research but include a more diverse international population. Results from investigations using a priori dietary patterns (i.e., diet quality scores) and a posteriori methods, which identify existing eating patterns (i.e., principal component analysis), continue to support the benefits of a plant-based diet with some dairy as a means to lower the risk of colorectal cancer, whereas a diet high in meats, refined grains, and added sugar appears to increase risk. The association between colorectal cancer and alcohol remains unclear.
Colorectal cancer; Dietary patterns; Factor analysis; Principal component analysis; Cluster analysis; Reduced rank regression; Total diet quality; Diet score
The standard of care in Locally-Advanced Non-Small Cell Lung Cancer (LA-NSCLC) is chemotherapy and radiation; however, Radiation-Induced Lung Injury (RILI), which may be prevented by the anti-inflammatory and anti-oxidant properties of Flaxseed (FS), impedes its maximum benefit.
Materials and Methods
Patients with LA-NSCLC requiring definitive RT were randomized to one FS or control muffin daily from start to 2 weeks after RT. Blood and urine were collected to quantify plasma FS metabolites, Enterodione (ED) and Enterolactone (EL), and urinary oxidative stress biomarkers, 8, 12-iso-iPF2a-VI (isoprostane) and 8-oxo-7,8-dihydro-2′deoxyguanosine (8-oxo-dGuo). Tolerability was defined as consuming ≥ 75% of the intended muffins and no ≥ grade 3 gastrointestinal toxicities.
Fourteen patients (control,7; FS,7) were enrolled. The tolerability rates were 42.9 versus 71.4% (p=0.59) for FS and control, respectively. Mean percentages of intended number of muffins consumed were 37% versus 73% (p=0.12). ED and EL increased at onset of FS and decreased with discontinuation, confirming bioavailability. Isoprostane and 8-oxo-dGuo were detectable. There was a trend towards decreased rates of pneumonitis in FS.
This is the first study to report FS bioavailability and quantify oxidative stress markers in NSCLC patients. FS in the administered muffin formulation did not meet tolerability criteria. Given the promising mechanism of FS as a radioprotectant, further investigations should focus on the optimal method for administration of FS.
Flaxseed; Lignan; Radiation; Isoprostane; 8-oxo dGuo; Non-small cell lung cancer; Radiation induced lung injury; RILI; Pneumonitis; Fibrosis; Esophagitis
The purpose of the study was to describe changes in a mother’s early internal working model (IWM) of infant feeding.
Design & Methods
In this qualitative study, 12 maternal responses to the semi-structured IWM interview were audio-recorded; once in the neonatal intensive care unit (NICU) after infants began oral feeding and once 2 weeks post-discharge. Interviews were analyzed using directed content analysis.
A change between mothers’ early and later nipple feeding experiences was identified.
Nurses and other clinicians can help mothers understand the infant’s behaviors and focus on the infant’s nutritional intake while simultaneously developing a relationship with the infant.
Infant feeding; infant, premature; models. psychological; models, theoretical; mother-infant relations; qualitative research
To extend the psychometric study of the Cognitive Change Checklist (3CL) by examining the reliability, factor structure, and external correlates of 3CL informant and self-report ratings in community dwelling adults. We also conducted ROC analyses examining rating scores from this normative sample with those of clinical samples.
Scale reliability and validity study.
Six hundred and seventy-nine older adults.
The pattern of scale relationships within and across versions, and the failure to find associations with age and education, were consistent with findings in clinic samples reported previously. Factor analysis replicated the four-factor structure of the informant ratings. All informant version scales significantly discriminated amnestic Mild Cognitive Impairment (MCI) cases and patients with mild dementia from normals.
These findings provide support for the use of the checklist as a clinical tool to facilitate identification of cases of MCI and early dementia.
rating scales; informant; activities of daily living; cognition; aging; cognitive decline; mild cognitive impairment; dementia
Bordetella avium continues to be an economic issue in the turkey industry as the causative agent of bordetellosis, which often leads to serious secondary infections. This study presents a broad characterization of the antibiotic resistance patterns in this diverse collection of B. avium strains collected over the past thirty years. In addition, the plasmid basis for the antibiotic resistance was characterized. The antibiotic resistance pattern allowed the development of a novel enrichment culture method that was subsequently employed to gather new isolates from diseased turkeys and a healthy sawhet owl. While a healthy turkey flock was shown to seroconvert by four weeks-of-age, attempts to culture B. avium from healthy turkey poults were unsuccessful. Western blot of B. avium strains using pooled serum from diseased and healthy commercial turkey flocks revealed both antigenic similarities and differences between strains. In sum, the work documents the continued exposure of commercial turkey flocks to B. avium and the need for development of an effective, inexpensive vaccine to control spread of the disease.
Bordetellosis incidence; serology; antibiotic resistance; Bordetella avium; poultry
To examine the hospitalization rate and mortality associated with forced mass transfer of nursing home residents with the highest levels of functional impairment.
Retrospective cohort study.
119 Texas and Louisiana nursing homes that were identified as being “at-risk” for evacuation for Hurricane Gustav.
6,464 long-stay residents residing in “at-risk” nursing homes for at least three consecutive months prior to landfall of Hurricane Gustav.
Using Medicare claims and instrumental variable analysis, we compared the differential mortality (death at 30 and 90 days) and hospitalization rates (at 30 and 90 days) of the most functionally-impaired long-stay residents who evacuated for Hurricane Gustav relative to the most functionally impaired residents who did not evacuate.
Results suggest that the effect of evacuation was associated with an 8% increase in hospitalizations by 30 and 90 days for the most functionally impaired residents. Evacuation was not significantly related to mortality for the most functionally impaired residents.
Our results suggest that the most functionally impaired nursing home residents experience an increase in hospitalizations but not mortality as a consequence of forced mass transfer. With the inevitability of nursing home evacuations for many different reasons, harm mitigation strategies focused on the most impaired residents are needed.
Nursing Home; Transitions; Hurricane
The study was designed to examine the 30- and 90-day mortality and hospitalization rates among nursing facility (NF) residents in the affected areas of Louisiana and Mississippi following Hurricane Katrina and to assess the rate of significant posthurricane functional decline.
A secondary data analysis was conducted using Medicare claims merged with NF resident data from the Minimum Data Set. Thirty- and 90-day mortality and hospitalization rates for long-stay (>90 days) residents residing in 141 at-risk NFs during Hurricane Katrina were compared to rates for residents residing at the same facilities during the same time period in prior nonhurricane years (2003 and 2004). Functional decline was assessed as a 4+ drop in function using a 28-point Minimum Data Set Activities of Daily Living Scale.
There were statistically significant differences (all P<.0001) in mortality, hospitalization, and functional decline among residents exposed to Hurricane Katrina. At 30 days, the mortality rate was 3.88% among the exposed cohort compared with 2.10% and 2.28% for residents in 2003 and 2004, respectively. The 90-day mortality rate was 9.27% compared with 6.71% and 6.31%, respectively. These mortality differences translated into an additional 148 deaths at 30 days and 230 deaths at 90 days. The 30-day hospitalization rate was 9.87% compared with 7.21% and 7.53%, respectively. The 90-day hospitalization rate was 20.39% compared with 18.61% and 17.82%, respectively. Finally, the rate of significant functional decline among survivors was 6.77% compared with 5.81% in 2003 and 5.10% in 2004.
NF residents experienced a significant increase in mortality, hospitalization, and functional decline during Hurricane Katrina.
nursing home; long term care; disaster preparedness; hurricanes; emergency management
In response to the hurricane-related deaths of nursing home residents, there has been a steady increase in the number of facilities that evacuate under storm threat. This study examined the effects of evacuation during Hurricane Gustav on residents who were cognitively impaired.
Nursing homes in counties located in the path of Hurricane Gustav were identified. The Minimum Data Set resident assessment files were merged with the Centers for Medicare enrollment file to determine date of death for residents in identified facilities. Difference-in-differences analyses were conducted adjusting for residents’ demographic characteristics and acuity.
The dataset included 21,255 residents living in 119 at risk nursing homes over three years of observation. Relative to the two years before the storm, there was a 2.8 percent increase in death at 30 days and a 3.9 percent increase in death at 90 days for residents with severe dementia who evacuated for Hurricane Gustav, controlling for resident demographics and acuity.
The findings of this research reveal the deleterious effects of evacuation on residents with severe dementia. Interventions need to be developed and tested to determine the best methods for protecting this at risk population when there are no other options than to evacuate the facility.
Alzheimer’s disease; disaster; nursing homes; evacuation; hurricane; mortality
Acute lung injury and the acute respiratory distress syndrome (ALI/ARDS) are characterized by pulmonary oedema, measured as extravascular lung water (EVLW). The chest radiograph (CXR) can potentially estimate the quantity of lung oedema while the transpulmonary thermodilution method measures the amount of EVLW. This study was designed to determine whether EVLW as estimated by a CXR score predicts EVLW measured by the thermodilution method and whether changes in EVLW by either approach predict mortality in ALI/ARDS.
Clinical data were collected within 48 hours of ALI/ARDS diagnosis and daily up to 14 days on 59 patients with ALI/ARDS. Two clinicians scored each CXR for the degree of pulmonary oedema, using a validated method. EVLW indexed to body weight was measured using the single indicator transpulmonary thermodilution technique.
The CXR score had a modest, positive correlation with the EVLWI measurements (r = 0.35, p < 0.001). There was a 1.6 ml/kg increase in EVLWI per 10-point increase in the CXR score (p < 0.001, 95% confidence interval 0.92-2.35). The sensitivity of a high CXR score for predicting a high EVLWI was 93%; similarly the negative predictive value was high at 94%; the specificity (51%) and positive predictive value (50%) were lower. The CXR scores did not predict mortality but the EVLW thermodilution did predict mortality.
EVLW measured by CXR was modestly correlated with thermodilution measured EVLW. Unlike CXR findings, transpulmonary thermodilution EVLWI measurements over time predicted mortality in patients with ALI/ARDS.
Extravascular lung water; Chest radiograph; Acute lung injury; Acute respiratory distress syndrome
To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf-hurricanes
Observational study using Medicare claims, and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 non-hurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days.
Among 36,389 NH residents exposed to a storm, the 30 and 90 day mortality/hospitalization rates increased compared to non-hurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7-5.3% and hospitalization by 1.8-8.3%, independent of other factors.
Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.