Sudden-Onset Disaster Mass-Casualty Incident Response: A Modified Delphi Study on Triage, Prehospital Life Support, and Processes.

The application and provision of prehospital care in disasters and mass-casualty incident response in Europe is currently being explored for opportunities to improve practice. The objective of this translational science study was to align common principles of approach and action and to identify how technology can assist and enhance response. To achieve this objective, the application of a modified Delphi methodology study based on statements derived from key findings of a scoping review was undertaken. This resulted in 18 triage, eight life support and damage control interventions, and 23 process consensus statements. These findings will be utilized in the development of evidence-based prehospital mass-casualty incident response tools and guidelines.

Advancing the scientific study of prehospital mass casualty response through a Translational Science process: the T1 scoping literature review stage.

PURPOSE: The European Union Horizon 2020 research and innovation funding program awarded the NIGHTINGALE grant to develop a toolkit to support first responders engaged in prehospital (PH) mass casualty incident (MCI) response. To reach the projects' objectives, the NIGHTINGALE consortium used a Translational Science (TS) process. The present work is the first TS stage (T1) aimed to extract data relevant for the subsequent modified Delphi study (T2) statements. METHODS: The authors were divided into three work groups (WGs) MCI Triage, PH Life Support and Damage Control (PHLSDC), and PH Processes (PHP). Each WG conducted simultaneous literature searches following the PRISMA extension for scoping reviews. Relevant data were extracted from the included articles and indexed using pre-identified PH MCI response themes and subthemes. RESULTS: The initial search yielded 925 total references to be considered for title and abstract review (MCI Triage 311, PHLSDC 329, PHP 285), then 483 articles for full reference review (MCI Triage 111, PHLSDC 216, PHP 156), and finally 152 articles for the database extraction process (MCI Triage 27, PHLSDC 37, PHP 88). Most frequent subthemes and novel concepts have been identified as a basis for the elaboration of draft statements for the T2 modified Delphi study. CONCLUSION: The three simultaneous scoping reviews allowed the extraction of relevant PH MCI subthemes and novel concepts that will enable the NIGHTINGALE consortium to create scientifically anchored statements in the T2 modified Delphi study.

Comprehensive security, disinformation, and COVID-19: An analysis of the impacts of mis- and disinformation and populist narratives during the pandemic.

The COVID-19 pandemic has generated many fundamental and challenging implications regarding security, for both states and people. This article addresses the pandemic as a security threat, whereby societal and human dimensions of security are intertwined with the narrower (so-called traditional) state dimensions, culminating in comprehensive security. This article uses mixed methods, combining desk research and a selection of narratives or stories from several parts of the world that signify how the intersection of disinformation and populist discourses exacerbated the COVID-19 security challenges. These are analysed through an innovative comprehensive security analytical approach. Drawing on both security theory and policy, the article examines how the COVID-19 pandemic jeopardised security on multiple levels. First, the state's capacity to effectively act and deliver in the domestic sphere waned. Second, the social contract between the state and its citizens eroded as public trust dissipated. This article argues, however, that the most pervasive threat to security during the pandemic pertained to the exploitation of the information domain in relation to the state, society, and people. The article interrogates how mis- and disinformation about the pandemic compounded and exacerbated the security challenges it posed, often relying on existing narratives within right-wing populism movements to increase mistrust and discontent. These largely right-wing populist narratives contributed to broadening the gap between states and people, besides weakening public compliance with state health security measures. The nature of populism and the narratives of particularly right-wing populism contributed to increases in fragmentation, polarisation, and discrimination impacting societal trust. The article concludes with recommendations to mitigate the adverse impacts of mis- and disinformation, including reinvigorating the relationship between state institutions and the people to strengthen comprehensive security.

Targeting the Rat's Small Bowel: Long-Term Infusion into the Superior Mesenteric Artery.

The superior mesenteric artery can be cannulated in humans through minimally invasive radiological catheterization of the femoral or axillary artery. SMA cannulation is more difficult in rats due to small anatomical dimensions. The aim of the study is to describe a surgical technique for cannulation of the SMA in rats to perform long-term infusion of drugs into the SMA vascular bed in unrestricted animals, which will result in a high rate of catheter patency after the post surgical recovery for 24 hours. To avoid the risk of SMA thrombosis or bleeding from direct access, a proximal branch of the SMA is isolated, ligated distally and cannulated with a 0.25 mm polyurethane capillary tube whose tip is advanced close to the origin of the SMA from the aorta. The cannula is then tunnelled subcutaneously to the back of the animal's neck and through the skin via an artificial valve. The external portion of the cannula is inserted in a semi-rigid support system and connected to the continuous infusion pump outside the cage where the rat is free to move. Correct positioning of the cannula was demonstrated by post-surgical angiography and autopsy findings. Catheter patency after 24 hours of saline infusion into the SMA region was assured in most rats by the total discharge of the pump and recognition of a functional cannula for blood sampling or saline infusion.

Necrotizing Fasciitis Following Herpes Zoster Ophthalmicus in an Immunocompromised Patient.

Necrotizing fasciitis (NF) is a rare infection that spreads rapidly along the subcutaneous soft tissue planes. NF rarely involves the periorbital region due to the excellent blood supply of this region. We report a case of periorbital necrotising fasciitis following herpes zoster (HZ) in an immunocompromised 70-year-old patient with a dramatically rapid evolution into septic shock. In our patient, the surprisingly rapid spread of the bacterial superinfection led the periorbital cellulitis to turn into frank NF within 2 hours, with an overwhelming evolution. Despite the prompt start of a systemic antibiotic therapy and the immediate surgical intervention, the patient had a septic shock; she was treated in ITU for 31 days and then discharged to a medical ward and eventually died for a mix of complications of the medical treatment and comorbidities. This case is unique because any documented cases of periorbital NF triggered by HZ had never led to a septic shock and death. Ophthalmologists should be aware that even common skin lesions caused by shingles can determine a dramatic clinical picture, in presence of predisposing factors.

Empirical measurement of pressure in negative pressure wound therapy for infected wounds: How long can it really stay under pressure?

Surgical site infections represent one of the most common surgical complications. Negative pressure wound therapy is considered an effective wound management system, based on the principle that a negative pressure inside the wound can suction fluids and approximate wound edges. With the negative pressure wound therapy systems commercially available it is assumed that the pressure inside the wound is stable at the set values. We conducted a prospective experimental study to investigate this. The negative pressure level achieved inside the dressing was investigated at a standard distance from the pad of suction and at specific times in patients with surgical site infections. Pressure measurements were performed in 28 dressings in 14 patients admitted to the Emergency Surgery Department between April 2016 and June 2017. In general, the machine was set at a pressure of -100 mmHg. Negative pressure was measured with a portable pressure reader in the dressing sponge at a distance of 0, 1.5, and 3 cm from the suction pad at the time of dressing change at 24 and 48 hours. The data suggest that there is a significant decrease in negative pressure at both 1.5 and 3 cm from the suction pad at 48 hours from the dressing change (p = 0.0001 and p < 0.0001, respectively). This preliminary study shows with statistical significance that the pressure inside the sponge of a negative pressure wound therapy system decreases after 48 hours, confirming that the pressure inside the system is not the same as the pressure reported by the machine and, instead of being stable, changes overtime.

Vacuum-assisted closure (VAC®) systems and microbiological isolation of infected wounds.

Background: Negative pressure wound therapy is now largely used to treat infected wounds. The prevention and reduction of healthcare-associated infections is a high priority for any Department of Health and great efforts are spent to improve infection control systems. It is assumed that vacuum-assisted closure (VAC®) dressings should be watertight and that all the secretions are gathered in a single container but there is no consistent data on air leakage and possible dispersion of bacteria from the machine. Methods: We have conducted a prospective experimental study on 10 patients with diagnosis of wound infection to verify whether the filtration process is microbiologically efficient. We compared the bacteria population present in the wound to the one present in the air discharged by the VAC® machine. Results: This study shows that the contamination of the VAC® machine is considerably lower than the environment or wound contamination. Conclusions: Negative pressure wound therapy system does not represent a risk factor for healthcare-associated infections.

Dedicated mass-casualty incident hospitals: An overview.

INTRODUCTION: Hospitals worldwide are preparing for mass casualty incidents (MCIs). The Major Incident Hospital in the Netherlands was constructed 25 years ago as a dedicated hospital for situations wherein a sudden increase in medical surge capacity is mandated to handle an MCI. Over the years, more initiatives of dedicated MCIs have arisen. Herein, we compared the MCI facilities from three countries considering the reasons for construction and the functionality. METHODS: Three dedicated mass casualty hospitals and one hospital with a largely fortified structure were compared. The centres were located in the Netherlands, Italy, and Israel. Between August 2015 and January 2016, structured interviews were conducted with representatives of the hospitals' medical operations. The interviews focussed on general information regarding the need for MCI preparedness and scenarios that require preparation, reasons for construction, hospital missions, and the experiences gained including training. RESULTS: All dedicated MCI hospitals had a common policy wherein they sought to create normal work circumstances for the medical staff by using similar equipment and resources as in normal hospitals. The MCI hospitals' designs differed substantially, as determined by the threats faced by the country. In Europe, these hospitals are designed as a solution to surge capacity and function as buffer hospitals offering readily available, short term, additional medical capacity to the local health care system. Israel faces constant threat from long-term conflicts; during the 2006 war, several hospitals suffered direct missile impacts. Therefore, Israeli MCI hospitals are designed to be fortified structures offering shelter against both conventional and non-conventional warfare and intended as a long-term solution during siege situations. CONCLUSION: Several dedicated MCI hospitals are presently being constructed. During construction, the local circumstances should be taken into account to determine the functionality for both short-term solutions for surge capacity and as fortified structures to withstand under-siege situations.

Simulation of Trauma Incidents : Modelling the Evolution of Patients and Resources.

Mathematical modeling and simulation with medical applications has gained much interest in the last few years, mainly due to the widespread availability of low-cost technology and computational power. This paper presents an integrated platform for the in-silico simulation of trauma incidents, based on a suite of interacting mathematical models. The models cover the generation of a scenario for an incident, a model of physiological evolution of the affected individuals, including the possible effect of the treatment, and a model of evolution in time of the required medical resources. The problem of optimal resource allocation is also investigated. Model parameters have been identified according to the expertise of medical doctors and by reviewing some related literature. The models have been implemented and exposed as web services, while some software clients have been built for the purpose of testing. Due to its extendability, our integrated platform highlights the potential of model-based simulation in different health-related fields, such as emergency medicine and personal health systems. Modifications of the models are already being used in the context of two funded projects, aiming at evaluating the response of health systems to major incidents with and without model-based decision support.

An unusual case of acute unilateral parotitis following abdominal surgery. Report of a case and review of the literature.

BACKGROUND: Postoperative parotitis is a well known entity which can develop in patients who undergo major abdominal surgery. METHODS: We present a case of postoperative parotitis which occurred after a laparotomy for incisional hernia repair. RESULTS: After establishing diagnosis by ultrasonography assessment and blood chemical tests, patient was successfully treated by morphine discontinuing and antibiotics therapy. CONCLUSION: Beside sialolithiasis, sitting position or dehydratation we suggest that morphine could play a substantial role in the development of postoperative parotitis.

Superior vena cava thrombosis treated by angioplasty and stenting in a cirrhotic patient with peritoneovenous shunt.

We report a case of superior vena cava (SVC) thrombosis in a patient with liver cirrhosis and peritoneovenous surgical Denver shunt, successfully treated by angioplasty. In 2005, a 75-year-old man with a criptogenetic liver cirrhosis and peritoneovenous surgical Denver shunt was admitted to our hospital for chylous ascites. Venography showed a stenosis near the junction of the SVC with the right atrium. Magnetic resonance confirmed an endoluminal filling defect, suggestive of thrombosis, close to the jugular extremity of the peritoneovenous surgical denver shunt. A percutaneous transluminal angioplasty of the SVC thrombosis was successfully performed. Dicumarolic treatment was started. Two and 8 months after percutaneous transluminal angioplasty, a computed tomography scan showed the patency of the SVC. The patient died in June 2006 due to severe liver function impairment and hepato-renal syndrome. The present case shows that percutaneous transluminal angioplasty represents a good choice for primary intervention.

Combined anterior and posterior open treatment in infected pancreatic necrosis.

OBJECTIVE: To compare the results of combined anterior and posterior open treatments (lesser sac marsupialization (LSM) + lumbostomy, LSM + L) in patients with infected pancreatic necrosis (IPN) with a previous experience of isolated LSM and with data in literature. MATERIALS AND METHODS: Thirty-four consecutive patients operated on for IPN from 1981 to 2005 were divided into two groups based on the surgical technique used: single LSM (n = 23; period A, 1981-1998) and combined LSM + L (n = 11; period B, 1999-2005). RESULTS: The postoperative mortality rate was 38.1 (n = 8) and 9% (n = 1) during period A and B, respectively. The most important cause of death was recurrent or persistent sepsis with multiple organ failure. The overall postoperative surgical morbidity was 57 (n = 13) and 27.2% (n = 3) in the two consecutive groups. CONCLUSIONS: IPN is a challenging condition associated with high mortality mainly because of a persistence of sepsis despite surgery. A comparative analysis of many proposed operative procedures is difficult because of the heterogeneity in the reported series. Open approaches seem to be more effective in controlling local infection and systemic sepsis. Combining open anterior and posterior approaches is in our experience an appropriate surgical treatment in IPN patients.

Parathyroid carcinoma in a chronic hemodialysis patient: case report and review of the literature.

Parathyroid carcinoma is a rare disease in normal population as well as in patients with end-stage renal disease. Approximately 700 cases have been reported and, of these, 20 occurred in patients receiving chronic hemodialysis. We describe a case of parathyroid carcinoma in a 59-year-old female patient with end-stage renal disease secondary to membranous glomerulonephritis treated by hemodialysis since 1995. In September 1998, the calcium level was 12.4 mg/dl and intact parathyroid hormone serum levels were 1366 pg/ml (normal range, 25-65). A routine ultrasonographic examination of the neck revealed enlargement of two parathyroid glands, the left inferior gland being the largest and measuring 2x3x2 cm. In October 1998, resection of two parathyroid glands was performed. On the basis of histology, which documented the presence of proliferating cells arranged in sheets or in a trabecular pattern, numerous mitosis and vascular invasion, a diagnosis of parathyroid carcinoma was made.

Botulinum toxin in gastric submucosa reduces stimulated HCl production in rats.

BACKGROUND: Botulinum toxin blocks acetylcholine release from nerve endings and acts as a long term, reversible inhibitor of muscle contraction as well as of salivary, sweat gland, adrenal and prostatic secretions. The aim of the present study is to investigate whether gastric submucosal injection of botulinum toxin type A reduces stimulated gastric production of HCl. METHODS: Sixty-four rats were randomized in two groups and laparotomized. One group was treated with botulinum toxin-A 10 U by multiple submucosal gastric injections, while the second group was injected with saline. Two weeks later, acid secretion was stimulated by pyloric ligation and acid output was measured. Body weight, food and water intake were also recorded daily. RESULTS: HCl production after pyloric ligation was found to be significantly lower in botulinum toxin-treated rats (657 +/- 90.25 micromol HCl vs. 1247 +/- 152. P = 0.0017). Botulinum toxin-treated rats also showed significantly lower food intake and weight gain. CONCLUSIONS: Botulinum toxin type A reduces stimulated gastric acidity. This is likely due either to inhibition of the cholinergic stimulation of gastric parietal cells, or to an action on the myenteric nervous plexuses. Reduction of growth and food intake may reflect both impaired digestion and decreased gastric motility.