Spina Bifida Global Learning Collaborative: Educating the next generation of clinicians, researchers, and advocates.

PURPOSE: This project aimed to launch an international learning community to guide the development of a spina bifida (SB) curriculum for global health trainees. METHODS: Using a descriptive study design, a convenience sample of SB curricula were identified in 2022-23 by members of the Spina Bifida World Congress Outreach Committee and evaluated during a series of monthly Zoom calls to discuss SB education in a global health context. Participants included (1) leadership from the ReachAnother Foundation, (2) invited panelists from the Spina Bifida World Congress Global Health Symposium, and (3) global health students and preceptors. Education initiatives in Ethiopia, Sweden, Argentina, Ecuador, and the United States were evaluated vis-à-vis format and content. RESULTS: All of the education initiatives referenced the framework of the World Health Organization International Classification of Functioning, Disability and Health. Formats varied and included both virtual and interactive workshops, print materials, videos, and guides for small group discussion. Content addressed four domains: Folate Prevention, Neurosurgical Training, After Care, and Data Collection. A multidisciplinary approach, partnerships with families, and workforce pipeline training were identified as guiding themes for educating the next generation of SB researchers and clinicians in global health settings. CONCLUSION: The Spina Bifida Global Learning Collaborative is a transnational group of advocates, clinicians, and investigators whose mission is the advancement of SB-related global health education. Lessons learned from the collaborative are being leveraged to develop a global health curriculum for learners, which may improve services for individuals with SB around the globe.

A case study of ReachAnother Foundation as a change champion for developing spina bifida neurosurgical care and advocating for primary prevention in Ethiopia.

Spina bifida is a serious birth defect affecting the central nervous system, characterized by incomplete closure of the neural tube. Ethiopia has a very high prevalence of spina bifida, affecting about 40 cases per 10,000 births. Babies born with spina bifida require early closure surgery, done within the first 2-3 days after birth. Some babies need repeat surgeries to address complications, including hydrocephalus. Without medical care, babies have a high risk of death within the first 5 years of their life. Neurosurgical capacity for spina bifida closure surgery at birth is a relatively new development in Ethiopia. ReachAnother Foundation, a not-for-profit organization based in OR, USA, started work in Ethiopia in 2009 and has been instrumental in training neurosurgeons and improving treatment for spina bifida and hydrocephalus. Along with the development of neurosurgical care, the Foundation has invested in training multi-disciplinary teams to conduct patient aftercare and has launched a platform for improved patient outcomes research. As of year 2022, they support six spina bifida "Centers of Excellence" nationwide and are continuously advocating for primary prevention of spina bifida through mandatory fortification of staple foods in Ethiopia. This paper describes ReachAnother's efforts in Ethiopia in a short interval of time, benefiting numerous patients and families with spina bifida and anencephaly. We document this as a case study for other countries to model where resources are limited and the prevalence of spina bifida and hydrocephalus is high, especially in Asia and Africa.

Pediatric Mortality at Pediatric versus Adult Trauma Centers.

INTRODUCTION: Pediatric trauma centers (PTCs) were created to address the unique needs of injured children with the expectation that outcomes would be improved. However, prior studies to evaluate the impact of PTCs have had conflicting results. Our study was conducted to further clarify this question. We hypothesize that severely injured children ≤ 14 years of age have better outcomes at PTCs and that better survival may be due to higher emergency department (ED) survival rates than at adult trauma centers (ATCs). METHODS: A retrospective analysis of severely injured children (ISS>15) ≤18 years of age entered into the National Trauma Data Bank (NTDB) between 2011 and 2012 was performed. Subjects were stratified into 2 age cohorts; young children (0-14 years) and adolescents (15-18 years). Primary outcomes were emergency department (ED) and in-patient (IP) mortality. Secondary outcomes included in-hospital complications, hospital and ICU length of stay, and ventilator days. Outcome differences were assessed using multilevel logistic and negative binomial regression analyses. RESULTS: A total of 10,028 children were included. Median ISS was 22 (Interquartile range 17-29). Adjusting for confounders on multivariate analysis, children ≤ 14 had lower odds of ED (0.42[CI 0.25-0.71], p=0.001) and IP mortality (0.73[CI 0.5-0.9], p=0.02) at PTCs. There were no differences in odds of ED mortality (0.81 [CI 0.5-1.3], p=0.4) or IP mortality (1.01 [CI 0.8-1.2], p=0.88) for adolescents between centers. There were no differences in complication rates between PTCs and ATCs (OR 0.86 [CI 0.69-1.06], p=1.7) but children were more likely to be discharged to home and have more ICU and ventilator free days if treated at a PTC. CONCLUSION: Young children but not adolescents have better ED survival at PTCs compared to ATCs.Level of Evidence: Level IV, Therapeutic.

Multidrug-resistant NDM-1 Klebsiella outbreak and infection control in endoscopic urology.

UNLABELLED: What's known on the subject? and What does the study add? Since the first case of multidrug-resistant New Delhi metallo-ß-lactamase (NDM-1) Klebsiella and Escherichia coli UTI in January 2008, there have been more reports of cases worldwide. Urology is a specialty uniquely vulnerable to these organisms because the NDM-1 carriers tend to be the common UTI-causing organisms. Further, the nature of the procedures involved in endoscopy in the urinary tract confers the potential for direct exposure and transmission of the organisms that commonly cause UTI. Although decontamination by sterilization of urological endoscopes and surgical instruments is well established in the operating theatre suite, there were no national standardized guidelines for infection control measures with respect to the video camera head in endoscopic urology in the UK. This paper reports the first UK outbreak of NDM-1 Klebsiella UTI, for which the common source of infection was rapidly traced to the endoscopic camera head in the urology theatre, where single-use sterile disposable plastic camera sheaths were not routinely used and the camera head was regularly cleaned with detergent wipes. We found that infection control practices vary across UK urology units. In the context of infection control, we highlight a need for standardized practice in the use of camera sheaths and in the decontamination process for endoscopic video camera heads. Either sterilization or use of single-use sterile disposable plastic camera sheaths with regular cleaning of the camera head using approved disinfectant for all endoscopy work is recommended. OBJECTIVES: • To report the first UK outbreak of NDM-1 Klebsiella, for which the common source of infection was rapidly traced to the endoscopic camera head in the urology theatre, where camera sheathing was not routinely used and the camera head was regularly cleaned with detergent wipes. • To survey the use of camera sheath and infection control practices in endoscopy in urology in the UK. PATIENTS AND METHODS: • A structured questionnaire was conducted via telephone interview with urological theatre sisters/charge nurses from all urological units across the UK. • Data on the use of camera sheath, cleaning practices, type of disinfectant used and choice of prophylactic antibiotics were obtained. RESULTS: • Out of 206 NHS urology units, 158 (77%) units across the UK were surveyed. Forty-one (25.9%) do not use camera sheaths, 16 (10.1%) were used dependent on the consultant's preference, and the remaining 101 (63.9%) routinely used camera sheath. • Twenty-one (13.3%) units clean the camera head only at the end of the operating list and the remainder clean after every case. • The choice of cleaning agent/disinfectant used varied considerably. They are broadly categorised as alcoholic wipes 90 (57%), detergent wipes 46 (29.1%) and soapy water 21 (13.3%). • The choice of prophylactic antibiotic includes gentamicin alone (96.3%), augmentin alone (1.4%), gentamicin/amoxicillin (0.7%) and cefuroxime alone (0.7%). CONCLUSIONS: • In the context of infection control, we highlight the need for a standardized practice in the use of camera sheaths and the process of decontamination of the endoscopic camera head. • Either sterilization or use of single-use sterile disposable plastic camera sheath with regular cleaning of the camera head using approved disinfectant for all endoscopy work is recommended.

Are general surgeons behind the curve when it comes to disaster preparedness training? A survey of general surgery and emergency medicine trainees in the United States by the Eastern Association for the Surgery for Trauma Committee on Disaster Preparedness.

PURPOSE: We think that general surgeons are underprepared to respond to mass casualty disasters. Preparedness education is required in emergency medicine (EM) residencies, yet such requirements are not mandated for general surgery (GS) training programs. We hypothesize that EM residents receive more training, consider themselves better prepared, and are more comfortable responding to disaster events than are GS residents. METHODS: From February to May 2009, the Eastern Association for the Surgery of Trauma-Committee on Disaster Preparedness conducted a Web-based survey cataloging training and preparedness levels in both GS and EM residents. Approximately 3000 surveys were sent. Chi-squared, logistic regression, and basic statistical analyses were performed with SAS. RESULTS: Eight hindered forty-eight responses were obtained, GS residents represented 60.6% of respondents with 39% EM residents, and four residents did not respond with their specialty (0.4%). We found significant disparities in formal training, perceived preparedness, and comfort levels between resident groups. Experience in real-life disaster response had a significant positive effect on comfort level in all injury categories in both groups (odds ratio, 1.3-4.3, p < 0.005). CONCLUSION: This survey confirms that EM residents have more disaster-related training than GS residents. The data suggest that for both groups, comfort and confidence in treating victims were not associated with training but seemed related to previous real-life disaster experience. Given wide variations in the relationship between training and comfort levels and the constraints imposed by the 80-hour workweek, it is critical that we identify and implement the most effective means of training for all residents.

Developmental progress and creatine restoration upon long-term creatine supplementation of a patient with arginine:glycine amidinotransferase deficiency.

BACKGROUND: Arginine:glycineamidinotransferase (AGAT/GATM) deficiency has been described in 9 patients across 4 families. Here we describe the clinical outcome and response to creatine supplementation in a patient of the second family affected with AGAT deficiency-a 9-year-old girl. PATIENT AND METHODS: Delayed motor milestones were noticed from 4 months of age and at 14 months moderate hypotonia, developmental delay and failure to thrive. Laboratory studies revealed low plasma creatine as well as extremely low levels of guanidinoacetic acid in urine and plasma. Proton magnetic resonance spectroscopy (MRS) of the brain showed absence of creatine. DNA sequence analysis revealed a homozygous mutation (c.484+1G>T) in the AGAT/GATM gene. AGAT activity was not detectable in lymphoblasts and RNA analysis revealed a truncated mRNA (r.289_484del196) that is degraded via Nonsense Mediated Decay. At 16 months, Bayley's Infant Development Scale (BIDS) showed functioning at 43% of chronologic age. Oral creatine supplementation (up to 800 mg/kg/day) was begun. RESULTS: At age 9 years she demonstrated advanced academic performance. Partial recovery of cerebral creatine levels was demonstrated on MRS at 25 months of age. Brain MRS at 40 months of age revealed a creatine/NAA ratio of about 80% of that in age-matched controls. CONCLUSIONS: 8 years post initiation of oral creatine supplementation, patient demonstrates superior nonverbal and academic abilities, with average verbal skills. We emphasize that early diagnosis combined with early treatment onset of AGAT deficiency may lead to improvement of developmental outcome.

Ropivacaine continuous wound infusion versus epidural morphine for postoperative analgesia after cesarean delivery: a randomized controlled trial.

BACKGROUND: The infusion of local anesthetic in the surgical wound is helpful in the multimodal management of postoperative pain. We hypothesized that local anesthetic wound infusion after cesarean delivery would provide better pain control than epidural morphine analgesia. METHODS: Healthy, term women scheduled for elective cesarean delivery were included in this assessor-blinded, randomized study. Patients were randomly assigned to receive analgesia through a multiorifice wound catheter placed below the fascia and connected to a 5 mL/h ropivacaine 2 mg/mL infusion or an epidural bolus of morphine 2 mg every 12 hours. Both analgesic regimens were continued for 48 hours. The primary outcome was pain at rest at 24 hours postoperatively using the verbal rating score for pain (0-10 scale). Pain intensity, rescue analgesia consumption, and side effects were assessed at 2, 6, 24, and 48 hours after cesarean delivery by an observer blinded to group allocation. Three months after discharge, patient satisfaction, residual pain, and surgical wound complications were assessed. RESULTS: Fifty-eight women participated in the study. At 24 hours, the median rest verbal rating score for pain was 0 (interquartile range: 0-0) in the continuous infusion group and 3 in the epidural morphine group (interquartile range: 2-3; 95% confidence interval of difference: 1-3 units; P < 0.001). The median scores of the 2-, 6-, and 48-hour pain assessments at rest were also lower in the continuous wound infusion group than in the epidural morphine group, and at 2, 6, and 24 hours with movement (P < 0.001). The incidence of nausea, vomiting, pruritus, and urinary retention was significantly lower in the wound infusion group and time to recovery of bowel function was shorter. During the 48-hour follow-up evaluation, the median number of nurse visits attributed exclusively to the analgesic regimen was 1 (interquartile range: 1-2) in the continuous wound infusion group and 8 (interquartile range: 7-10) in the epidural morphine group (95% confidence interval of difference: 6-8 visits; P < 0.001). CONCLUSIONS: Continuous wound infusion with ropivacaine for 48 hours after cesarean delivery was associated with better analgesia, a lower incidence of side effects, less need for nursing care, and shorter duration of stay compared with epidural morphine analgesia.

The relationship between annual hospital volume of trauma patients and in-hospital mortality in New York State.

BACKGROUND: Several studies in the literature have examined the volume-outcome relationship for trauma, but the findings have been mixed, and the associated impact of the trauma center level has not been examined to date. The purposes of this study are to (1) determine whether there is a significant relationship between the annual volume of trauma inpatients treated in a trauma center (with "patients" defined in multiple ways) and short-term mortality of those patients, and (2) examine the impact on the volume-mortality relationship of being a Level I versus Level II trauma center. METHODS: Data from New York's Trauma Registry in 2003 to 2006 were used to examine the impact of total trauma patient volume and volume of patients with Injury Severity Score (ISS) of at least 16 on in-hospital mortality rates after adjusting for numerous risk factors that have been demonstrated to be associated with mortality. RESULTS: The adjusted odds of in-hospital mortality patients in centers with a mean annual volume of less than 2,000 patients was significantly higher (adjusted odds ratio = 1.46, 95% confidence interval, 1.25-1.71) than the odds for patients in higher volume centers. The adjusted odds of mortality for patients in centers with an American College of Surgeons-recommended annual volume of less than 240 patients with an ISS of at least 16 was 1.41 times as high (95% confidence interval, 1.17-1.69) as the odds for patients in higher volume centers. However, for both volume cohorts analyzed, the variation in risk-adjusted in-hospital mortality rate was greater among centers within each volume subset than between these volume subsets. CONCLUSION: When considering the trauma system as a whole, higher total annual trauma center volume (2,000 or higher) and higher volume of patients with ISS ≥16 (240 and higher) are significant predictors of lower in-hospital mortality. Although the American College of Surgeons-recommended 1,200 total volume is not a significant predictor, hospitals in New York with ISS ≥16 volumes in excess of 240 also have total volumes in excess of 2,000. However, when considering individual trauma centers, high volume centers do not consistently perform better than low volume centers. Thus, despite the association between volume and mortality, we believe that the most accurate way to assess trauma center performance is through the use of an accurate, complete, comprehensive database for computing center-specific risk-adjusted mortality rates, rather than volume per se.

Myocardial infarction in the 31st week of pregnancy--case report.

BACKGROUND AND OBJECTIVES: The occurrence of acute myocardial infarction (AMI) during pregnancy is rare. The authors describe the case of MI in a 31-week pregnant woman and the importance of a multidisciplinary team for its approach. CASE REPORT: Thirty-one week pregnant woman with history of smoking, alcoholism and hypertension was admitted after an episode of syncope. On admission she was conscious and asymptomatic, although hypotensive. The electrocardiogram showed marked ST-segment elevation in D1, aVL, V1-V6. The cardiac enzymes were positive. The transthoracic echocardiogram showed reduction in septal and left ventricular contractility and an ejection fraction of 30%. Angiography revealed proximal occlusion of the left anterior descending artery. After a non-successful balloon angioplasty, a metallic stent was placed. The patient started therapy with beta-blockers, aspirin and clopidogrel. As for the delivery, we chose to perform a cesarean section four weeks after MI. Clopidogrel was suspended seven days before delivery. The preoperative cardiac function was improved by infusion of levosimendan started the day before. Cesarean section occurred under epidural block. The intraoperative period showed no complications, except for mild hypotension easily corrected with phenylephrine. The Apgar score for the newborn was 9/10. CONCLUSIONS: This is one of the few cases of myocardial infarction and angioplasty reported during pregnancy. The authors discuss the decisions taken by the multidisciplinary team consisting of anesthesiologists, obstetricians, neonatologists and cardiologists, particularly with regard to dual antiplatelet therapy, the type of delivery and anesthesia.

Infarto agudo do miocárdio na 31ª semana de gravidez: relato de caso / Myocardial infarction in the 31st week of pregnancy: case report

JUSTIFICATIVA E OBJETIVOS: A ocorrência de infarto agudo do miocárdio (IAM) durante a gravidez é rara. Os autores descrevem o caso de IAM numa grávida de 31 semanas e a importância da existência de uma equipe multidisciplinar para sua abordagem. RELATO DO CASO: Grávida de 31 semanas, com antecedentes de tabagismo, alcoolismo e hipertensão, internada após um episódio de síncope. Na admissão, encontrava-se consciente e assintomática, embora hipotensa. O eletrocardiograma evidenciou marcada elevação do segmento ST em DI, AVL, V1-V6. Pesquisa de enzimas cardíacas foi positiva. O ecocardiograma transtorácico demonstrou redução da contratilidade ventricular esquerda e septal e uma fração de ejeção de 30 por cento. A angiografia revelou oclusão proximal da artéria descendente anterior. Por insucesso da angioplastia por balão, foi colocado um stent metálico. A paciente iniciou terapêutica com b-bloqueadores, aspirina e clopidogrel. Em relação ao parto, optou-se por realizar cesariana eletiva, quatro semanas após o IAM. Suspendeu-se o clopidogrel sete dias antes do parto. A função cardíaca pré-operatória foi otimizada com infusão de levosimendana iniciada no dia anterior. A cesariana decorreu sob bloqueio peridural. O período intraoperatório decorreu sem complicações, à exceção de moderada hipotensão facilmente corrigida com fenilefrina. O índice de Apgar do recém-nascido foi de 9/10. CONCLUSÕES: Este é um dos poucos casos de infarto agudo do miocárdio e angioplastia descritos durante a gravidez. Os autores discutem as decisões tomadas pela equipe multidisciplinar, constituída por anestesiologistas, obstetras, cardiologistas e neonatologistas, notadamente no que se refere à dupla antiagregação plaquetária, ao tipo de parto e à anestesia.

BACKGROUND AND OBJECTIVES: The occurrence of acute myocardial infarction (AMI) during pregnancy is rare. The authors describe the case of MI in a 31-week pregnant woman and the importance of a multidisciplinary team for its approach. CASE REPORT: Thirty-one week pregnant woman with history of smoking, alcoholism and hypertension was admitted after an episode of syncope. On admission she was conscious and asymptomatic, although hypotensive. The electrocardiogram showed marked ST-segment elevation in D1, aVL, V1-V6. The cardiac enzymes were positive. The transthoracic echocardiogram showed reduction in septal and left ventricular contractility and an ejection fraction of 30 percent. Angiography revealed proximal occlusion of the left anterior descending artery. After a non-successful balloon angioplasty, a metallic stent was placed. The patient started therapy with beta-blockers, aspirin and clopidogrel. As for the delivery, we chose to perform a cesarean section four weeks after MI. Clopidogrel was suspended seven days before delivery. The preoperative cardiac function was improved by infusion of levosimendan started the day before. Cesarean section occurred under epidural block. The intraoperative period showed no complications, except for mild hypotension easily corrected with phenylephrine. The Apgar score for the newborn was 9 / 10. CONCLUSIONS: This is one of the few cases of myocardial infarction and angioplasty reported during pregnancy. The authors discuss the decisions taken by the multidisciplinary team consisting of anesthesiologists, obstetricians, neonatologists and cardiologists, particularly with regard to dual antiplatelet therapy, the type of delivery and anesthesia.

JUSTIFICATIVA Y OBJETIVOS: El aparecimiento del infarto agudo del miocardio (IAM), durante el embarazo es raro. Los autores describen el caso de IAM en una mujer embarazada de 31 semanas y la importancia de la existencia de un equipo multidisciplinario para su abordaje. RELATO DEL CASO: Embarazada de 31 semanas, con antecedentes de tabaquismo, alcoholismo e hipertensión, que fue ingresada después de presentar un episodio de síncope. A su llegada, estaba consciente y asintomática, aunque hipotensa. El electrocardiograma mostró una fuerte elevación del segmento ST en DI, AVL, V1-V6. La enzimología cardíaca fue positiva. El ecocardiograma transtorácico acusó una reducción en la contratilidad ventricular izquierda y septal, y una fracción de eyección del 30 por ciento. La angiografía reveló la oclusión proximal de la arteria descendiente anterior. Ya que la angioplastia por balón no tuvo éxito, se colocó un stent metálico. La paciente inició terapéutica con b-bloqueantes, aspirina y clopidogrel. Con relación al parto, se optó por realizar la cesárea electiva 4 semanas después del IAM. Se suspendió el clopidogrel siete días antes del parto. La función cardíaca preoperatoria se optimizó con infusión de levosimedan iniciada el día anterior. La cesárea transcurrió bajo el bloqueo epidural. El período intraoperatorio transcurrió sin complicaciones, con excepción de una moderada hipotensión fácilmente corregida con fenilefrina. El índice de Apgar del recién nacido fue de 9/10. CONCLUSIONES: Este es uno de los pocos casos de infarto agudo del miocardio y angioplastia descritos durante el embarazo. Los autores discuten las decisiones tomadas por el equipo multidisciplinario, que estaba constituido por anestesiólogos, obstetras, cardiólogos y neonatólogos, en lo que se refiere a la doble antiagregación plaquetaria, al tipo de parto y a la anestesia.

Wheelchair ramp navigation in snow and ice-grit conditions.

OBJECTIVE: To explore manual wheelchair propulsion strategies for ramp ascent and descent in snow and snow-ice-grit conditions. DESIGN: Cross-sectional study. SETTING: Climatic Engineering and Testing Chamber (Ottawa, Canada). PARTICIPANTS: Manual wheelchair users (N=11) who typically self-propel their wheelchair in winter. INTERVENTIONS: Ramp ascent and descent at 3 grades (1:10, 1:12, 1:16) and 2 winter conditions (packed snow, packed snow with a freezing rain cover, and traction grit). MAIN OUTCOMES MEASURES: Type of ascent and descent strategy, success rate, number and severity of obstructions, average speed, and perceived ramp navigation rating. A questionnaire regarding the subject's past experiences with wheelchair propulsion in winter. RESULTS: Snow accumulation on ramps at 1:10 grade will render the ramp inaccessible for many wheelchair users who do not have external assistance. For snow conditions, the transition area from the level group to the first 2m of ramp incline were the most difficult to traverse for both ascent and descent. All subjects were able to ascend and descend the ramp for the ice-grit condition. Two-railing propulsion is a preferred strategy for ice-grit ramp navigation because of enhanced trajectory control and reducing the potential for wheel-slip problems. Backwards ramp ascent was a successful strategy for ascent in soft-snow conditions. CONCLUSIONS: The 1:16 grade is preferred for winter ramp navigation. Backwards ramp ascent for snow conditions should be considered for people with sufficient shoulder and trunk range of motion. Two handrails are recommended for exterior ramps for both propulsion and wheelchair extraction from ruts and other snow-related obstacles. For ice ramp navigation, the amount of grit required and the effective time (ie, time to when grit becomes embedded in snow-ice, becoming much less effective) should be addressed in further research. Front wheels typically available with manual wheelchairs are not appropriate for soft-snow conditions.

Designing a tobacco counter-marketing campaign for African American youth.

The objectives of this qualitative study were to: a) identify common marketing themes and tactics used by the tobacco industry to entice African Americans (AA's) and youth to initiate and maintain smoking behavior, especially smoking mentholated brands of cigarettes, and b) determine AA youths' knowledge, attitudes, intentions, and beliefs about smoking and the tobacco industry. Together, these activities could aid in the development of effective tobacco counter-marketing campaigns for AA youth. Using publicly available tobacco industry documents, computerized searches using standardized keywords were run and results were cataloged and analyzed thematically. Subsequently, 5 focus groups were conducted with n = 28 AA middle school-aged youth. Results suggest that the tobacco industry consistently recruited new AA smokers through a variety of means, including social and behavioral marketing studies and targeted media and promotional campaigns in predominantly AA, urban, and low income areas. AA youth interviewed in this study were largely unaware of these tactics, and reacted negatively against the industry upon learning of them. Youth tended to externalize control over tobacco, especially within the AA community. In designing a counter-marketing campaign for this population, partnering knowledge of tobacco industry practices with youth needs and community resources will likely increase their effectiveness.

Disasters and mass casualties: II. explosive, biologic, chemical, and nuclear agents.

Terrorists' use of explosive, biologic, chemical, and nuclear agents constitutes the potential for catastrophic events. Understanding the unique aspects of these agents can help in preparing for such disasters with the intent of mitigating injury and loss of life. Explosive agents continue to be the most common weapons of terrorists and the most prevalent cause of injuries and fatalities. Knowledge of blast pathomechanics and patterns of injury allows for improved diagnostic and treatment strategies. A practical understanding of potential biologic, chemical, and nuclear agents, their attendant clinical symptoms, and recommended management strategies is an important prerequisite for optimal preparation and response to these less frequently used agents of mass casualty. Orthopaedic surgeons should be aware of the principles of management of catastrophic events. Stress is less an issue when one is adequately prepared. Decontamination is essential both to manage victims and prevent further spread of toxic agents to first responders and medical personnel. It is important to assess the risk of potential threats, thereby allowing disaster planning and preparation to be proportional and aligned with the actual casualty event.

Disasters and mass casualties: I. General principles of response and management.

Disaster planning and response to a mass casualty incident pose unique demands on the medical community. Because they would be required to confront many casualties with bodily injury and surgical problems, surgeons in particular must become better educated in disaster management. Compared with routine practice, triage principles in disasters require an entirely different approach to evaluation and care and often run counter to training and ethical values. An effective response to disaster and mass casualty events should focus on an "all hazards" approach, defined as the ability to adapt and apply fundamental disaster management principles universally to any mass casualty incident, whether caused by people or nature. Organizational tools such as the Incident Command System and the Hospital Incident Command System help to effect a rapid and coordinated response to specific situations. The United States federal government, through the National Response Plan, has the responsibility to respond quickly and efficiently to catastrophic incidents and to ensure critical life-saving assistance. International medical surgical response teams are capable of providing medical, surgical, and intensive care services in austere environments anywhere in the world.

Effect of vowel type on reliability of nasality ratings.

UNLABELLED: This study investigated the effects of high front (HF) vowels and low back (LB) vowels on inter-listener and intra-listener reliability in rating hypernasality. Audio recorded samples of two sentences, one containing only high front vowels and one containing only low back vowels, were judged by two expert listeners. Speakers were 25 children; 20 hypernasal and 5 with normal resonance. The inter-listener ratings for LB samples were more similar than the inter-listener ratings for HF samples (t=3.20, (24), p=.004). The mean difference between the two listeners' ratings for the LB samples was 46.32 (S.D. 49.66) and for the HF samples 85.39 (S.D. 85.81). For intra-listener reliability, the ratings for the LB vowels were significantly more similar for one listener but not for the other. Additionally, the HF samples were rated as significantly more nasal than the LB samples. These findings suggest that listener reliability can be influenced by the vowel content of the stimulus. LEARNING OUTCOMES: As a result of this activity, the participant will be able to (1) describe the general effects of phonemes on judgments of hypernasality; (2) describe the specific effects of vowel types on the reliability of inter-listener and intra-listener judgments of nasality; and (3) appreciate how this information might be used in clinical and research applications.

Triage and outcome of patients with mediastinal penetrating trauma.

BACKGROUND: A retrospective study was conducted detailing an experience with echocardiography and contrast-enhanced helical computed tomographic angiographic (CTA) scans in the evaluation of stable patients with mediastinal penetrating trauma (MPT). METHODS: Unstable patients underwent emergent operative intervention, and stable patients underwent chest roentgenogram, transthoracic echocardiography (TTE), and CTA. Further testing (angiogram, bronchoscopy, esophagoscopy, esophagogram) was done only if one of these studies revealed evidence of a trajectory in the vicinity of major vasculature or viscera. RESULTS: Between 1997 and 2003, 207 patients had MPT. Seventy-two (35%) were unstable (45 gun shot wounds, 27 stab wounds) and 19 died in the emergency department. Fifty-three had emergent intervention and 32 survived. Work-up was done on 135 stable patients (65%) consisting of 46 gunshot wounds and 89 stab wounds, of which 5 had a positive TTE result and underwent a repair of a cardiac injury. CTA evaluation was normal in almost 80% of patients, who subsequently did not require further evaluation or treatment. In the stable patients, endoscopy or esophagography confirmed one tracheal injury and no esophageal injury. In the entire group, 10 patients (7%) had occult injury, and there were no deaths or missed injuries. CONCLUSIONS: In cases of MPT, unstable patients require surgery, and in stable patients, TTE and chest CTA are effective screening tools. Patients with a negative TTE and CTA results can be observed and may not require further testing or endoscopy, whereas patients with positive TTE or CTA results require further assessment to exclude occult injury.

An update on the surgeons scope and depth of practice to all hazards emergency response.

This article outlines the position of The Eastern Association of the Surgery of Trauma (EAST) in defining the role of surgeons, and specifically trauma/critical care surgeons, in the development of public health initiatives that are designed to react to and deal effectively with acts of terrorism. All aspects of the surgeon's role in response to mass casualty incidents are considered, from prehospital response teams to the postevent debriefing. The role of the surgeon in response to mass casualty incidents (MCIs) is substantial in response to threats and injury from natural, unintentional, and intentional disasters. The surgeon must take an active role in pre-event community preparation in training, planning, and executing the response to MCI. The marriage of initiatives among Departments of Public Health, the Department of Homeland Security, and existing trauma systems will provide a template for successful responses to terrorist acts.

Geographic and socioeconomic variation in meningococcal disease: a rural/urban comparison.

OBJECTIVES: To examine the incidence of meningococcal disease in a defined geographic area and relate this to rural/urban residence and material deprivation. METHODS: Retrospective review of statutory notifications, laboratory records and death registrations from 1 January 1996 through 31 December 2001 in an English health area. Incidence of disease was analysed in two populations residing within the area, one rural and one urban. Deprivation was measured using the Townsend material deprivation score. RESULTS: Altogether, 183 cases of meningococcal disease were identified. Average annual incidence was significantly higher (P=0.019) in the urban area (8.8/10(5)) compared to the rural area (6.2/10(5)). In 1996, the relative risk (RR) was greater in the urban area (RR 3.20 95% CI 1.40-7.32) compared to the rural area. During the study period a significant upward trend in disease incidence in the rural area (chi2 for trend P=0.018) was identified whereas a non-significant decrease was observed in the urban area. In the urban area, but not in the rural area, increasing deprivation was strongly associated with increasing disease incidence (chi2 for trend P=0.00010). CONCLUSIONS: Meningococcal disease places a disproportionate disease burden on certain populations. Further research is required to identify measures to address the inequalities identified.