Predatory fish invasion induces within and across ecosystem effects in Yellowstone National Park

Predatory fish introduction can cause cascading changes within recipient freshwater ecosystems. Linkages to avian and terrestrial food webs may occur, but effects are thought to attenuate across ecosystem boundaries. Using data spanning more than four decades (1972-2017), we demonstrate that lake trout invasion of Yellowstone Lake added a novel, piscivorous trophic level resulting in a precipitous decline of prey fish, including Yellowstone cutthroat trout. Plankton assemblages within the lake were altered, and nutrient transport to tributary streams was reduced. Effects across the aquatic-terrestrial ecosystem boundary remained strong (log response ratio ≤ 1.07) as grizzly bears and black bears necessarily sought alternative foods. Nest density and success of ospreys greatly declined. Bald eagles shifted their diet to compensate for the cutthroat trout loss. These interactions across multiple trophic levels both within and outside of the invaded lake highlight the potential substantial influence of an introduced predatory fish on otherwise pristine ecosystems.

MEDULLARY THYROID CANCER THAT STAINS NEGATIVE FOR CA 19-9 HAS DECREASED METASTATIC POTENTIAL

OBJECTIVE

Presently, no clinical tools are available to diagnose the metastatic potential of medullary thyroid cancer (MTC) at disease presentation. Surveillance with calcitonin (Ct) and carcinoembryonic antigen (CEA) is currently recommended for the observation and diagnosis of metastatic disease after initial treatment of MTC. Recently, carbohydrate antigen (CA)19-9 staining has been associated with aggressive forms of MTC and metastatic spread. This pilot study explored whether positive CA19-9 staining of MTC tissue is associated with its metastatic potential.

METHODS

Sixteen cases of MTC were identified, and tissue specimens were immunostained for CA 19-9 and other MTC tumor markers. Clinical information about patients' MTC was collected through a retrospective chart review.

RESULTS

Overall, 63% of the specimens stained positive for CA19-9. The median size of positively staining specimens was 2.6 cm (interquartile range [IQR] 1.2-3.2) compared to 0.7 cm (0.5-1.2) in negatively staining MTC specimens (P = .04). All specimens from patients diagnosed with stage IV MTC stained positive for CA19-9, compared to only 40% of cases that were classified as stages I to III (P = .03). Furthermore, 100% of the primary specimens that were documented to have metastatic spread stained positive for CA19-9. The sensitivity for ruling out stage IV MTC based on negative staining for CA 19-9 was 100%.

CONCLUSION

Based on these results, we conclude that negative staining of MTC for CA19-9 may be associated with its decreased metastatic potential.

A team-based approach to autopsy education: integrating anatomic and clinical pathology at the rotation level

CONTEXT

Pathology residency training programs should aim to teach residents to think beyond the compartmentalized data of specific rotations and synthesize data in order to understand the whole clinical picture when interacting with clinicians.

OBJECTIVE

To test a collaborative autopsy procedure at Montefiore Medical Center (Bronx, New York), linking residents and attending physicians from anatomic and clinical pathology in the autopsy process from the initial chart review to the final report. Residents consult with clinical pathology colleagues regarding key clinical laboratory findings during the autopsy. This new procedure serves multiple functions: creating a team-based, mutually beneficial educational experience; actively teaching consultative skills; and facilitating more in-depth analysis of the clinical laboratory findings in autopsies.

DESIGN

An initial trial of the team-based autopsy system was done from November 2010 to December 2012. Residents were then surveyed via questionnaire to evaluate the frequency and perceived usefulness of clinical pathology autopsy consultations.

RESULTS

Senior residents were the most frequent users of clinical pathology autopsy consultation. The most frequently consulted services were microbiology and chemistry. Eighty-nine percent of the residents found the clinical pathology consultation to be useful in arriving at a final diagnosis and clinicopathologic correlation.

CONCLUSION

The team-based autopsy is a novel approach to integration of anatomic and clinical pathology curricula at the rotation level. Residents using this approach develop a more holistic approach to pathology, better preparing them for meaningful consultative interaction with clinicians. This paradigm shift in training positions us to better serve in our increasing role as arbiters of outcomes measures in accountable care organizations.

Mass-Casualty Terrorist Bombings In Istanbul, Turkey, November 2003: Report of the Events and the Prehospital Emergency Response

Background:

This paper describes the two mass-casualty, terrorist attacks that occurred in Istanbul, Turkey in November 2003, and the resulting prehospital emergency response.

Methods:

A complex, retrospective, descriptive study was performed, using open source reports, interviews, direct measurements of street distances, and hospital records from the American Hospital (AH) and Taksim Education and Research State Hospital (TERSH) in Istanbul.

Results:

On 15 November, improvised explosive devices (IEDs) in trucks were detonated outside the Neve Shalom and Beth Israel Synagogues, killing 30 persons and injuring an estimated additional 300. Victims were maldistributed to 16 medical facilities. For example, AH, a private hospital located six km from both synagogues, received 69 injured survivors, of which 86% had secondary blast injuries and 13% were admitted to the hospital. The TERSH, a government hospital located 1 km from both synagogues, received 48 injured survivors. On 20 November, IEDs in trucks were detonated outside the Hong Kong Shanghai Banking Corporation (HSBC) headquarters and the British Consulate (BC), killing 33 and injuring an estimated additional 450. Victims were maldistributed to 16 medical facilities. For example, TERSH, located 18 km from the HSBC site and 2 km from the the BC received 184 injured survivors, of which 93% had secondary blast injuries and 15% were hospitalized. The AH, located 9 km from the HSBC site and 6 km from the BC, received 16 victims.

Conclusion:

The twin suicide truck bombings on 15 and 20 November 2003 were the two largest terrorist attacks in modern Turkish history, collectively killing 63 persons and injuring an estimated 750 others. The vast majority of victims had secondary blast injuries, which did not require hospitalization. Factors associated with the maldistribution of casualties to medical facilities appeared to include the distance from each bombing site, the type of medical facility, and the personal preference of injured survivors.

Risk and Risk Assessment in Health Emergency Management

This article considers the critical roles of risk and risk assessment in the management of health emergencies and disasters. The Task Force on Quality Control of Disaster Management (TFQCDM) has defined risk as the “objective (mathematical) or subjective (inductive) probability that something negative will occur (happen)”. Risks with the greatest relevance to health emergency management include: (1) the probability that a health hazard exists or will occur; (2) the probability that the hazard will become an event; (3) the probability that the event will lead to health damage; and (4) the probability that the health damage will lead to a health disaster. The overall risk of a health disaster is the product of these four probabilities.

Risk assessments are the tools that help systems at risk—healthcare organizations, communities, regions, states, and countries—transform their visceral reactions to threats into rational strategies for risk reduction. Type I errors in risk assessment occur when situations are predicted that do not occur (risk is overestimated). Type II errors in risk assessment occur when situations are not predicted that do occur (risk is underestimated). Both types of error may have serious, even lethal, consequences.

Errors in risk assessment may be reduced through strategies that optimize risk assessment, including the:(1) adoption of the TFQCDM definition of risk and other terms; (2) specification of the system at risk and situations of interest (hazard, event, damage, and health disaster); (3) adoption of a best practice approach to risk assessment methodology; (4) assembly of the requisite range of expert participants and information; (5) adoption of an evidence-based approach to using information; (6) exclusion of biased, irrelevant, and obsolete information; and (7) complete characterizations of any underlying fault and event trees.

Mass-Casualty, Terrorist Bombings: Epidemiological Outcomes, Resource Utilization, and Time Course of Emergency Needs (Part I)

Introduction:

This article characterizes the epidemiological outcomes, resource utilization, and time course of emergency needs in mass-casualty, terrorist bombings producing 30 or more casualties.

Methods:

Eligible bombings were identified using a MEDLINE search of articles published between 1996 and October 2002 and a manual search of published references. Mortality, injury frequency, injury severity, emergency department (ED) utilization, hospital admission, and time interval data were abstracted and relevant rates were determined for each bombing. Median values for the rates and the inter-quartile ranges (IQR) were determined for bombing subgroups associated with: (1) vehicle delivery; (2) terrorist suicide; (3) confined-space setting; (4) open-air setting; (5) structural collapse sequela; and (6) structural fire sequela.

Results:

Inclusion criteria were met by 44 mass-casualty, terrorist bombings reported in 61 articles. Median values for the immediate mortality rates and IQRs were: vehicle-delivery, 4% (1–25%); terrorist-suicide, 19% (7–44%); confined-space 4% (1–11%); open-air, 1% (0–5%); structural-collapse, 18% (5–26%); structural fire 17% (1–17%); and overall, 3% (1–14%). A biphasic pattern of mortality and unique patterns of injury frequency were noted in all subgroups. Median values for the hospital admission rates and IQRs were: vehicle-delivery, 19% (14–50%); terrorist-suicide, 58% (38–77%); confined-space, 52% (36–71%); open-air, 13% (11–27%); structural-collapse, 41% (23–74%); structural-fire, 34% (25–44%); and overall, 34% (14–53%). The shortest reported time interval from detonation to the arrival of the first patient at an ED was five minutes. The shortest reported time interval from detonation to the arrival of the last patient at an ED was 15 minutes. The longest reported time interval from detonation to extrication of a live victim from a structural collapse was 36 hours.

Conclusion:

Epidemiological outcomes and resource utilization in mass-casualty, terrorist bombings vary with the characteristics of the event.

Recommended Modifications and Applications of the Hospital Emergency Incident Command System for Hospital Emergency Management

The Hospital Emergency Incident Command System (Hospital Emergency Incident Command System), nowin its third edition, has emerged asa popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the Hospital Emergency Incident Command System in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (Severe Acute Respiratory Syndrome) outbreaks in eastern Asia and Toronto, Canada.

Several modifications of the Hospital Emergency Incident Command System are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the Hospital Emergency Incident Command System to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in chemical, biological, radiological, nuclear emergencies; (3) new unit leaders in theOperations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, anddependents in terrorismrelated emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types ofpatients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems.

New uses of the Hospital Emergency Incident Command System in hospital emergency management also are recommended, including: (1) the adoption of the Hospital Emergency Incident Command System as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the Hospital Emergency Incident Command System not only to healthcare facilities, but also to healthcare systems.

Finally, three levels of healthcare worker competencies in the Hospital Emergency Incident Command Systemare suggested: (1) basic understanding of the Hospital Emergency Incident Command System for all hospital healthcare workers; (2) advanced understanding and proficiency in the Hospital Emergency Incident Command Systemfor hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the Hospital Emergency Incident Command System ad hoc from existing healthcare workers in resource-deficient settings. The Hospital Emergency Incident Command System should be viewed asa work in progress that will mature as additional challenges arise and ashospitals gain further experience with its use.

Mass-Casualty, Terrorist Bombings: Implications for Emergency Department and Hospital Emergency Response (Part II)

This article reviews the implications of mass-casualty, terrorist bombings for emergency department (ED) and hospital emergency responses. Several practical issues are considered, including the performance of a preliminary needs assessment, the mobilization of human and material resources, the use of personal protective equipment, the organization and performance of triage, the management of explosion-specific injuries, the organization of patient flow through the ED, and the efficient determination of patient disposition. As long as terrorists use explosions to achieve their goals, mass-casualty, terrorist bombings remain a required focus for hospital emergency planning and preparedness.

A Proposed Universal Medical and Public Health Definition of Terrorism

The lack of a universally applicable definition of terrorism has confounded the understanding of terrorism since the term was first coined in 18th Century France. Although a myriad of definitions of terrorism have been advanced over the years, virtually all of these definitions have been crisis-centered, frequently reflecting the political perspectives of those who seek to define it.

In this article, we deconstruct these previously used definitions of terrorism in order to reconstruct a definition of terrorism that is consequence-centered, medically relevant, and universally harmonized. A universal medical and public health definition of terrorism will facilitate clinical and scientific research, education, and communication about terrorism-related events or disasters.

We propose the following universal medical and public definition of terrorism: The intentional use of violence — real or threatened — against one or more non-combatants and/or those services essential for or protective of their health, resulting in adverse health effects in those immediately affected and their community, ranging from a loss of well-being or security to injury, illness, or death.

A survey of emergency medicine in 36 countries

OBJECTIVE

To assess the current level of development of emergency medicine (EM) systems in the world.

DESIGN

Survey of EM professionals from 36 countries during a 90-day period from Aug. 25 to Nov. 24, 1998.

PARTICIPANTS

Thirty-six EM professionals from 36 countries and 6 continents completed the survey. Thirty-five (97%) were physicians, of whom 25 (69%) gave presentations at 1 of 4 international EM conferences during the study period. Three potential participants from 3 countries were excluded because of language barriers. Five additional participants from 5 other countries did not respond within the study period and were excluded.

MEASUREMENTS

Respondents completed a 103-question questionnaire about the presence of EM specialty, academic, patient care, information and management systems and the factors influencing the future of EM in their countries.

RESULTS

The overall response rate was 88%. Nearly all respondents (97%) stated that their countries had hospital-based emergency departments (EDs). More than 80% of respondents reported that their countries have emergency medical services (EMS), national EMS activation phone numbers and ED systems for pediatric emergency care. More than 70% stated that their countries had national EM organizations, EM research, ED systems for patient transfer and peer review and emergency physician (EP) training in Advanced Cardiac Life Support (ACLS) and the ability to perform rapid sequence intubation. More than 60% reported ED systems for trauma care and triage and EP training in Advanced Trauma Life Support (ATLS) and the ability to perform thrombolysis for acute myocardial infarction. Fifty percent reported EM residency training programs, official recognition of EM as an independent specialty, and EM journals.

CONCLUSIONS

Basic emergency medicine components now exist in the majority of countries surveyed. These include many specialty, academic, patient care and administrative systems. The foundation for further EM development is widely established throughout the world.

Impact of the terrorist bombings of the Hong Kong Shanghai Bank Corporation headquarters and the British Consulate on two hospitals in Istanbul, Turkey, in November 2003

BACKGROUND

The authors sought to estimate the impact of the terrorist bombings of the Hong Kong Shanghai Banking Corporation headquarters and the British consulate in Istanbul, Turkey, on November 20, 2003, on two nearby hospitals, in terms of epidemiologic outcomes, resource utilization, and time course of emergency needs.

METHODS

The authors used data from hospital records of injured survivors who used the emergency departments (EDs) at the Taksim Education and Research State Hospital (TERSH) and the American Hospital (AH) in Istanbul on November 20, 2003, to determine the totals and rates of mortality (early, late, and critical), injury, critical injury (Injury Severity Score > 15), ED use, hospitalization, operative care, and in-hospital overtriage and the time intervals of ED arrival.

RESULTS

The TERSH received 184 victims in the first hour after the initial blast, of which 88 (48%) were brought by emergency medical services, 171 (93%) had lacerations, 7 (4%) had penetrating eye injuries, 28 (15%) were hospitalized, 18 (10%) received operative care, and 7 (4%) were critically injured. Three deaths occurred in critically injured survivors, including one early death in the operating room and two late deaths on days 5 and 6. The AH received 16 victims, of which 14 (88%) had lacerations, 3 (19%) were hospitalized, 2 (13%) received operative care, and 1 (6%) was critically injured. An additional 4 victims were transferred to the AH from other hospitals, of which 3 were hospitalized and none were critically injured. No early or late deaths occurred.

CONCLUSION

Mortality, injury, and hospitalization rates at both hospitals were consistent with previous reports of open-air mass-casualty terrorist bombings. The TERSH experienced an unprecedented demand for ED surge capacity in an open-air bombing.

Lessons learned from international emergency medicine development

The lessons learned from development of EM around the world span several key areas including general development, systems comparisons, models of EM practice, and education and training. Neither definitive nor exhaustive, these lessons learned are intended to be viewed as sign posts along the road traveled at this point in international EM development. It is hoped that future participants in international EM development can assimilate these lessons learned, adopt the most relevant ones, and add their own insight and wisdom to this growing list. Most importantly, it is hoped that by whichever path future development takes, we all reach the same destination of providing the best possible emergency medical care for the people of the world.

Impact of an outbreak of severe acute respiratory syndrome on a hospital in Taiwan, ROC

STUDY OBJECTIVE

To estimate the impact of the severe acute respiratory syndrome (SARS) outbreak in early 2003 on a tertiary care hospital in Taiwan, ROC.

METHODS

The study estimated the utilisation of resources related to infection control, SARS related medical services, and routine medical services, and SARS related medical outcomes at National Cheng Kung University Hospital (NCKUH) from 25 March to 16 June 2003 through a cross sectional survey of hospital records.

RESULTS

A mean of 5100 persons per day (95%CI 4580 to 5610) underwent fever screening at the outpatient and emergency department (ED) entrances to the hospital, of which 35 per day (95% CI 30 to 40) were referred for further evaluation for suspected or probable SARS. ED isolation surge capacity was created via 12 new beds outside the ED: eight for SARS assessment, three for patients awaiting in hospital bed assignment, and one for resuscitation. A total of 382 patients were fully evaluated for suspected or probable SARS outside the ED, of which 27 were admitted. The mean numbers of outpatient clinic patient visits, ED visits, ED trauma patient visits, ED admissions, hospital admissions, and operative procedures decreased during the outbreak. Thirty eight patients were hospitalised with suspected SARS, of which three received the final diagnosis of probable SARS. Two patients with probable SARS died. No cases of nosocomial SARS transmission occurred.

CONCLUSIONS

This SARS outbreak was associated with substantial use of hospital and ED resources aimed at infection control, comparatively less use of resources related to the medical care of patients with suspected or probable SARS, and decreased use of routine medical services.

Implementation of the Hospital Emergency Incident Command System during an outbreak of severe acute respiratory syndrome (SARS) at a hospital in Taiwan, ROC

We sought to describe the implementation of the Hospital Emergency Incident Command System (HEICS) at National Cheng Kung University Hospital (NCKUH) in Taiwan, ROC during the outbreak of severe acute respiratory syndrome (SARS) in early 2003. We administered a 14-question survey via structured interviews to individuals occupying activated HEICS leadership positions at NCKUH to identify the organization, structure, and function of the HEICS units and subunits they led and the job actions they performed from 25 March to 16 June 2003 Thirty-three of 38 persons (87%) occupying 39 of 44 (89%) activated HEICS leadership positions directly participated in the survey. The participants collectively reported: 1) the creation of four new HEICS unit leader positions and corresponding units during the outbreak, including the infection control officer (administrative section) and SARS assessment, isolation, and critical care unit leaders (operations section); 2) the creation of six new HEICS subunits, including functional areas for fever screening, SARS assessment, and resuscitation outside the hospital, and SARS patient care, SARS critical care, and employee isolation inside the hospital; and 3) the performance of new job actions related to infection control by all HEICS unit leaders. HEICS provides a flexible framework that seems to have assisted NCKUH in the organization of its emergency response to the SARS outbreak in Taiwan, ROC.

Impact of the terrorist bombings of the Neve Shalom and Beth Israel Synagogues on a hospital in Istanbul, Turkey

OBJECTIVES

The authors sought to estimate the impact of the open-air mass-casualty terrorist bombings of the Neve Shalom and Beth Israel Synagogues in Istanbul, Turkey, on November 15, 2003, on the American Hospital (AH) in terms of resource utilization, epidemiologic outcomes, and time course of emergency needs.

METHODS

A retrospective descriptive study using data from hospital records of injured survivors who used the emergency department at AH on November 15, 2003, to determine the number and percentage of injured survivors who were hospitalized, received operative care, had specific injury types, had an Injury Severity Score >/=16, died, and arrived within certain time intervals.

RESULTS

AH received 69 (91%) injured survivors from the scene, of which nine (12%) were hospitalized and three (4%) received operative care. Starting four hours after the initial blast, seven (9%) injured survivors were transferred to AH from other hospitals, of which five (7%) were hospitalized and four (5%) received operative care. Of the 49 injured survivors from the scene with documented injuries, 43 (88%) had injuries to the head or face, 42 (86%) had lacerations, five (10%) had fractures, one (2%) had a penetrating eye injury, one (2%) had a serious intracranial injury, and none had primary blast injuries. Four (5%) injured survivors at AH had an Injury Severity Score >/=16, and none died.

CONCLUSIONS

Seventy-six injured survivors used the emergency department at AH, including a delayed wave of injured survivors transferred from other hospitals. The majority of injured survivors with documented injuries had non-life-threatening lacerations of the head or face, and relatively few injured survivors were hospitalized or received operative care.

Information-sharing in out-of-hospital disaster response: the future role of information technology

Numerous examples exist of the benefits of the timely access to information in emergencies and disasters. Information technology (IT) is playing an increasingly important role in information-sharing during emergencies and disasters. The effective use of IT in out-of-hospital (OOH) disaster response is accompanied by numerous challenges at the human, applications, communication, and security levels. Most reports of IT applications to emergencies or disasters to date, concern applications that are hospital-based or occur during non-response phases of events (i.e., mitigation, planning and preparedness, or recovery phases). Few reports address the application of IT to OOH disaster response. Wireless peer networks that involve ad hoc wireless routing networks and peer-to-peer application architectures offer a promising solution to the many challenges of information-sharing in OOH disaster response. These networks offer several services that are likely to improve information-sharing in OOH emergency response, including needs and capacity assessment databases, victim tracking, event logging, information retrieval, and overall incident management system support.

Case report: penetrating cardiac injury secondary to a terrorism-related nail bomb explosion

Penetrating cardiac injuries commonly occur secondary to gunshot or stab wounds. This is a report an unusual case of a patient who sustained a penetrating cardiac injury due to a nail from a terrorism-related, nail-bomb explosion. Associated problems included pericardial tamponade, penetrating cardiac injuries, acute, traumatic, myocardial infarction, and a penetrating lung injury. Prompt diagnosis and aggressive surgical intervention resulted in full recovery of the patient.

Terrorism in Japan

Although the 1995 Tokyo subway sarin attack probably was the most widely reported terrorist event in Japan to date (5,500 injured, 12 dead), the country has suffered numerous other large terrorism-related events in recent decades, including bombings of the headquarters of Mitsubishi Heavy Industries in Tokyo in 1974 (207 injured, 8 dead), the Hokkaido Prefectural Government office building in Sapporo in 1976 (80 injured, 2 dead), and the Yosakoi-Soran Festival in Sapporo in 2000 (10 injured, none dead). Japan also has experienced two other mass-casualty terrorist events involving chemical releases, including the 1994 Matsumoto sarin attack (600 injured, 7 dead) and the 1998 Wakayama arsenic incident (67 injured, 4 dead). Until 1995, emergency management in Japan focused on planning and preparedness at the local level for the frequent disasters caused by natural events. Since that time, substantial progress has been made in advancing emergency planning and preparedness for terrorism-related events, including the designation of disaster centers in each prefecture, the implementation of several education and training programs for nuclear, biological, and chemical terrorism, and the establishment of a national Anti terrorism Office within the Ministry of Health, Labor, and Welfare.

Mass casualty terrorist bombings

STUDY OBJECTIVE

We compared the epidemiologic outcomes of terrorist bombings that produced 30 or more casualties and resulted in immediate structural collapse, occurred within a confined space, or occurred in open air.

METHODS

We identified eligible studies of bombings through a MEDLINE search of articles published between 1966 and August 2002 and a manual search of published references. Pooled and median rates of mortality, immediately injured survival, emergency department use, hospitalization, and injury were determined for each bombing type.

RESULTS

We found 35 eligible articles describing 29 terrorist bombings, collectively producing 8,364 casualties, 903 immediate deaths, and 7,461 immediately surviving injured. Pooled immediate mortality rates were structural collapse 25% (95% confidence interval [CI] 6% to 44%), confined space 8% (95% CI 1% to 14%), and open air 4% (95% CI 0% to 9%). Biphasic distributions of mortality were identified in all bombing types. Pooled hospitalization rates were structural collapse 25% (95% CI 6% to 44%), confined space 36% (95% CI 27% to 46%), and open air 15% (95% CI 5% to 26%). Unique patterns of injury rates were found in all bombing types.

CONCLUSION

Patterns of injury and health care system use vary with the type of terrorist bombing.

International emergency medicine: recent trends and future challenges

In the past two decades, emergency physicians have increasingly looked beyond their national borders to examine how emergency medicine is practised elsewhere in the world. A major result of their efforts is international emergency medicine, which can be defined as the area of emergency medicine concerned with the development and delivery of emergency medical care in the world. Several international trends are currently occurring in emergency medicine, including an increasing number of venues for information exchange, the spread of emergency medicine practice guidelines, an increasing number of international collaborations, and an increasing number of transnational special interest groups in emergency medicine. A closely related trend is the spread of the specialty model of emergency medicine, a key organizational system in which emergency medicine is viewed as a uniquely integrated horizontal body of medical knowledge and skills concerning the acute phases of all types of disease and injury. Multiple challenges await those involved in international emergency medicine, including the need for internationally accepted definitions, a 'systems approach' to analysing emergency medicine systems, and more useful and affordable information. A related challenge is the need for effective consensus-based processes, including international standardization processes. Many of these challenges may be met through the effective leadership of international emergency medicine organizations.

Disaster medicine in the 21st century: future hazards, vulnerabilities, and risk

The prediction of future disasters drives the priorities, urgencies, and perceived adequacies of disaster management, public policy, and government funding. Disasters always arise from some fundamental dysequilibrium between hazards in the environment and the vulnerabilities of human communities. Understanding the major factors that will tend to produce hazards and vulnerabilities in the future plays a key role in disaster risk assessment. The factors tending to produce hazards in the 21st Century include population growth, environmental degradation, infectious agents (including biological warfare agents), hazardous materials (industrial chemicals, chemical warfare agents, nuclear materials, and hazardous waste), economic imbalance (usually within countries), and cultural tribalism. The factors tending to generate vulnerabilities to hazardous events include population growth, aging populations, poverty, maldistribution of populations to disaster-prone areas, urbanization, marginalization of populations to informal settlements within urban areas, and structural vulnerability. An increasing global interconnectedness also will bring hazards and vulnerabilities together in unique ways to produce familiar disasters in unfamiliar forms and unfamiliar disasters in forms not yet imagined. Despite concerns about novel disasters, many of the disasters common today also will be common tomorrow. The risk of any given disaster is modifiable through its manageability. Effective disaster management has the potential to counter many of the factors tending to produce future hazards and vulnerabilities. Hazard mitigation and vulnerability reduction based on a clear understanding of the complex causal chains that comprise disasters will be critical in the complex world of the 21st Century.

Emergency medicine in Southern Brazil

Emergency medicine is developing rapidly in southern Brazil, where elements of both the Franco-German and the Anglo-American models of emergency care are in place, creating a uniquely Brazilian approach to emergency care. Although emergency medical services (EMS) in Brazil have been directly influenced by the French mobile EMS (SAMU) system, with physicians dispatched by ambulances to the scenes of medical emergencies, the first American-style emergency medicine residency training program in Brazil was recently established at the Hospital de Pronto Socorro (HPS) in Porto Alegre. Emergency trauma care appears to be particularly developed in southern Brazil, where advanced trauma life support is widely taught and SAMU delivers sophisticated trauma care en route to trauma centers designated by the state.

International emergency medicine and the recent development of emergency medicine worldwide

Emergency medicine is being established as a unique and independent specialty throughout the world. Two major models of emergency care delivery exist in the world today: the Anglo-American and the Franco-German model. Most countries developing new systems of emergency care are following the Anglo-American model and are recapitulating the sequence of steps taken to establish the systems of emergency medicine in the United States. The most important step in the development of emergency medicine in other countries is the recognition that emergency medicine incorporates a unique body of knowledge requiring specialized practitioners or emergency physicians. A global network of international emergency medicine is assisting the development of emergency medicine worldwide and now includes international organizations, academic institutions, and individuals in countries where emergency medicine is mature and their counterparts in countries where emergency medicine is developing. The multilevel exchange of information through various modalities, such as international conferences, physician exchange programs, and print or electronic media, is playing a vital role in the search for internationally applicable systems of emergency care.

The recent development of emergency medicine in South Korea

Emergency medicine has developed rapidly in South Korea in the past decade, giving Korea one of the most advanced systems of emergency medical care in Asia. This article reviews the overall health care system and medical climate in Korea, as well as the great progress made in establishing emergency medicine as a specialty. It also describes the many improvements implemented in academic emergency medicine, emergency patient care, and emergency medicine management systems. Although the current economic crisis offers new challenges, much optimism remains about the future of this new Korean specialty.

Colorectal neoplasms detected colonoscopically in at-risk members of colorectal cancer families stratified by the demonstration of DNA microsatellite instability

This study compared colonoscopic findings in families meeting the Amsterdam criteria (A) for hereditary non-polyposis colorectal cancer (HNPCC) but stratified according to whether the familial cancers showed DNA microsatellite instability. DNA was extracted from paired samples of normal and cancer, and microsatellite instability was analysed at up to six loci. Families were termed replication error positive (RER+) when at least 50% of tumours tested per family were positive. Of 26 families studied 17 were RER+ and 9 were RER-. Cancers in the A/RER- families showed no right-sided predilection (P < 0.001). Colonoscopies have been performed on 182 at-risk members of A/RER+ families and 60 members of A/RER- families. More of the at-risk members of A/RER-families were found to have adenomas at colonoscopy (P = 0.095), but these were smaller than those of A/RER+ families (P = 0.19). The adenoma:carcinoma ratio was twice as high in A/RER- families (13:1) as in A/RER+ families (7:1). One of the A/RER- families had hyperplastic polyposis. The others do not appear to have attenuated familial adenomatous polyposis and are similar to the adenoma families or late-onset colorectal cancer families described by others. This study illustrates the importance of molecular technology in separating HNPCC from syndromes with overlapping phenotypes.

Changing Children's Perceptions of the Elderly:

Age-integrated programming has become an effective way to bring the young and old closer together. This article reviews some of the relevant literature and then describes a study involving the Intergenerational Partners Project, a program which stressed the use of age-integrated friendship. The project involved a number of activities shared by fourth graders and elderly volunteers. The Children's Perception of Aging and Elderly (CPAE) inventory administered before and after the program indicated significant attitude improvement toward the elderly by participating students. Other information from the youth and elderly participants also indicated positive qualities of the partners program. The format used to organize the project is presented and the planned activities are identified. Recommendations for intergenerational programming are discussed.

Erythropoietin levels with treatment of obstructive sleep apnea

The effect of nasal continuous positive pressure (CPAP) treatment on erythropoietin (EPO) was examined by measuring diurnal serum EPO levels before and twice (over the 3rd day and over 1 day on recall after > or = 1 mo of therapy) after initiation of treatment in 12 obstructive sleep apnea syndrome patients with normal hemoglobin, hematocrit, creatinine, blood urea nitrogen, and albumin levels. Over each study day, oxygen saturation was measured by an ambulatory pulse oximetry system. Patients spent 27 +/- 9% (SE) of time below oxygen saturation of 88% vs. 2.1 +/- 0.6% after initiation of nasal CPAP treatment (P < 0.01). The number of desaturation events per hour of sleep before nasal CPAP treatment was 62 +/- 6 vs. 9 +/- 2 with nasal CPAP (P < 0.01). EPO levels measured by radioimmunoassay were drawn every hour before and at 3 days (n = 9) and before and at recall (n = 0) after initiation of CPAP therapy. The mean serum EPO level was higher before treatment (61 +/- 14 mU/ml) than that at 3 days (38 +/- 10 mU/ml, P < 0.01) or at recall (32 +/- 7 mU/ml, P < 0.01). We conclude that nasal CPAP treatment of sleep-disordered breathing will reduce diurnal levels of EPO.

Nasal response to carrot and lettuce challenge in allergic patients

BACKGROUND

Food allergies are usually recognized by historical triggers; yet, on occasion, objective testing may be needed to demonstrate allergic causes more convincingly.

OBJECTIVE

Two atopic adult patients presented with respiratory and/or ocular symptoms with an unusual association to handling or eating of vegetables. A third atopic patient presented without attribution of symptoms to vegetable exposure. In all, work-up had revealed positive skin tests and in vitro assays for specific IgE to carrot and/or lettuce; none had gastrointestinal complaints.

METHODS

To assess further these unusual histories and/or IgE antibody findings, laboratory challenge was performed with nasal resistance being used as a monitor of rhinitic reaction.

RESULTS

The first two patients had prolonged nasal objective responses to challenge; the third had a transient response to one of two challenges.

CONCLUSION

We conclude that lettuce and carrot can account for clinically significant IgE-mediated allergic reactions, manifested by nasal obstruction. This laboratory reaction to foodstuffs appears to correlate with patient-reported upper airway and ocular symptoms.

Functional electrical stimulation and respiration during sleep

During obstructive sleep apnea (OSA), respiratory activation of upper airway muscles, particularly genioglossus, is ineffective during sleep. Functional electrical stimulation (FES) of muscles reportedly reduces the number and length of OSAs. Our goals were to examine the effect of FES on sensation during wakefulness and on OSA events. Studies were performed in 11 subjects: 4 healthy asymptomatic subjects and 7 patients with OSA. Surface electrodes placed on the submental region produced discomfort; however, during sleep, the stimulus intensity producing arousal was significantly greater than that producing barely tolerable discomfort during wakefulness. Additionally, we developed a protocol for placement of fine-wire electrodes into the neurovascular bundle of the hypoglossal nerve, using recognizable radiographic features and computerized axial tomography as guides. In these patients, while awake, optimal wire placement was associated with visible tongue protrusion without discomfort. With both surface stimulation and fine-wire FES, during sleep the stimulus intensity required to produce obvious electroencephalographic arousal was significantly greater than that producing a barely tolerable sensation while awake. During apneic events, the application of surface stimulation had an inconsistent effect, terminating 22% of the apneas, and fine-wire FES also had a limited impact, terminating 23% of the apneic events. We conclude from our studies that subjects tolerate surface and fine-wire FES to higher stimulus parameters during sleep than during wakefulness but that both approaches have an inconsistent effect on apneas during sleep.

Arterial oxygen saturation over time and sleep studies in quadriplegic patients

This study evaluated arterial oxygen saturation (SaO2) over time in a randomly selected group of quadriplegic patients to assess whether clinical history prospectively correlated with profiles of oxygen saturation. In 16 stable male quadriplegic patients (C4-T5), we used pulse oximetry to measure SaO2 over a 24 hour period. Measured values of SaO2 were formatted into a cumulative frequency distribution of SaO2 over time. The cumulative SaO2 values from the quadriplegic patients were compared to SaO2 values in a control group of 12 age-matched healthy male subjects. Ten quadriplegic patients had SaO2 profiles comparable to the range observed in healthy subjects. Six quadriplegic patients had SaO2 profiles outside of the normative range. These 6 exhibited cyclic desaturations (> 4%) during periods of behaviorally-defined sleep, suggestive of sleep-disordered breathing. During wakefulness, however, their values of SaO2 were within the normative range. With respect to level of injury, age, time after injury, or medication use, there was no difference between the six 'hypoxic' quadriplegic patients and the 10 'normoxic' quadriplegic patients. Five of the 6 hypoxic patients had a positive medical history of snoring and increased daytime sleepiness, as compared to 6 of 10 normoxic patients who gave a similar history. We also performed polysomnographic studies in a subgroup of 7 quadriplegic patients. In this subgroup, sleep-disordered breathing was observed in 3 patients (AHI of 54/53/12 per hour, respectively). We conclude that in quadriplegic patients, in whom there is a low clinical suspicion for sleep-disordered breathing, there can occur significant decreases in SaO2 over time.

The nasal response to exercise in patients with cystic fibrosis

This study has evaluated the nasal response to exercise in patients with cystic fibrosis (CF), a genetic disease in which factors such as chronic lung disease and/or nasal polyposis might be anticipated to modify nasal function responses. Measurements of nasal resistance (NAR) by posterior rhinomanometry and specific airway resistance (sRAW) were made before and 1, 5, 10, and 30 min after a 4-min period of exhausting legwork exercise (50% predicted maximal) in 19 CF patients (aged 11-29 years) and 10 healthy subjects (aged 11-31 years). One minute after exercise, healthy subjects showed a 54 +/- 5% (mean +/- SEM; standard error of the mean) relative fall from baseline in NAR and CF patients showed a 31 +/- 8% relative fall from baseline (p < 0.05). There were no significant differences in the magnitude or pattern of recovery in NAR after exercise (1 to 30 min) between the groups, largely because of the variability in NAR responses in CF patients. Exercise did not result in significant changes in sRAW in either group. We also found that a history or presence of nasal polyposis does not significantly affect functional nasal responses to exercise. Our conclusion is that the CF genotype and its airway sequelae do not substantively affect the control of the nasal response to exercise.

Extended monitoring of oxygen saturation in chronic lung disease

The goal was to determine values of oxygen saturation from oximetry measurements over extended time periods in the context of prescribing or discontinuing supplemental oxygen. For group 1, when supplemental oxygen therapy was not in use, mean SpO2 values were significantly lower than when it was in use. Without supplemental oxygen, six of eight patients spent greater than 10 percent of the time at or below 88 percent saturation. For group 2, three of the nine patients spent 10 percent of the time at or below 88 percent SpO2. In 16 of 17 patients, lowest room air recorded values of SpO2 were less than 88 percent. We conclude that in many patients with chronic respiratory illness, prolonged monitoring of SpO2 will disclose the presence of hypoxemia. There may be substantial differences in health care cost and outcome depending upon the criteria chosen to prescribe or continue supplemental oxygen.

Serum erythropoietin levels and blood component therapy after autologous bone marrow transplantation: implications for erythropoietin therapy in this setting

To determine the potential impact of recombinant human erythropoietin (EPO) therapy in patients undergoing autologous bone marrow transplantation (BMT) and colony-stimulating factor therapy, we assayed endogenous serum EPO levels and noted blood transfusion requirements in relapsed non-Hodgkin's lymphoma patients treated with high-dose chemo-radiation therapy and autologous BMT. Hematocrit and reticulocyte counts were determined daily, and hematocrit was maintained in the 25-30% range by transfusion according to criteria established by our hospital transfusion committee. EPO levels were measured by radioimmunoassay and were determined at baseline, throughout therapy, and 2 and 3 months after BMT. Serum EPO levels increased more than 25-fold above baseline in most subjects after initiating chemoradiation therapy. No correlation was noted between serum EPO and hematocrit, reticulocyte count or serum creatinine. Total red blood cell units transfused ranged from 4 to 15 (mean 7.7). Mean total donor exposures (red blood cell plus platelet units transfused) were 83.6 units (range 16-175). Serum EPO levels increased early in the course of preparation for autologous BMT and remained elevated for at least 2-3 weeks thereafter although at a lower level. Red blood cell transfusions were required despite very high EPO levels after BMT. Red cell transfusions, moreover, accounted for only 9.2% (69 of 746) of total donor exposures and only 5.8% (42 of 746) of donor exposures during the interval when pharmacologic doses of erythropoietin might be of benefit. In contrast to the potential benefit of colony-stimulating factors such as G-CSF and GM-CSF in BMT, our study suggests limited value for erythropoietin therapy in this setting.

Diurnal variations in serum erythropoietin levels in healthy subjects and sleep apnea patients

We measured arterial oxygen saturation (SaO2) and serum erythropoietin (EPO) levels in patients with obstructive sleep apnea syndrome (OSAS) and in healthy subjects. SaO2 profile was analyzed as the cumulative distribution of SaO2 over time. OSAS patients spent 25.5 +/- 30.9% (SD) of the time at SaO2 of less than 88% vs. 0.64 +/- 1.6% in healthy subjects (P less than 0.05) and had 59 +/- 25 desaturations (greater than 4%) per hour vs. less than 5 per hour in healthy subjects (P less than 0.05). EPO measurements (radioimmunoassay) were made in blood samples withdrawn every 1 or 2 h over a 24-h period. The mean EPO concentration was higher (P less than 0.05) for OSAS patients (45 +/- 33 mU/ml) than for normal subjects (17 +/- 8 mU/ml). There was a significant variability in EPO values over the 24-h period. To analyze the EPO pattern over 24 h, EPO time series were fit to a general cosine function. Data from normal subjects conformed to a cosine function with an amplitude of 3.5 +/- 2.1 (CV of 60%) and an acrophase of 1,000 +/- 184 min after 0800 (CV of 18%), indicating a zenith about 1 A.M. and a nadir around 1 P.M. Data from OSAS subjects fit a similar cosine function with an amplitude of 19.9 +/- 41.0 (CV of 206%) and acrophase of 582 +/- 408 min (CV of 70%), indicating a greater variability in the magnitude and the timing of peak serum EPO levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Nasal flow-resistive responses to challenge with cold dry air

Recent studies have suggested that the inhalation of cold air through the nose is associated with the subsequent release of mediators of immediate hypersensitivity. To determine if mucosal surface heat and water loss influence the nasal functional response to cold air, we measured nasal resistance by posterior rhinomanometry before and 1, 5, and 10 min after a 4-min period of isocapnic hyperventilation (30 l/min) through the nose in nine healthy subjects (5 males, 4 females; aged 25-39 yr) while they inhaled air at 0 degrees C. During the challenge period, the subjects breathed either in and out of the nose or in through the nose and out through the mouth. No changes in nasal resistance developed when subjects breathed exclusively through the nose; however, when subjects breathed in through the nose and out through the mouth, nasal resistance was increased 200% at 1 min (P less than 0.01) after the challenge and returned to baseline values by 10 min after cessation of the challenge. These data indicate that nasal functional responses to cold dry air are dependent on the pattern of the ventilatory challenge. If the heat given up from the nasal mucosa to the incoming air is not recovered during expiration (as is the case with inspiration through the nose and expiration through the mouth), nasal obstruction will occur. Hyperpnea of cold air, per se, does not influence nasal resistance.

Occupational allergic rhinitis in the hair care industry: reactions to permanent wave solutions

This report details our observations on rhinitic reactions in nonatopic professional beauticians in whom an etiologic agent for occupational symptoms was not previously determined. Exposure to permanent wave solutions in a laboratory setting caused clinical symptoms and significant laboratory evidence of nasal airway obstruction. In one patient, previous treatment with cromolyn sodium reduced, but did not completely eliminate, the reaction.

A comparison of a new reflectance oximeter with the Hewlett-Packard ear oximeter

The purpose of this study was to characterize the accuracy and dynamic response characteristics of traditional transmittance pulse oximeters and a new reflectance pulse oximeter with regard to the current standard in oximetry, the Hewlett-Packard ear oximeter. Studies were performed with 15 healthy male and female subjects. A rebreathing technique was employed to produce a steady fall in oxygen saturation and to maintain constant, eucapnic, end-tidal CO2 levels. The oximeters' analog outputs were recorded by a Western Graphtec Linearecorder and by an IBM-PC utilizing an analog-to-digital converter for data collection at 5 Hz. The agreement between two clinical methods of measurement was used as the statistical technique of comparing new technology (pulse oximetry) with the current standard (Hewlett-Packard ear oximetry). The mean of the difference between the Hewlett-Packard and the pulse oximeter with reflectance sensor was 0.28%, with a range of difference of +/- 3.49%. This value was similar to that of the transmittance oximeters (Criticare 501+: 0.92 +/- 2.11), (Physio-Control: 3.15 +/- 2.04), (Ohmeda 3700: 2.05 +/- 2.06). There was virtually no response-time difference between the reflectance oximeter with the sensor placed on the subject's forehead and the Hewlett-Packard ear oximeter. The authors conclude that the accuracy of the reflectance oximeter is within the limits of clinical acceptance for monitoring and trending of arterial oxygen saturation in healthy subjects.

Occupational allergic rhinitis reaction to psyllium

We report studies that document a specific rhinitic reaction that developed as a result of occupational exposure to a psyllium-based powdered laxative. This nurse had a nonatopic family history, personal evidence of atopy (skin test reactions to pollen, cat dander, and house dust), and a significant elevation of antipsyllium IgE. Measurements of nasal and lower airway resistance documented only nasal obstruction to brief inhalational challenge to the laxative. Symptomatic relief was achieved with prior treatment with cromolyn. We suggest that nasal airway challenge can document and assess treatment for occupational rhinitis.

Natural cytotoxicity of human serum. A natural IgM 'antibody' sensitizes transformed murine cells to the lytic action of complement

The natural cytotoxicity of human serum on murine L cells, EA and Sa 180 cells is expressed as a rapid cytolysis at 37 degrees C. This cytotoxic system is analyzed as to its active constituents and their functional relationships. Ultrastructural studies indicate that cell injury and death are initiated within 10 min by membrane disruption. A trypan blue assay for cell death was used to study serum toxicity in individual normal healthy adults, pregnant females and newborn infants. Pregnancy sera, particularly in the 2nd and 3rd trimesters, were consistently more toxic than male serum or nonpregnant females. Cord serum was typically nontoxic. Pools of normal fresh pregnancy serum were used for immunochemical analysis of the cytotoxic activity. By a variety of immunologic and immunochemical techniques it was shown that the cytotoxicity was, in part, due to the combined action of alternative and classical pathways of complement, the former being more prominent. The lytic action of complement was shown to be greatly amplified by the prior adsorption of IgM on the target cells' surface. This IgM is a critical determinant of the cytotoxic reaction. It probably contains a natural 'antibody' to cell surface antigen(s), whose combination activates both pathways of C.

Transformation of an arachidonic acid hydroperoxide into epoxyhydroxy and trihydroxy fatty acids by liver microsomal cytochrome P-450

In the absence of NADPH, the addition of an arachidonic acid hydroperoxide, 15-hydroperoxyeicosa-5,8,11,13-tetraenoic acid, to liver microsomes, prepared from phenobarbital-treated rats, resulted in the formation of two major metabolites and several minor products, some of which have been purified by reverse-phase high-performance liquid chromatography. We propose the structures of the two major products to be 13-hydroxy-14,15-epoxyeicosa-5,8,11-trienoic acid and 11,14,15-trihydroxyeicosa-5,8,12-trienoic acid based on spectral characteristics and mass spectral analysis of derivatives of the compounds. A potential heterolytic cleavage product, 15-hydroxyeicosa-5,8,11,13-tetraenoic acid, was not a product of the reaction. Ferric cytochrome P-450 catalyzed the formation of these products as shown by the inability of boiled microsomes to support the reaction, the inhibition of epoxyhydroxy and trihydroxy fatty acid formation by imidazole derivatives which bind tightly to the ferric heme iron of cytochrome P-450, and the inability of carbon monoxide (which binds to ferrous P-450) and free iron chelators (EDTA and diethylenetriaminepentaacetic acid) to inhibit product formation. These results show that liver microsomal cytochrome P-450, in addition to its role in the NADPH-dependent metabolism of arachidonic acid, can utilize a hydroperoxide to produce an interesting series of potentially important arachidonic acid metabolites.