From Didactics to Disasters: Unveiling CBRNe and Counter-Terrorism Medicine Training in US Medical Schools.

INTRODUCTION: The threat of chemical, biological, radiologic, nuclear, and explosive (CBRNe) terrorist attacks has increased over time. The need for rapid and effective responses to such attacks is paramount. Effective medical counter-measures to CBRNe events are critical and training for such may effectively occur early in physician training. While some medical specialties are more involved than others, counter-terrorism medicine (CTM) spans all medical specialties. METHODS: All United States allopathic medical schools were examined via online curriculums and queries for academic content related to CBRNe and terrorist medical counter-measures. RESULTS: Analysis of 153 United States allopathic medical schools demonstrated that 15 (9.8%) medical schools offered educational content related to CBRNe and terrorist counter-measures. This is in contrast to legislation following the September 11, 2001 attacks that called for high priority for such education. CONCLUSION: Effective CBRNe medical counter-measures are currently in place; however, there is room for improvement in education that may begin during medical school. While certain medical specialties such as emergency medicine, primary care, and dermatology may have specific niches in such events, physicians of all medical specialties have something to offer, and even a basic education in medical school can help best prepare the nation for future attacks.

Low-Cost Model for Battlefield Wound and Hemorrhage Training.

INTRODUCTION: Exsanguination is the leading cause of preventable death on the battlefield and in austere environments. Multiple courses have been developed to save lives by stopping hemorrhage. Training for this requires simulation models; however, many models are expensive, preventing the further expansion of this life-saving training. We present a low-cost model for hemorrhage training and realistic moulage based on simple medical supplies and grocery store meats. MATERIALS AND METHODS: Wound packing training was completed by use of a block of pork shoulder roast with an incision simulating a wound and IV tubing connected to a syringe with fake blood. Hemostasis was obtained with proper wound packing by the student, causing the bleeding to be tamponaded. Wound moulage utilized remaining supplies of pork roast being attached to patient actors or mannequins and adorned with fake blood creating wounds with the appearance and feel of real tissues. RESULTS: Tactical Combat Casualty Care (TCCC) training was completed at a small military medical facility with a start-up cost of less than $70 and a single course as cheap as $15. These methods have been utilized to establish other TCCC training centers while keeping costs low. CONCLUSIONS: We present low-cost models for simulating massive hemorrhage for wound packing with pork roast and realistic moulage. These methods can be utilized for other hemorrhage training courses such as TCCC, Advanced Wilderness Life Support, and Stop the Bleed.

Reconstruction of Large Transmural Nasal Defects With a Nasolabial Turnover Interpolation Flap.

BACKGROUND: Reconstruction of large nasal surgical defects often warrant the use of mucosal flaps to repair the inner lining. This often presents a challenge for surgical reconstruction. OBJECTIVE: To describe a unique reconstructive option for the repair of large surgical wounds that necessitate mucosal nasal lining. MATERIALS AND METHODS: This study is a retrospective review of 10 patients who underwent surgical reconstruction of large nasal and/or heminasal surgical defects following Mohs micrographic surgery. A nasolabial turnover interpolation flap was used to repair missing nasal mucosal lining, coupled with a cutaneous flap which typically involved a paramedian forehead flap. The duration of follow-up was 8 months. An aesthetic and functional surgical outcomes measure was used to assess the final repair. RESULTS: Favorable aesthetic outcomes were obtained in all patients and without need of revision surgery by the use of a nasolabial turnover interpolation flap. CONCLUSION: The nasolabial turnover interpolation flap offers a reliable and effective method of repair for large transmural nasal surgical wounds. We typically paired this nasal lining flap with a paramedian forehead flap with reliable and aesthetic outcomes. This technique is straightforward, reproducible, and with both good aesthetic and functional outcomes.

Bioterrorism and disaster preparedness among medical specialties.

OBJECTIVE: A core priority of all medical specialties includes information for members regarding inherent priorities and principles. The authors sought to investigate the priority and contribution of various medical specialties to the fields of bioterrorism, terrorism, disaster preparedness, and emergency preparedness. DESIGN: A mixed study design (quantitative and qualitative) was used to identify pertinent characteristics of various medical specialties. A scored survey analysis of resources available from the representative organizations and/or societies of the primary medical specialties and select subspecialties was examined and scored based on availability, ease of accessibility, updated status, and content. A MEDLINE search completed through PubMed using the medical subject headings bioterrorism, terrorism, disaster preparedness, and emergency preparedness coupled with specific medical specialties was conducted to assess the involvement and contribution of each to the medical literature. MAIN OUTCOME MEASURES: The primary study outcome was to evaluate the priority of and existing resources available to members for bioterrorism/terrorism and disaster/emergency preparedness among various medical specialties as reflected by their representative organizations and scientific publication. RESULTS: The search of individual medical specialties and of the medical literature (2000-2010) revealed that these topics (via keywords bioterrorism, terrorism, disaster preparedness, and emergency preparedness) are indeed a priority topic for the majority of medical specialties. A number of specialties with expectant priority in these topics were confirmed. All seven primary care specialties demonstrated a core priority of these topics and offered resources. The MEDLINE (PubMed) search yielded 7,228 articles published from 2000 to 2010. CONCLUSION: Bioterrorism/terrorism and disaster/ emergency preparedness are priority topics of most medical specialties. This core priority is demonstrated by both the medical specialty resources in addition to the contribution of scientific articles from these medical specialties. This reflects the diverse medical care that is necessary for terrorist threats and the collaborative efforts that will help to make the medical response to these threats more cohesive.

Perineural involvement of squamous cell carcinoma presenting with formication.

Perineural involvement of a cutaneous neoplasm marks an aggressive feature. Tumors with perineural involvement share an increased propensity for local invasion via perineural spread. Formication may be an indicator of perineural involvement by cutaneous neoplasms. We present a case of an 82-year-old man with perineural involvement of a squamous cell carcinoma (SCC) identified by clinical symptoms of formication. Successful resolution of these symptoms was achieved with radiation therapy.

Self-induced nasal ulceration from trigeminal trophic syndrome.

Trigeminal trophic syndrome is a rare entity characterized by the presence of ala nasi ulceration, trigeminal anesthesia, and paresthesia. It arises secondary to trigeminal nerve injury. Patients with this diagnosis often undergo repeated skin biopsies to rule out suspected nonmelanoma skin cancer due to the clinical appearance. Recognition of this entity is paramount to avoid unnecessary surgical intervention and to attempt therapy.

A report of Epstein-Barr virus-positive primary cutaneous natural killer-/T-cell lymphoma.

We describe a patient who presented with Epstein-Barr virus-positive tumor-stage primary cutaneous lymphoma. Our patient had previously been treated with oral methotrexate for long-standing rheumatoid arthritis. Tissue analysis revealed large tumor cells that were surface CD2- and CD3-positive; T-cell-restricted intracellular antigen-positive; CD56-, CD20-, and CD30-negative; and stained positively for Epstein-Barr virus. Our case is noteworthy for several reasons. Although the presence of rheumatoid arthritis and therapy with methotrexate are putative risk factors for the development of immune suppression-related and Epstein-Barr virus-related lymphomas, the vast majority of lymphomas in this setting are of B-cell origin, and rarely are these primary cutaneous in nature. In addition, our patient's tumor displayed an unusual phenotype, with immunophenotypic features suggestive of an atypical natural killer-/T-cell lymphoma. Methotrexate was withdrawn, and our patient was successfully treated with local radiotherapy. She has remained in complete remission 28 months since diagnosis.