Learning from terrorist mass casualty incidents: a global survey

BACKGROUND

Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses.

METHODS

We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale.

RESULTS

Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement).

CONCLUSION

This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.

Frailty and hospital outcomes within a low socioeconomic population

BACKGROUND

Clinical frailty scales (CFS) predict hospital-related outcomes. Frailty is more common in areas of higher socioeconomic disadvantage, but no studies exclusively report on the impact of CFS on hospital-related outcomes in areas of known socioeconomic disadvantage.

AIMS

To evaluate the association of the CFS with hospital-related outcomes.

DESIGN

Retrospective observational study in a community hospital within a disadvantaged area in Australia (Social Economic Index for Areas = 0.1%).

METHODS

The CFS was used in the emergency department (ED) for people aged ≥ 75 years. Frailty was defined as a score of ≥4. Associations between the CFS and mortality, admission rates, ED presentations and length of stay (LOS) were analysed using regression analyses.

RESULTS

Between 11 July 2017 and 31 March 2018, there were 5151 ED presentations involving 3258 patients aged ≥ 75 years. Frail persons were significantly more likely to be older, represent to the ED and have delirium compared with non-frail persons. CFS was independently associated with 28-day mortality, with odds of mortality increasing by 1.5 times per unit increase in CFS (95% CI: 1.3-1.7). Frail persons with CFS 4-6 were more likely to be admitted (OR: 1.2; 95% CI: 1.0-1.5), have higher geometric mean LOS (1.43; 95% CI 1.15-1.77 days) and higher rates of ED presentations (IRR: 1.12; 95% CI 1.04-1.21) compared with non-frail persons.

CONCLUSIONS

The CFS predicts community hospital-related outcomes in frail persons within a socioeconomic disadvantage area. Future intervention and allocation of resources could consider focusing on CFS 4-6 as a priority for frail persons within a community hospital setting.

Binding of polyphenols to plant cell wall analogues - Part 2: Phenolic acids

Bacterial cellulose and cellulose-pectin composites were used as well-defined model plant cell wall (PCW) systems to study the interaction between phenolic acids (PA) derived from purple carrot juice concentrate (PCJC) and PCW components. Significant PA depletion from solution occurred, with pure cellulose initially (30s-1h) absorbing more than cellulose-pectin composites in the first hour (ca 20% cf 10-15%), but with all composites absorbing similar levels (ca 30%) after several days. Individual PAs bound to different relative extents with caffeic acid>chlorogenic acid>ferulic acid. Extrapolation of data for these model systems to carrot puree suggests that nutritionally-significant amounts of PAs could bind to cell walls, potentially restricting bioavailability in the small intestine and, as a consequence, delivering PAs to the large intestine for fermentation and metabolism by gut bacteria.

A Comparison of Three Minimally Invasive Cardiac Output Devices with Thermodilution in Elective Cardiac Surgery

This study compared the cardiac output responses to haemodynamic interventions as measured by three minimally invasive monitors (Oesophageal Doppler Monitor, the VigileoFlotrac and the LiDCOrapid) to the responses measured concurrently using thermodilution, in cardiac surgical patients. The study also assessed the precision and bias of these monitors in relation to thermodilution measurements.

After a fluid bolus of at least 250 ml, the measured change in cardiac output was different among the devices, showing an increase with thermodilution in 82% of measurements, Oesophageal Doppler Monitor 68%, VigileoFlotrac 57% and LiDCOrapid 41%. When comparing the test devices to thermodilution, the kappa statistic showed at best only fair agreement, Oesophageal Doppler Monitor 0.34, LiDCOrapid 0.28 and VigileoFlotrac -0.03. After vasopressor administration, there was also significant variation in the change in cardiac output measured by the devices. Using Bland-Altman analysis, the precision of the devices in comparison to thermodilution showed minimal bias, but wide limits of agreement with percentage errors of Oesophageal Doppler Monitor 64.5%, VigileoFlotrac 47.6% and LiDCOrapid 54.2%. These findings indicate that these three devices differ in their responses, do not always provide the same information as thermodilution and should not be used interchangeably to track cardiac output changes.

A polymerase chain reaction (PCR) investigation of oral verrucae which contain HPV types 2 and 57 by in situ hybridization

The polymerase chain reaction (PCR) and direct DNA sequencing have been used to identify strain variants of HPV types 2a/57 in formalin-fixed sections of human oral verrucae, where the virus had previously been detected by both immunofluorescence and in situ hybridization. By employing type-specific and type-common PCR primers we show that these lesions contain a mixture of viral DNAs which vary by up to 27% in DNA sequence, in a region where the variation between HPV types 2a and 57 is only 4%. The extra discriminatory power of fluorescent sequencing indicates that the lesions may also contain wild-type HPV2a/57 DNA which could provide a helper function for defective viral DNA molecules or indicate a mosaic origin for the lesions.

Human papillomavirus (HPV) types 2 and 57 in oral verrucae demonstrated by in situ hybridization

Twenty-one cases of verrucae vulgaris (oral warts) were investigated for human papillomavirus (HPV)-group specific antigen by immunocytochemistry and for HPV types 1, 2, 4, 6, 11, 16, 18 and 57 by DNA in situ hybridization with biotinylated probes. Twelve (57%) cases demonstrated the presence of HPV-group specific antigen. Fifteen (71%) cases showed the presence of HPV DNA, 13 of which (87%) demonstrated both HPV types 2 and 57 in the same cells and 2 of which (13%) demonstrated only HPV 2. Six cases were negative for HPV 2 and 57 and all 21 cases (100%) were negative for HPV types 1, 4, 6, 11, 16 and 18. Results indicate the association of a new and as yet unidentified HPV type, closely related to HPV 2 and 57, with oral warts. The identification of both cutaneous type HPV 2 and another type closely related to HPV 2 and 57 in oral verrucae on keratinized and non-keratinized mucosal surfaces indicates the possibility of a latent infection; three patients had a history of warts on their hands, suggesting autoinoculation. This study indicated that future investigations of oral warts, based on a correlation of clinical and histological features with HPV types by DNA in situ hybridization, are called for.

The areca nut chewing habit and oral squamous cell carcinoma in South African Indians. A retrospective study

A retrospective study (1983-1989) of oral squamous carcinomas and concomitant oral habits was undertaken in South African Indians from Natal. Information came from hospital records and interviews with patients, families and friends. There were 143 oral squamous carcinomas; these occurred in a ratio of 1:1,6 for men and women respectively. Squamous carcinomas of the cheek (buccal mucosa, alveolar sulcus and gingiva) occurred most frequently, especially in women (57/89--64%), while in men tongue cancer predominated (22/54--41%). Ninety-three per cent of women (83/87) and 17% of men (9/54) habitually chewed the areca nut. Thirty-nine of 57 women (68%) with cheek cancer and 21/25 (84%) with tongue cancer only chewed the nut (no tobacco, snuff or smoking). Analyses confirmed an association between nut chewing and cheek cancer. The odds ratio (OR) for oral cancer in women 25 years and older who only chewed the nut was 43,9 and the attributable risk (AR) 0,89 (89%). With tobacco the OR increases to 47,42 and the AR to 0,91 (91%). The data showed that the areca nut habit with or without tobacco use is important in the development of oral squamous carcinoma. Elimination of this habit can reduce the risk in these women substantially (89-91%) if all other factors remain the same.

Relationship between the clinical course and HPV typing of recurrent laryngeal papillomatosis. The Red Cross War Memorial Children's Hospital experience 1982-1988

During the period 1982-1988, 20 new cases of laryngeal papillomatosis in children were seen at The Red Cross War Memorial Children's Hospital. HPV typing of biopsy specimens was performed. Their clinical course was reviewed and age at presentation ranged from 1 to 10 years. There was no correlation between age and either aggression or a prolonged clinical course. HPV DNA was identified in all 20 cases (100%). Fifteen (75%) were HPV Type 11 and 5 (25%) were HPV Type 6. There were no mixed infections. HPV Type 6 infection was more clinically aggressive than HPV Type 11 infection. The intensity of the virus signal in the biopsy specimens was not in general indicative of the clinical behavior of the disease, although two children with particularly strong intensity exhibited aggressive disease. It is suggested that identification of HPV type 6 infection has prognostic significance.

Sphenoid sinus disease. Experience at King Edward VIII Hospital, Durban

The increasing use of computed tomography (CT) to evaluate sinus disease in general, appears to have led to an increased pickup rate in isolated sphenoid sinus disease. It is probable that subtle disease of the sphenoid sinus was missed before the use of CT as a diagnostic tool. Six patients with sphenoid sinus disease and related pathological conditions seen during the past 2 years, are reviewed; these included 4 mucoceles, 1 case of aspergillosis and 1 of squamous cell carcinoma. Experience with sphenoid disease, with particular reference to the diagnosis, management and complications of this condition, is discussed.

Human papillomavirus (HPV) DNA in focal epithelial hyperplasia by in situ hybridization

Eighteen cases of focal epithelial hyperplasia (FEH) were investigated for the presence of human papillomavirus (HPV) group specific antigen by immunocytochemistry and HPV types 1, 6, 11, 13, 16, 18 and 32 by DNA in situ hybridization employing biotinylated probes. Seven (39%) specimens demonstrated the presence of HPV group specific antigen. Fifteen (83%) specimens were positive for HPV DNA: 9 (60%) showed HPV 32, of which 6 were on non-keratinized mucosa and 3 on border of keratinized and non-keratinized mucosa; 5 (33%) showed HPV 13, 4 lesions on keratinized mucosa and 1 on non-keratinized mucosa; 1 (7%) specimen on non-keratinized mucosa showed HPV-11 related. Two specimens on different sites from one patient showed the same HPV type and one patient had, in addition to FEH, a squamous papilloma also demonstrating the same HPV type. Results show a specific HPV distribution pattern in the epithelium indicating areas of high viral concentration adjacent to areas of low or no viral concentration. This study also indicates the possibility of tissue-site specificity or a latent infection and the possibility of a yet unidentified HPV type associated with FEH. It is suggested that future monitoring of patients be carried out with special reference to HPV type and anatomical distribution pattern for FEH lesions.

A rapidly fatal palatal ulcer: rhinocerebral mucormycosis

A case of a patient with a palatal ulcer who was in a diabetic ketoacidotic coma is described. This ulcer proved to be the presenting sign of rhinocerebral mucormycosis. The patient had hemifacial swelling, ocular signs, and gross tissue destruction and died less than 4 weeks after she was first seen.

Rathke's cleft cyst: incidental finding in an orthognathic surgery patient

A case of this rare parasellar cyst is reported in a patient presenting for orthognathic surgery. The pathogenesis, clinical, histologic and radiologic features of this cyst are reviewed. This case underscores the necessity of careful evaluation of cephalometric radiographs.

Two cystic lesions with features of both the botryoid odontogenic cyst and the central mucoepidermoid tumour: sialo-odontogenic cyst?

Two cases are reported with identical clinical, radiographical and histological features. These features share a combination of the botryoid odontogenic cyst and a central mucoepidermoid tumour, and it is suggested that the term sialo-odontogenic cyst be adopted for such lesions to avoid confusion and mismanagement.

Primary intraosseous carcinoma involving the anterior mandible

A case is reported of a primary intraosseous carcinoma arising in the anterior mandible with metastasis to the submandibular lymph node in a 69 year-old Caucasian female. The patient initially presented with a burning sensation in the oral cavity in 1983, when no obvious pathological finding was noted; she returned 2 years later with a firm buccal swelling which had increased in size after the extraction of a mobile tooth. The tumour proved to be a primary intraosseous intraosseous carcinoma; extensive investigation did not reveal a primary carcinoma elsewhere.

Human papillomavirus (HPV) in oral squamous cell papillomas

One hundred and forty oral squamous cell papillomas (SCPs) were subjected to immunocytochemical staining for papillomavirus antigen using the immunoperoxidase-PAP method 41% of the oral squamous papillomas showed positive intranuclear staining, 50% were negative and the remaining 9% showed both intranuclear and cytoplasmic staining. In view of these findings it is suggested that a review of the etiology of lesions diagnosed as oral SCPs should be considered.