Managing mild casualties in mass-casualty incidents: lessons learned from an aborted terrorist attack

INTRODUCTION: Mildly injured and "worried well" patients can have profound effects on the management of a mass-casualty incident. The objective of this study is to describe the characteristics and lessons learned from an event that occurred on 28 August 2005 near the central bus station in Beer-Sheva, Israel. The unique profile of injuries allows for the examination of the medical and operational aspects of the management of mild casualties. METHODS: Data were collected during and after the event, using patient records and formal debriefings. They were processed focusing on the characteristics of patient complaints, medical response, and the dynamics of admission. RESULTS: A total of 64 patients presented to the local emergency department, including two critical casualties. The remaining 62 patients were mildly injured or suffered from stress. Patient presentation to the emergency department was bi-phasic; during the first two hours following the attack (i.e., early phase), the rate of arrival was high (one patient every three minutes), and anxiety was the most frequent chief complaint. During the second phase, the rate of arrival was lower (one patient every 27 minutes), and the typical chief complaint was somatic. Additionally, tinnitus and complaints related to minor trauma also were recorded frequently. Psychiatric consultation was obtained for 58 (91%) of the patients. Social services were involved in the care of 47 of the patients (73%). Otolaryngology and surgery consultations were obtained for 45% and 44%, respectively. The need for some medical specialties (e.g., surgery and orthopedics) mainly was during the first phase, whereas others, mainly psychiatry and otolaryngology, were needed during both phases. Only 13 patients (20%) needed a consultation from internal medicine. CONCLUSIONS: Following a terrorist attack, a large number of mildly injured victims and those experiencing stress are to be expected, without a direct relation to the effectiveness of the attack. Mildly injured patients tend to appear in two phases. In the first phase, the rate of admission is expected to be higher. Due to the high incidence of anxiety and other stress-related phenomena, many mildly injured patients will require psychiatric evaluation. In the case of a bombing attack, many of the victims must be evaluated by an otolaryngologist.     

Perioperative venous thromboembolism prophylaxis in Israel: a survey of academic surgical departments

OBJECTIVE: Postoperative venous thromboembolism (VTE) represents a serious threat to patients undergoing surgical procedures. Without thromboprophylaxis, deep vein thrombosis occurs in up to 60% of patients undergoing major orthopedic surgery and 15% of patients undergoing major abdominal surgery. Although, many studies have shown the efficacy of pharmacologic and mechanical means of VTE prophylaxis, practice variations in this area abound worldwide. The purpose of this study was to determine the attitudes and practice of VTE prophylaxis of academic surgical department heads in Israel. METHODS: A questionnaire covering various aspects of VTE prophylaxis was mailed to all surgical department heads of university teaching hospitals in Israel. Three months later, the same questionnaire was sent to department heads who had not yet replied. Data retrieved from the returned questionnaires were analyzed. RESULTS: A total of 250 departments in 23 hospitals affiliated to the four medical schools in Israel were identified; 130 department heads (52%) returned the questionnaires. The current study analyzes results obtained from the general surgical, orthopedic, urological, vascular and gynecological departments only. The total number of responses from these departments was 90 (69% response rate). Sixty-seven percent of the departments considered VTE to be a clinical problem. Ninety-four percent of departments have a policy for VTE prophylaxis. The most frequently used modalities for VTE prophylaxis (more than one option possible) were low-molecular-weight heparin (LMWH) (59%), unfractionated heparin (43%) and an intermittent pneumatic compression device (20%). VTE prophylaxis is begun 12 h preoperatively by 33% of departments, 2-4 h preoperatively by 20% of departments and with premedication by 8% of departments. VTE prophylaxis was continued during the postoperative period by all departments, with 52% stopping prophylaxis upon patient mobilization. Bleeding complications have been noted by 55% of departments, of these 9% were considered major. In general surgical, orthopedic and gynecologic departments, VTE prophylaxis was widely used for those procedures for which published guidelines exist, while considerable variation in VTE prophylaxis administration was demonstrated in a number of commonly encountered clinical situations for which there are no published recommendations. CONCLUSIONS: This study confirms that academic surgical departments in Israel conform to standard VTE prophylaxis guidelines. However, considerable variations in practice exist regarding the means of prophylaxis, onset of prophylaxis and its duration. These areas should be the focus of ongoing educational efforts including the development of uniform practice guidelines to improve the quality of care regarding VTE prophylaxis. Furthermore, attention should be given to methods for decreasing hemorrhage caused by LMWH and unfractionated heparin usage.     

Rosuvastatin versus atorvastatin in achieving lipid goals in patients at high risk for cardiovascular disease in clinical practice: A randomized, open-label, parallel-group, multicenter study (DISCOVERY Alpha study)

Background:

The majority of clinical trials investigating the clinical benefits of lipid-lowering therapies (LLTs) have focused on North American or western and nothern European populations. Therefore, it is timely to confirm the efficacy of these agents in other patient populations in routine clinical practice.

Objective:

The aim of the Direct Statin COmparison of low-density lipoprotein cholesterol (LDL-C) Values: an Evaluation of Rosuvastatin therapY (DISCOVERY) Alpha study was to compare the effects of rosuvastatin 10 mg with those of atorvastatin 10 mg in achieving LDL-C goals in the Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice guidelines.

Methods:

This randomized, open-label, parallel-group study was conducted at 93 centers in eastern Europe (Estonia, Latvia, Romania, Russia, Slovenia), Central and South America (Chile, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, Panama), and the Middle East (Israel, Kuwait, Saudi Arabia, United Arab Emirates). Male and female patients aged ≥18 years with primary hypercholesterolemia (LDL-C level, >135 mg/dL if LLT-naive or ≥120 mg/dL if switching statins; triglyceride [TG] level, <400 mg/dL) and a 10-year coronary heart disease (CHD) risk >20% or a history of CHD or other established atherosclerotic disease were eligible for inclusion in the study. Patients were randomly assigned to receive rosuvastatin 10-mg or atorvastatin 10-mg tablets QD for 12 weeks. No formal statistical analyses or comparisons were performed on lipid changes between switched and LLT-naive patients because of the different lipid inclusion criteria for these patients. The primary end point was the proportion of patients achieving 1998 European LDL-C goals after 12 weeks of treatment. A subanalysis was performed to assess the effects of statins in patients who had received previous statin treatment versus those who were LLT-naive. Tolerability was assessed using laboratory analysis and direct questioning of the patients.

Results:

A total of 1506 patients (52.1% women, 47.9% men; mean [SD] age, 58.2 [10.8] years) participated in the study (rosuvastatin, 1002 patients; atorvastatin, 504 patients; previous LLT, 567 patients). A significantly higher proportion of patients achieved 1998 European LDL-C goals after 12 weeks with rosuvastatin 10 mg than with atorvastatin 10 mg (72.5% vs 56.6%; P < 0.001). Similarly, more patients achieved the 2003 European LDL-C goals with rosuvastatin 10 mg compared with atorvastatin 10 mg (57.5% vs 39.2%). Rosuvastatin 10 mg was associated with a significantly greater change in LDL-C levels compared with atorvastatin 10 mg, in patients who were LLT-naive (LDL-C: −44.7% vs −33.9%; P < 0.001) and in patients who had received previous LLT (LDL-C: −32.0% vs −26.5%; P = 0.006). TG levels were also decreased with rosuvastatin 10 mg and atorvastatin 10 mg, although there was no significant difference between treatments. Similarly, there was no significant difference in the increase in high-density lipoprotein cholesterol levels between treatments. The most common adverse events overall were headache 16/1497 (1.1%), myalgia 10/1497 (0.7%), and nausea 10/1497 (0.7%).

Conclusions:

In this study in patients with primary hypercholesterolemia in clinical practice, greater reductions in LDL-C levels were achieved with a starting dose (10 mg) of rosuvastatin compared with atorvastatin 10 mg, with more patients achieving European LDL-C goals. Both treatments were well tolerated     

Genetic and Structural Analysis of a <Emphasis Type="Italic">SKIV2L</Emphasis> Mutation Causing Tricho-hepato-enteric Syndrome

Background

Advances in genomics have facilitated the discovery of monogenic disorders in patients with unique gastro-intestinal phenotypes. Syndromic diarrhea, also called tricho-hepato-enteric (THE) syndrome, results from deleterious mutations in SKIV2L or TTC37 genes. The main features of this disorder are intractable diarrhea, abnormal hair, facial dysmorphism, immunodeficiency and liver disease.

Aim

To report on a patient with THE syndrome and present the genetic analysis that facilitated diagnosis.

Methods

Whole-exome sequencing (WES) was performed in a 4-month-old female with history of congenital diarrhea and severe failure to thrive but without hair anomalies or dysmorphism. Since the parents were first-degree cousins, the analysis focused on an autosomal recessive model. Sanger sequencing was used to validate suspected variants. Mutated protein structure was modeled to assess the effect of the mutation on protein function.

Results

We identified an autosomal recessive C.1891G > A missense mutation (NM_006929) in SKIV2L gene that was previously described only in a compound heterozygous state as causing THE syndrome. The mutation was determined to be deleterious in multiple prediction models. Protein modeling suggested that the mutation has the potential to cause structural destabilization of SKIV2L, either through conformational changes, interference with the protein’s packing, or changes at the protein’s interface.

Conclusions

THE syndrome can present with a broad range of clinical features in the neonatal period. WES is an important diagnostic tool in patients with congenital diarrhea and can facilitate diagnosis of various diseases presenting with atypical features.

     

Permanent tracheostomy

A technique designed to create a permanent, wide open, and stable tracheal stoma is based on two corresponding U-shaped flaps: one from the anterior tracheal wall, the other from the skin in the suprasternal notch. The method described in this article has proved to be efficient, practical, well tolerated, and readily reversible. Its applications when indicated may reduce the side effects and complications associated with tracheostomy. Our clinical experience with this technique covers eight patients who tolerated the procedure well. The follow-up period exceeds 2 years.     

Factors that may influence the preparation of standards of procedures for dealing with mass-casualty incidents

INTRODUCTION: General hospitals in Israel are required to develop standards of procedures (SOPs) to facilitate the management of mass-casualty incidents (MCIs). These SOPs represent the initial step in a continuous process, providing guidelines for hospitals to manage MCIs in an organized and efficient manner. Evaluation of the preparedness levels of hospitals in dealing with MCIs is required in order to promote an effective response, and to identify factors that might impact the quality of SOPs. The aim of this study was to identify the characteristics of hospitals that have an impact on the preparation of SOPs. METHODS: An evaluation tool was developed to assess the SOPs from 22 hospitals during the management of a MCI. The results of the evaluations were analyzed, in relation to the size, trauma capabilities, ownership, geographic location, urban versus rural status of the hospitals, the proximity to other hospitals, participation in drills during the year prior to the evaluation, and number of actual MCIs the hospital managed in the past three years. RESULTS: The evaluation scores of the SOPs of 11 of the 22 hospitals (50%) were very high, so their SOPs did not require modifications. The SOPs of four hospitals (18%) were rated highly, requiring only minor modifications. The SOPs of four hospitals (18%) received poor ratings, requiring major modifications, and three hospitals (14%) were found to have incomplete SOPs and received very poor ratings. No significant differences were found between the ratings of SOPs in relation to the different characteristics of the hospitals analyzed. A low correlation between the level of SOPs and the number of MCIs that the hospital managed was found (r = 0.266, NS). CONCLUSIONS: The tool developed to evaluate the quality of the SOPs of hospitals to manage MCIs was logistically feasible and capable of differentiating between hospital SOPs. The comprehensiveness and completeness of the SOPs appears to be unrelated to the characteristics of the hospitals included in this study. Of particular note was the lack of a significant correlation between the SOP rating and the number of actual MCIs managed by a hospital.     

Abrupt tonsillar hemorrhage from a metastatic hemangiosarcoma of the breast: case report and literature review

We describe a case of primary breast hemangiosarcoma with tonsillar metastasis that manifested as a profuse oropharyngeal hemorrhage. The patient was a 54-year-old woman who presented to the emergency department with oral bleeding. A thorough examination revealed a distorted morphology of the left tonsil and a hemorrhage originating from it. Conservative methods to control the hemorrhage failed, and tonsillectomy was carried out. Histopathologic analysis revealed that the left tonsil contained hemangiosarcoma cells of the same kind that had been removed from the breast. Primary hemangiosarcomas of the breast are rare; when they do occur, they usually recur locally and spread hematogenously. To the best of our knowledge, this is the first case of a primary breast hemangiosarcoma with tonsillar metastasis to be reported in the literature. We present a detailed analysis of this case, and we review the relevant literature on metastatic tonsillar tumors, with attention to the role of therapeutic embolization.