Trauma Care in Mongolia: INTACT Evaluation and Recommendations for Improvement.

INTRODUCTION: Injury is the third leading cause of death in Mongolia, with a 29% increase in motor vehicle fatalities over the past decade. Half of the population lives outside the urbanized capital of Ulaanbaatar, where access to care is limited. This study evaluates and describes the Mongolian trauma system and makes recommendations for improvements. METHODS: Hospital-level data were collected, and an International Assessment of Capacity for Trauma (INTACT) score (0-10) was calculated. INTACT is a validated measure for evaluating trauma capacity in developing countries based on resource availability; a score of 10 reflects ideal staffing and equipment. The survey was administered to key staff members at 10 rural and urban hospitals in spring 2016. INTACT scores were calculated for each hospital and compared to expected INTACT scores based on the World Health Organization Guidelines for Essential Trauma Care (GETC). RESULTS: Ulaanbaatar enjoys a centralized prehospital transportation service and two appropriately resourced tertiary hospitals. Rural Mongolians rely upon regionally located tertiary facilities with similar capabilities. INTACT scores for secondary-level hospitals (n = 2) failed to meet expected GETC minimums, as did 2 of 4 primary facilities. There are no national standards guiding prehospital care, triage, or transfer. No outpatient rehabilitation facilities exist within Mongolia. CONCLUSION: The Mongolian trauma system utilizes regionalized care to provide emergency services. Among surveyed hospitals, 60% met GETC standards. Areas for improvement include increased resourcing of primary and secondary facilities, development of rural prehospital systems, adoption of universal standards for patient care, and creation of post-acute rehabilitation facilities.

Histologic study of the effects of chemoembolization with preloaded doxorubicin beads in patients with hepatocellular carcinoma.

OBJECTIVE: To determine the degree of tumor necrosis in surgical specimens of hepatocellular carcinomas treated with microspheres preloaded with doxorubicin and to analyze the relationship between the degree of necrosis and a) morphologic factors and b) imaging biomarkers. MATERIAL AND METHODS: We studied the livers of 21 patients who had undergone selective arterial chemoembolization with DC beads (Biocompatibles, UK) before receiving liver transplants. RESULTS: Imaging techniques detected 43 nodules (mean size, 25 mm). Angiography showed 25 hypervascularized nodules, 12 slightly vascularized nodules, and 6 avascular nodules. A total of 81 hepatocellular carcinomas (mean size, 15 mm) were detected in the specimens: two were capsular and two had vascular infiltration. The mean degree of necrosis after chemoembolization was 39%; necrosis was greater than 60% in 28 hepatocellular carcinomas and less than 60% in 52. The degree of necrosis correlated significantly with the time elapsed between the last chemoembolization treatment and liver transplantation (the degree of necrosis decreased as time increased), with the number of nodules in the specimen, and with capsular infiltration. When imaging techniques detected 1 or 2 nodules, there was a greater probability of achieving greater than 90% necrosis. No relation with the degree of necrosis achieved was found for the size of the nodules detected at imaging, the enhancement pattern, or the number of chemoembolization treatments. CONCLUSION: The degree of necrosis achieved depends on the time spent on the waiting list, on the number of nodules in the specimen, and on whether capsular infiltration is present.

Asphyxia with a blunt instrument: which forensic evidence to use in complex cases of murder.

Background: The blunt injuries may be heterogeneous. Due to the diversity, it is often difficult to establish the type of weapon used. Particular attention must be paid to the circumstantial data and previous diseases because the injuries often could not correspond to the presumed instruments used. Case Report: A man was found dead in his bedroom wearing pajamas. On the bed there was a blanket with visible traces of blood, which had dried. There were around 10 dogs in the house, poor hygienic and sanitary conditions, widespread excrements and unbreathable air. Testimonies from general practitioner, neighbors and the partner were collected. An autopsy, histological and toxicological examination was performed. On external examination the face showed blood smearing down the nose, subconjunctival hemorrhages, and labial cyanosis. Mo-reover, a hypochromic skin area was present on the right lateral region of the neck. The inguinal region showed large de-epithelized areas with multiple purplish red ecchymoses which were histologically analyzed. These areas showed hemorrhagic infiltration in the superficial and deep dermis up to the adipose tissue due to traumatic action. Conclusion: The reconstruction of the case allowed us to state a strangulation probably attributable to a belt. The discovery of intradermal hemorrhagic infiltrations, supported by histopathological investigations, confirmed the diagnosis of blunt force injuries, excluding other type of non-violent causes of lesions. Therefore, we recommended the use of experimental methods and procedures to evaluate the harmful suitability on biological matrices.

Data on the design optimization, indoor characterization and outdoor testing of GaAs/Bifacial Si heterojunction four-terminal photovoltaic systems.

The development of a highly efficient multijunction technology is a key challenge for the future of photovoltaic and for the transition to more renewable energy sources. In this scenario, four-terminal architecture (4T) compared to the classic tandem design allows a large intrinsic robustness to the variations of the solar spectrum, which continuously occur under normal outdoor operation conditions. On the other hand, bifacial solar cells and modules have already proven to be able to increase the energy yield of solar farms at reduced costs. For these reasons, a thorough investigation of the compatibility between these two solutions has been performed by combining a III-V semiconductor with the silicon heterojunction technology in a four-terminal device. This work has been designed in support of the research article entitled "Outdoor performance of GaAs/Bifacial Si Heterojunction four-terminal system using optical spectrum splitting" [1], which showed, through data modeling and an accurate daily analysis of the spectral distribution of solar light, how a four-terminal architecture guarantees the consistency of the bifacial gain and more robust performances than a two-terminal system. Here additional data on the manufacturing, optimization and characterization of the device are presented.

Selling androgenic anabolic steroids by the pound: identification and analysis of popular websites on the Internet.

Internet websites offering androgenic anabolic steroids (AAS) were identified and available products were examined. Keywords for the website search were: "anabolic steroids," "anabolic steroids buy," "anabolic steroid purchase." The first 10 websites offering AAS in the first 10 pages of results were considered. At least two AAS-containing products per website were selected. Thirty AAS-selling websites were identified, mainly located in the United States (46.7%) and Europe (30%). Most websites sold other anabolic/ergogenic products (clenbuterol, 76.7%; GH/IGF, 60.0%; thyroid hormones, 46.7%; erythropoietin, 30.0%; insulin, 20.0%) or products for AAS-related adverse effects (mainly: estrogen antagonists, 63.3%; products for erectile dysfunction, 56.7%; 5α-reductase inhibitors, 33.3%; anti-acne products, 33.3%). AAS were sold as medicines (69.6%) or as dietary supplements (30.4%). AAS in medicines were mainly: nandronole (20.4%), methandrostenolone (18.4%), and testosterone (12.2%). Dietary supplements contained mainly DHEA and included several fake compounds. Manufacturers were declared for 97.9% of medicines and 66.7% of dietary supplements; however, several manufacturers were not found on the Internet. Described benefits were usually few adverse effects and no estrogenicity. Toxicity was seldom reported and presented as mild. Recommended doses were two-fourfold higher than current medical recommendations. In conclusion, misleading information and deceiving practices were common findings on AAS-selling websites, indicating their deleterious potential for public health.

Heart rhythm characterisation during unexplained transient loss of consciousness in dogs.

The identification of the heart rhythm during an episode of transient loss of consciousness (TLOC) is considered the reference standard method to elucidate the underlying aetiology. This study aimed to characterise heart rhythm in dogs during TLOC using Holter and external loop recorder monitoring. We retrospectively reviewed 24-h Holter monitoring and external loop recorder tracings from 8084 dogs. Heart rhythms from dogs that experienced TLOC during the recording was analysed to identify rhythm disturbances that occurred during episodes of TLOC. Electrocardiograms (ECGs) were subsequently categorised into Type 1 (ventricular arrest), Type 2 (sinus bradycardia), Type 3 (no/slight rhythm variations), and Type 4 (tachycardia). Transient LOC was documented in 92 dogs over 230 episodes of TLOC. Percentage of cases with ECGs compatible with each classification were as follows: 72.1%, Type 1; 6.1%, Type 2; 20.9%, Type 3; and 0.9%, Type 4. Cardiac rhythm during the TLOC could have been a consequence of a neurocardiogenic mechanism in 46.7% cases, while intrinsic rhythm disturbances of the sinus node or of the atrioventricular node were diagnosed in 31.5% cases. In two cases, tachycardia was the possible cause of the TLOC. ECG patterns in dogs presenting with multiple TLOC episodes were completely reproducible during each episode. TLOC in dogs was primarily caused by ventricular arrest. Most dogs with TLOC had electrocardiographic finding suggestive of a reflex or neurally-mediated syncope, but one third had an ECG more suggestive of a conduction disorder. Distinguishing these two entities could help inform diagnostic, therapeutic, and prognostic plans.

Quantum dot networks in dielectric media: from compact modeling of transport to the origin of field effect luminescence.

We present a compact model of transport through a random distribution of interacting quantum dots embedded in a dielectric matrix. The model is based on a network of interconnected tunnel junctions sandwiched between two electrodes, resulting in a system of nonlinear differential equations which is numerically solved for a given time-dependent voltage applied to the gate. The capacitance matrix, electron/hole tunneling currents and the effective area of conduction between quantum dots are calculated at each integration step. The transport properties obtained from the model are successfully validated against experimental data for a silicon nanocrystal basic MOS cell, showing its potential applicability to non-volatile memories. In addition, through a simple rate equation, the calculated charge flux tunneling or impacting the nanocrystals is converted into electroluminescence. In this regard, we discuss the origin of the recently reported field effect luminescence in silicon nanocrystals. It is found that the idea of quantum-confined exciton creation through sequential injection of opposite sign carriers is in contradiction with the model and with the electron/hole tunneling time ratio obtained through the WKB approximation due to the difference in the electron and hole potential barrier heights. We show how our model of transport, along with a rate equation with the reported value for the absorption cross section for electrical excitation of silicon nanocrystals (approximately 10(-14) cm(2)), is in good agreement with experimental data obtained under pulsed excitation, without requiring further assumptions such as the formation of excitons from hole tunneling into electron-charged nanocrystals, revealing impact excitation of electrons/holes from the same substrate as the physical origin of the observed field effect luminescence.

The keys to successful TIPS in patients with portal vein thrombosis and cavernous transformation. / Trombosis y cavernomatosis portal: las claves para el éxito de un TIPS.

Portal vein thrombosis is a common complication in patients with cirrhosis. Anticoagulation involves a high risk of bleeding secondary to portal hypertension, so placing transjugular intrahepatic portosystemic shunts (TIPS) has become an alternative treatment for portal vein thrombosis. Three strategies for TIPS placement have been reported: 1) portal recanalization and conventional implantation of the TIPS through the jugular vein; 2) portal recanalization through percutaneous transhepatic/transsplenic) access; and (3) insertion of the TIPS between the suprahepatic vein and a periportal collateral vessel without portal recanalization. We describe different materials that can be used as fluoroscopic targets for the TIPS needle and for portal recanalization. This article aims to show the success of TIPS implantation using different combinations of the techniques listed above, which is a good treatment alternative in these patients whose clinical condition makes them difficult to manage, and to show that portal vein thrombosis/cavernous transformation should not be considered a contraindication for TIPS.

Experimental study of single-electron phenomena in silicon nanocrystal memories.

In this paper we present experimental evidence for single-electron phenomena in solid-state memories based on silicon nanocrystals as storage elements. The stepwise evolution of the channel current of a written memory cell biased in the subthreshold regime is monitored by means of a purposely designed low noise acquisition system with a bandwidth of 1 kHz. Each channel current step-up is ascribed to a single-electron emission from the silicon nanocrystal to the silicon substrate and each current step-down is ascribed to a single-electron capture from the silicon substrate into the silicon nanocrystal. The effect of the measurement system bandwidth on the detection of single-electron events is discussed and a procedure for extracting the threshold voltage shift associated to these events is proposed. It is shown that single-electron charging and discharging events in a memory cell with an area of 4.5 x 10(-10) cm2 can cause threshold voltage shift at room-temperature of the order of several millivolts. Qualitative explanation for the observed threshold voltage shift distribution is given.

Adhesive restorations: comparative evaluation between the adhesion of the glass-ceramics to the composite cement and the adhesion of the ceromer to the composite cement.

AIM: The aim of this work is to compare the adhesion of the glass-ceramic (empress II) to the composite cement and the adhesion of the ceromer to the composite cement. METHODS: From each of the above materials, 10 little blocks, of 8 x 6 x 2 mm size, have been prepared. All the surface treatments suggested by the manufacturing industry have been performed: sandblasting and acid-etching of the ceramic, ceromer surface roughening with diamond bur and silanization and bonding application on both materials. A homogeneous layer of cement has been placed between couples of blocks of the same material and photopolymerised. Every sample, consisting of 2 bonded blocks, has been submitted to a traction force on a universal test machine connected with a computerized measure system (SINTEC D/10). Samples have been anchored to the machine binding devices by a bicomponent epoxy glue. Data on the breaking charge have been recorded and an analysis of the broken surfaces has been performed in order to classify the breaking modalities. RESULTS: The results ontained showed that the composite-glass-ceramic adhesion force (mean value 64 Mpa) was remarkably higher than the composite-ceromer adhesion (mean value 37.21 Mpa). CONCLUSIONS: The analysis of the broken surfaces by SEM showed that a mixed fracture occurred in all samples (both partly adhesive and cohesive).

The nutraceutical response of two globe artichoke cultivars to contrasting NPK fertilizer regimes.

Globe artichoke contributes to the healthiness of the Mediterranean diet, but its nutraceutical value in response to its agronomy has not been investigated in any detail to date. Here, the effect of two contrasting fertilizer regimes (one balanced and the other excessive) on the sugar, ascorbic acid and total polyphenol content, the polyphenol profile and the antioxidant activity of the two cultivars 'Apollo' and 'Tema 2000' were monitored in plants grown in three locations in Sicily ('Landolina', 'Iannarello' and 'Zotto'), which contrasted for soil type. The balanced fertilizer regime favored the content of sucrose, inulin, ascorbic acid and polyphenols (in particular that of 1,5-di- and 5-O-caffeoylquinic acid, along with apigenin 7-O-glucuronide). It was also more supportive of a high antioxidant activity. There was a pronounced cultivar and trial location effect, especially in terms of the accumulation of antioxidant compounds. Plants grown at 'Landolina' responded more strongly than at the other two locations to the fertilizer regime with respect to both ascorbic acid and total polyphenol content. The conclusion was that providing a balanced supply of nitrogen/phosphorus/potassium (NPK) via fertilizer application can enhance the nutraceutical value of globe artichoke, although the effect is modulated by both genetic factors and soil type.

Fractures of the distal femoral epiphyses. Factors influencing prognosis: a review of thirty-four cases.

In a review of thirty-four fractures through the distal femoral epiphyseal plate followed for an average of four years, limb-length discrepancy of 2.0 centimeters or more (measured roentgenographically) occurred in 36% and varus or valgus deformity measured as a difference of 5 degrees or more between the involved and uninvolved extremities occurred in 33%. Reconstructive procedures (osteotomy, epiphyseodesis, or both) were required in 20%. Limitation of knee motion (eleven patients), ligament laxity (eight patients), and quadriceps atrophy (five patients) were also observed. Prognoses made on the basis of the Salter-Harris classification alone were not reliable. The development of deformity appears to be related to the degree of initial displacement of the fracture, the exactness of the reduction, and the type of fracture.

Reconstruction of the ulnar collateral ligament in athletes.

Reconstruction of the ulnar collateral ligament using a free tendon graft was performed on sixteen athletes. All participated in sports that involved throwing (mostly professional baseball), and all had valgus instability of the elbow. After reconstruction and rehabilitation, ten of the sixteen patients returned to their previous level of participation in sports, one returned to a lower level of participation, and five retired from professional athletics. Despite precautions, there was a high incidence of complications related to the ulnar nerve. Two patients had postoperative ulnar neuropathy (one late and one early) that required a secondary operation, but they eventually recovered completely. Three others reported some transient postoperative hypoesthesia along the ulnar aspect of the forearm that resolved after a few weeks or months.

Non-operative treatment of ruptures of the anterior cruciate ligament in middle-aged patients. Results after long-term follow-up.

We retrospectively reviewed the records of fifty-two patients who had had a rupture of the anterior cruciate ligament between the ages of forty and sixty years, to determine the results of aggressive non-operative treatment. We were able to locate and re-examine thirty of these patients (mean age, forty-six years) after a mean duration of follow-up of seven years (range, five to thirteen years), and to assess the clinical, radiographic, and functional results. The mean score, according to the scale of Lysholm and Gillquist, was 82 points; eight of the eleven patients who had combined ligamentous injuries had a score of less than 84 points (symptoms with daily activities). Thirteen substantial reinjuries had occurred in eleven patients (37 per cent) during the follow-up period. Twenty-nine patients (97 per cent) had a grade-2 or 3 Lachman test, and a positive pivot-shift test was elicited in twenty-five patients (83 per cent). Plain radiographs revealed minimum or no changes in twenty-six patients (87 per cent). Magnetic resonance imaging in nine patients revealed scarring of the remnant of the anterior cruciate ligament to the posterior cruciate ligament in six. The mean difference in anterior-posterior laxity between the injured knee and the normal, contralateral knee, as measured with the KT-1000 arthrometer, was five millimeters at twenty pounds (eighty-nine newtons). Twenty-five (83 per cent) of these thirty middle-aged patients, who had had guided rehabilitation and had modified activity, had a satisfactory outcome without an operation. However, a few patients, who had combined instabilities and who wished to resume competitive sports activity that required pivoting, were dissatisfied. Such patients may need operative reconstruction to achieve their goals.

Radiographic abnormalities of the iliac apophysis in adolescent athletes.

Nine of thirteen adolescent patients with a diagnosis of a so-called hip-pointer injury demonstrated a discontinuity of the anterior part of the iliac apophysis on radiographs. Eight of the nine patients improved with conservative treatment and there was total resolution of symptoms in one to eight months. The remaining patient, who was skeletally mature at the time of writing, continued to have recurrent symptoms of discomfort over the iliac crest during athletic activity. Other reports have described the discontinuity as a stress fracture, but the natural history in our patients did not reveal evidence of fracture-healing. However, the discontinuity disappeared at skeletal maturity in all patients. The radiographic discontinuity may be an anatomical anomaly, since it was present bilaterally in all nine patients although only two had symptoms on both sides.

The coracoid transfer for recurrent anterior instability of the shoulder in adolescents.

Thirty-six shoulders with recurrent anterior dislocation or subluxation in thirty-four adolescent patients were treated with a modified Bristow procedure. The average length of follow-up was five years and ten months. Postoperatively, two patients had recurrent anterior subluxation on one occasion and none had recurrent anterior dislocation. The average loss of external rotation was 10 degrees. Despite the fact that young patients have a high rate of recurrence after anterior dislocation or subluxation of the shoulder, the modified Bristow procedure is an effective method of treating recurrent anterior instability of the shoulder in adolescents.

Surgical treatment of tears of the rotator cuff in athletes.

Forty-five athletes with either a partial or a complete tear of the rotator cuff were treated with anterior acromioplasty and repair of the tear. The minimum duration of follow-up was twenty-four months (average, forty-two months). Thirty patients had an incomplete tear and fifteen had a complete tear. Postoperatively, thirty-nine (87 per cent) of the patients stated that they were improved compared with their preoperative status, although only thirty-four patients (76 per cent) felt that they had a significant reduction of pain postoperatively. Objectively, twenty-five (56 per cent) of the patients were rated as having a good result, which allowed them to return to their former competitive level without significant pain. Twelve (41 per cent) of the twenty-nine athletes who had been involved in pitching and throwing returned to their former competitive status. Seven (32 per cent) of the twenty-two pitchers and throwers who had been active at a professional or collegiate level returned to the same competitive level. In our experience, a repair of the rotator cuff combined with an acromioplasty in a young athletic population provides satisfactory relief of pain but does not guarantee that the patient will be able to return to his or her former competitive status in all sports.

Isolated lateral meniscectomy. A study of twenty-six patients with isolated tears.

To better define the role that the lateral meniscus plays in stabilizing the knee, a study was made of twenty-six patients who had an uncomplicated lateral meniscectomy between 1972 and 1977. Patients with any degree of ligament instability, cruciate or collateral, prior to lateral meniscectomy were eliminated from the study. Also eliminated were any patients with roentgenographic evidence of degenerative arthrits, osteochondritis dissecans, or loose bodies. Only patients whose operative reports stated that the articular cartilage of the lateral compartment was either grossly normal or showed Grade-1 chondromalacia (less than one centimeter in diameter and only softening of the cartilage) at the time of surgery were included in the review. The meniscal lesions included bucket-handle tears, horizontal cleavage tears, and multiple linear defects. No grossly cystic menisci were included in the study. Two menisci demonstrated cystic degenerative changes on histological section. In sixteen patients some degree of ligament instability developed. The longer the interval between injury to the meniscus and its excision, the less satisfactory the result. Only fifteen (54 per cent) of the patients reported satisfactory results, and twenty lost some motion of the knee. We concluded that stability of the knee joint is a multifactorial problem, in which the lateral meniscus certainly plays an important part.

The modified Bristow procedure for recurrent dislocation of the shoulder.

A review of fifty-one cases of the modified Bristow procedure for recurrent anterior shoulder instability is presented. The results were favorable. The redislocation rate was 2% with few complications. The average limitation of motion was 11 degrees of external rotation. Athletic individuals with involvement of the dominant shoulder were not capable of returning to high performance levels of overhead sports activity (particularly throwing) after the operation.

Serum hepatitis G virus (HGV) RNA in multitransfused thalassemics from eastern Sicily.

The prevalence of hepatitis G in a multitransfused population was studied. HGV did not appear to be a major contributor to liver pathology in this group and the prevalence was surprisingly low.