Challenges in handling a civilian mass pediatric disaster during flood relief in a partially inundated armed forces medical facility.

BACKGROUND: Armed forces hospitals are often called upon to provide medical aid to civilians during natural calamities. Though children are often the most vulnerable segment of population in these events, research that addresses their unique needs and the role of armed forces hospitals remains sparse. OBJECTIVES: We examined pediatric morbidity and mortality at a flooded armed forces hospital. Factors that affected outcomes were identified. METHODS: 158 patients were evacuated en masse from a children's hospital in northern India that was submerged by flood to an adjacent partially inundated armed forces hospital specializing in military medicine and adult trauma. The children were provided case-based clinical care as per existing disaster management protocol. Geoclimatic vulnerability factors, morbidity/mortality, and medical and logistical challenges for future intervention were investigated. RESULTS: One pediatrician who provided initial triage was joined by two others after 48 hours. A limited load of adult patients permitted more resources for the children, majority (49 percent) of whom were neonates. Intensive care was necessitated for 32 (20.2 percent) cases, with half managed in adult ICU. Overall in-hospital mortality was 5.7 percent. Experienced staff, cross-specialty multitasking, and innovative and noncensorious leadership were identified as assets amidst resources compromised by flooding. Clear delineation of primary caregiver role of pediatrician at outset, pediatric emergency care training, pediatric triage, resource allocation for thermoregulation, oxygen therapy and ventilation, earmarking centers for transfer of cases, and safe transportation to the centers were identified as areas meriting further attention. CONCLUSION: Armed forces hospitals in vulnerable geoclimatic zones must address pediatric concerns in disaster management plans.

Challenges in handling a civilian mass pediatric disaster during flood relief in a partially inundated armed forces medical facility.

BACKGROUND: Armed forces hospitals are often called upon to provide medical aid to civilians during natural calamities. Though children are often the most vulnerable segment of population in these events, research that addresses their unique needs and the role of armed forces hospitals remains sparse. OBJECTIVES: We examined pediatric morbidity and mortality at a flooded armed forces hospital. Factors that affected outcomes were identified. METHODS: 158 patients were evacuated en masse from a children's hospital in northern India that was submerged by flood to an adjacent partially inundated armed forces hospital specializing in military medicine and adult trauma. The children were provided case-based clinical care as per existing disaster management protocol. Geoclimatic vulnerability factors, morbidity/mortality, and medical and logistical challenges for future intervention were investigated. RESULTS: One pediatrician who provided initial triage was joined by two others after 48 hours. A limited load of adult patients permitted more resources for the children, majority (49 percent) of whom were neonates. Intensive care was necessitated for 32 (20.2 percent) cases, with half managed in adult ICU. Overall in-hospital mortality was 5.7 percent. Experienced staff, cross-specialty multitasking, and innovative and noncensorious leadership were identified as assets amidst resources compromised by flooding. Clear delineation of primary caregiver role of pediatrician at outset, pediatric emergency care training, pediatric triage, resource allocation for thermoregulation, oxygen therapy and ventilation, earmarking centers for transfer of cases, and safe transportation to the centers were identified as areas meriting further attention. CONCLUSION: Armed forces hospitals in vulnerable geoclimatic zones must address pediatric concerns in disaster management plans.

Unconventional Hall response in the quantum limit of HfTe5.

Interacting electrons confined to their lowest Landau level in a high magnetic field can form a variety of correlated states, some of which manifest themselves in a Hall effect. Although such states have been predicted to occur in three-dimensional semimetals, a corresponding Hall response has not yet been experimentally observed. Here, we report the observation of an unconventional Hall response in the quantum limit of the bulk semimetal HfTe5, adjacent to the three-dimensional quantum Hall effect of a single electron band at low magnetic fields. The additional plateau-like feature in the Hall conductivity of the lowest Landau level is accompanied by a Shubnikov-de Haas minimum in the longitudinal electrical resistivity and its magnitude relates as 3/5 to the height of the last plateau of the three-dimensional quantum Hall effect. Our findings are consistent with strong electron-electron interactions, stabilizing an unconventional variant of the Hall effect in a three-dimensional material in the quantum limit.

Supraglottic airway devices in short gynecological procedures: A randomized, clinical study comparing the Baska® mask and I-Gel® device.

BACKGROUND: Supraglottic airway devices are used for anesthesia in elective surgical procedures circumventing the need for intubation. We investigated the efficacy and safety of Baska® mask in comparison to an I-Gel® device. METHODS: In this cross-sectional, observational study, we randomized 100 female patients (age 18-45 years, American Society of Anaesthesiologists grade I or II) undergoing elective short gynecological procedures into two groups, to receive ventilation with either Baska mask® (group 1, n = 50) or an I-Gel® device (group 2, n = 50). We excluded patients with obesity, short neck, and known systemic and upper airway disorders. The primary outcome was the oropharyngeal airway seal pressure, and the secondary outcomes were the ease of insertion and the complication rate. The results were analyzed using Mann-Whitney U-test and Fisher's exact test, and correlation analysis was done by Spearman's correlation test. RESULTS: A total of 56 patients underwent dilatation and curettage, whereas the remaining had hysteroscopy in the study. The airway seal pressure achieved was higher with Baska® mask than I-Gel® device (35.8 ± 10.3 and 26.9 ± 7.5 of cm H2O, respectively; P < 0.0001). The ease of insertion (P < 0.0001) was better in group 1 and the complication rates were similar in both the groups (P > 0.05). CONCLUSION: Baska® mask offers a superior airway seal pressure with minimum complications in comparison to an I-Gel® device. Further studies with a large number of patients in different surgical settings are required to confirm our findings.

Brain stem death certification protocol.

Transplantation of Human Organs is guided by laid down specific Laws in India. The organs which are targeted to be transplanted are liver, kidney and cornea. The waiting list is enormous but the donor pool is meagre. This document has been made with a view that the donor pool can be enlarged by identifying patients who are 'Brain Dead' while still not having 'Cardiac Death'. The steps include the prerequisite conditions which must be satisfied by patients who have suspicion of being brain dead, detailed examination of the patient, confirmation of the Brain Death and Counselling of the relatives for organ donation.

Outpatient total shoulder arthroplasty: A cost-identification analysis.

BACKGROUND: As demand for total shoulder arthroplasty (TSA) rises, containing costs will become increasingly important. We hypothesize that performing ambulatory TSA procedures results in significant cost savings. METHODS: A model was created to evaluate cost savings. Hospital stay length and cost, pain control method and cost, and number of annual outpatient TSA procedures were estimated based on literature. RESULTS: Estimated cost savings per patient were $747 to $15,507 (base case $5594), total annual savings of $4.1M to $349M (base case $82M), and ten-year savings of $51M to $5.4B (base case $1.1B). CONCLUSION: Ambulatory TSA procedures result in significant cost savings.

The psychological well-being and prenatal bonding of gestational surrogates.

STUDY QUESTION: How does the psychological well-being and prenatal bonding of Indian surrogates differ from a comparison group of mothers? SUMMARY ANSWER: Surrogates had higher levels of depression during pregnancy and post-birth, displayed lower emotional connection with the unborn baby, and greater care towards the healthy growth of the foetus, than the comparison group of mothers. WHAT IS ALREADY KNOWN: Studies in the West have found that surrogates do not suffer long-term psychological harm. One study has shown that surrogates bond less with the foetus than expectant mothers. STUDY, DESIGN, SIZE, DURATION: This study uses a prospective, longitudinal and cross-sectional design. Surrogates and a matched group of expectant mothers were seen twice, during 4-9 months of pregnancy and 4-6 months after the birth. PARTICIPANTS/MATERIALS, SETTING, METHODS: Semi-structured interviews and standardized questionnaires were administered to 50 surrogates and 69 expectant mothers during pregnancy and 45 surrogates and 49 expectant mothers post-birth. All gestational surrogates were hosting pregnancies for international intended parents. MAIN RESULTS AND THE ROLE OF CHANCE: Surrogates had higher levels of depression compared to the comparison group of mothers, during pregnancy and post-birth (P < 0.02). Low social support during pregnancy, hiding surrogacy and criticism from others were found to be predictive of higher depression in surrogates post-birth (P < 0.05). Regarding prenatal bonding, surrogates interacted less with and thought less about the foetus but adopted better eating habits and were more likely to avoid unhealthy practices during pregnancy, than expectant mothers (P < 0.05). No associations were found between greater prenatal bonding and greater psychological distress during pregnancy or after relinquishment. LIMITATIONS, REASONS FOR CAUTION: All surrogates were recruited from one clinic in Mumbai, and thus the representativeness of this sample is not known. Also, the possibility of socially desirable responding from surrogates cannot be ruled out. WIDER IMPLICATIONS OF THE FINDINGS: As this is the first study of the psychological well-being of surrogates in low-income countries, the findings have important policy implications. Providing support and counselling to surrogates, especially during pregnancy, may alleviate some of the psychological problems faced by surrogates. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the Wellcome Trust [097857/Z/11/Z] and Nehru Trust, Cambridge. K.K. is the Medical Director of Corion Fertility Clinic. All other authors have no conflict of interest to declare.

Indian egg donors' characteristics, motivations and feelings towards the recipient and resultant child.

This is the first study to examine characteristics, motivations and experiences of Indian egg donors. In-depth interviews were conducted with 25 egg donors who had donated during the previous 8 months at a fertility clinic in Mumbai. The semi-structured interviews were conducted in Hindi and English. In addition to demographic information, data were collected on donors' motivations for donating, with whom they had discussed donation, and feelings towards the recipients. The response rate was 66%. All participants were literate and had attended school. Twenty (80%) egg donors had children and five (20%) did not. The most common motivation (19, 76%) for donating was financial need. Egg donors had discussed their donation with their husband or with close family/friends, with almost all mentioning that wider society would disapprove. The majority (20, 80%) had no information about the recipients and 11 (44%) preferred not to. The findings highlight the similarities and differences between egg donors from India and those from other countries and that egg donors are of a more varied demographic background than surrogates in India. Given that India has been a popular destination for fertility treatment, the findings have important implications for regulation and practice within India and internationally.

In vitro investigation of the blood response to medical grade PVC and the effect of heparin on the blood response.

This paper reports the results of an investigation into the blood response of polymers in vitro, using non-anticoagulated and heparinised blood and plasma. The materials studied were regenerated cellulose, (Cuprophan), an acrylonitrile-allyl sulphonate copolymer (AN69S), and medical grade polyvinyl chloride plasticised with di-2-ethyl-hexyl-phthalate (PVC/DEHP). Blood-material or plasma-material contact was achieved using a parallel plate flow cell, and C3a generation and FXII-like activity measured. The results of the study with non-anticoagulated human blood show that PVC/DEHP is a high complement activator. C3a concentration in the blood was higher after contact with PVC/DEHP than after contact with regenerated cellulose. The introduction of heparin in the blood induced complex alterations in the blood response. C3a generation could be elevated, decreased, or remain the same, depending on the material. The FXII-like activity on the surface of the PVC/DEHP after contact with plasma was also higher than the other two polymers. The introduction of heparin could increase or decrease FXII-like activity, depending on material. The patterns of response obtained with non-anticoagulated blood in vitro for AN69S and Cuprophan bore a strong resemblance with patterns of response obtained in the clinic, whereas those obtained with heparinised blood in vitro did not.

The influence of thrombus components in mediating bacterial adhesion to biomaterials.

Thrombosis and infection represent the two largest limiting factors determining the long term success of implanted biomaterials. Infections associated with biomaterials are difficult to treat, and appear to evade the host defense systems. Mechanisms relating infection to thrombosis are described. Investigations into the role of receptors in mediating adhesion to thrombi are also discussed, in addition to strategies to reduce bacterial adhesion to biomaterial surfaces.

NEUROMUSCULAR BLOCKADE AND INTUBATION CONDITIONS OF THE SINGLE BOLUS DOSE (2xED90) OF ROCURONIUM BROMIDE.

Rocuronium bromide (2xED90), a new non depolarising neuromuscular blocking drug with rapid onset, intermediate duration of action and cardiostability was studied in open randomised trial in 30 patients. Neuromuscular block was monitored using a Train of Four stimulus by stimulator electrodes placed on the ulnar never close to the wrist. Intubation conditions were assessed subjectively by scoring the jaw relaxation, vocal cord and the response to intubation with same technique of anaesthesia. Clinical recovery (Dur25) of neuromuscular blockade was monitored. Haemodynamic changes were recorded. Intubation conditions were clinically acceptable in 99.6% of patients, (excellent 73%; good 26.6%) at 90s. Time to onset (Lag time) of neuromuscular block was 22.5 ± 12.6 sec and average time for the onset of block (maximum effect) was 90.9 ±10.6 sec. The duration of clinical muscular relaxation (25% recovery of twitch height) was 22.4 ± 8.30 min. Stability of cardiocirculatory system was seen.

MIDAZOLAM, A NEW MORE POTENT BENZODIAZEPINE, COMPARED WITH DIAZEPAM AS SEDATIVE DURING SPINAL ANALGESIA, A RANDOMISED DOUBLE BLIND STUDY.

Midazolam, a new benzodiazepine was compared with diazepam as intraoperative sedative during spinal anaesthesia in a double blind study. Eighty five patients participated in this clinical trial (placebo 25, midazolam 30, diazepam 30). Drug treatment was administered after spinal anaesthesia at 5 min of supine position. Level of spinal anaesthesia in terms of sympathetic blocade was similar in all the patients. Dosage of drug were tailored to the needs of each patient till the end point of undisturbed sleep. Intraoperative sedation based on predetermined criteria, recovery by Trieger's test at 4 hr after the drug administration, antegrade amnesia by memory card and haemodynamics were assessed. Mean doses of 240 µg kg-1 and 500 µg kg-1 of midazolam and diazepam were required to induce sleep which suggest an equivalent dose ratio of midazolam: diazepam as 1: 2.1. Both the drugs produced effective sedation during spinal anaesthesia, 86.6% patient with midazolam and 93.3% patients with diazepam had deep undisturbed sleep. Clinical recovery was fast in midazolam administered patients but did not meet the criteria of early discharge by Trieger's test at 4 hr after the administration of the drug. There were no gross changes in the circulatory effects of the two drugs. Decrease in mean systolic pressure (<10%) and marginal increase in heart rate was seen. The frequency of antegrade amnesia was greater with midazolam. Global assessment as judged by anaesthesiologist and patients satisfaction for anaesthesia and recovery was higher (93.3%) with midazolam as compared to (79.9%) diazepam.

Complement activation by cellulose: investigation of the effects of time, area, flow rate, shear rate and temperature on C3a generation in vitro, using a parallel plate flow cell.

The development and utilization of a parallel plate flow system to study the blood response to flat sheet biomaterials, is described. Unlike most other parallel plate flow systems, which have been used to study cellular interactions with biomaterials, the controlled flow test cell described below employs the test materials on both sides of the channel through which the blood flows. The flow cell is used to conduct an investigation into the in vitro generation of C3a by a regenerated cellulose membrane, Cuprophan. The effects of experimental variables such as temperature, blood flow rate, contact area and wall shear rate on C3a generation by Cuprophan were studied. The results show that C3a generation by Cuprophan is lower at 12 degrees C than at 22 degrees C, which is in turn lower than C3a generation at 37 degrees C. Furthermore, a decrease in contact area, and increase in wall shear rate and blood flow rate, can produce a decrease in C3a concentration.

In vitro blood compatibility evaluation of hollow fibre membrane using a controlled flow system: a comparative study.

A procedure has been established for the in vitro assessment of hollow fibre haemodialysis membranes. A 30 ml syringe containing 20 ml of fresh non-anticoagulated blood was mounted onto a non-pulsatile syringe pump and blood was perfused through minimodules constructed from 80 fibres retrieved from Cuprophan (Baxter ST15), cellulose acetate (M57-12, JMS Co Ltd, Hiroshima, Japan), and AN69HF (Filtral 20, Hospal, France) dialysers. Samples were collected before perfusion, 3, 6, 9 and 12 minutes. The modules were clamped vertically to minimise the effect of red cell pooling and the dialysate compartment was filled with 0.9% saline to minimise ultrafiltration. After sample processing, complement C3a, thrombin-antithrombin III complexes, prothrombin F1 + 2, and factor XII-like activity were evaluated. The results indicated that the system could discriminate between the membranes evaluated and therefore was a relevant procedure for the assessment of hollow fibre haemodialysis membranes.

Blood-contacting biomaterials: bioengineering viewpoints.

The investigation of blood-contacting biomaterials is an important challenge and is relevant for an improvement in the clinical application of biomaterials. With the purpose of improved clinical treatment, bioengineering viewpoints of blood-contacting biomaterials cover the material options and selection, the utilization of materials, the development of materials with better properties, and processing characteristics, and the design of relevant evaluation procedures. The bioengineering objective remains that of achieving an enhanced understanding of the relationship between a biomaterial and the biological response.

Polymeric biomaterials: influence of phosphorylcholine polar groups on protein adsorption and complement activation.

The introduction to polymeric biomaterials of phosphorylcholine polar groups represents an approach towards the development of materials with improved blood compatibility. In this respect, two biomaterials, one a copolymer of butyl methacrylate and 2-methacryloyloxyethylphosphorylcholine (MPC), (poly(BMA-co-MPC) and the other, MPC-grafted Cuprophan, were examined with respect to their influence on protein adsorption and complement activation. Protein adsorption was studied by measurement of the adsorption of radiolabelled single proteins (albumin and fibrinogen), while complement activation was measured using radioimmunoassay for C3a des Arg. The investigation demonstrated that the polymers containing phosphorylcholine polar groups can achieve a marked reduction in protein adsorption and complement activation and supports the utilization of phosphorylcholine polar groups as a means of improving the compatibility of biomaterials for blood-contacting applications.

Biomaterials for blood-contacting applications.

Consideration of biomaterials for blood-contacting applications should take into account blood-biomaterial interactions, factors influencing the blood response and evaluation procedures. Examination of blood-biomaterial interactions indicates that relevant features are protein adsorption, platelet reactions, intrinsic coagulation, fibrinolytic activity, erythrocytes, leucocytes and complement activation. Factors influencing the blood response to a biomaterial in clinical application are the biomaterial structure, the presence of an antithrombotic agent, the patient status as determined by the disease and drug therapy, and the nature of the application. Evaluation options for biomaterials are clinical, in vivo, ex vivo and in vitro, with ex vivo and in vitro procedures relevant for biomaterial development.

Monitoring of the blood response in blood purification.

A principal objective of monitoring the blood response in procedures such as hemodialysis and cardiopulmonary bypass is to achieve an enhanced understanding of the relationship between blood component alterations and the biomaterials employed. The aim in a study of blood-biomaterial interactions of deriving a correlation between a characteristic of the biomaterial and a representative parameter of the blood response can be influenced in a clinical situation by antithrombotic agents, multimaterial contact, device utilization, blood condition, drug therapy, and the nature of the application. The selection of parameters representative of the blood response may require a compromise between the advantages of multiparameter assessment and the benefit of measuring a single parameter by a consistent methodology. Representative parameters are protein adsorption, platelet reactions, intrinsic coagulation and the contact activation phase, fibrinolysis, leukocyte alterations, and complement activation. Assessment during clinical application can be approached by consideration of blood response patterns.