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.

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.

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.

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.

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.

Recommended modifications and applications of the Hospital Emergency Incident Command System for hospital emergency management.

The Hospital Emergency Incident Command System (HEICS), now in its third edition, has emerged as a popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the HEICS 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 (SARS) outbreaks in eastern Asia and Toronto, Canada. Several modifications of the HEICS are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the HEICS 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 CBRN emergencies; (3) new unit leaders in the Operations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, and dependents in terrorism-related 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 of patients 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 HEICS in hospital emergency management also are recommended, including: (1) the adoption of the HEICS as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the HEICS not only to healthcare facilities, but also to healthcare systems. Finally, three levels of healthcare worker competencies in the HEICS are suggested: (1) basic understanding of the HEICS for all hospital healthcare workers; (2) advanced understanding and proficiency in the HEICS for hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the HEICS ad hoc from existing healthcare workers in resource-deficient settings. The HEICS should be viewed as a work in progress that will mature as additional challenges arise and as hospitals gain further experience with its use.

Mass casualty terrorist bombings: a comparison of outcomes by bombing type.

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.

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.

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.

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 pre-hospital 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.

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.

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.

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.

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 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.