A 5-year analysis of the helicopter air mercy service in Richards Bay, South Africa.

BACKGROUND: A helicopter emergency medical service (HEMS) was established in 2005 in Richards Bay, KwaZulu-Natal, South Africa, to provide primary response and inter-facility transfers to a largely rural area with a population of 3.4 million people. OBJECTIVE: To describe the first 5 years of operation of the HEMS. METHODS: A chart review of all flights from 1 January 2006 to 31 December 2010 was conducted. RESULTS: A total of 1 429 flights were undertaken; 3 were excluded from analysis (missing folders). Most flights (88.4%) were inter-facility transfers (IFTs). Almost 10% were cancelled after takeoff. The breakdown by age was 61.9% adult, 15.1% paediatric and 21.6% neonate. The main indications for IFTs were obstetrics (34.5%), paediatrics (27.9%) and trauma (15.9%). For primary response most cases were trauma (72.9%) and obstetrics (11.3%). The median on-scene time for neonates was significantly longer (48 min, interquartile range (IQR) 35 - 64 min) than that for adults (36 min, IQR 26 - 48; p < 0.001) and paediatrics (36 min, IQR 25 - 51; p < 0.02). On-scene times for doctor-paramedic crews (45 min, IQR 27 - 50) were significantly longer than for paramedic-only crews (38 min, IQR 27 - 57; p < 0.001). CONCLUSION: The low flight-to-population ratio and primary response rate may indicate under-utilisation of the air medical service in an area with a shortage of advanced life support crews and long transport distances. Further studies on HEMSs in rural Africa are needed, particularly with regard to cost-benefit analyses, optimal activation criteria and triage systems.

The relative risk of neurosensory deficit following removal of mandibular third molar teeth: the influence of radiography and surgical technique.

OBJECTIVE: The aim of this study was to identify the relative risk of damage to the inferior dental (ID) and lingual nerves in patients undergoing lower third molar removal. STUDY DESIGN: A single surgeon reviewed 1,000 patients. RESULTS: Temporary ID neurosensory deficit was highest (11%) when root apices were intimate to the ID nerve and lowest (0.9%) when close or distant from the nerve. Permanent ID neurosensory deficit was 0.4% per tooth but only when intimate to the canal. Bone removal, tooth division, and lingual split technique increase the risk of excessive hemorrhage which appears to be linked to the highest risk of temporary ID neurosensory deficit (20%). Permanent lingual nerve injury was rare (0.06%) and not related to lingual retraction. CONCLUSIONS: Preoperative warning for lower third molar removal can be individually tailored depending on the intimacy of the ID canal to the root apices and the anticipated surgical technique.

Comparison of mean on-scene times: road versus air transportation of critically ill patients in the Western Cape of South Africa.

BACKGROUND: The South African setting lends itself to the extensive use of air transport. There is a perception with healthcare providers that flight crews spend too much time with a patient before departure. The main advantage of aero medical transport is to minimise the delay to definitive care and prolonged on-scene time defies this objective. A study was carried out to examine the mean on-scene times of aero medical and road transport of critically ill patients in the Western Cape of South Africa. METHODS: In this retrospective observational study, all critically ill patients transported in the Western Cape between September 2005 and May 2006 were evaluated. The mean on-scene time for each transport mode was calculated. Road transport was compared with air transport (rotor and fixed wing). Every transport mode was further divided into mission types: "scene" missions (scene to a healthcare facility) or "inter-facility" missions (from one healthcare facility to another). RESULTS: A total of 7924 transports were included in the study, 7580 of which (95.7%) were road transports. The air transport group spent 53.2 min (95% CI 51.1 to 55.4) at the scene compared with 27.9 min (95% CI 27.5 to 28.4) for the road transport group. There was a significant difference between scene and inter-facility missions in the air transport group (mean 31.7 min for scene missions vs 58.7 min for inter-facility missions; p<0.001). A significant difference was also found in the road transport (mean 24.6 min for scene missions vs 31.9 min for inter-facility missions; p<0.001). CONCLUSION: The on-scene time for transport missions by road is significantly less than for those done by air. There are significant differences between scene and inter-facility missions in both transport modes. Capacity building programmes with ongoing education and training of staff at referring facilities should be implemented.

Resequencing of the human major histocompatibility complex in patients with rheumatoid arthritis and healthy controls in Alaska Natives of Southeast Alaska.

High prevalence and severity of rheumatoid arthritis (RA) with an early age of onset have previously been described in Alaska Native and American Indian (AN/AI) populations. The contribution of HLA-DRB1 alleles encoding a similar amino acid sequence, referred to as the shared epitope (SE), to RA risk is well recognized in multiple populations worldwide. DRB1*1402 allele is the major SE-encoding allele in AN/AI populations. However, DRB1*1402 is highly prevalent in healthy Alaska Natives of Southeast Alaska (AN), with no significant difference from RA patients, indicating this allele alone is not informative for defining genetic risk and non-human leukocyte antigen (non-HLA) genes are likely important in AN. We sought to deep resequence the human major histocompatibility complex (MHC) to characterize the single-nucleotide polymorphism (SNP) haplotypes within this region in RA cases and controls in AN. Approximately 99 kb of the MHC was resequenced with 95 amplicons throughout this region. Thirty-four cases and 74 controls were examined. A total of 696 SNPs were discovered from 85 of the selected 95 amplicons. Disease association signals were detected for nine of the 95 amplicons analyzed. Increased risk of RA was associated with five amplicons in the class I, class II or class III region and resistance to disease with four amplicons in the class I region. Our results indicate that non-HLA MHC genes and/or unknown exogenous factors likely modulate risk of RA in the AN population.

Topical proteolytic enzymes affect epidermal and dermal properties.

Although proteolytic enzymes have a history of use in skin care products it is not known whether they simply induce superficial exfoliation or with continued use can alter epidermal and dermal skin properties. We examined herein whether enhanced exfoliation resulting from treatment with an aspartyl dependent acid protease produces appearance improvements and over time, changes in the epidermis and dermis. Test participants applied 15% enzyme containing serum and a simple moisturizer twice daily for 3 months; a matched control group applied the same serum (without enzyme) and moisturizer. Changes in skin smoothness and texture, the depth and number of lines and wrinkles, and epidermal and dermal firmness and thickness were examined in a double-blind fashion. Treatment with 15% enzyme product(s) resulted in significant improvement in epidermal properties after 1 month and both epidermal and dermal properties after 3 months. The control group showed modest improvements in surface properties only. These results demonstrate that significant appearance benefits can be derived from use of exfoliative proteolytic enzymes. Such improvements are the result of changes to the epidermis and dermis and are strikingly similar to results observed with higher concentrations of AHAs (alpha hydroxy acids).

Eruption of teeth in the nose following trauma to the primary and permanent dentitions.

Oro-facial trauma is common and forms a large component of any maxillofacial service workload. Even minor trauma can result in significant oro-facial and dental injury. This report reinforces the importance of a careful dental history and thorough examination, particularly when teeth remain missing after initial inspection. Other anatomical sites should be considered to ensure they do not contain traumatically displaced teeth. These two case reports show the late presentation of incisor teeth in the nasal cavity following dentoalveolar trauma.

Capture and release of a conditional state of a cavity QED system by quantum feedback.

Detection of a single photon escaping an optical cavity QED system prepares a nonclassical state of the electromagnetic field. The evolution of the state can be modified by changing the drive of the cavity. For the appropriate feedback, the conditional state can be captured (stabilized) and then released. This is observed by a conditional intensity measurement that shows suppression of vacuum Rabi oscillations for the length of the feedback pulse and their subsequent return.

Endocannabinoids and pain: spinal and peripheral analgesia in inflammation and neuropathy.

Analgesia is an important physiological function of the endocannabinoid system and one of significant clinical relevance. This review discusses the analgesic effects of endocannabinoids at spinal and peripheral levels, firstly by describing the physiological framework for analgesia and secondly by reviewing the evidence for analgesic effects of endocannabinoids obtained using animal models of clinical pain conditions. In the spinal cord, CB(1) receptors have been demonstrated in laminae of the dorsal horn intimately concerned with the processing of nociceptive information and the modulation thereof. Similarly, CB(1) receptors have been demonstrated on the cell bodies of primary afferent neurones; however, the exact phenotype of cells which express this receptor requires further elucidation. Local administration, peptide release and electrophysiological studies support the concept of spinally mediated endocannabinoid-induced analgesia. Whilst a proportion of the peripheral analgesic effect of endocannabinoids can be attributed to a neuronal mechanism acting through CB(1) receptors expressed by primary afferent neurones, the antiinflammatory actions of endocannabinoids, mediated through CB(2) receptors, also appears to contribute to local analgesic effects. Possible mechanisms of this CB(2)-mediated effect include the attenuation of NGF-induced mast cell degranulation and of neutrophil accumulation, both of which are processes known to contribute to the generation of inflammatory hyperalgesia. The analgesic effects of cannabinoids have been demonstrated in models of somatic and visceral inflammatory pain and of neuropathic pain, the latter being an important area of therapeutic need. Analgesia is one of the principal therapeutic targets of cannabinoids. This review will discuss the analgesic effects of endocannabinoids in relation to two areas of therapeutic need, persistent inflammation and neuropathic pain. The more general aspects of the role of cannabinoids, endogenous and exogenous, in analgesia have been recently reviewed elsewhere (Rice, Curr Opi Invest Drugs 2001; 2: 399-414; Pertwee, Prog Neurobil 2001; 63: 569-611; Rice, Mackie, In: Evers A. S, ed. Anesthetic Pharmacology: Physiologic Principles and Clinical Practice. St. Louis: Harcourt Health Sciences, 2002). Since a major goal in the development of cannabinoid-based analgesics is to divorce the antinociceptive effects from the psychotrophic effects, the discussion will focus on the antinociceptive effects produced at the spinal cord and/or peripheral level as these areas are the most attractive targets in this regard. A mechanistic discussion of the "framework" for analgesia will be followed by a description of studies examining the role of endocannabinoids in relieving pain; since the elucidation of these effects was undertaken using synthetic cannabinoids, reference will also be made to such studies, in the context of endocannabinoids.

Administration of endocannabinoids prevents a referred hyperalgesia associated with inflammation of the urinary bladder.

BACKGROUND: Referred hyperalgesia to a somatopically appropriate superficial site is a cardinal symptom of visceral inflammatory pain and has been demonstrated after turpentine-induced urinary bladder inflammation in the rat. The authors examined the effect of the endocannabinoids anandamide and palmitoylethanolamide on the referred hyperalgesia associated with this model. METHODS: After measurement of baseline limb withdrawal latencies to a noxious heat stimulus, the bladders of 50 female Wistar rats were inflamed by intravesical administration of 0.5 ml 50% turpentine. Ten or 25 mg/kg of anandamide or palmitoylethanolamide or vehicle were administered immediately before introduction of turpentine. Antagonists to both the cannabinoid CB1 and CB2 receptors were coadministered with the higher dose of endocannabinoids. Latencies were recorded 2, 4, 6, 8, and 24 h after removal of turpentine. The difference between forelimb and hind limb withdrawal latencies was plotted against time, and areas under these curves were compared. RESULTS: Inflammation of the urinary bladder was associated with a relative thermal hyperalgesia referred to the hind limb. Anandamide and palmitoylethanolamide attenuated this referred hyperalgesia at doses of 10 and 25 mg/kg. The CB1 receptor antagonist SR141716A reduced the antihyperalgesic effect of anandamide, but the CB2 antagonist SR144528 did not. Coadministration of SR141716A with palmitoylethanolamide did not affect the antihyperalgesic effect but was reduced by SR144528. CONCLUSIONS: Anandamide (via CB1 receptors) and palmitoylethanolamide (putatively via CB2 receptors) attenuated a referred hyperalgesia in a dose-dependent fashion. CB1 and CB2 receptors are strategically situated to influence the nerve growth factor-driven referred hyperalgesia associated with inflammation of the urinary bladder. These data implicate cannabinoids as a novel treatment for vesical pain.

Defects of the external auditory canal: a new reconstruction technique.

This report describes the clinical and radiographic findings together with surgical management of temporomandibular joint contents herniation through the tympanic plate of the external auditory canal. Two patients are reported. A review of the literature is presented, including a brief discussion of the embryological development of the external auditory canal. Excluding infection, trauma or neoplasm, the defect in the tympanic plate of the external auditory canal represents a developmental aberration with failure of the foramen of Huschke to close during development. A pre-auricular approach with insertion and fixation of an onlay polyethylene implant to prevent prolapse of the peri-articular tissues into the ear canal is presented and described.

Cannabinoid CB(1) receptor expression in rat spinal cord.

While evidence implicates the endogenous cannabinoid system as a novel analgesic target at a spinal level, detailed analysis of the distribution of the cannabinoid receptor CB(1) in spinal cord has not been reported. Here, immunocytochemical studies were used to characterize the CB(1) receptor expression in rat spinal cord. Staining was found in the dorsolateral funiculus, the superficial dorsal horn (a double band of CB(1) immunoreactivity (ir) in laminae I and II inner/III transition), and lamina X. Although CB(1)-ir was present in the same laminae as primary afferent nociceptor markers, there was limited colocalization at an axonal level. Interruption of both primary afferent input by dorsal root rhizotomy and descending input by rostral spinal cord hemisection produced minor changes in CB(1)-ir. This and colocalization of CB(1)-ir with interneurons expressing protein kinase C subunit gamma-ir suggest that the majority of CB(1) expression is on spinal interneurons. These data provide a framework and implicate novel analgesic mechanisms for spinal actions of cannabinoids at the CB(1) receptor.

Role of the endogenous cannabinoid system in the formalin test of persistent pain in the rat.

It has been suggested that administration of a cannabinoid CB(1) (SR141716A ¿N-(piperidin-1-yl)-5-(4-chlorophenyl)-1-(2, 4-dichlorophenyl)-4-methyl-1-H-pyrazole-3-carboxamide) and CB(2) (SR144528 ¿N-[(1S)-endo-1, 3, 3-trimethyl bicyclo ¿2.2.1 heptan-2-yl]-5-(4-chloro-3-methylphenyl)-1-(4-methylbenzyl)-pyr azo le- 3-carboxamide¿) receptor antagonists to mice potentiates inflammatory hyperalgesia by removing an endogenous cannabinoid tone. We examined whether the behavioural response to s.c. formalin injection in rats is similarly enhanced. A total of 30 animals received SR141716A (0.5 or 5 mg/kg) or SR144528 (0.3 or 3 mg/kg) 30 min before 1% formalin. Pain behaviour was quantified using the composite weighted pain score technique (CPS-WST(0,1,2)). An overall CPS-WST(0,1,2) was calculated for each phase and groups were compared (analysis of variance). The results obtained in the control group confirmed the characteristic biphasic behavioural response to formalin injection. None of antagonist groups had a significant increase in overall CPS-WST(0,1,2) compared to the control. Indeed, a significant decrease in CPS-WST(0,1,2) scores for both phases was detected in most of all of the groups, except SR141716A at 5 mg/kg. Levels of endogenous cannabinoids (anandamide, palmitoylethanolamide, 2-arachidonylglycerol) were measured from rats hind-paw skin 1 h after s.c. injection of 0.9% saline (100 microl), 1% (50 microl), 2. 5% (50 microl) and 5% (100 microl) formalin. The concentration of endocannabinoids did not differ between control and formalin-induced inflammation groups. The activity of anandamide amidohydrolase in hind-paw skin also did not change after treatment with formalin. In conclusion, cannabinoid antagonists do not enhance formalin-evoked pain behaviour. These results suggest that, in this model, endogenous cannabinoids do not tonically attenuate inflammatory hyperalgesia.

The effects of topical l(+) lactic Acid and ascorbic Acid on skin whitening.

Subjects with medium to dark skin and many exhibiting facial age spots or discolorations participated in this twelve week study to evaluate the skin whitening ability of lactic and ascorbic acid. Using clinical and biophysical test methods we observed prolonged treatment with 8.8% L(+) lactic acid resulted in no significant effects on skin pigmentation. However treatment with L(+) lactic acid supplemented with ascorbic acid (1%) did produce a whitening effect which becomes apparent after three months. These effects were demonstrated clinically by the test panelists, and trained clinicians, and with objective instrumental methods. We observed a general skin lightening and did see a modest preferential lightening of age spots with the combination of acids.

The diagnostic and treatment approach to two common conditions by the physician members of a community health maintenance organization.

We retrospectively collected data from one community managed care organization on all ambulatory care patients initially diagnosed with pneumonia or acute bronchitis from October, 1, 1992, to March 31, 1993, and from November 1, 1993, to January 31, 1994. We considered treatment to be successful when patients did not return for any related service within 15 days of initial diagnosis. We identified 2,490 episodes of illness, 85.7% which were acute bronchitis and 14.3% which were pneumonia. Overwhelmingly, physicians approached these conditions empirically (no diagnostic test); just 8.6% of patients had a diagnostic test during the 15-day episode of illness. Two-hundred twenty-nine of the episodes (9.2%) were apparently related to initial diagnoses, as they occurred during the 15-day period. More branded prescriptions (vs. generic) were dispensed during these related episodes. One patient was hospitalized and 19 patients used the emergency room either for first or subsequent visits. Empiric treatment is associated with effective diagnosis and therapy in ambulatory care patients with acute bronchitis and pneumonia. It remains unclear, however, if this strategy is the most cost-effective or if it leads to the most effective utilization of services.

Social comparison and task prediction: ability similarity and the use of a proxy.

It is argued that an important aspect of the self-appraisal of ability involves a person's prediction of his or her own performance level on untried tasks through acquisition of knowledge about how other people have fared at the task. These others are treated as substitutes for a person's own participation in the task--as proxies. It is further argued that social comparison plays a significant role in both the selection of proxies and the impact of proxy information on task prediction. The first experiment, following earlier research on comparison preference in the context of performance prediction, showed that participants interested in performance prediction chose a proxy who had performed at about the same level as they had on a reference task, while those interested in improving their performances chose to see the performances of someone who had done far better than they on the reference task. The second study indicated that participants made more confident predictions for themselves from a similar proxy's task outcome than from that of a proxy whose ability was unknown to them. Participants predicted they would do worse than a more able proxy and better than a less able proxy, but were less confident in their predictions than were those with a similar proxy. Ratings of usefulness of the proxy followed the patterns of confidence ratings closely.

Smoking is not a predictor of mortality and morbidity following coronary artery bypass grafting.

BACKGROUND: The objective of this study was to determine the significant differences in preoperative and operative characteristics, and postoperative outcomes in patients having coronary artery bypass grafting (CABG) who are smokers and in those who are not smokers. METHODS: Data were collected prospectively in all (2916) patients having their first CABG. The patients were cared for in a regional medical center by private physicians. No operations were denied because of smoking status. Smokers differed from nonsmokers in several characteristics. RESULTS: Analysis of morbidity and mortality showed no instance in which smokers fared worse than nonsmokers. Stepwise logistic regression analysis showed that smoking was not predictive of mortality. Smoking was not predictive of morbidity except that it was predictive of less probability of need for intra-aortic balloon pump (7.5% in nonsmokers and 4.7% in smokers). We then created groups of smokers and nonsmokers that were individually matched for age and sex. Analysis of the matched groups of smokers and nonsmokers showed that there was no significant difference in the incidence or magnitude of preoperative and operative factors except that recent myocardial infarction was more common in smokers. Nonsmokers had greater weight, body mass index (obesity), and ejection fraction. There was no difference in smokers and nonsmokers in mortality or morbidity at the 99% confidence level. CONCLUSION: We conclude that there is no need to delay CABG for the patients who are smokers.

Epidermal and dermal effects of topical lactic acid.

BACKGROUND: Many alpha-hydroxy acid products, containing low- or high-acid concentrations, are being used. It is not known whether different products perform differently or whether they modulate changes in both the epidermis and dermis. OBJECTIVE: The purpose was to examine whether treatment with 5% and 12% lactic acid produces different cosmetic results and produces changes in the epidermis and dermis. METHODS: Test participants applied either 5% or 12% lactic acid twice a day for 3 months. Changes in skin smoothness and texture, the depth and number of lines and wrinkles, and epidermal and dermal firmness and thickness were determined. RESULTS: Treatment with 12% lactic acid resulted in increased epidermal and dermal firmness and thickness and clinical improvement in skin smoothness and in the appearance of lines and wrinkles. No dermal changes were observed after treatment with 5% lactic acid; however, similar clinical and epidermal changes were noted. CONCLUSION: The results demonstrate that cosmetic benefits from the use of alpha-hydroxy acids are caused by modification of the skin surface, the epidermis and the dermis. Although 5% lactic acid modulates surface and epidermal changes, 12% lactic acid influences both the epidermis and the dermis.