Biomedical Research in Times of Emergency: Lessons From History.

Coronavirus disease 2019 (COVID-19) has sickened millions, killed hundreds of thousands, and utterly disrupted the daily lives of billions of people around the world. In an effort to ameliorate this devastation, the biomedical research complex has allocated billions of dollars and scientists have initiated hundreds of clinical trials in an expedited effort to understand, prevent, and treat this disease. National emergencies can stimulate significant investment of financial, physical, and intellectual resources that catalyze impressive scientific accomplishments, as evident with the Manhattan Project, penicillin, and the polio vaccines in the 20th century. However, pressurized research has also led to false promises, disastrous consequences, and breaches in ethics. Antiserum in the 1918 flu epidemic, contaminated yellow fever vaccines in World War II, and unethical human experimentation with mustard gas offer just a few cautionary exemplars. It is critical to continue biomedical research efforts to address this pandemic, and it is appropriate that they receive priority in both attention and funding. But history also demonstrates the importance of treating early results-such as those associated with hydroxychloroquine-with caution as we only begin to understand the biology, epidemiology, and potential target points of COVID-19.

Hippocratic concepts of acute and urgent respiratory diseases still relevant to contemporary medical thinking and practice: a scoping review.

BACKGROUND: The collected works of Hippocrates were searched for concepts on the diagnosis, prognosis, and treatment of acute and urgent respiratory diseases, with the objective to trace their origins in the Hippocratic Collection. METHODS: A scoping review was performed to map out key concepts of acute and severe respiratory diseases in the entire Hippocratic Collection. The digital library Thesaurus Lingua Graeca (TLG) was researched for references in the entire Hippocratic Collection regarding the epidemiology, pathophysiology, prognosis, diagnosis and treatment of acute respiratory diseases; then, the relevant texts were studied in their English translation by the Loeb Classical Library. RESULTS: Hippocratic physicians followed principles of treatment for pneumonia and pleurisy, still relevant, such as hydration, expectoration, analgesia and prompt mobilisation. Other approaches, including the inhalation of "vapours through tubes" in angina, can be considered as forerunners of modern medical practice. Thoracic empyema was diagnosed by shaking the patient and direct chest auscultation after "applying your ear to his sides". In case of an emergency from upper airway obstruction, urgent insertion of primitive airway equipment, such as a small pharyngeal tube, was applied. CONCLUSIONS: The main Hippocratic concepts on four still common acute and urgent respiratory diseases -pneumonia, pleurisy, thoracic empyema and upper airway obstruction- were identified and most of them were found to be in agreement with contemporary medical thinking and practice.

Preparation for the next major incident: are we ready? A 12-year update.

OBJECTIVES: A major incident is any emergency that requires special arrangements by the emergency services and generally involves a large number of people. Recent such events in England have included the Manchester Arena bombing and the Grenfell Tower disaster. Hospitals are required by law to keep a major incident plan (MIP) outlining the response to such an event. In a survey conducted in 2006 we found a substantial knowledge gap among key individuals that would be expected to respond to the enactment of an MIP. We set out to repeat this survey study and assess any improvement since our original report. METHODS: We identified NHS trusts in England that received more than 30 000 patients through the emergency department in the fourth quarter of the 2016/2017 period. We contacted the on-call anaesthetic, emergency, general surgery, and trauma and orthopaedic registrar at each location and asked each individual to answer a short verbal survey assessing their confidence in using their hospital's MIP. RESULTS: Of those eligible for the study, 62% were able to be contacted and consented to the study. In total 50% of respondents had read all or part of their hospital's MIP, 46.8% were confident that they knew where their plan was stored, and 36% knew the role they would play if a plan came into effect. These results show less confidence among middle-grade doctors compared with 2006. CONCLUSIONS: Confidence in using MIPs among specialty registrars in England is still low. In light of this, we make a number of recommendations designed to improve the education of hospital doctors in reacting to major incidents.

Centers for Disease Control and Prevention Public Health Response to Humanitarian Emergencies, 2007-2016.

Humanitarian emergencies, including complex emergencies associated with fragile states or areas of conflict, affect millions of persons worldwide. Such emergencies threaten global health security and have complicated but predictable effects on public health. The Centers for Disease Control and Prevention (CDC) Emergency Response and Recovery Branch (ERRB) (Division of Global Health Protection, Center for Global Health) contributes to public health emergency responses by providing epidemiologic support for humanitarian health interventions. To capture the extent of this emergency response work for the past decade, we conducted a retrospective review of ERRB's responses during 2007-2016. Responses were conducted across the world and in collaboration with national and international partners. Lessons from this work include the need to develop epidemiologic tools for use in resource-limited contexts, build local capacity for response and health systems recovery, and adapt responses to changing public health threats in fragile states. Through ERRB's multisector expertise and ability to respond quickly, CDC guides humanitarian response to protect emergency-affected populations.

Good governance of animal health systems and public-private partnerships: an Australian case study.

The animal health system in Australia has evolved over more than 100 years and includes innovative public-private partnership arrangements. The establishment in 1996 of Animal Health Australia (AHA), a not-for-profit company, was a crucial development which formalised arrangements for shared decision-making and funding across both government and industry stakeholders. However, Federal and State governments retain legislative authority for animal health control. Accordingly, all programmes must recognise that the public sector remains an executive arm of government, accountable for its actions. Hence, much effort has been invested in ensuring that the governance arrangements within AHA are lawful and transparent. The Emergency Animal Disease Response Agreement (EADRA) is a very good example of governance arrangements that are sustainably financed, widely available, provided efficiently, without waste or duplication, and in a manner that is transparent and free of fraud or corruption. The benefits of EADRA include certainty and greater transparency of funding; greater efficiency through increased probability of a rapid response to an occurrence of any of 65 diseases; and industry participation in the management and financing of such a response.

Object-oriented sociology and organizing in the face of emergency: Bruno Latour, Graham Harman and the material turn.

This paper explores the material turn in sociology and the tools it provides for understanding organizational problems highlighted by the Royal Commission into the 2009 'Black Saturday' bushfires during which 173 people died in the Australian State of Victoria. Often inspired by Bruno Latour's material-semiotic sociology of associations, organization scholars employing these tools focus on the messy details of organization otherwise overlooked by approaches assuming a macroscopic frame of analysis. In Latour's approach no object is reducible to something else - such as nature, the social, or atoms - it is instead a stabilized set of relations. A Latourian approach allows us to highlight how the Royal Commission and macroscopic models of organizing do unwitting damage to their objects of inquiry by purifying the 'natural' from the 'social'. Performative elements in their schemas are mistaken for descriptive ones. However, a long standing critique of this approach claims that it becomes its own form of reduction, to nothing but relations. Graham Harman, in his object-oriented philosophy develops this critique by showing that a 'relationist' metaphysics cannot properly accommodate the capacity of 'objects' to cause or mediate surprises. Through our case of the Victorian Bushfires Royal Commission, we argue that a purely relational model of objects loosens a productive tension between the structural and ephemeral that drives sociological analysis. By drawing on elements of Harman's ontology of objects we argue that it is necessary for material-semiotic sociology to retain a central place for the emergence of sociological objects.

The Emergency Use Authorization of Pharmaceuticals: History and Utility During the COVID-19 Pandemic.

The Emergency Use Authorization (EUA) originated in 2004 because of the need for emergency medical countermeasures (MCMs) against potential bioterrorist attacks. The EUA also proved useful in dealing with subsequent pandemics and has emerged as a critical regulatory pathway for therapeutics and vaccines throughout the Coronavirus Disease 2019 (COVID-19) pandemic. With the EUA process in the USA, we witnessed emergency authorizations, their expansions, as well as withdrawal of previously authorized products, which exemplifies the dynamic nature of scientific review of EUA products. EUAs proved vital for the first group of COVID-19 vaccines, including the temporary pause of one vaccine while emergency safety issues were evaluated. Although this review on the EUA is primarily focused on the USA, distinctions were made with other jurisdictions such as Europe and Canada with respect to the emergency authorizations of the vaccines. Finally, we discuss some important differences following EUA and formal new drug/vaccine application (NDA/BLA) approvals.

Surgeons without borders: a brief history of surgery at Médecins Sans Frontières.

Médecins Sans Frontières (MSF) is a humanitarian organization that performs emergency and elective surgical services in both conflict and non-conflict settings in over 70 countries. In 2006 MSF surgeons departed on approximately 125 missions, and over 64,000 surgical interventions were carried out in some 20 countries worldwide. Historically, the majority of MSF surgical projects began in response to conflicts or natural disasters. During an emergency response, MSF has resources to set up major operating facilities within 48 h in remote areas. One of MSF strengths is its supply chain. Large pre-packaged surgical kits, veritable "operating theatres to go," can be readied in enormous crates and quickly loaded onto planes. In more stable contexts, MSF has also strengthened the delivery of surgical services within a country's public health system. The MSF surgeon is the generalist in the broadest sense and performs vascular, obstetrical, orthopaedic, and other specialized surgical procedures. The organization aims to provide surgical services only temporarily. When there is a decrease in acute needs a program will be closed, or more importantly, turned over to the Ministry of Health or another non-governmental organization. The long-term solution to alleviating the global burden of surgical disease lies in building up a domestic surgical workforce capable of responding to the major causes of surgery-related morbidity and mortality. However, given that even countries with the resources of the United States suffer from an insufficiency of surgeons, the need for international emergency organizations to provide surgical assistance during acute emergencies will remain for the foreseeable future.

[Trends in research on the history of medicine in Korea before the modern era].

Research on the history of medicine in Korea in the form of modern scholarship began with the publication in 1930 of Yi Neunghwa's "A History of the Development of Medicine in Korea." The purpose of the present study lies in surveying studies on the history of medicine in Korea in the past 80 years since the publication of Yi's paper. In terms of periodization, research on the history of medicine in Korea is bifurcated by the publication of two comprehensive histories-i. e., Miki Sakae's A History of Medicine and Disease in Korea (1963) and Kim Du-jong's The Complete History of Medicine in Korea (1966). Indeed, all earlier studies converged in these two books. Because Miki and Kim both had majored in Western medicine and conducted research based on similar perspectives, data, and methods, the two works overlap considerably, and Kim's book, as the later of the two, unfortunately lost the initiative to the former to a considerable extent. As a result of these two scholars' research, it became possible to trace the overall flow of the history of medicine in Korea. Following the publication of works by Miki and Kim and with the advent of the 1980's, research on the history of medicine in premodern Korea was renovated with the emergence of no fewer than some dozen new doctoral degree holders in the field. In fact, these young scholars went beyond surveying trends in each era to expand the scope of specific discussions and topics per era, to delve into the actual contents, and to elucidate the function of medicine in society. The fruits of studies conducted in the past 80 years on the history of medicine in premodern Korea can be summarized as follows. 1) before the 5th century AD: the existence of a comprehensive medical practice in regions inhabited by those considered to be the ancestors of the Korean people; and information on medication including ginseng. 2) 5th-10th centuries: the existence of professional medical posts; the management of medicine by the royal household; institutions for medical education; the import and use of Chinese medical texts; the compilation of independent medical texts; the transmission of medical knowledge to Japan; and the import and export of medicinal ingredients. 3) 10th-14th centuries: public medical organs; medicine focusing on domestic medication; the invitation of medical doctors and the transmission of new medicine from Song China; the inclusion of medicine in the civil service examinations; the compilation of diverse types of Korean medical texts including those on native medicinal ingredients; disaster relief organs; regional medical organs; regional medicinal ingredient tribute system; and the state's measures against infectious diseases. 4) 14th-17th centuries: the consolidation of traditional East Asian medicine; the consolidation of Korean medicine including native medicinal ingredients; the emergence of a medical tradition that stresses the Daoist preservation of health ; and the publication of dozens of types of Chinese and Korean medical texts led by the entral and regional governments. Also noteworthy is the emergence of simple medical texts on emergency relief, pregnancy and childbirth, smallpox, and epidemics ( as well as the dissemination of their vernacular editions. In addition, there were phenomena such as the increasing occupation of the posts of medical officials by the non-aristocratic middling jung'in class; the existence of Confucian scholar-physicians and women physicians; and the compilation of texts on independent external medicine. 5) 17th-19th centuries: the formation of medicinal ingredient markets; the spread of pharmacies throughout the provinces; a vogue for Ming Chinese medical texts; veneration for the Treasured Mirror of Eastern Medicine; the emergence of a positivistic stance toward medical research; a vogue for experiential remedies; interest in Western medicine; compilation of several medical texts on measles; criticism of Chinese traditional medicine and/or Korean traditional medicine; the spread of variolation; attempts to introduce smallpox vaccination ; Korean-Japanese medical exchange through the dispatch of Korean goodwill missions to Japan; a great vogue for the Treasured Mirror of Eastern Medicine in both China and Japan; the emergence of independent medical texts on acupuncture; the successful cultivation and massive export of ginseng; and the birth of the Sasang (4-type) constitutional typology, a native medical tradition.

["Crisis"--oscillating between keyword and buzzword. On the discourse about a "crisis of medicine" in the Weimar Republic]. / "Krise"--zwischen Schlüsselbegriff und Schlagwort. Zum Diskurs über eine "Krise der Medizin" in der Weimarer Republik.

The buzzword "crisis" has not only become omnipresent since the recent financial crisis. The term that originated in Ancient Greece underwent several different usages--quantitatively as well as qualitatively; especially in the Weimar Republic, the time period that has long been considered as the crisis era par excellence. Using the discourse about the "crisis of medicine" in the 1920s and the early 1930s as an example, the article attempts to provide a critical reflection on the concept of "crisis". The focus of this article is on the idea's construction, the different semantic usages of "crisis" and the motives of the different authors for their respective rhetorical applications of this term. The analysis of the examined publications on the "crisis of medicine", how they influenced other periods and the reconstruction of their origin show that the semantics of the word "crisis" went far beyond a simply negative connotation, and with regard to its rhetorical usage have oscillated between keyword and a meaningless but catchy buzzword.

Emergency suboccipital decompression for respiratory arrest during supratentorial surgery: the untold story of a surgeon's courage in times of despair.

The odyssey leading to the discovery of herniation syndromes was prolonged due to a lack of early understanding of the underlying pathophysiology. In 1896, Leonard Hill documented transtentorial pressure gradients as the intervening phenomenon involved in uncal herniation. In 1904, James Collier became the first to describe cerebellar tonsillar herniation as a "false localizing sign" often associated with intracranial tumors. During the infancy of neurological surgery, management of increased intracranial pressure and an improved understanding of brain herniation syndromes were of the utmost importance in achieving a safe technique. Harvey Cushing provided seminal contributions in understanding the pathophysiology of increased intracranial pressure and resulting cardiopulmonary effects. Cushing believed that tonsillar herniation was a cause of acute cardiorespiratory compromise in patients with intracranial tumors. In this vignette, we describe the untold story of Cushing's heroic attempt to treat respiratory arrest operatively during supratentorial tumor surgery with an emergency suboccipital craniectomy to relieve the medullary dysfunction that he believed was caused by compression from tonsillar herniation. This case illustrates a surgeon's determination and courage in fighting for his patient's life in the most desperate of times.

La Defensa Pasiva y su división médica de emergencia / Passive Defense and its emergency medical division / Passive Defence e sua divisão médica de emergência

Durante la Segunda Guerra Mundial el gobierno de Uruguay intentó prepararse para una eventual defensa militar del territorio y la defensa de la población civil en caso de sufrir ataques aéreos. La Defensa Pasiva, fue la estructura gubernamental que junto a la voluntad en todas las clases sociales, funcionó en todo el territorio nacional con la finalidad de proteger a la población civil de los ataques aéreos y guerra química, generando un espíritu de solidaridad a través de su División Médica de Emergencia.

During the Second World War, the government of Uruguay tried to prepare for an eventual military defense of the territory and the defense of the civilian population in case of air raids. The Passive Defense was the governmental structure that, together with the will of every social class, operated throughout the national territory with the purpose of protecting the civilian population from air raids and chemical weapons, generating a spirit of solidarity through its Emergency Medical Division.

Durante a Segunda Guerra Mundial, o governo uruguaio tentou se preparar para uma eventual defesa militar do território e para a defesa da população civil em caso de ataques aéreos. A Defesa Passiva era a estrutura governamental que, juntamente com a vontade de todas as classes sociais, operava em todo o território nacional com o objetivo de proteger a população civil de ataques aéreos e da guerra química, gerando um espírito de solidariedade por meio de sua Divisão Médica de Emergência.

Emergencies and acute diseases in the collected works of Hippocrates: observation, examination, prognosis, therapy.

The collected works οf Hippocrates include a wealth of references to emergencies and acute conditions; if the physician could treat these, he would be considered superior to his colleagues. Works most relevant to current Emergency Medicine are presented. They indicate Hippocrates' remarkable insight and attention to the value of close observation, meticulous clinical examination, and prognosis. Hippocrates and his followers disdained mystery and were not satisfied until they had discovered a rational cause to diseases. They assigned great significance to distressing signs and symptoms - the famous Hippocratic face, the breathing pattern, pain, seizures, opisthotonus - pointing to a fatal outcome, which they reported to their patient. The principles of treatment of emergencies, such as angina, haemorrhage, empyema, ileus, shoulder dislocations and head injuries, are astonishingly similar to the ones used nowadays.

Visualizing diurnal population change in urban areas for emergency management.

There is an increasing need for a quick, simple method to represent diurnal population change in metropolitan areas for effective emergency management and risk analysis. Many geographic studies rely on decennial U.S. Census data that assume that urban populations are static in space and time. This has obvious limitations in the context of dynamic geographic problems. The U.S. Department of Transportation publishes population data at the transportation analysis zone level in fifteen-minute increments. This level of spatial and temporal detail allows for improved dynamic population modeling. This article presents a methodology for visualizing and analyzing diurnal population change for metropolitan areas based on this readily available data. Areal interpolation within a geographic information system is used to create twenty-four (one per hour) population surfaces for the larger metropolitan area of Salt Lake County, Utah. The resulting surfaces represent diurnal population change for an average workday and are easily combined to produce an animation that illustrates population dynamics throughout the day. A case study of using the method to visualize population distributions in an emergency management context is provided using two scenarios: a chemical release and a dirty bomb in Salt Lake County. This methodology can be used to address a wide variety of problems in emergency management.

The early days of appendicectomy.

I suppose the commonest abdominal emergency operation performed throughout most of the world today is an appendicectomy--usually through an abdominal incision of various shapes and now, increasingly, by laparoscopic surgery. The results are excellent, with a low morbidity and tiny mortality. Indeed, in my own experience of 40 years of surgery, (1948 to 1989), there was not a single death in the various units that I worked on, although we had some fairly hairy near-misses among patients with advanced peritonitis at the time of their surgery.