bluuebunny/crossref_metadata_2025 huggingface dataset:
Employees’ Perceptions of Social Norms as a Result of Implementing the Participatory Approach at Supervisor Level: Results of a Randomized Controlled Trial
Authors: Ketelaar S. M. , Schaafsma F. G. , Geldof M. F. , Boot C. R. L. , Kraaijeveld R. A. , Shaw W. S. , Bültmann U. , Twisk J. , Anema J. R.
Published: August 2016

Purpose A multifaceted implementation strategy was targeted at supervisors to encourage them to apply a participatory approach (PA) in dealing with employees’ work functioning problems due to health concerns. This paper assesses the effect on employees’ perceived social norms regarding the use of the PA to deal with work functioning problems. Methods Three organizations participated in a cluster randomized controlled trial, with randomization at the department level. Supervisors in the PA intervention departments received the implementation strategy consisting of a working group meeting, supervisor training, and optional coaching. Supervisors in the control departments received written information about the PA only. In two of the organizations, employees were invited to complete surveys at baseline and at 6-month follow-up. The primary outcome was perceived social norms regarding the use of the PA to deal with work functioning problems. Secondary measures included attitudes and self-efficacy, and intention regarding joint problem solving, and sick leave data. Effects were analyzed using multilevel analyses to account for nesting of cases. Results At baseline, 273 employees participated in the survey, with follow-up analyses of 174 employees. There were no statistically significant group effects on employee outcome measures. The intervention group showed a larger reduction in mean sick days (from 4.6 to 2.4 days) versus the control group (from 3.8 to 3.6 days), but this difference did not reach statistical significance (p > .05). Conclusion The multifaceted strategy to implement the participatory approach for supervisors did not show effects on outcomes at the employee level. To gain significant effects at the employee level, may require that an implementation strategy not only targets management and supervisors, but also employees themselves.

Trial registration: NTR3733.
Let's Make a Start: From Marketing to Markets?
Authors: Maclaran Pauline
Published: August 2016

Welcoming Roger Layton's call for marketing to be recognised as a social science, this commentary suggests marketers will need to build a stronger body of marketing theory in order to achieve this goal. Both inter-disciplinary and intra-disciplinary insights will play a significant role, as well as challenging the managerial emphasis of our discipline.
Associations between serum placental leucine aminopeptidase and pregnancy outcomes
Authors: Tian Chunfang , Huang Zhihang , Wen Zhanchong
Published: August 2016

Objective

To investigate the association between serum concentrations of placental leucine aminopeptidase (P‐LAP) and hypertensive disorders in pregnancy (HDP), gestational diabetes mellitus (GDM), and perinatal mortality.

Methods

In a prospective study, women with singleton pregnancies and affected by HDP, GDM, or fetal death, and those who were healthy, were enrolled at Shenzhen Seventh People's Hospital, Shenzhen, China, between January 2014 and July 2015. Serum P‐LAP concentrations at delivery/fetal death were compared among the groups. The predictive value of serum P‐LAP levels in fetal death was evaluated.

Results

Serum P‐LAP concentrations were (mean ± SEM) 74.02 ± 8.45 U/L in the HDP group (n = 38), 72.57 ± 12.03 U/L in the GDM group (n = 35), and 3.76 ± 3.02 U/L in the fetal death group (n = 14), all of which were significantly lower than the mean concentration of 107.11 ± 30.68 U/L in the control group (n = 30; P = 0.031, P = 0.042, and P < 0.001, respectively). On the basis of the receiver operating characteristic curve, low serum P‐LAP levels had high sensitivity and specificity for predicting fetal death (100% and 78.9%, respectively, for a serum P‐LAP cutoff of 47.07 U/L).

Conclusion

Serum P‐LAP levels were reduced among patients with HDP and GDM, and extremely low among patients affected by fetal death. Serum P‐LAP is potentially a viable predictor of fetal death.
Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta
Authors: Chen Zhenyu , Li Ju , Shen Jian , Jin Jiaxi , Zhang Wei , Zhong Wan
Published: August 2016

Objective

To evaluate direct puncture embolization of the internal iliac artery with hemostatic gelatin sponge particles to treat pernicious placenta previa coexisting with placenta accreta during cesarean delivery.

Methods

A retrospective study was conducted of data from women with pernicious placenta previa and placenta accreta who underwent direct puncture embolization of the internal iliac artery during cesarean delivery at a center in China between September 1, 2013, and February 28, 2015. Information regarding surgical procedures, operative data, and outcomes during hospitalization were obtained from medical records.

Results

The procedure was successful in all 16 cases included. Mean operative time was 78 minutes (range 65–90) and mean estimated blood loss was 1550 mL (range 1000–2500). Complications such as fever, buttock pain, or acute limb ischemia were not observed. The procedure was performed after partial cystectomy for two patients with bladder invasion. Postoperative Doppler imaging indicated uterine recovery and normalized uterine blood flow in all patients.

Conclusion

Direct puncture embolization of the internal iliac artery during cesarean delivery was a safe, effective, simple, and rapid method to control hemorrhage among women with pernicious placenta previa and placenta accreta.
Improving the use of biological data in Antarctic management
Authors: Lynch Maureen A. , Foley Catherine M. , Thorne Lesley H. , Lynch Heather J.
Published: August 2016

The Antarctic Treaty System requires that the effects of potential human disturbance be evaluated, such as through the development and evaluation of Initial and Comprehensive Environmental Evaluations (IEEs and CEEs), and through the implementation of Management Plans for Antarctic Specially Protected Areas (ASPAs) and Antarctic Specially Managed Areas (ASMAs). The effectiveness of these management processes hinges on the quality and transparency of the data presented, particularly because independent validation is often difficult or impossible due to the financial and logistical challenges of working in the Antarctic. In a review of these documents and their treatment of wildlife survey data, we find that the basic elements of best data practices are often not followed; biological data are often uncited or out-of-date and rarely include estimates of uncertainty that would allow any subsequent changes in the distribution or abundance of wildlife to be rigorously assessed. We propose a set of data management and use standards for Antarctic biological data to improve the transparency and quality of these evaluations and to facilitate improved assessment of both immediate and long-term impacts of human activities in the Antarctic.
Preventing Post-injury Hypothermia During Prolonged Prehospital Evacuation
Authors: Husum Hans , Olsen Tone , Murad Mudhafar , Heng Yang Van , Wisborg Torben , Gilbert Mads
Published: August 2016

Introduction:

Post-injury hypothermia is a risk predictor in trauma patients whose physiology is deranged. The aim of the present study was to examine the effect of simple, in-field, hypothermia prevention to victims of penetrating trauma during long prehospital evacuations.

Methods:

A total of 170 consecutively injured landmine victims were included in a prospective, clinical study in Northern Iraq and Cambodia. Thirty patients were provided with systematic prehospital hypothermia prevention, and for 140 patients, no preventive measures were provided.

Results:

The mean value for the time from injury to hospital admission was 6.6 hours (range: 0.2–72). The incidence of hypothermia (oral temperature <36°C) before prevention/rewarming was 21% (95% confidence interval: 15% to 28%). The Prevention Group had a statistically significant lower rate of hypothermia on hospital admission compared to the control group (95% confidence interval for difference: 6% to 24%).

Conclusion:

Simple, preventive, in-field measures help to prevent hypothermia during protracted evacuation, and should be part of the trauma care protocol in rural rescue systems.
Injury Severity Score versus New Injury Severity Score for Penetrating Injuries
Authors: Husum Hans , Strada Gino
Published: August 2016

Introduction:

The New Injury Severity Score (NISS) was introduced in 1997 to improve outcome prediction based on anatomical severity scoring in trauma victims. Studies on populations of blunt trauma victims indicate that the NISS, predicts better than the Injury Severity Score (ISS) mortality post-injury, which is why the NISS has been recommended as the new “gold standard” for severity scoring. However, so far the accuracy of the NISS for penetrating injuries has not been validated against the ISS.

Methods:

ISS and NISS scores were collected retrospectively for 1,787 war-and landmine victims in North Iraq. All victims only had penetrating injuries. The two tests were compared for prediction of short-term mortality and post-operative complications using Receiver Operating Characteristics (ROC) analysis.

Results:

Both the ISS and the NISS predicted mortality with high accuracy (ROC area under curve 0.9). There were no significant differences between the two tests. The predictive accuracy for post-operative complications was moderate for both tests (ROC-AUC <0.8), with the NISS performing significantly better than the ISS.

Conclusion:

The NISS does not perform better than the ISS in penetrating injuries. However, this study was done on a low-risk trauma population, thus the results should not be extrapolated to high severity trauma. Due to statistical shortcomings in studies previously published, studies on far larger cohorts are necessary before the NISS should be adopted as the new “gold standard” for severity scoring.
Physician Attitudes About Prehospital 12-Lead ECGs in Chest Pain Patients
Authors: Brainard Andrew H. , Froman Philip , Alarcon Maria E. , Raynovich Bill , Tandberg Dan
Published: August 2016

Introduction:

The prehospital 12-lead electrocardiogram (ECG) has become a standard of care. For the prehospital 12-lead ECG to be useful clinically, however, cardiologists and emergency physicians (EP) must view the test as useful. This study measured physician attitudes about the prehospital 12-lead ECG.

Hypothesis:

This study tested the hypothesis that physicians had “no opinion” regarding the prehospital 12-lead ECG.

Methods:

An anonymous survey was conducted to measure EP and cardiologist attitudes toward prehospital 12-lead ECGs. Hypothesis tests against “no opinion” (VAS = 50 mm) were made with 95% confidence intervals (CIs), and intergroup comparisons were made with the Student-t-test.

Results:

Seventy-one of 87 (81.6%) surveys were returned. Twenty-five (67.6%) cardiologists responded and 45 (90%) EPs responded. Both groups of physicians viewed prehospital 12-lead ECGs as beneficial (mean = 69 mm; 95% CI = 65–74mm). All physicians perceived that ECGs positively influence preparation of staff (mean = 63 mm; 95% CI = 60–72mm) and that ECGs transmitted to hospitals would be beneficial (mean = 66 mm; 95% CI = 60–72mm). Cardiologists had more favorable opinions than did EPs. The ability of paramedics to interpret ECGs was not seen as important (mean = 50 mm; 95% CI = 43–56mm). The justifiable increase in field time was perceived to be 3.2 minutes (95% CI = 2.7–3.8 minutes), with 23 (32.8%) preferring that it be done on scene, 46 (65.7%) during transport, and one (1.4%) not at all.

Conclusions:

Prehospital 12-lead ECGs generally are perceived as worthwhile by cardiologists and EPs. Cardiologists have a higher opinion of the value and utility of field ECGs. Since the reduction in mortality from the 12-lead ECG is small, it is likely that positive physician attitudes are attributable to other factors.
Mortality in Land-Mine Accidents in Iran
Authors: Jahunlu Hameed Reza , Husum Hans , Wisborg Torben
Published: August 2016

Objective:

To study the rate of prehospital mortality before establishment of a rescue system for victims of land-mines in Iran.

Method:

Survey at rural clinics in mine-affected areas, and retrospective review of public patient records.

Results:

A total of 36.4% of casualties from land-mines in the study area died during the period of 1989–1999. The mortality seems highest in those victims who were torso injured.

Conclusion:

The mortality rate from accidents involving land-mines in the study area was high. Most fatalities seemingly occurred in the prehospital setting.
Ukranian's Disaster Medicine Team Mission to India following the Earthquake of 2001
Authors: Roshchin George G. , Mazurenko Oleg V.
Published: August 2016

This article describes the basic principles around establishing a Disaster Medicine Camp and the organization of the Ukrainian Disaster Medicine Mobile Hospital, which provided medical aid to victims of the 2001 earthquake in India. All of the information was obtained through direct observation and estimates based on empirical data gathered in the field.
Prehospital Interventions: On-scene-Time and Ambulance-Technicians' Experience
Authors: Birk Hans O. , Henriksen Lars O.
Published: August 2016

Introduction:

Very little evidence is available on the experience of ambulance-personnels or on the impact of prehospital interventions on total prehospital time.

Hypothesis:

On-scene-time increases with the number of prehospital techniques used, and ambulance-technicians achieve only limited clinical experience in prehospital techniques.

Methods:

Prospective, observational registry study including 56 ambulance technicians from two ambulance stations in the mixed urban/rural county and 5,557 patients who were brought to a hospital in 1998. The number of cases in which each ambulance-technician performed various kinds of prehospital techniques, and the average on-scene time for each prehospital technique and several combinations of prehospital techniques were calculated.

Results:

There were large differences between the number of times each technique was used. On-scene time was smallest when no techniques were used and tended to increase with the number of interventions used. On-scene-time was relatively low for patients with cardiac arrest.

Conclusion:

The Danish ambulance-technicians' curriculum includes interventions for which the technicians only achieve limited practical experience. Prehospital interventions are associated with an increase of on-scene time.
Disasters and Development: Part 2: Understanding and Exploiting Disaster-Development Linkages
Authors: Stephenson Rob S. , DuFrane Charles
Published: August 2016

Disasters can impede the effectiveness of development resource allocation. The damage sustained from an event can be classified into four categories: (1) Loss of resources; (2) Interruption of programs and switching of crucial resources to other, shorter-term needs; (3) Negative impacts upon investment climates; and/or (4) Disruption of the non-formal sector (local businesses). Disasters have a particularly destructive economic impact in areas in which there are few alternatives for assets that are destroyed or in areas in which the resources already are at critical levels. Development processes can both increase and/or decrease the vulnerability of a society to hazards. There are clearly established linkages between poverty, marginalization, over-population, and vulnerability. To a large extent, vulnerability derives from poverty. The poor are more likely to live in vulnerable areas (slopes prone to landslides, flood plains, marginal agricultural land), have difficulty accessing education and information, have fewer assets to invest in resources to reduce vulnerability, and are more prone to become malnourished and have chronic illnesses that predispose them to injury and death. Development may be associated with the production of new hazards accepted by a society because the perceived benefits of the development project far exceed the relative risk associated with the project. Therefore, risk assessments must be part of any program planning and evaluation. Training and education are of critical importance in preventing increased vulnerability as a result of development strategies.

Development also can progress in a manner that will result in mitigation of the impacts of an event on a given society (increase absorbing capacity and/or buffering capacity, elimination of hazards or the risk of them producing a disaster). Such mitigation measures can be either structural or non-structural. There exists a wide range of options for incorporating mitigation measures in development projects.

Two case studies provide exercises that incorporate the concepts provided in this discussion: (1) The 1985 earthquake in Mexico City; and (2) Agricultural development in northern Sudan.
Doctor-based Basic Cardiopulmonary Resuscitation Course: An Alternative
to the Conventional Approach
Authors: Kin-kwan Lam , Fei-lung Lau , Wai-kwong Chan , Kai-Shing Leung , Tsan-fai Chan
Published: August 2016

United Christian Hospital initiated a doctor-based cardiopulmonary
resuscitation (CPR) Program. It is a two-hour, focused, adult CPR course,
suitable for adults of different age groups and of different educational
levels. The course was rated highly by the participants. Most trainees
acquired CPR knowledge and skills, and had confidence to perform CPR. This
type of training could improve the rate of bystander CPR for out-of-hospital
cardiac arrest patients in this region. Avoiding the complexity and
pass-fail psychology that is used in the traditional CPR training
curriculum, it can be an alternative to the traditional four-hour
instructor-based Basic Life Support (BLS) course.
Medical Support for Children's Mass Gatherings
Authors: Thierbach Andreas R. , Wolcke Benno B. , Piepho Tim , Maybauer Marc , Huth Rainer
Published: August 2016

Introduction:

Medical care must be well-planned for mass gatherings. Events such as fairs, concerts, parades, and rallies cause many people to gather in one place, increasing the chance of injuries and for the development of a disaster. In this study, the level and quality of medical care were evaluated at a mass gathering of approximately 100,000 children. The event was a television-sponsored fun fair.

Methods:

Every patient contact was documented on printed forms, including data such as the number of patients treated, gender of the patients, presence or absence of a parental escort, time distribution of patient contacts, the diagnoses for the patient contacts, specific therapies applied, duration of the treatment, and patient discharge information. All data were coded after the event and transferred into a computer database. These data were analyzed using descriptive statistics.

Results:

Of the 100,000 spectators, 192 patients (81 male [42.2%] and 111 female [57.8%]) were treated during the nine-hour period, from 09:00 hours (h) until 18:00 h. Twenty percent of all the children up to the age of 10 years needing medical assistance were not accompanied by an adult. Seventy-five percent of all patient contacts were made during the afternoon. Of those treated, 164 patients (85.4%) suffered only minor injuries and were seen for <10 minutes. The most common type of complaint was minor trauma (103 patients, 53.6%); followed by minor medical problems such as headaches or light allergic reactions (21 patients, 10.9%); insect bites (20 patients, 10.4%); and serious medical problems or trauma such as severe arterial hypertension or long bone fractures (19 patients, 9.9%). Treatment included, but was not limited to, dressings (100 patients; 52.1%), local therapy (68 patient, 35.4%), and analgesic therapy (10 patients, 5.2%). Four patients (2%) were transferred to local hospitals.

Conclusion:

Most of the medical needs in the patients attending the children's fun fair were minor. Nevertheless, for similar events in the future, the medical team should be qualified for all serious medical emergencies, as well as major trauma; and should be prepared to meet the requirements of the specific group of spectators.

The overall usage rate in the children's fun fair described was 19.2 patient encounters per 10,000 spectators. Half of all of the patients were children below the age of 14 years. Medical services should consider that this study shows that up to 33% of children seeking medical assistance may not be accompanied by adults.
World Association for Disaster and Emergency Medicine: Psychosocial Task
Force—Alert and Impact
Authors: Leon Gloria R. , Masten Ann , Frazier Patricia , Gewirtz Abi , Hubbard John , Najarian Louis M. , Noy Shabtai , Mortensen Heather
Published: August 2016

The Stage of Alert refers to the time period
leading up to a disaster or terrorism event, usually defined by warnings
disseminated by the federal government about increased risk of a disaster or
terrorism situation. The general consensus was the need for more accurate
information from appropriate governmental agencies to the public about
specific impending threats, to ensure better coping. The purpose of
providing this information to the public is to avoid panic or inertia, and
to encourage normal adaptive reactions. It is important for people in
positions of leadership to realize that past experiences have shown that
panic has not occurred if people were given accurate information about the
anticipated threat and specific guidelines about what to do.
Medical Preparation for Terrorism in Australia. Is Luck Running Out for
“The Lucky Country?”
Authors: Caldicott David G.E. , Edwards Nicholas A.
Published: August 2016

Recent world events have forced Australia to re-examine its role on the
world stage and its susceptibility to terrorist attacks. The authors examine
the brief historical exposure of Australia to the phenomenon of terrorism,
and review the geopolitical climate and features that may render it more
susceptible to attack in the future. Australia's emergency management
structure is outlined, and its current state of medical preparedness for a
terrorist incident is critically reviewed.
Terrorism in Croatia
Authors: Bradic Nikola , Cuculic Drazen , Jancic Ervin
Published: August 2016

Abstract

Introduction:

This report illustrates Croatia's experience with the terrorist
attack in the city of Rijeka in October 1995. Also, the intention of
this report is to outline how emergency services were functioning in
this sudden-onset situation.

Methods:

The medical documentation of 27 wounded citizens in the attack was
analyzed and the appearance of bodily wounds, severity of wounds, and
the mechanisms of injury are described. From the forensic medical
report, the wounds and damages sustained by the terrorist also were
analyzed. All findings were compared with similar cases from around the
world.

Results:

In the 27 wounded citizens, three (11%) had head injuries, and
injuries of the abdomen in only two cases (7%) were found. The most
common injuries sustained involved one or more extremities: 16 (59%)
persons had wounds of an upper or lower extremity or a combination of
multiple wounds. The main cause of death of the terrorist was explosive
wounds to the chest and abdomen with destruction of multiple inner
organs (primarily kidneys, liver, abdomen, and lung). Furthermore, the
terrorist had a fracture of the skull base and multiple injuries to the
brain.

Conclusion:

Comparing the findings with other data from the literature, the
distribution in the percentages of wounded is almost the same as
reported in many bomb attacks. In this case, the walls of the building
protected many citizens, which is why so few were seriously injured.
Forensic examination of the terrorist's body showed all of the
characteristics of blast injuries.
The Burden of Terrorism in Malaysia
Authors: Aziz Azhar Abdul
Published: August 2016

In the peace-loving, moderate and progressive country of
Muslim-dominated Malaysia, violence generally is alien to the culture.
Terrorism initially took shape during the post-independence, communist era
by jungle recalcitrant actions. In recent years, this has been superceded by
a more internationally related trend of violence. Only very few incidents
were based locally, while the majority were linked to international groups
or organizations abroad, including the Kumpulan Mujahidin Malaysia (KMM),
Jemaah Islamiyah (JI), and the Abu Sayyaf Group (ASG).

Kidnapping with ransom seemed to have been the most commone
modus operandi, while killing and robbery
accounted for very few of these incidents. The number of victims in each
event so far has been small, and smaller for those physically harmed or
killed. This pattern of terrorist attacks suggests that the current level of
provision of emergency medical services is sufficient to handle such
incidents. Recent advances in local emergency medicine also have witnessed
the establishment of various teaching and training modules, a pivotal role
played by university hospitals and supported by the Ministry of
Health.

However, the spate of ongoing events of mass destruction such as the
conflict in Israel/Palestine, wars in Afghanistan and Iraq, the World Trade
Center and Pentagon tragedies of 11 September 2001, and the Bali bombing in
Indonesia, remain as great concerns to Malaysians. Both the government and
the people of Malaysia abhor such unjustified uses of terror, and take every
measure to curtail them. The National Security Council policies of Arahan
No. 18 and Arahan No. 20 detail specific roles and responsibilities of
various agencies in managing terrorism and disasters respectively, while the
use of the stern Internal Security Act that allows indefinite detention
without trial, evidently has been an efficient intelligence and security
apparatus.

With more recent developments of terrorist events regionally and
globally, Malaysia continues to face an ongoing threat from such activities.
Various measures have been and will be actively undertaken both by
government and non-governmental agencies in facing these
challenges.
Educational and Training Systems in Sweden for Prehospital Response to Acts of Terrorism
Authors: Kulling Per E.J. , Holst Jonas E.A.
Published: August 2016

Sweden has a long tradition in planning for disaster situations in which the National Board of Health and Welfare has a key responsibilty within the health sector. One important part of this disaster preparedness is education and training. Since 11 September 2001, much focus has been placed on the acts of terrorism with special reference to the effects of the use of chemical, biological, or nuclear/radiological (CBNR) agents. In the health sector, the preparedness for such situations is much the same as for other castastrophic events. The National Board of Health and Welfare of Sweden is a national authority under the government, and one of its responsibilities is planning and the provision of supplies for health and medical services, environmental health, and social services in case of war or crises. “Joint Central Disaster Committees” in each County Council/Region in the country are responsible for overseeing major incident planning for their respective counties/regions. The “Disaster Committee” is responsible for ensuring that: (1) plans are established and revised; (2) all personnel involved in planning receive adequate information and training; (3) equipment and supplies are available; and (4) maintenance arrangements are in place.

Sweden adopts a “Total Defense” strategy, which means that it places a high value in preparing for peacetime and wartime major incidents. The Swedish Emergency Management Agency coordinates the civilian Total Defense strategy, and provides funding to the relevant responsible authority to this end. The National Board of Health and Welfare takes responsibility in this process. In this area, the main activities of the National Board of Health and Welfare are: (1) the establishment of national guidelines and supervision of standards in emergency and disaster medicine, social welfare, public health, and prevention of infectious diseases; (2) the introduction of new principles, standards, and equipment; (3) the conducting education and training programmes; and (4) the provision of financial support. The budget for National Board of Health and Welfare in this area is approximately 160 million SEK (US$18 million). The National Board of Health and Welfare also provides funding to the County Councils/Regions for the training of healthcare professionals in disaster medicine and crises management by arranging (and financing) courses primarily for teachers and by providing financial support to the County Councils/Regions for providing their own educational and training programmes. The National Board of Health and Welfare provides funding of approximately 20 million SEK (US$2.4 million) to the County Councils/Regions for this training of healthcare professionals in disaster medicine and crises.
The Chemical Disaster Response System in Japan
Authors: Okumura Tetsu , Ninomiya Norifumi , Ohta Muneo
Published: August 2016

During the last decade, Japan has experienced the largest burden of chemical terrorism-related events in the world, including the: (1) 1994 Matsumoto sarin attack; (2) 1995 Tokyo subway sarin attack; (3) 1998 Wakayama arsenic incident; (4) 1998 Niigata sodium-azide incident; and (5) 1998 Nagano cyanide incident. Two other intentional cyanide releases in To kyo subway and railway station restrooms were thwarted in 1995. These events spurred Japan to improve the following components of its chemical disaster-response system: (1) scene demarcation; (2) emergency medical care; (3) mass decontamination; (4) personal protective equipment; (5) chemical detection; (6) information-sharing and coordination; and (7) education and training. Further advances occurred as result of potential chemical terrorist threats to the 2000 Kyushu-Okinawa G8 Summit, which Japan hosted. Today, Japan has an integrated system of chemical disaster response that involves local fire and police services, local emergency medical services (EMS), local hospitals, Japanese Self-Defense Forces, and the Japanese Poison Information Center.
Decontamination of Mass Casualties — Re-evaluating Existing Dogma
Authors: Levitin Howard W. , Siegelson Henry J. , Dickinson Stanley , Halpern Pinchas , Haraguchi Yoshikura , Nocera Anthony , Turineck David
Published: August 2016

The events of 11 September 2001 became the catalyst for many to shift their disaster preparedness efforts towards mass-casualty incidents. Emergency responders, healthcare workers, emergency managers, and public health officials worldwide are being tasked to improve their readiness by acquiring equipment, providing training and implementing policy, especially in the area of mass-casualty decontamination. Accomplishing each of these tasks requires good information, which is lacking. Management of the incident scene and the approach to victim care varies throughout the world and is based more on dogma than scientific data. In order to plan effectively for and to manage a chemical, mass-casualty event, we must critically assess the criteria upon which we base our response.

This paper reviews current standards surrounding the response to a release of hazardous materials that results in massive numbers of exposed human survivors. In addition, a significant effort is made to prepare an international perspective on this response.

Preparations for the 24-hour threat of exposure of a community to hazardous material are a community responsibility for first-responders and the hospital. Preparations for a mass-casualty event related to a terrorist attack are a governmental responsibility. Reshaping response protocols and decontamination needs on the differences between vapor and liquid chemical threats can enable local responders to effectively manage a chemical attack resulting in mass casualties. Ensuring that hospitals have adequate resources and training to mount an effective decontamination response in a rapid manner is essential.
Future Considerations for the Medical Management of Nerve-Agent Intoxication
Authors: Aas Pål
Published: August 2016

The use of chemical warfare agents against civilians and unprotected troops in international conflicts or by terrorists against civilians is considered to be a real threat, particularly following the terrorist attacks on 11 September 2001 against the World Trade Center in New York and against the Pentagon in Washington, DC. Over the past 10 years, terrorists have been planning to use or have used chemical warfare agents on several occasions around the world, and the attacks in 2001 illustrate their willingness to use any means of warfare to cause death and destruction among civilians. In spite of new international treaties with strong verification measures and with an aim to prohibit and prevent the use of weapons of mass destruction, nevertheless, some countries and terrorist groups have been able to develop, produce, and use such weapons, particularly nerve agents, in domestic terrorist attacks or during warfare in international conflicts. This article reviews current medical therapy for nerve-agent intoxication and discusses possible future improvement of medical therapies.

Present medical counter-measures against nerve agents are not sufficiently effective particularly in protecting the brain. Therefore, new and more effective countermeasures must be developed to enable better medical treatment of civilians and military personnel following exposure to nerve agents. Therefore, it is important with an enhanced effort by all countries, to improve and increase research in medical countermeasures, in the development of protective equipment, and in carrying out regular training of medical and emergency personnel as well as of military nuclear, biological, or chemical (NBC) units. Only then will nations be able to reduce the risk from and prevent the use of such weapons of mass destruction (WMD).
The Impact of Terrorism on Children: A Two-Year Experience
Authors: Waisman Yehezkel , Aharonson-Daniel Limor , Mor Meirav , Amir Lisa , Peleg Kobi
Published: August 2016

Objectives:

To review and analyze the cumulative two-year, Israeli experience with medical care for children victims of terrorism during the prehospital and hospital phases.

Methods:

Data were collected from the: (1) Magen David Adom National Emergency Medical System Registry (prehospital phase); (2) medical records from the authors’ institutions (pediatric triage); and (3) Israel Tr auma Registry (injury characteristics and utilization of in-hospital resources). Statistical analyses were performed as appropriate.

Introduction:

During the recent wave of violence in Israel and the surrounding region, hundreds of children have been exposed to and injured by terrorist attacks. There is a paucity of data on the epidemiology and management of terror-related trauma in the pediatric population and its effects on the healthcare system. This study focuses on four aspects of terrorism-related injuries: (1) tending to victims in the prehospital phase; (2) triage, with a description of a modified, pediatric triage algorithm; (3) characteristics of trauma-related injuries in children; and (4) utilization of in-hospital resources.

Results:

During the study period, 41 mass-casualty events (MCEs) were managed by Magen David Adom. Each event involved on average, 32 regular and nine mobile intensive care unit ambulances with 93 medics, 19 paramedics, and four physicians. Evacuation time was 5–10 minutes in urban areas and 15–20 minutes in rural areas. In most cases, victims were evacuated to multiple facilities. To improve efficiency and speed, the Magen David Adom introduced the use of well-trained “first-responders” and volunteer, off-duty professionals, in addition to “scoop and run” on-the-scene management. Because of differences in physiology and response between children and adults, a pediatric triage algorithm was developed using four categories instead of the usual three. Analysis of the injuries sustained by the 160 children hospitalized after these events indicates that most were caused by blasts and penetration by foreign objects. Sixty-five percent of the children had multiple injuries, and the proportion of critical to fatal injuries was high (18%). Compared to children with non-terrorism-related injuries, the terrorism-related group had a higher rate of surgical interventions, longer hospital stays, and greater needs for rehabilitation services.

Conclusion:

Terrorism-related injuries in children are severe and increase the demand for acute care. The modifications in the management of pedi-atric casualties from terrorism in Israel may contribute to the level of preparedness of medical and paramedical personnel to cope with future events. Further studies of other aspects of traumatic injuries, such as its short- and long-term psychological consequences, will provide a more comprehensive picture of the damage inflicted on children by acts of terrorism.
Case Report: Penetrating Cardiac Injury Secondary to a Terrorism-Related Nail Bomb Explosion
Authors: Asai Yasufumi , Yoshida Masashi , Kurimoto Yoshihiko , Arnold Jeffrey L.
Published: August 2016

Penetrating cardiac injuries commonly occur secondary to gunshot or stab wounds. This is a report an unusual case of a patient who sustained a penetrating cardiac injury due to a nail from a terrorism-related, nail-bomb explosion. Associated problems included pericardial tamponade, penetrating cardiac injuries, acute, traumatic, myocardial infarction, and a penetrating lung injury. Prompt diagnosis and aggressive surgical intervention resulted in full recovery of the patient.
The Spectrum of Human Reactions to Terrorist Attacks with Weapons of Mass Destruction: Early Management Considerations
Authors: DiGiovanni Cleto
Published: August 2016

Residents of a community who are intentionally exposed to a hazardous biological, chemical, or radiological agent (including medical first-responders and other civil defense personnel who live in that community) will exhibit a spectrum of psychological reactions that will impact the management of the incident. These reactions will range from a variety of behaviors of normal people under abnormal circumstances that either will help or hinder efforts to contain the threatening agent, deliver medical care, and reduce the morbidity, mortality, and costs associated with the disaster, to the development of new, or exacerbation of preexisting, mental disorders.

Anticipating the decisions that people will make and actions they will take as the crisis develops is hindered by the limited number of previous disasters that bear crucial similarities to a terrorist attack with a weapon of mass destruction. Such actions, therefore, could serve as models to predict community reactions. One result of a study that attempted to fill in these gaps suggested that medical first-responders and their spouses/significant others may require separately crafted information and advice to reduce the potential for disharmony within the family that could affect job performance during the crisis.

For those persons who exhibit emotional lability or cognitive deficits, evaluation of their psychiatric signs and symptoms may be more difficult than imagined, especially with exposure to nerve agents. Appreciation of these difficulties, and possession of the skill to sort through them, will be required of those assigned to triage stations. The allocation and utilization of mental health resources as the incident unfolds will be the responsibility of local consequence managers; these managers should be aware of the results of a recently-held workshop that attempted to reach consensus among experts in disaster mental health, based on the peer-reviewed literature, on the efficacy and safety of various approaches to early psychological interventions for victims of mass trauma and disasters.

Thus, psychological factors are likely to be significant in the management of a terrorist incident that involves an agent of mass destruction. Emergency medical workers with managerial responsibilities, whether limited in scope or community-wide, should be aware of these factors, and should train to handle them through effective risk communication as part of their planning and preparation.
Measures of Effectiveness in Large-scale Bioterrorism Events
Authors: Burkle Frederick M.
Published: August 2016

Measures of effectiveness (MOEs) are defined as operationally quantifiable management tools that provide a means for measuring effectiveness, outcome, and performance. No clear MOEs exist for determining success or failure of the management of a bioterrorism response. This is especially critical because management requires a multi-agency and multi-disciplinary decision-making and evaluation process. It is suggested that the minimum MOEs required to operationally measure outcome must contain a measuring response capacity for: (1) real-time public health surveillance system; (2) full coverage health information system; (3) capacity to measure variance across management timelines; (4) demonstrated decline in mortality and morbidity; (5) control of transmission rates of communicable agents; and (6) resource distribution across the entire population.
From Complex Emergencies to Terrorism — New Tools for Health-Sector Coordination in Conflict-Associated Disasters
Authors: Bradt David A. , Drummond Christina M.
Published: August 2016

Inter-agency coordination in humanitarian assistance dates as a discipline from the 1960s. The United Nations, Red Cross, governmental, and nongovernmental agencies have evolved different mechanisms to achieve it. Present practices in field-based, inter-agency coordination of the health sector remain variable and non-standardized. International experiences in coordination of humanitarian assistance reveal numerous issues of jurisdiction, authority, capacity, and competency. New tools to help overcome these issues in the health-sector coordination include binding principles of engagement, protocols for the assumption of responsibilities, standardized minimum essential data sets, and health-sector component summaries.
Israeli Defense Forces Medical Corps Humanitarian Mission for Kosovo's
Refugees
Authors: Amital Howard , Alkan Michael L , Adler Jakov , Kriess Iyzhak , Levi Yehezkel
Published: August 2016

In April 1999, during the crisis in Kosovo, the Israeli government
launched a medical, field hospital in order to provide humanitarian aid to
the Albanian refugees that fled from their homes in Kosovo. This facility
was set up by the Medical Corps of the Israeli Defense Forces, in a refugee
camp located in Northern Macedonia. During the 16 days during which the
hospital functioned, the medical staff treated 1,560 patients and
hospitalized >100. The field hospital served as a referral center for all
of the other primary clinics that were hastily erected in the camp and its
surroundings. This communication elaborates on the various aspects of the
humanitarian medical aid that were provided by this medical facility and the
conclusions that learned from such a mission.
Standardized Emergency Management System and Response to a Smallpox
Emergency
Authors: Kim-Farley Robert J. , Celentano John T. , Gunter Carol , Jones Jessica W. , Stone Rogelio A. , Aller Raymond D. , Mascola Laurene , Grigsby Sharon F. , Fielding Jonathan E.
Published: August 2016

The smallpox virus is a high-priority, Category-A agent that poses a
global, terrorism security risk because it: (1) easily can be disseminated
and transmitted from person to person; (2) results in high mortality rates
and has the potential for a major public health impact; (3) might cause
public panic and social disruption; and (4) requires special action for
public health preparedness. In recognition of this risk, the Los Angeles
County Department of Health Services (LAC-DHS) developed the Smallpox
Preparedness, Response, and Recovery Plan for LAC to prepare for the
possibility of an outbreak of smallpox.

A unique feature of the LAC-DHS plan is its explicit use of the
Standardized Emergency Management System (SEMS) framework for detailing the
functions needed to respond to a smallpox emergency. The SEMS includes the
Incident Command System (ICS) structure (management, operations,
planning/intelligence, logistics, and finance/administration), the
mutual-aid system, and the multi/interagency coordination required during a
smallpox emergency. Management for incident command includes setting
objectives and priorities, information (risk communications), safety, and
liaison. Operations includes control and containment of a smallpox outbreak
including ring vaccination, mass vaccination, adverse events monitoring and
assessment, management of confirmed and suspected smallpox cases, contact
tracing, active surveillance teams and enhanced hospital-based surveillance,
and decontamination. Planning/intelligence functions include developing the
incident action plan, epidemiological investigation and analysis of smallpox
cases, and epidemiological assessment of the vaccination coverage status of
populations at risk. Logistics functions include receiving, handling,
inventorying, and distributing smallpox vaccine and vaccination clinic
supplies; personnel; transportation; communications; and health care of
personnel. Finally, finance/administration functions include monitoring
costs related to the smallpox emergency, procurement, and administrative
aspects that are not handled by other functional divisions of incident
command systems.

The plan was developed and is under frequent review by the LAC-DHS
Smallpox Planning Working Group, and is reviewed periodically by the LAC
Bioterrorism Advisory Committee, and draws upon the Smallpox Response Plan
and Guidelines of the Centers for Disease Control and Prevention (CDC) and
recommendations of the Advisory Committee on Immunization Practices (ACIP).
The Smallpox Preparedness, Response, and Recovery Plan, with its SEMS
framework and ICS structure, now is serving as a model for the development
of LAC-DHS plans for responses to other terrorist or natural-outbreak
responses.