Anti-Inflammatory, Antioxidant, and Anti-Atherosclerotic Effects of Natural Supplements on Patients with FMF-Related AA Amyloidosis: A Non-Randomized 24-Week Open-Label Interventional Study.

We aimed to evaluate the effect of a combination of natural products on parameters related to inflammation, endothelial dysfunction, and oxidative stress in a cohort of familial Mediterranean fever (FMF) patients with Serum Amyloid A amyloidosis, in a non-randomized, 24-week open-label interventional study. Morinda citrifolia (anti-atherosclerotic-AAL), omega-3 (anti-inflammatory-AIC), and extract with Alaskan blueberry (antioxidant-AOL) were given to patients with FMF-related biopsy-proven AA amyloidosis. Patients were >18 years and had proteinuria (>3500 mg/day) but a normal estimated glomerular filtration rate (eGFR). Arterial flow-mediated dilatation (FMD), carotid intima media thickness (CIMT), and serum biomarkers asymmetric dimethylarginine (ADMA), high sensitivity C-reactive protein (hs-CRP), pentraxin (PTX3), malondialdehyde (MDA), Cu/Zn-superoxide dismutase (Cu/Zn-SOD), and glutathione peroxidase (GSH-Px) were studied at baseline and after 24 weeks of treatment. A total of 67 FMF-related amyloidosis patients (52 male (77.6%); median age 36 years (range 21−66)) were enrolled. At the end of a 24-week treatment period with AAL, AIC, and AOL combination therapy, ADMA, MDA, PTX3, hsCRP, cholesterol, and proteinuria were significantly decreased compared to baseline, while CuZn-SOD, GSH-Px, and FMD levels were significantly increased. Changes in inflammatory markers PTX3, and hsCRP were negatively correlated with FMD change, and positively correlated with decreases in proteinuria, ADMA, MDA, cholesterol, and CIMT. Treatment with AAL, AIC and AOL combination for 24 weeks were significantly associated with reduction in inflammatory markers, improved endothelial functions, and oxidative state. Efficient control of these three mechanisms can have long term cardiovascular and renal benefits for patients with AA amyloidosis.

Hemostatic efficacy of local chitosan linear polymer granule in an experimental sheep model with severe bleeding of arteria and vena femoralis.

BACKGROUND: The aim of the present study was to evaluate the hemostatic effect of chitosan linear polymer in a sheep model with femoral bleeding. METHODS: Following induction of anesthesia and intubation of sheep, groin injury was induced to initiate hemorrhage. Animals were randomly assigned to study and control groups. In the control group, absorbent pads were packed on the wound, and pressure was supplied by a weight placed over the dressing. In the study group, chitosan linear polymer was poured onto the bleeding site; absorbent pads and pressure were applied in the same manner. At 5-min intervals, bleeding was evaluated. Primary endpoint was time to hemostasis. RESULTS: Bleeding had stopped by the 1st interval in 5 members of the study group, and by the 2nd interval in 1 member. One sheep was excluded. The bleeding stopped after the 1st interval in 1 member of the control group and after the 2nd interval in 4 members. Bleeding stopped in 2 cases following ligation of the bleeding vessel. Hemostasis was achieved earlier in the study group, compared to the control group, and the difference was statistically significant. CONCLUSION: Hemostasis was achieved earlier following application of chitosan linear polymer.

Hemostatic effects of microporous polysaccharide hemosphere in a rat model with severe femoral artery bleeding.

An appropriate hemostatic dressing for prehospital use should lower mortality due to uncontrolled hemorrhage. In this study, the investigators explored the hemostatic effects of Microporous Polysaccharide Hemosphere (MPH) applied in a rat model with severe femoral artery bleeding. Twelve rats were randomly assigned to MPH and control groups: The femoral artery of each rat was pierced to initiate bleeding. Then, 0.25 g MPH was poured into the bleeding site. A 200-g scale weight was placed over the bleeding site for 30 sec. At 30-sec intervals, the scale weight was removed, and hemostasis was assessed visually. After 30 sec, if the bleeding had ceased, the test was scored and checked as "passed at 30 sec." If the bleeding had not stopped, the same procedures were repeated a maximum of 3 times. If hemostasis could not be achieved even after the third application, the test was scored as failed. The same sequence of procedures was repeated for the control group without use of MPH and with only standard compression. Application of MPH resulted in complete control of bleeding in 2 of 6, 4 of 6, and 6 of 6 rats at 30, 60, and 90 sec, respectively. In the control group, however, hemostasis could not be achieved in all 6 rats, even at 90 sec. The difference between the 2 groups was statistically significant (P=.007). Application of MPH and compression with a scale weight significantly decreased the time of hemostasis in the rat model with femoral arterial bleeding.

Recommended modifications and applications of the Hospital Emergency Incident Command System for hospital emergency management.

The Hospital Emergency Incident Command System (HEICS), now in its third edition, has emerged as a popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the HEICS in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (SARS) outbreaks in eastern Asia and Toronto, Canada. Several modifications of the HEICS are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the HEICS to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in CBRN emergencies; (3) new unit leaders in the Operations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, and dependents in terrorism-related emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types of patients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems. New uses of the HEICS in hospital emergency management also are recommended, including: (1) the adoption of the HEICS as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the HEICS not only to healthcare facilities, but also to healthcare systems. Finally, three levels of healthcare worker competencies in the HEICS are suggested: (1) basic understanding of the HEICS for all hospital healthcare workers; (2) advanced understanding and proficiency in the HEICS for hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the HEICS ad hoc from existing healthcare workers in resource-deficient settings. The HEICS should be viewed as a work in progress that will mature as additional challenges arise and as hospitals gain further experience with its use.

Impact of the terrorist bombings of the Hong Kong Shanghai Bank Corporation headquarters and the British Consulate on two hospitals in Istanbul, Turkey, in November 2003.

BACKGROUND: The authors sought to estimate the impact of the terrorist bombings of the Hong Kong Shanghai Banking Corporation headquarters and the British consulate in Istanbul, Turkey, on November 20, 2003, on two nearby hospitals, in terms of epidemiologic outcomes, resource utilization, and time course of emergency needs. METHODS: The authors used data from hospital records of injured survivors who used the emergency departments (EDs) at the Taksim Education and Research State Hospital (TERSH) and the American Hospital (AH) in Istanbul on November 20, 2003, to determine the totals and rates of mortality (early, late, and critical), injury, critical injury (Injury Severity Score > 15), ED use, hospitalization, operative care, and in-hospital overtriage and the time intervals of ED arrival. RESULTS: The TERSH received 184 victims in the first hour after the initial blast, of which 88 (48%) were brought by emergency medical services, 171 (93%) had lacerations, 7 (4%) had penetrating eye injuries, 28 (15%) were hospitalized, 18 (10%) received operative care, and 7 (4%) were critically injured. Three deaths occurred in critically injured survivors, including one early death in the operating room and two late deaths on days 5 and 6. The AH received 16 victims, of which 14 (88%) had lacerations, 3 (19%) were hospitalized, 2 (13%) received operative care, and 1 (6%) was critically injured. An additional 4 victims were transferred to the AH from other hospitals, of which 3 were hospitalized and none were critically injured. No early or late deaths occurred. CONCLUSION: Mortality, injury, and hospitalization rates at both hospitals were consistent with previous reports of open-air mass-casualty terrorist bombings. The TERSH experienced an unprecedented demand for ED surge capacity in an open-air bombing.

Impact of the terrorist bombings of the Neve Shalom and Beth Israel Synagogues on a hospital in Istanbul, Turkey.

OBJECTIVES: The authors sought to estimate the impact of the open-air mass-casualty terrorist bombings of the Neve Shalom and Beth Israel Synagogues in Istanbul, Turkey, on November 15, 2003, on the American Hospital (AH) in terms of resource utilization, epidemiologic outcomes, and time course of emergency needs. METHODS: A retrospective descriptive study using data from hospital records of injured survivors who used the emergency department at AH on November 15, 2003, to determine the number and percentage of injured survivors who were hospitalized, received operative care, had specific injury types, had an Injury Severity Score >/=16, died, and arrived within certain time intervals. RESULTS: AH received 69 (91%) injured survivors from the scene, of which nine (12%) were hospitalized and three (4%) received operative care. Starting four hours after the initial blast, seven (9%) injured survivors were transferred to AH from other hospitals, of which five (7%) were hospitalized and four (5%) received operative care. Of the 49 injured survivors from the scene with documented injuries, 43 (88%) had injuries to the head or face, 42 (86%) had lacerations, five (10%) had fractures, one (2%) had a penetrating eye injury, one (2%) had a serious intracranial injury, and none had primary blast injuries. Four (5%) injured survivors at AH had an Injury Severity Score >/=16, and none died. CONCLUSIONS: Seventy-six injured survivors used the emergency department at AH, including a delayed wave of injured survivors transferred from other hospitals. The majority of injured survivors with documented injuries had non-life-threatening lacerations of the head or face, and relatively few injured survivors were hospitalized or received operative care.

Mass-casualty terrorist bombings in Istanbul, Turkey, November 2003: report of the events and the prehospital emergency response.

BACKGROUND: This paper describes the two mass-casualty, terrorist attacks that occurred in Istanbul, Turkey in November 2003, and the resulting pre-hospital emergency response. METHODS: A complex, retrospective, descriptive study was performed, using open source reports, interviews, direct measurements of street distances, and hospital records from the American Hospital (AH) and Taksim Education and Research State Hospital (TERSH) in Istanbul. RESULTS: On 15 November, improvised explosive devices (IEDs) in trucks were detonated outside the Neve Shalom and Beth Israel Synagogues, killing 30 persons and injuring an estimated additional 300. Victims were maldistributed to 16 medical facilities. For example, AH, a private hospital located six km from both synagogues, received 69 injured survivors, of which 86% had secondary blast injuries and 13% were admitted to the hospital. The TERSH, a government hospital located 1 km from both synagogues, received 48 injured survivors. On 20 November, IEDs in trucks were detonated outside the Hong Kong Shanghai Banking Corporation (HSBC) headquarters and the British Consulate (BC), killing 33 and injuring an estimated additional 450. Victims were maldistributed to 16 medical facilities. For example, TERSH, located 18 km from the HSBC site and 2 km from the the BC received 184 injured survivors, of which 93% had secondary blast injuries and 15% were hospitalized. The AH, located 9 km from the HSBC site and 6 km from the BC, received 16 victims. CONCLUSION: The twin suicide truck bombings on 15 and 20 November 2003 were the two largest terrorist attacks in modern Turkish history, collectively killing 63 persons and injuring an estimated 750 others. The vast majority of victims had secondary blast injuries, which did not require hospitalization. Factors associated with the maldistribution of casualties to medical facilities appeared to include the distance from each bombing site, the type of medical facility, and the personal preference of injured survivors.

A proposed universal medical and public health definition of terrorism.

The lack of a universally applicable definition of terrorism has confounded the understanding of terrorism since the term was first coined in 18th Century France. Although a myriad of definitions of terrorism have been advanced over the years, virtually all of these definitions have been crisis-centered, frequently reflecting the political perspectives of those who seek to define it. In this article, we deconstruct these previously used definitions of terrorism in order to reconstruct a definition of terrorism that is consequence-centered, medically relevant, and universally harmonized. A universal medical and public health definition of terrorism will facilitate clinical and scientific research, education, and communication about terrorism-related events or disasters. We propose the following universal medical and public definition of terrorism: The intentional use of violence--real or threatened--against one or more non-combatants and/or those services essential for or protective of their health, resulting in adverse health effects in those immediately affected and their community, ranging from a loss of well-being or security to injury, illness, or death.

Terrorism in Turkey.

Over the past two decades, terrorism has exacted an enormous toll on the Republic of Turkey, a secular democracy with a 99.8% Muslim population. From 1984 to 2000, an estimated 30,000 to 35,000 Turkish citizens were killed by a nearly continuous stream of terrorism-related events. During this period, the Partiya Karekerren Kurdistan (PKK), a Kurdish separatist group (re-named KADEK in 2002), was responsible for the vast majority of terrorism-related events (and casualties), which disproportionately affected the eastern and southeastern regions of Turkey, in which the PKK has focused its activities. Most terrorist attacks over the past two decades have been bombings or shootings that produced < 10 casualties per event. From 1984 to 2003, 15 terrorist attacks produced > or = 30 casualties (eight shootings, five bombings, and two arsons). The maximum number of casualties produced by any of these events was 93 in the Hotel Madimak arson attack by the Turkish Islamic Movement in 1993. This pattern suggests that terrorist attacks in Turkey rarely required more than local systems of emergency medical response, except in rural areas where Emergency Medical Services (EMS) are routinely provided by regional military resources. The last decade has seen the development of several key systems of local emergency response in Turkey, including the establishment of the medical specialty of Emergency Medicine, the establishment of training programs for EMS providers, the spread of a generic, Turkish hospital emergency plan based on the Hospital Emergency Incident Command System, and the spread of advanced training in trauma care modeled after Advanced Trauma Life Support.