Between the devil and the deep blue sea: A review of 25 modern naval mass casualty incidents with implications for future Distributed Maritime Operations.

ABSTRACT: In the future, United States Navy Role 1 and Role 2 shipboard medical departments will be caring for patients during Distributed Maritime Operations in both contested and noncontested austere environments; likely for prolonged periods of time. This literature review examines 25 modern naval mass casualty incidents over a 40-year period representative of naval warfare, routine naval operations, and ship-based health service support of air and land operations. Challenges, lessons learned, and injury patterns are identified to prepare afloat medical departments for the future fight. LEVEL OF EVIDENCE: Literature Review, level V.

Natural Oregano Essential Oil May Replace Antibiotics in Lamb Diets: Effects on Meat Quality.

A study was conducted to investigate the effect of oregano essential oil (OEO) and monensin sodium on the oxidative stability, colour, texture, and the fatty acid profile of lamb meat (m. Longissimus lumborum). Twenty Dorper x Pelibuey lambs were randomly divided into five treatments; control (CON), monensin sodium (SM, Rumensin 200® 33 mg/kg), a low level of OEO (LO, 0.2 g/kg dry matter (DM)), a medium level of OEO (MO, 0.3g/ kg DM), and a high level of OEO (HO, 0.4 g/kg DM). Dietary supplementation of OEO at any concentration lowered the compression strength in comparison with CON and SM. MO had the highest a* values (7.99) and fatty acid concentration (C16:1n7, C18:1n9c, C18:1n6c, C20:1n9, and C18:2n6c) during storage for 7 d at 3 °C. Lipid oxidation was not promoted (p > 0.05) by the moderated supplementation of oregano essential oil; however, OEO at 0.3 g/kg DM showed a slight lipid pro-oxidant effect. Dietary supplementation of MO and SM had the same effect on colour, tenderness, and the fatty acid profile of lamb (L. lumborum). It was demonstrated that oregano essential oil was beneficial for lambs feeding, and it could be a natural alternative to replace monensin in lamb diets with improvements in the quality of the meat.

Remediation of an oil-contaminated soil by two native plants treated with biochar and mycorrhizae.

Soil contamination by petroleum compounds threatens the health of soil and water resources. This research was conducted with the objective of reaching an efficient technique for the removal or reduction of harmful effects caused by total petroleum hydrocarbons (TPH) in soils. In a greenhouse experiment, the effect of biochar (B), mycorrhizae (M) and combination of mycorrhizae and biochar (M + B) on the growth of two native species; clover (Trifolium arvense) and mallow (Malva sylvestris L.), and removal efficiency of TPH (16.79 mg kg-1) from an oil-contaminated soil were studied. The plant analyses after 50 days of growth period showed a significant (p ≤ 0.05) increase in shoot dry weight of mallow in B and M + B treatments but no significant effect was observed for clover compared to the control (C). The initial TPH concentration, determined by gas chromatography technique was reduced from 9.4% in unplanted soil until 56.4% (clover) and 55.9% (mallow) in M + B treatment. The relative concentration of long chain alkanes (LCAs) were also reduced when treatments were applied, in which the highest and lowest reductions was found in C21-C25 and C11-C15, respectively, though octacosane (C28) was increased or unchanged in soil. This result suggests that likely the occurrence of C28 in the mycorrhizal hyphae or the higher removal of the other alkanes increase octacosane relative concentration in soil, which more research is necessary.

Atmospheric dust characterisation in the mining district of Cartagena-La Unión, Spain: Air quality and health risks assessment.

Nowadays, air pollution has a major impact on the environment and human health. Owen gauges allow the sampling of atmospheric depositions in polluted sites for further characterisation. This paper shows the study of the air particles of an old mining zone in Cartagena-La Unión (South-east of Spain) in order to quantify their potential risk on human health. There were 4 strategic sites monitored: the main mining tailing (Avenque), the urban area (La Unión), an agricultural zone (formerly mining) and a site in the Mediterranean coast. Physico-chemical and mineralogical characterisation was applied to atmospheric fallouts. The granulometry revealed a dust particle size around 15 µm, with the coarsest particles in the urban area and the thinnest at the tailing site. XRD analyses showed the presence of quartz, carbonates, sulphides and sulphates. Observations with SEM-EDX confirmed chemical spectra and allowed us to classify the particles into well-crystallised minerals and heterogeneous dusts. Total metal content determination was carried out by ICP-MS analyses and results showed Zn, Pb, As and Cd fluxes (respectively 2549, 1275, 68 and 7 µg·m-2·d-1) exceeding the limit values set by European legislations in the mining area. The fluxes of Zn, Pb and As also exceed these standards in the urban area whereas the coastal zone only exceeds the thresholds in the case of As. Inhalation health risk (defined by US EPA, 2009) was quantified in the sites using total and bioaccessible metal contents of the dusts. Risk calculations using total metal content considering a residential scenario showed acceptable risk for all sites except for the mining tailing which presented non-acceptable cancer and hazard risk mainly due to the total As and Pb contents. When considering the bioaccessible fraction of As and Pb, the risk diminished to acceptable values, demonstrating the overestimation produced when using total metal contents.

Greenhouse gas emissions and soil organic matter dynamics in woody crop orchards with different irrigation regimes.

Water scarcity in arid, semiarid and dry regions is a limiting factor for the development of sustainable agriculture. As a consequence, the adoption of new strategies such as regulated deficit irrigation (RDI) to reduce water and energy consumption will be essential. Decreases in irrigation water content may also have positive effects on soil C cycle. Thus, an experiment was setup in three woody crop orchards during two years, with the objective of assessing if RDI can reduce soil CO2 and N2O emissions, modify soil inorganic C and organic C quality and stability and affect soil aggregation. Soil CO2 and N2O emissions were measured every two weeks while soil samplings were carried out every three months. Results indicated that decreases in soil moisture by RDI implementation were related to significant decreases in CO2 emissions in all crops. RDI contributed to an average decrease, compared with full irrigation, of 1088-1664 g CO2 m-2 in the experimental period. Furthermore, CO2 emission was negatively correlated with inorganic C, suggesting the protective effect of soil carbonates towards organic matter. RDI also contributed to significantly decrease soil N2O emissions. However, N2O emission patterns did not directly follow soil moisture patterns and were constant in the experimental period. RDI contributed to an average decrease, compared with full irrigation, of 90-409 mg N2O m-2. No physicochemical property was significantly affected by irrigation regime. Although microbial biomass was not significantly affected by RDI, ß-glucosidase activity was significantly higher under full irrigation during the warm seasons, with significant positive correlation with CO2 emissions. This seems to suggest that a significant fraction of CO2 emitted from soil derives from organic matter degradation, which is limited with low water content. So, RDI could contribute to promote soil C sequestration by reduced greenhouse gas emissions, with no negative effects on soil structure at short-term.

Hidrocefalia ligada al cromosoma X o síndrome de Bickers-Adams: presentación de un caso / X-linked hydrocephalus or Bickers-Adams syndrome: a case presentation

Introducción: la hidrocefalia es una enfermedad con transmisión recesiva ligada al cromosoma X, y una tasa de recurrencia del 50 por ciento en los fetos masculinos. Es la forma más común genética de hidrocefalia congénita, con una incidencia de 1 / 30, 000 nacimientos de varones. Se caracteriza por la dilatación de los ventrículos laterales y el retraso mental, suelen ser graves. Caso clínico: recién nacido que al momento de su nacimiento se observa con macrocefalia evidente con antecedente familiar de un primo con el mismo problema, con igual cuadro clínico y la misma neuroimagen por lo que se diagnosticó una hidrocefalia ligada al cromosoma X. Conclusiones: el caso que se presentó por sus características clínicas y el estudio de scanner cerebral se pudo llegar a un diagnóstico de hidrocefalia ligada al cromosoma X o llamado síndrome de Bickers-Adams.

Introduction: hydrocephalus (HL) is a recessive transmission disease linked to X- chromosome. It presents a 50 % recurrence rate in male fetuses. It is the commonest form of congenital hydrocephalus, with an incidence of 1/30 000 male births. It is characterized by dilation of lateral ventricles and mental retardation, usually severe. Clinical case: a newborn at birth is observed with evident macrocephaly with a family history of a cousin with the same problem. X-linked hydrocephalus (HLX) was diagnosed. Conclusions: a case of X- linked hydrocephalus or Bickers-Adams syndrome was presented, diagnosed by their clinical characteristics and brain scanner study.

Caracterización clínica, epidemiológica y terapéutica de pacientes con infarto agudo del miocardio / Clinical, epidemiological and therapeutic characterization of patients with acute myocardial infarction

Se efectuó un estudio descriptivo y transversal de 140 pacientes con infarto agudo del miocardio egresados de la Unidad de Cuidados Intensivos del Hospital Clinicoquirúrgico Docente "Dr. Joaquín Castillo Duany" de Santiago de Cuba, desde enero del 2010 hasta diciembre del 2011, a fin de caracterizarles según aspectos clinicoepidemiológicos y terapéuticos. Entre las variables analizadas figuraron: edad, sexo, factores de riesgo asociados, topografía, gradación de Killip y Kimball, complicaciones, tratamiento trombolítico y estado al egreso. En la casuística predominaron el sexo masculino, el grupo etario de 60-69 años y el infarto de cara anterior. Los factores de riesgo más frecuentes fueron la hipertensión arterial (60,0 %), la cardiopatía isquémica previa (44,3 %) y el hábito de fumar (30,0 %). Aunque hubo dificultades en la aplicación de la trombolisis, la mayoría de los afectados (85,7 %) egresaron con vida.

A descriptive and cross-sectional study of 140 patients with acute myocardial infarction discharged from the Intensive Care Unit of "Dr. Joaquín Castillo Duany" Teaching Clinical Surgical Hospital in Santiago de Cuba was carried out from January, 2010 to December, 2011, in order to characterize them according to clinical, epidemiological and therapeutic aspects. Among the analyzed variables there were: age, sex, associated risk factors, topography, Killip and Kimball gradation, complications, thrombolytic treatment and state at discharge. Male sex, the age group 60-69 years and the heart attack of anterior aspect prevailed in the case material. The most frequent risk factors were hypertension (60.0 %), the previous ischemic cardiopathy (44.3 %) and the smoking habit (30.0 %). Although there were difficulties in the application of the thrombolysis, most of those affected (85.7 %) were discharged alive.

Surgical resident and attending physician attitudes toward glucose control in the surgical patient.

Hyperglycemia is a common occurrence in postoperative surgical patients and has been related to adverse outcomes, including increased infections, delayed wound healing, and increased postoperative mortality. Therefore, the management of hyperglycemia has become an increasingly important part of surgical practice. A 16-point questionnaire was distributed to general surgery housestaff and attending physicians at three teaching hospitals in southern California. The survey was scaled 1 to 5 (1, strongly disagree; 5, strongly agree). Answers of 1 and 2 were considered a negative response, whereas 4 and 5 were considered affirmative responses. There were 105 survey respondents (60 surgical residents, 45 surgical attendings). Only half of respondents were confident in their ability to adequately control blood sugar in their hospitalized patients. Approximately 60 per cent of attendings rely on residents to manage glucose control. Less than half of the attendings (49%) and less than one-third of residents (27%) stated they were current with the latest guidelines for glucose control. Only one-third of the attendings would consult an internist or endocrinologist to assist in glycemic management. This study reveals an important knowledge deficit among surgical resident and attending physicians. Focused education on glycemic control in the perioperative patient should be a mandatory component of surgical training.

Human endometriosis is associated with plasma cells and overexpression of B lymphocyte stimulator.

Endometriosis affects 10-20% of women of reproductive age and is associated with pelvic pain and infertility, and its pathogenesis is not well understood. We used genomewide transcriptional profiling to characterize endometriosis and found that it exhibits a gene expression signature consistent with an underlying autoimmune mechanism. Endometriosis lesions are characterized by the presence of abundant plasma cells, many of which produce IgM, and macrophages that produce BLyS/BAFF/TNFSF13B, a member of the TNF superfamily implicated in other autoimmune diseases. B lymphocyte stimulator (BLyS) protein was found elevated in the serum of endometriosis patients. These observations suggest a model for the pathology of endometriosis where BLyS-responsive plasma cells interact with retrograde menstrual tissues to give rise to endometriosis lesions.

Developing a trauma registry in a forward deployed military hospital: Preliminary report.

BACKGROUND: The 325th Field Surgical Team (FST), a US Army trauma surgical group, was deployed to Afghanistan during Operation Enduring Freedom. Unlike civilian trauma centers, complete trauma registries are lacking from the FST care model. METHODS: A trauma registry was created using a commercially available relational database. Data entry was done using a handheld personal data organizer (PDA). RESULTS: In 82 days, 125 trauma patients were evaluated and treated. The mean age was 23 +/- 11.69 and 85 (68%) were local Afghan nationals. Most patients were transported by helicopter (83; 66%); the remaining arrived by ground transportation (42; 34%). The average US military casualty arrival time from injury was 1 hour 38 minutes +/-46. The most common injury was gunshot wounds 47(38%) and the mean Injury Severity Score was 9, with 29 (23%) patients scoring > or =15. Initial mean vitals were systolic blood pressure (SBP); 119 +/- 23.7, heart rate; 103 +/- 7.35, respiratory rate; 20 +/- 7.35, and temperature (degrees C); 36.6 +/- 1.6. The median Glasgow Coma Scale was 15, and presenting mean hematocrit and base deficit were 35 +/- 9.56 and -5.02 +/- 5.03, respectively. Operative procedures were performed in 54 (43.2%) patients, and the mean time to surgery from admission was 80 +/- 11.5 minutes. The most common operative procedure was debridement or completion of amputation of lost limb debridement and completion of amputations (13). The average length of stay was 4.37 +/- 2.88 days. The mortality rate was 8%. CONCLUSION: The collection of comprehensive prospective data using a PDA can be an efficient and effective method in expanding trauma base registries in forward deployed surgical units.

Surgical complications and causes of death in trauma patients that require temporary abdominal closure.

Temporary abdominal closure (TAC) has increasingly been employed in the management of severely injured patients to avoid abdominal compartment syndrome (ACS) and as part of damage control surgery (DCS). Although the use of TAC has received great interest, few data exist describing the morbidity and mortality associated with its use in trauma victims. The main goal of this study is to describe the incidence of surgical complications following the use of TAC as well as to define the mortality associated with this procedure. A retrospective review of patients admitted to a state-designated level 1 trauma center from April 2000 to February 2003 was performed. Inclusion criteria were age >18 years, traumatic injury, and need for exploratory laparotomy and use of TAC. A total of 120 patients were included in the study. The overall mortality of trauma patients requiring TAC was 59.2 per cent. The most common causes of death were acute inflammatory process (50.7%), followed by hypovolemic shock (43.7%). The incidence of surgical complications was 26.6 per cent. Intra-abdominal abscesses were the most frequent surgical complication (10%). After multiple logistic regression analysis, increasing age and a numerically greater initial base deficit were found to be independent predictors of mortality in trauma patients that require TAC.

Helical computed tomographic angiography for the diagnosis of traumatic arterial injuries of the extremities.

BACKGROUND: The radiologic study of choice for evaluation of traumatic arterial injuries is conventional arteriography, but it poses the risks of an invasive procedure. Computed tomographic arteriography (CTA) is emerging as a new way to study arterial anatomy, with the additional advantages of being noninvasive and a technique that allows evaluation of different body areas simultaneously. Our experience using CTA for evaluation of traumatic arterial injuries is provided in this study. METHODS: A retrospective review over a 22-month period of all adult patients undergoing CTA for evaluation of traumatic injuries to the extremities was performed. RESULTS: A total of 97 CTA studies were performed in the 95 patients. CTA adequately demonstrated the nature and location of all the arterial injuries when compared with conventional arteriography or surgical exploration. Abnormal CTA results included 21 arterial occlusions, 2 intimal flap defects, and 2 pseudoaneurysms. Nine of these 25 injuries were confirmed by surgery only, 10 by surgery and arteriography, and 6 by arteriography only. Normal CTA results were confirmed with arteriography in 10 cases. No missed injuries were encountered in patients with normal CTA results. CONCLUSION: CTA is a reliable technique for the detection and characterization of traumatic extremity arterial injuries. These results suggest CTA may be an alternative to conventional arteriography for the diagnosis of traumatic arterial injuries.

Lumbar fractures in adult blunt trauma: axial and single-slice helical abdominal and pelvic computed tomographic scans versus portable plain films.

BACKGROUND: Our hypothesis was that abdominal and pelvic computed tomographic (AP-CT) scans are equivalent to portable two-view plain films in detecting lumbar spine fractures in adults. Since many trauma patients often undergo AP-CT scanning to evaluate for possible intra-abdominal injuries, using the AP-CT scan to screen for lumbar fractures could make the trauma evaluation process more efficient. METHODS: The institutional trauma registry at a Level I trauma center was used to identify all blunt lumbar fractures during a 6-year period. Medical records were reviewed. RESULTS: A total of 7,216 adult blunt trauma patients were evaluated, and 115 patients were identified as having a lumbar fracture, for an incidence rate of 1.6%. Missed fracture rates were high for both AP-CT scans (23.2%, 13 of 56) and portable two-view films (12.7%, 14 of 110, = 0.08). Fifty-two patients had both AP-CT scans and plain films. In this group, AP-CT scans missed 23.1% (12 of 52) of the lumbar fractures and plain films missed 15.4% (8 of 52). However, the combination of the two diagnostic methods did not miss any fractures (0 of 52). The missed fractures required surgery or brace in 50% (7 of 14) patients who had fractures missed by plain films and 46% (6 of 13) patients whose fractures were missed by AP-CT scanning. CONCLUSION: Both AP-CT scans and plain films failed to diagnose significant lumbar fractures that required therapy. When screening for lumbar fractures, obtaining both AP-CT scans and portable two-view plain films may decrease missed lumbar fractures in blunt adult trauma.

Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: a multicenter study.

BACKGROUND: Although the use of stapling devices in elective colon surgery has been shown to be as safe as handsewn techniques, there have been concerns about their safety in emergency trauma surgery. The purpose of this study was to compare stapled with handsewn colonic anastomosis following penetrating trauma. METHODS: This was a prospective multicenter study and included patients who underwent colon resection and anastomosis following penetrating trauma. Multivariate logistic regression analysis was used to identify independent risk factors for abdominal complications and compare outcomes between stapled and handsewn repairs. RESULTS: Two hundred seven patients underwent colon resection and primary anastomosis. In 128 patients (61.8%) the anastomosis was performed with handsewing and in the remaining 79 (38.2%) with stapling devices. There were no colon-related deaths and the overall incidence of colon-related abdominal complications was 22.7% (26.6% in the stapled group and 20.3% in the handsewn group, p = 0.30). The incidence of anastomotic leak was 6.3% in the stapled group and 7.8% in the handsewn group (p = 0.69). Multivariate analysis adjusting for blood transfusions, fecal contamination, and type of antibiotic prophylaxis showed that the adjusted odds ratio (OR) of complications in the stapled group was 0.83 (95% CI, 0.38-1.74, p = 0.63). In a second multivariate analysis adjusting for blood transfusions, hypotension, fecal contamination, Penetrating Abdominal Trauma Index, and preoperative delays the adjusted OR in the stapled group was 0.99 (95% CI, 0.46-2.11, p = 0.99). CONCLUSION: The results of this study suggest that the method of anastomosis following colon resection for penetrating trauma does not affect the incidence of abdominal complications and the choice should be surgeon's preference.