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Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. Acute ischemic priapism, characterized by little or no cavernous blood flow and abnormal cavernous blood gases (ie, hypoxic, hypercarbic, acidotic) represents a medical emergency and may lead to cavernosal fibrosis and subsequent erectile dysfunction.A comprehensive search of the literature was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. Searches identified 2948 potentially relevant articles, and 2516 of these were excluded at the title or abstract level for not meeting inclusion criteria for any key question. Full texts for the remaining 432 articles were reviewed, and ultimately 137 unique articles were included in the report.This Guideline was developed to inform clinicians on the proper diagnosis and surgical and non-surgical treatment of patients with acute ischemic priapism. This Guideline addresses the role of imaging, adjunctive laboratory testing, early involvement of urologists when presenting to the emergency room, discussion of conservative therapies, enhanced data for patient counseling on risks of erectile dysfunction and surgical complications, specific recommendations on intracavernosal phenylephrine with or without irrigation, the inclusion of novel surgical techniques (eg, tunneling), and early penile prosthesis placement.All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention. Treatment of the acute ischemic patient must be based on patient objectives, available resources, and clinician experience. As such, a single pathway for managing the condition is oversimplified and no longer appropriate. Using a diversified approach, some men may be treated with intracavernosal injections of phenylephrine alone, others with aspiration/irrigation or distal shunting, and some may undergo non-emergent placement of a penile prosthesis.

BACKGROUND: Use of the electronic health record (EHR) is a standard component of modern patient care. Although EHRs have improved since inception, cumbersome workflows decrease the time for residents to spend on clinical and educational activities. This study aims to quantify the time spent interacting with the EHR during a 3‐year emergency medicine (EM) residency. METHODS: System records of time spent actively engaged in EHR use were analyzed for 98 unique EM residents over a period of 5 years from July 2015 to June 2020. Time spent on the EHR was totaled to give a career time, with a “work month” defined as a 4‐week period of 70.5 h per week, based on Accreditation Council for Graduate Medical Education work hour restrictions for EM residents. Engagement in specific activities such as chart review, documentation preparation, and order entry were separately analyzed. RESULTS: Over their 3‐year training, a resident interacted with the EHR for 2,171 continuous hours. This amounts to 30.8 work weeks or 7.7 work months. Chart review was the most time‐intensive activity at 11.42 weeks. Documentation accounted for 9.91 weeks, with an average career total of 7,280 notes created. Additionally, each resident spent 4.57 weeks on order entry, with 46,347 orders entered during training. While the number of charts opened increased after first year of residency, average time spent on each activity per patient decreased. CONCLUSIONS: This unique study quantifies the total time an EM resident spends on the EHR during a 3‐year residency. Use of the EHR accounted for over 7.5 work months or nearly 21% of their training. Residents spend a substantial portion of their training interacting with the EHR and workflow improvements to reduce EHR time are critical for maximizing training time.

An otherwise healthy nine-year-old female who spoke only French presented with abdominal pain, vomiting, intermittent fevers, fatigue, and headache. She then quickly became febrile and altered requiring intubation. When treating a healthy child, the physician may initially develop a differential that includes common illnesses. Yet, as emergency medicine providers, we must be thinking about the “zebras” in order to not miss potentially deadly, curable diseases.

In 1900, the Dreikikir people were a completely naked, forest-dwelling people whose lives revolved around their kin. During the 1890s, Malay and Chinese bird shooters and labour recruiters crossed the mountains and made contact with the northernmost villages. They employed men from these villages to abduct young men from the Dreikikir area as labourers and sometimes took young women as wives to the northern villagers or the coast. Tumam and Ngahmbole are about 20 kilometres south of the crest of the coastal range. Steel tools meant Dreikikir gardens could be cleared into heavier forest, from ridgelines towards watercourses. If one-quarter of the Dreikikir villagers also died in the 1890s, the rapid population growth that began in the 1980s started from a lower base than it otherwise would have. Culturally, the Dreikikir people have made some progress towards modernity, in that most now deny cargo cults have any basis in truth.

Trauma remains a leading cause of mortality in the USA.1 In 2016, the American College of Emergency Physicians (ACEP) and the American College of Surgeons Committee on Trauma were major stakeholders in the National Academy of Science, Engineering and Medicine report that suggested there are up to 30 000 preventable deaths from trauma annually in the USA, many from uncontrolled hemorrhage.2 As the front-line provider, the emergency physician (EP) must receive extensive training in the care of traumatically injured patients. Several procedural interventions, including the performance of an emergency department resuscitative thoracotomy (EDRT), ultrasound, and arterial catheter insertion, are therefore included as part of the model of clinical practice for emergency medicine (EM).3 Resuscitative endovascular balloon occlusion of the aorta (REBOA)4 has emerged as a potential technique for controlling previously lethal truncal hemorrhage in the extremis trauma patient. Advances in ultrasound and catheter technology have simplified placement, decreasing the need for postplacement vascular access site repair. Programs to educate providers in the use of REBOA have emerged, but have been designed exclusively for surgeons with limited ability for EP participation. We strongly think that with appropriate training, EPs can develop the …

In the late 1960s, Harold Brookfield and Doreen Hart were 'startled' by the order of mag- nitude differences in incomes from village cash cropping in different parts of Papua New Guinea (PNG). This paper traces these differences, back into a pre-colonial past and forward to the present and concludes, as Brookfield did in the 1960s, that severe environmental constraints, rather than mar- ket forces, are the primary cause of the pattern of spatial inequalities observable in PNG. Brookfield noted the existence of an 'acute dilemma' in 1960s development funding: should funds be invested where the returns will be highest, or where the need is greatest. This dilemma is as acute today as it was then. However, in the meantime, people from poor places are moving to better-off places, seeking access to markets for their produce and health and education services for their families.

The Magarini Settlement Project in Kenya is typical of many large Third World rural development projects of recent years, not least in its failure to fulfil even minimum goals. First published in 1991, Development in Practice explores the reasons for this projects failure, and looks at the lessons to be learned from this experience for development in general. Challenging many assumptions and approaches, its provocative conclusions will generate much interest amongst development practitioners.

Data from a 1990–96 nationwide study of Papua New Guinea systems – the Mapping Agricultural Systems in PNG study (MASP) – is used to re-examine Brookfield with Hart's (1971) findings on the association between agricultural intensity and population density in Papua New Guinea. A significant association exists between these variables, both within the MASP data, and within the agricultural systems examined by Brookfield with Hart, when the MASP data is applied to them. However, a large amount of variation exists in the data. Systems in which ‘mismatches’ occur between population density and agricultural intensity are found to be associated with small island environments, the substitution of purchased food for locally produced food, migration and high levels of child malnutrition. Child malnutrition may be one of the consequences of a failure to innovate and thus maintain food production. It is argued that Boserup's (1965) model of agricultural transformation and Brookfield's past work on intensification which he now downplays, continue to provide valuable insights into agricultural change in contemporary Papua New Guinea.

Almost four decades since Ester Boserup’s ground-breaking introduction of the concept of intensification in agricultural production, what value does the concept still hold for researchers seeking to account for transformations in smallholder production in the newer nations of the Asia-Pacific region? In countries such as Papua New Guinea, smallholder production is still of paramount significance, in terms both of overall production, and of the proportion of the population dependent upon it. In November 1998 a group of international researchers with a common interest in agricultural transformation came together for a workshop at the Australian National University in Canberra. The meeting was organised partly to consider information from the recently completed Mapping Agricultural Systems in Papua New Guinea project (MASP), and also to reflect on what this information might contribute to the ongoing debate over the process of agricultural intensification. In recognition of his pioneering research on the geography of Papua New Guinea and on broader theories of agricultural intensification, Harold Brookfield was invited to present a keynote address. It is a mark of his exceptional influence as a thinker and his appetite for scholarship that Brookfield should continue to be integral to a debate organised in celebration of his work, and that he remains his own most stringent critic. As one participant observed, if we came to praise Harold Brookfield, he seemed determined to bury his younger self. Drawing on a review of recent international papers on agricultural change, Brookfield presented a sweeping critique of his own early work and of the usefulness of ‘intensification’ in understanding transformations of agriculture. Brookfield’s interest in intensification was initially stimulated by attempts to explain the highly uneven distribution of population in Papua New Guinea. He drew heavily on Ester Boserup’s (1965) revolutionary ideas about the role of population growth on the historical development of agriculture. In Brookfield with Hart (1971), itself a tour de force in the geographical literature, he proposed a process of intensification in Melanesia, defined as ‘essentially the degree to which technology is applied to

Spatial statistical analyses of child anthropometric data were undertaken to assess the influence of systems of subsistence agriculture, in terms of staple foods and cash crops cultivated, on patterns of child growth in Papua New Guinea. These agricultural data explained between a quarter and half of the geographical variation in anthropometric growth indicators. Accounting for differences in altitude, relief and rainfall patterns, though explaining additional geographical variation, did not improve the predictions. Child growth was better in agriculture systems with cassava and sweet potato as staple crops, but worse in systems where banana, sago and taro were staple crops. Both the cultivation of all major cash crops, and sales of fish and food crops improved child growth. More intensive agricultural systems were associated with larger children indicating that the nutritional status of children benefited from intensification as well as from the introduction of cash crops into traditional subsistence sys...

Anthropometric data from the 1982/83 Papua New Guinea (PNG) National Nutrition Survey were analysed to identify geographical patterns of child growth and investigate their relation to a wide range of environmental, dietary and socio-economic variables. Standardized growth scores for length-for-age (LAZ), weight-for-age (WAZ) and weight-for-length (WLZ) were calculated based on an internal PNG growth reference. Hierarchical Bayesian spatial models based on conditional autoregressive (CAR) priors were subsequently used to model spatial patterns in scores and their relation to different sets of covariates. The geographical differences were bigger for linear growth than for increases in weight. Growth was most reduced in parts of Milne Bay Province, Madang Province, the Torricelli/Prinz Alexander Ranges, and in the area occupied by Angan people. Socio-economic status was the most important factor determining variation in growth within populations. Differences in diet and, to a lesser extent, the physical environment were the main determining factor of differences among populations. Covariate adjustment accounted for more spatially structured variation in LAZ and WAZ than in WLZ. All variables indicating higher socio-economic status were correlated with better growth, as was a high consumption of imported and local high quality foods such as cereals, legumes, tinned fish/meat or fresh fish. This indicates that nutritional interventions in PNG should aim at promoting the consumption of such high energy and high protein foods as well as strengthening the general economic base of rural populations.

The author discusses a number of recent migrations in Papua New Guinea, recorded in ethnographic and linguistic data. They offer interesting case studies of how groups of different ethnolinguistic background can intermix, and how small numbers of migrants can grow into large numbers of settlers, if and when they reach fertile terrain. Keywords: indigenous peoples; Holocene; Oceania, New Guinea

Papua New Guinea offers an opportunity to study the Intensification and sustainability of village agriculture under the pressures of demographic change and social and economic development. This paper describes research investigating the process of agricultural intensification. Theories of intensification suggest the process is associated with increasing population, or with increased production for social purposes, or both. Intensification brings about changes that must be overcome by innovation. Innovation may demand temporary or permanent increases in labour, and changes in the social relations of production, but intensification without innovation is likely to lead to land degradation. A tension exists between the environment, social organization, production and the adoption of innovative techniques, which may determine whether intensification is sustainable. The research is presently identifying, mapping and systematically describing agricultural systems. Preliminary results suggest intensification is positively associated with altitude, sweet potato (lpomoea batatas) cultivation, and with a number of innovative agronomic techniques.

Southern Highlands Province (SHP) is located almost in the middle of the mainland of Papua New Guinea. It is on the south-western end of the Highlands Highway and subject to the vicissitudes of landslides, bridge failures, potholes and criminal activity along the whole 600 km of the highway to Lae. The province is 25,698 km in area and is the eighth largest province in terms of land area in Papua New Guinea. Land in the SHP ranges from below 600 m to over 2800 m in altitude. Land above 2800 m is not used for agriculture in Papua New Guinea and is usually not permanently occupied, although it is used extensively for hunting and harvesting pandanus, an important seasonal food source. Around 14 per cent of SHP is below 600 m altitude and just over five per cent is above 2800 m (Table 3.1).

In Papua New Guinea the shrub Piper aduncum (L) has invaded the humid lowlands and locally dominates the fallow vegetation, mainly in Morobe and Madang Provinces. It is not known when or how Piper aduncum arrived in Papua New Guinea, but it is likely that seeds were introduced by accident from Papua (Irian Jaya) or perhaps from Fiji, where it was introduced in the 1920s (Hartemink, 2001). The botanist Mary Clemens first observed Piper aduncum (hereafter referred to as piper) in 1935 near the Heldsbach mission station near Finschhafen in Morobe Province. It was not very widespread by the early 1970s and is not listed in the standard text

Summary Solutions to the problem of equitable spatial distribution of the benefits of social, economic and political change will have incorporated within them a better understanding of the spatial diffusion process. Diffusion and information flow are directly related. This paper examines the operation of formal and informal information systems in rural areas of Papua New Guinea and suggests ways in which the flow of information into rural villages may be made more effective.

The traditional shifting cultivation system in the lowlands of Papua New Guinea consists of mixed food crop gardens in which yams (Dioscorea spp.), bananas, taro (Colocasia esculenta) and sugarcane predominate. The cropping cycle is usually for 18 months, followed by a fallow cycle of up to 30 years. During the cropping cycle, two species of fruit trees, Pometia pinnata and Artocarpus altilis are also planted, the leaves of the former also being used as a mulch and green manure in yam cultivation. Fallow succession follows rather systematic patterns about which farmers have a thorough understanding. Robusta coffee, a cash-crop component, has been added to the system in some areas since the late 1950s. It is usually grown in permanent blocks, but is interplanted with Leucaena as shade. Food crops are planted in the establishment stage, bananas and Xantohosoma being retained even in mature coffee gardens. The system seems to be a potentially promising one. But very little quantitative information is available on the production and performance of the system and practically no systematic research has been undertaken. Since the Papua New Guinea fallow gardeners are willing to accept innovations, it will be appropriate and timely to undertake serious studies so that the system can be improved. A few items that merit immediate research attention are indicated.

(1983). A bomb or a bullet or the bloody flux? Population change in the Aitape Inland, Papua New Guinea, 1941–1945. The Journal of Pacific History: Vol. 18, No. 4, pp. 218-235.

A short but intensive survey of subsistence gardens and child malnutrition revealed an area of high population densities where food shortages are occurring in association with extremely low yields from the staple sweet potato gardens. Child malnourishment is associated with larger households and with households with less garden area per person. The major responsibility for gardening falls upon the women who are incapable of maintaining adequate food production in the face of low and declining yields.

The available climatological record for Papua New Guinea is studied. Rainfall records are longer, more numerous, and less broken than those for temperature, and frost is clearly associated with periods of low rainfall. Longer records from lowland sta- tions are examined against shorter highland records in order to extrapolate the highland data into the past. A method is devised for identifying anomalously 'dry' years in PNG and is compared to four different measures of the Southern Oscillation. Probable frost-event years are identified from patched-together records of extreme screen minimum temperatures and are compared to the 'dry-year' index.

This paper brings together some of the main conclusions from the other papers in the collection. The debate about 'famine relief is re-examined in the context of changing attitudes, and it is unlikely that the over-reaction of 1972 would be repeated; indeed, new conditions may make it much more difficult for distressed mountain people to obtain aid in the future. Second, it is then argued that exceptional events-not all of which arise from frost and/or drought-need to be clearly separated from the lesser events, which are more frequent. The highland production and social systems in Papua New Guinea are well adapted to the latter, but major events create subsistence crises. In order to be prepared for future crises, a monitoring programme is suggested, together with close attention to the greatly improved reporting on the ENSO phenomenon. The question of'global warming' and its effects is then briefly reviewed, and it is argued that whatever amelioration might occur at higher altitudes could well be offset by extreme events, at least in the short term. The paper concludes with some discussion of frost, and cultural adaptations to frost, in other montane areas of the low-latitude tropics, particularly in South America. Much less is known about the effects of frost in Africa. There is little literature on the fre- quency and variability over time of the frost hazard in either area, and it is suggested that information from the three long-settled highland areas of the low-latitude tropics needs to be brought together in a comparative framework.

This paper introduces the New Guinea highland environment, settlement history, and agriculture. The conditions conducive to frost formation in the high valleys are then analysed, both in regard to the meteorological environment, and to the terrain and ground cover. Due to the normal presence of convectional conditions, the highlands remain free of frost most of the time up to alti- tudes above those in other tropical regions. From time to time, however, subsidence becomes established, creating the conditions for both drought and frost. There follows a brief review of the El Nifio/Southern Oscillation phenomenon, as a major force in creating the conditions for periodic severe frost of wide extent in the mountains. Finally, the hazards of frost and drought are put in perspec- tive with that of excessive rain.