Αρχειοθήκη ιστολογίου

Δευτέρα 29 Αυγούστου 2016

Three-Versus Two-Dimensional Sonographic Biometry for Predicting Birth Weight and Macrosomia in Diabetic Pregnancies

Objectives—

The purpose of this study was to test the hypothesis that a formula incorporating 3-dimensional (3D) fractional thigh volume would be superior to the conventional 2-dimensional (2D) formula of Hadlock et al (Am J Obstet Gynecol 1985; 151:333–337) for predicting birth weight and macrosomia.

Methods—

We conducted a prospective cohort study of pregnancies complicated by pregestational or gestational diabetes and delivered after 38 weeks. Two-dimensional and 3D sonographic examinations were performed for fetal biometry and factional thigh volumes at 34 to 37 weeks. Fetal weight was estimated by Hadlock's 2D formula IV, which uses only 2D biometry, and formula 6 from Lee et al (Ultrasound Obstet Gynecol 2009; 34:556–565), which incorporates 3D fractional thigh volume and 2D biometry. The gestation-adjusted projection method was used to estimate predicted birth weights from 2D and 3D estimates. The primary outcome was fetal macrosomia, which was defined as birth weight of 4000 g or higher.

Results—

A total of 115 women with diabetes met inclusion criteria, and 17 (14.8%) delivered macrosomic neonates. The mean percentage error was significantly lower for the 2D than the 3D projected estimate (1.0% versus 12.0%; P < .01). The standard deviation of the mean percentage error was also significantly lower for the 2D projected estimate (10.2% versus 17.2%; P< .01). Two-dimensional biometry was overall superior to 3D biometry for predicting macrosomia (area under the receiver operating characteristic curve, 0.88 versus 0.75; P = .03). Specificity was significantly higher for 2D biometry (85% versus 66%; P < .01), whereas the difference in sensitivity was not statistically significant (59% versus 71%; P = .22).

Conclusions—

In this study, the Hadlock 2D formula was superior to the 3D method for predicting birth weight and macrosomia in diabetic women when used approximately 2 weeks before delivery, based on the gestation-adjusted projection method.



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Can Fetal Limb Soft Tissue Measurements in the Third Trimester Predict Neonatal Adiposity?

Objectives—

Neonatal adiposity is associated with chronic metabolic sequelae such as diabetes and obesity. Identifying fetuses at risk for excess neonatal body fat may lead to research aimed at limiting nutritional excess in the prenatal period. We sought to determine whether fetal arm and leg soft tissue measurements at 28 weeks' gestation were predictive of neonatal percent body fat

Methods—

In this prospective observational cohort study of singleton term pregnancies, we performed sonography at 28 and 36 weeks' gestation, including soft tissue measurements of the fetal arm and thigh (fractional limb volume and cross-sectional area). We estimated the neonatal body composition (percent body fat) using anthropometric measurements and air displacement plethysmography. We estimated Spearman correlations between sonographic findings and percent body fat and performed modeling to predict neonatal percent body fat using maternal characteristics and sonographic findings.

Results—

Our analysis of 44 women yielded a mean maternal age of 30 years, body mass index of 26 kg/m2, and birth weight of 3382 g. Mean neonatal percent body fat was 8.1% by skin folds at birth and 12.2% by air displacement plethysmography 2 weeks after birth. Fractional thigh volume measurements at 28 weeks yielded the most accurate model for predicting neonatal percent body fat (R2 = 0.697; P = .001), outperforming models that used abdominal circumference (R2= 0.516) and estimated fetal weight (R2= 0.489).

Conclusions—

Soft tissue measurements of the fetal thigh at 28 weeks correlated better with neonatal percent body fat than currently used sonographic measurements. After validation in a larger cohort, our models may be useful for prenatal intervention strategies aimed at the prevention of excess fetal fat accretion and, potentially, optimization of long-term metabolic health.



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Edwin L. Carstensen, PhD: DECEMBER 8, 1919 - JUNE 24, 2016

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Intramural Pregnancy Implanted Into a Myometrial Defect Caused by Curettage: Diagnosis With Transvaginal Sonography and Preconception and Postconception Magnetic Resonance Imaging

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Sonographic Visualization of the Rotator Cable in Patients With Symptomatic Full-Thickness Rotator Cuff Tears: Correlation With Tear Size, Muscular Fatty Infiltration and Atrophy, and Functional Outcome

Objectives—

To assess the prevalence of sonographic visualization of the rotator cable in patients with symptomatic full-thickness rotator cuff tears and asymptomatic controls and to correlate rotator cable visualization with tear size, muscular fatty infiltration and atrophy, and the functional outcome in the patients with rotator cuff tears.

Methods—

Fifty-seven patients with rotator cuff tears and 30 asymptomatic volunteers underwent shoulder sonography for prospective assessment of the rotator cable and rotator cuff tear and responded to 2 functional outcome questionnaires (shortened Disabilities of the Arm, Shoulder, and Hand [QuickDASH] and Constant). In the patients with rotator cuff tears, appropriate tests were used to correlate rotator cable visualization with the tear size, functional outcome, muscular fatty infiltration, and atrophy.

Results—

The patients with rotator cuff tears included 25 women and 32 men (mean age,57 years; range, 39–67 years), and the volunteers included 13 women and 17 men (mean age, 56 years; range, 35–64 years). The rotator cable was identified in 77% (23 of 30) of controls and 23% (13 of 57) of patients with rotator cuff tears. In the patients, nonvisualization of the rotator cable correlated with larger tears (P < 0.001) and higher grades of supraspinatus atrophy (P = .049) and fatty infiltration (P = .022). There was no significant correlation with functional outcome scores (QuickDASH, P = .989; Constant, P = .073) or infraspinatus fatty infiltration (P = .065).

Conclusions—

Nonvisualization of the rotator cable was more prevalent in patients with symptomatic rotator cuff tears than asymptomatic controls and was associated with a larger tear size and greater supraspinatus fatty infiltration and atrophy. Diligent assessment of the supraspinatus muscle should be done in patients with rotator cuff tears without a visible rotator cable, as the integrity of these anatomic structures may be interdependent.



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Elastic Characteristics of the Normal Achilles Tendon Assessed by Virtual Touch Imaging Quantification Shear Wave Elastography

Objectives—

To assess the elastic properties of the normal Achilles tendon in different age groups by Virtual Touch imaging quantification (VTIQ; Siemens Medical Solutions, Malvern, PA) shear wave elastography.

Methods—

A total of 326 healthy volunteers older than 18 years were divided into different groups by sex and age. The thickness, shear wave velocity (SWV) in sagittal and axial sections, and anisotropic coefficient of the Achilles tendon in a state of relaxation were obtained by conventional sonography and Virtual Touch imaging quantification elastography. These parameters were compared in different age and sex groups, and their correlations with age were evaluated.

Results—

The thickness of the Achilles tendon in men and women increased gradually with age, and it was larger in men than in women in each age group (P < .05). The SWV of the tendon in the sagittal section decreased slightly with age, but the sagittal and axial SWVs and anisotropic coefficient had no significant differences among different age groups (P > .05), and they also had no significant differences between men and women within any group (P > .05). The SWVs in the sagittal and axial sections and anisotropic coefficient had no correlation with age. Intraclass correlation coefficients for sagittal and axial SWVs obtained by 2 independent observers were 0.923 and 0.870, respectively.

Conclusions—

The thickness of the Achilles tendon increased gradually with age. We confirmed that tendinous elastographic anisotropy and the stiffness of the tendon had no significant correlation with age.



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Epicardial Adipose Tissue Is Increased in Patients With Inflammatory Bowel Disease

Objectives—

Patients with inflammatory bowel disease (IBD) have high cardiovascular morbidity, and, in general, epicardial adipose tissue thickness is related to atherosclerotic vascular disease. This study aimed to investigate the association between epicardial adipose tissue thickness and carotid intima-media thickness as markers of early atherosclerosis in patients with IBD.

Methods—

The study comprised 47 patients with IBD (25 with Crohn disease and 22 with ulcerative colitis) and 35 control participants. In all individuals, epicardial adipose tissue and carotid intima-media thickness values were measured by sonography.

Results—

The mean age ± SD of the 47 patients with IBD was 42.3 ± 11.2 years, versus 41.4 ± 10.1 years for the control group. The epicardial adipose tissue thickness was higher in both the Crohn disease and ulcerative colitis groups compared to the control group (P < .001), but not the carotid intima-media thickness (P = .695 and .917, respectively). There was a strong positive correlation between the carotid intima-media and epicardial adipose tissue thickness values in the Crohn disease and ulcerative colitis groups (r = 0.757; 95% confidence interval, 0.711–0.901; r = 0.786; 95% confidence interval, 0.364–0.615; both P < .001). However, there was no significant difference between the patients who were in the active and inactive disease periods in both groups in terms of carotid intima-media and epicardial adipose tissue thickness values.

Conclusions—

Our findings suggest that epicardial adipose tissue thickness might be a marker for detection of early atherosclerosis in patients with IBD. There was a strong positive correlation between carotid intima-media thickness and epicardial adipose tissue thickness values in the patients with IBD. However, there was no correlation between IBD activity and carotid intima-media or epicardial adipose tissue thickness.



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Ultrasound Versus Computed Tomographic Guidance for Percutaneous Biopsy of Chest Lesions

Objectives—

To compare ultrasound (US) versus computed tomography (CT) for primary guidance during needle biopsy of chest lesions.

Methods—

Institutional Review Board approval was obtained for this Health Insurance Portability and Accountability Act–compliant retrospective study, and the need for informed consent was waived. All US- and CT-guided chest biopsy procedures performed between January 1, 2012, and October 15, 2014, at our institution were reviewed, and all procedures targeting peripheral intrathoracic and chest wall lesions were included. Axillary lesions, lung lesions without peripheral pleural contact, and mediastinal lesions without a transcutaneous US window were excluded. Radiologic, pathologic, and clinical records were reviewed.

Results—

Fifty-five procedures with primary US guidance (23 lung, 6 pleural, 2 mediastinal, and 24 chest wall) and 130 CT procedures (88 lung, 10 pleural, 7 mediastinal, and 25 chest wall) were performed. Diagnostic samples were obtained in 98% (54 of 55) of US procedures and 87% (113 of 130) of CT procedures (P = .02). Pneumothorax requiring treatment occurred in 2% (1 of 55) of US procedures and 5% (7 of 130) of CT procedures (P = .25). Computed tomographic localization was used in 29% (16 of 55) of US procedures. Nevertheless, the average patient radiation dose was significantly less in US procedures (182 mGy-cm) versus CT procedures (718 mGy-cm; P< .01). The average procedure time was 40 minutes for US and 38 minutes for CT (P = .39). The average lesion size was 4.5 cm for US and 4.9 cm for CT (P = .14).

Conclusions—

During biopsy of peripheral intrathoracic lesions and chest wall lesions, primary US guidance resulted in a higher likelihood of a diagnostic sample and a decreased patient radiation dose compared with CT guidance.



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Quantitative Ultrasound Assessment of Duchenne Muscular Dystrophy Using Edge Detection Analysis

Objectives—

The purpose of this study was to investigate the ability of quantitative ultrasound (US) using edge detection analysis to assess patients with Duchenne muscular dystrophy (DMD).

Methods—

After Institutional Review Board approval, US examinations with fixed technical parameters were performed unilaterally in 6 muscles (biceps, deltoid, wrist flexors, quadriceps, medial gastrocnemius, and tibialis anterior) in 19 boys with DMD and 21 age-matched control participants. The muscles of interest were outlined by a tracing tool, and the upper third of the muscle was used for analysis. Edge detection values for each muscle were quantified by the Canny edge detection algorithm and then normalized to the number of edge pixels in the muscle region. The edge detection values were extracted at multiple sensitivity thresholds (0.01–0.99) to determine the optimal threshold for distinguishing DMD from normal. Area under the receiver operating curve values were generated for each muscle and averaged across the 6 muscles.

Results—

The average age in the DMD group was 8.8 years (range, 3.0–14.3 years), and the average age in the control group was 8.7 years (range, 3.4–13.5 years). For edge detection, a Canny threshold of 0.05 provided the best discrimination between DMD and normal (area under the curve, 0.96; 95% confidence interval, 0.84–1.00). According to a Mann-Whitney test, edge detection values were significantly different between DMD and controls (P < .0001).

Conclusions—

Quantitative US imaging using edge detection can distinguish patients with DMD from healthy controls at low Canny thresholds, at which discrimination of small structures is best. Edge detection by itself or in combination with other tests can potentially serve as a useful biomarker of disease progression and effectiveness of therapy in muscle disorders.



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Description and Comparison of the Sonographic Characteristics of Poorly Differentiated Thyroid Carcinoma and Anaplastic Thyroid Carcinoma

Objectives—

Although poorly differentiated thyroid carcinoma and anaplastic thyroid carcinoma account for a substantial portion of the morbidity and mortality associated with thyroid cancer, a chance of a cure exists with aggressive treatment, especially in patients with poorly differentiated thyroid carcinoma. The goal of this study was to evaluate the sonographic characteristics of poorly differentiated thyroid carcinoma and to compare the sonographic findings of poorly differentiated and anaplastic thyroid carcinomas.

Methods—

The study included 29 patients with 30 poorly differentiated thyroid carcinomas and 26 patients with 26 anaplastic thyroid carcinomas. Two radiologists retrospectively reviewed sonographic findings. Clinical and sonographic findings were compared between poorly differentiated and anaplastic thyroid carcinomas by univariate and multivariate analyses.

Results—

In the group of patients with poorly differentiated thyroid carcinoma, the mean age was 53.7 years (range, 14–73 years), and the mean tumor size was 3.6 cm (range, 0.6–10.0 cm). The common sonographic findings of poorly differentiated thyroid carcinoma were heterogeneous echogenicity (93.3%), solitary nodules (80.0%), a circumscribed margin (63.3%), an oval-to-round shape (63.3%), and hypoechogenicity (60.0%). A circumscribed margin (P = .003) and an oval-to-round shape (P = .015) were significantly more frequent in poorly differentiated thyroid carcinoma than in anaplastic thyroid carcinoma. In the multivariate analysis, only the circumscribed margin on sonography was an independent predicting factor for poorly differentiated thyroid carcinoma (odds ratio, 4.642).

Conclusions—

Both poorly differentiated thyroid carcinoma and anaplastic thyroid carcinoma commonly present as a relatively large malignant mass on sonography; however, poorly differentiated thyroid carcinoma showed a significantly higher incidence of a circumscribed margin and an oval-to-round shape than anaplastic thyroid carcinoma. Knowledge of sonographic characteristics will be useful for differentiation of poorly differentiated and anaplastic thyroid carcinomas.



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Differentiation of Small Solid Renal Tumors: A Pattern Recognition Approach

The incidence of small renal masses (SRMs) has shown significant increase due to more widespread use of cross-sectional imaging. These SRMs include various subtypes of renal cell carcinomas (RCCs) and several types of benign tumors including angiomyolipomas. Differentiation between RCC and benign SRMs is crucial for the patient to receive optimal management. Therefore it is important for the radiologist to recognize imaging patterns that are characteristic for or diffferent between RCCs and benign SRMs when confronting a SRM.

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Med19 promotes breast cancer cell proliferation by regulating CBFA2T3/HEB expression

Abstract

Background

Mediator complex 19 (Med19) is a pivotal subunit of the Mediator complex, and its aberrant expression is involved in tumourigenesis. We aimed to explore the mechanism by which Med19 promotes the proliferation of breast cancer.

Methods

Lentivirus-mediated inhibition of Med19, ectopic expression of Med19 and ectopic expression of core-binding factor subunit alpha 2 to translocation 3 (CBFA2T3) were applied in human breast cancer cell lines. Human breast cancer cell proliferation was determined using CCK8 and colony formation assays after lentivirus infection. The expression of Med19, CBFA2T3 and HEB was measured by real-time reverse transcription polymerase chain reaction and Western blotting. The correlation between Med19 and CBFA2T3 expression in tissue from 25 cases of human breast cancer was analysed.

Results

In this study, we demonstrate that cell proliferation and colony formation capacity were significantly inhibited after Med19 inhibition in vitro. The expression of CBFA2T3 was distinctly up-regulated in MDA-MB-231 and MCF-7 human breast cancer cells when Med19 was knocked down; however, the expression of HEB, which is targeted by CBFA2T3, was down-regulated. Meanwhile, ectopic expression of Med19 in BT-549 and Hs578T human breast cancer cells inhibited CBFA2T3 expression but enhanced HEB expression. The proliferation capacity of human breast cancer cells was increased when Med19 was overexpressed, but the effect of Med19 up-regulation could be reversed by CBFA2T3 overexpression. Furthermore, a negative correlation between Med19 and CBFA2T3 expression was demonstrated by Western blotting in human breast cancer tissue.

Conclusions

These results suggest that Med19 promotes breast cancer cell proliferation and that this effect is associated with CBFA2T3 and HEB. These results provide new insights into the potential role of Med19 in the regulation of breast carcinogenesis, and Med19 may be a useful therapeutic target in breast cancer therapy.



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Interspecific correlation between red blood cell mitochondrial ROS production, cardiolipin content and longevity in birds

Abstract

Mitochondrial respiration releases reactive oxygen species (ROS) as by-products that can damage the soma and may in turn accelerate ageing. Hence, according to "the oxidative stress theory of ageing", longer-lived organisms may have evolved mechanisms that improve mitochondrial function, reduce ROS production and/or increase cell resistance to oxidative damage. Cardiolipin, an important mitochondrial inner-membrane phospholipid, has these properties by binding and stabilizing mitochondrial inner-membrane proteins. Here, we investigated whether ROS production, cardiolipin content and cell membrane resistance to oxidative attack in freshly collected red blood cells (RBCs) are associated with longevity (range 5–35 years) in 21 bird species belonging to seven Orders. After controlling for phylogeny, body size and oxygen consumption, variation in maximum longevity was significantly explained by mitochondrial ROS production and cardiolipin content, but not by membrane resistance to oxidative attack. RBCs of longer-lived species produced less ROS and contained more cardiolipin than RBCs of shorter-lived species did. These results support the oxidative stress theory of ageing and shed light on mitochondrial cardiolipin as an important factor linking ROS production to longevity.



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How to apply a tourniquet



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Faces of an emergency

EMS artwork by Daniel Sundahl. Check out more of his work here.

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The effectiveness of osteopathic manipulative treatment in an abnormal uterine bleeding related pain and health related quality of life (HR-QoL) - A case report

Publication date: Available online 29 August 2016
Source:Journal of Bodywork and Movement Therapies
Author(s): Kanu Goyal, Manu Goyal, Kanimozhi Narkeesh, Asir John Samuel, Sorabh Sharma, Subhasish Chatterjee, Narkeesh Arumugam
Abnormal uterine bleeding is characterized by painful and/or excessive menorrhea, chronic pelvic pain due to the endometriosis (Em). Osteopathic treatment is commonly used in the gynecological dysfunctions. The aim of the present case study was to explore the effect of osteopathic treatment (OT) for a woman with abnormal uterine bleeding related pain and quality of life (QoL). We reported a case of 29 year old female who presented with chief complaints of increased flow during periods, lower abdominal pain, leukorrhoea, lower back pain and with occasional constipation for the last 3 years. Patient is a mother of 6 years old male child born with normal delivery. On diagnostic ultrasonography the uterus was found bulky with insignificant endometriosis and no other abnormality was detected. She did not have any relevant past medical and surgical history. The pre and post osteopathic treatment measurements were measured using Visual Analog Scale (VAS) and the health related quality of life (HR-QoL) questionnaire called short form Endometriosis Health Profile Questionnaire (EHP) – 5. In the present case the pain due to the endometriosis was treated with the osteopathic treatment consists of all the major diaphragms' release (release of pelvic diaphragm, abdominal diaphragm, thoracic outlet release and hyoid diaphragm) during the first session and in the second session gastro-esophageal (GE) junction release, sigmoid colon release, cranial therapy to the occiput, sacral release and dural tube rocking. Following that improvement of pain from VAS 8.3/10 to 3.9/10 and QoL improvement from EHP-5, 72/100 to 26/100 was noted. Osteopathic manipulative approach (OMA) in the patient with Em might improve the abnormal uterine bleeding related pain and health related quality of life (HR-QoL).



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Orbitocerebral Impalement: Case Discussion and Management Algorithm

Cranial Maxillofac Trauma Reconstruction
DOI: 10.1055/s-0036-1592098

Orbitocerebral impalement by inanimate objects is a relatively uncommon event. If orbitocerebral impalement is suspected, management entails prompt referral to a trauma facility with neurosurgical, neuroanesthesiological, craniomaxillofacial, and ophthalmological expertise. The aim of this report is to describe the unique mechanism and perioperative considerations of a remarkable, deep orbitocerebral impalement from a walker brake lever through the orbital roof after a fall from standing. We discuss clinical vignette, evaluation, anesthetic approach, and considerations and review the literature on the epidemiology, pathophysiology, surgical and anesthetic management, and prognosis of this traumatic mechanism. We also offer a management algorithm that aims to streamline management.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text



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Reconstruction of the Cranial Vault Contour Using Tissue Expander and Castor Oil Prosthesis

Cranial Maxillofac Trauma Reconstruction
DOI: 10.1055/s-0036-1584403

Nowadays the reconstruction of craniofacial defects can be performed with different kinds of materials, which include the bone and the so-called biomaterials, which have the advantage of not needing a surgical site donor. Among these materials, great attention is given to polymers. In this large group, current attention is focused on the castor oil polymer, since this polymer is biocompatible, low cost, and has adequate strength for reconstruction of the craniomaxillofacial complex. This study aims to report the use of a prosthetic castor oil polymer for reconstruction of extensive defect, caused by a trauma, in the temporoparietal region.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text



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Surgical Treatment of Orbital Blowout Fractures: Complications and Postoperative Care Patterns

Cranial Maxillofac Trauma Reconstruction
DOI: 10.1055/s-0036-1584892

Orbital fractures are a common result of facial trauma. Sequelae and indications for repair include enophthalmos and/or diplopia from extraocular muscle entrapment. Alloplastic implant placement with careful release of periorbital fat and extraocular muscles can effectively restore extraocular movements, orbital integrity, and anatomic volume. However, rare but devastating complications such as retrobulbar hematoma (RBH) can occur after repair, which pose a risk of permanent vision loss if not addressed emergently. For this reason, some surgeons take the precaution of admitting patients for 24-hour postoperative vision checks, while others do not. The incidence of postoperative RBH has not been previously reported and existing data are limited to case reports. Our aim was to examine national trends in postoperative management and to report the incidence of immediate postoperative complications at our institution following orbital repair. A retrospective assessment of orbital blowout fractures was undertaken to assess immediate postoperative complications including RBH. Only patients treated by a senior surgeon in the Department of Otolaryngology were included in the review. In addition, we surveyed AO North America (AONA) Craniomaxillofacial faculty to assess current trends in postoperative management. There were 80 patients treated surgically for orbital blowout fractures over a 9.5-year period. Nearly all patients were observed overnight (74%) or longer (25%) due to other trauma. Average length of stay was 17 hours for those observed overnight. There was one (1.3%) patient with RBH, who was treated and recovered without sequelae. Results of the survey indicated that a majority (64%) of responders observe postoperative patients overnight. Twenty-nine percent of responders indicated that they send patients home the same day of surgery. Performance of more than 20 orbital repairs annually significantly increased the likelihood that faculty would manage patients on an outpatient basis postoperatively (p = 0.04). For orbital blowout fractures, the number of immediate postoperative complications at our institution is low. In addition, North American trends in postoperative management of orbital blowout fractures may suggest that selected patients can be managed on an outpatient basis, which would have a positive effect on conservation of diminishing healthcare resources.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text



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Faces of an emergency

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Faces of an emergency

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PulmCrit- The siren’s call: Double-coverage for ventilator associated PNA

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Some theories are so attractive that they are nearly irresistible. No matter how many times they are disproven, these theories still seem compelling. One example is double-coverage for pseudomonas. Recently, the IDSA recommended this for ventilator-associated PNA (VAP), despite openly admitting that RCTs found it to be ineffective.

EMCrit by Josh Farkas.



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Association of sleep time in supine position with apnea-hypopnea index as evidenced by successive polysomnography

Abstract

Purpose

The purpose of this study is to evaluate the impact of body position during sleep on apnea-hypopnea index (AHI) and night-to-night variability in polysomnography (PSG) parameters.

Methods

Totally, 30 patients with obstructive sleep apnea syndrome (OSAS) were assessed prospectively with successive PSGs performed. The patients were categorized as increased (group A), decreased (group B), and unchanged (group C) AHI between the first and second PSG evaluations performed at least 1-week interval.

Results

The mean AHI values were significantly higher in the second night (p = 0.02). A change in AHI was found in almost 85 % of the patients between two successive measurements. According to multivariate and correlation analyses and differences in total AHI in supine position (r = 0.897), it was found that the influence of the supine position was the primary factor contributing to the night-to-night variability. Supine AHI, non-supine AHI, and non-supine time findings did not add any significance on total AHI.

Conclusions

The variability observed in the AHI seems related to amount of sleeping time spent in supine position, suggesting that mean AHI alone is not that reliable in the accurate diagnosis of OSAS severity. A thorough evaluation of AHI in supine and non-supine positions is needed in order to understand better the severity of OSAS.



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Zervixkarzinom und seine Vorstufen

Zusammenfassung

Hintergrund

Die Nomenklatur plattenepithelialer und glandulärer Vorläuferläsionen des Zervixkarzinoms wurde in der WHO-Klassifikation und in nationalen und internationalen Leitlinien in den letzten Jahren reformiert.

Methoden

Die Arbeit basiert auf einer PubMed-Literaturrecherche sowie nationalen und internationalen Leitlinien zum Thema.

Ergebnisse

Bei den HPV-assoziierten zervikalen intraepithelialen Neoplasien wurde eine scharfe Abgrenzung der plattenepithelialen Läsionen geringen und hohen Risikos (LSIL bzw. HSIL) in den Vordergrund gestellt. Morphologische Veränderungen, die mit der produktiven Phase der HPV-Infektion assoziiert sind, werden als LSIL bezeichnet und Veränderungen, die mit einer Deregulation der HPV-Expression und des Zellzyklus einhergehen, als HSIL. Für das klinische Management ist jedoch weiterhin die Angabe der dreistufigen CIN-Klassifikation unverzichtbar. Zur Differenzialdiagnose HPV-assoziierter Vorläufer und insbesondere der Abgrenzung metaplastischer squamöser und glandulärer Läsionen ist die p16-Immunhistochemie (ggf. in Kombination mit Ki67) in der Diagnosestellung von Relevanz. Das Staging des Zervixkarzinoms wurde durch Unterteilung von Stadium IIA in IIA1 und IIA2 ergänzt und die Bedeutung einer standardisierten Bestimmung morphologischer Prognosefaktoren hervorgehoben. Die Differenzierung spezieller Typen des Plattenepithelkarzinoms und seltener, nicht HPV-assoziierter Adenokarzinome erfordert besondere Aufmerksamkeit.

Schlussfolgerung

Die kürzlich aktualisierten Empfehlungen zur Diagnostik und Klassifikation des Zervixkarzinoms berücksichtigen das verbessertes Verständnis der Biologie und des Verlaufs der Erkrankung.



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Photodynamically dealing with bisphosphonate-related osteonecrosis of the jaw: successful case reports

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Publication date: Available online 29 August 2016
Source:Photodiagnosis and Photodynamic Therapy
Author(s): Mayara Santos de Castro, Noé Vital Ribeiro, Marina Lara de Carli, Alessandro Antônio Costa Pereira, Felipe Fornias Sperandio, João Adolfo Costa Hanemann




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The Authors Respond

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9
Author(s): Flavie Frémondière, Franck Lacoeuille, Avigaëlle Sher, Olivier Couturier, Philippe Menei, Isabelle Richard, Mickaël Dinomais




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Editorial Board

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9





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Table of Contents

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9





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Editors' Selections From This Issue: Volume 97 / Number 9 / September 2016

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9





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Measurement Characteristics and Clinical Utility of the Spinal Cord Independence Measure-III Among Individuals With Spinal Cord Injury

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9
Author(s): Kristian P. Nitsch, Kelsey L. Stipp




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Masthead

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9





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Prediction of Adiposity by Body Mass Index in Patients With Multiple Sclerosis

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9
Author(s): Tomoyuki Kawada




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Isotopic Scintigraphy Coupled With Computed Tomography for the Investigation of Intrathecal Baclofen Device Malfunction

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9
Author(s): Elmar Delhaas, Alida Froberg, Fred Verzijlbergen, Aad van der Lugt, Biswadjiet Harhangi, Frank Huygen




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Graphical User Interface to Identify Optimal Combinations of Isometric Normalization Tests for the Production of Maximum Voluntary Activation of the Shoulder Muscles

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9
Author(s): Fabien Dal Maso, Patrick Marion, Mickaël Begon




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Correction

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9





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Request for Proposals

Publication date: September 2016
Source:Archives of Physical Medicine and Rehabilitation, Volume 97, Issue 9





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Systematic Approach to Optimization of Experimental Conditions in Nonequilibrium Capillary Electrophoresis of Equilibrium Mixtures

TOC Graphic

Analytical Chemistry
DOI: 10.1021/acs.analchem.6b02882
ancham?d=yIl2AUoC8zA


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Fluorescent and Photostable Silicon Nanoparticles Sensors for Real-Time and Long-Term Intracellular pH Measurement in Live Cells

TOC Graphic

Analytical Chemistry
DOI: 10.1021/acs.analchem.6b02488
ancham?d=yIl2AUoC8zA


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Timing in Analytical Pyrolysis: Py(HMDS)-GC/MS of Glucose and Cellulose Using Online Micro Reaction Sampler

TOC Graphic

Analytical Chemistry
DOI: 10.1021/acs.analchem.6b02910
ancham?d=yIl2AUoC8zA


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Firefighter/Paramedic - Umatilla County Fire District #1

UMATILLA COUNTY FIRE DISTRICT #1 320 SOUTH 1ST STREET HERMISTON, OREGON 97838 Updated: August 24, 2016 Job Classification: Firefighter/Paramedic Umatilla County Fire District #1 anticipates hiring 6-8 Firefighter/Paramedics in early 2017. We will be requesting the list of applicants in mid -October 2016 and candidates moving forward to the interview steps will be provided additional information. Oral ...

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Re-irradiation for head and neck squamous cell carcinoma

Publication date: Available online 29 August 2016
Source:Journal of the Egyptian National Cancer Institute
Author(s): Rony Benson, Prashant Giridhar, Bhanu Prasad Venkatesulu, Supriya Mallick, Mohd Waseem Raza, Goura Kishor Rath
IntroductionLocal recurrences after curative treatment have a potential for cure with salvage surgery or with re-irradiation.MethodsWe reviewed the PubMed for articles published in English with key words squamous cell carcinoma, recurrent, re-irradiation, prognostic factors to find relevant articles describing prognostic factors, re-irradiation, and outcome for recurrent head and neck squamous cell carcinoma.ResultsVarious factors including age, performance status, time for recurrence, previous radiation dose volume and site of recurrence, previous use of chemotherapy are all prognostic factors in recurrent head and neck squamous cell carcinoma. Surgery is feasible in very select subgroup of patients and must be done when feasible. Re-irradiation with the aid of modern sophisticated technology is safe and confers durable and clinically meaningful survival benefit. Re-irradiation in head and neck recurrent squamous cell carcinoma may provide an expected median survival of 10–12months. Chemotherapy may be added along with radiation in the recurrent setting.ConclusionTreatment approaches may have to be personalized. Re surgery must be done in all patients in whom it is feasible. In patients in whom surgery is not feasible, re-irradiation must be evaluated as a therapeutic option especially in patients with limited volume recurrence.



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External beam radiation techniques for breast cancer in the new millennium: New challenging perspectives

Publication date: Available online 29 August 2016
Source:Journal of the Egyptian National Cancer Institute
Author(s): Dodul Mondal, Daya Nand Sharma
Radiation therapy in breast cancer has evolved dramatically over the past century. It has traveled a long path touching different milestones and taking unprecedented turns. At the end, a fine tune of clinical understanding, skill, technological advancement and translation of radiobiological understanding to clinical outcome has taken place. What all these have given is better survival with quality survivorship. It is thus prudent to understand breast irradiation in a new perspective suitable for the current millennium.



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Dietary Supplements by Ton Shen Health/Life Rising: Recall - Elevated Lead Levels

Audience: Consumer, Emergency Medicine [Posted 08/29/2016] ISSUE: FDA is investigating DHZC-2 tablets by Ton Shen Health/Life Rising for lead and other hazardous material and is also investigating to see if other Life Rising products from this...

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Lamotrigine Orally Disintegrating Tablet 200 mg by Impax: Recall - Incorrect Labeling of Blister Cards

Audience: Pharmacy, Patient [Posted 08/29/2016] ISSUE: Impax Laboratories, Inc. issued a voluntary nationwide retail level recall on August 19, 2016 for one lot of Lamotrigine Orally Disintegrating Tablet (ODT) 200 mg, NDC 0115-1529-08, Lot #...

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Stenosis in Middle Cerebral Artery Duplication: Assessment With Transcranial Color-Coded Duplex Sonography

Duplication of the middle cerebral artery is an unusual anatomic variant. Stenosis of one of its branches can be an exceptional cause of stroke and is very difficult to diagnose with transcranial duplex sonography. We report 2 patients with duplication of the middle cerebral artery in whom stenosis of one of its branches led to ischemic stroke and describe the sonographic findings in comparison to other neuroimaging modalities. These cases highlight the utility of adding a coronal insonation plane on top of the traditional axial plane to avoid identification pitfalls in patients with anatomic variants.



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Three-Dimensional Color/Power Doppler Sonography and HD live Silhouette Mode for Diagnosis of Molar Pregnancy

We present our experience of using new 3-dimensional color/power Doppler sonography (HDliveFlow; GE Healthcare Japan, Tokyo, Japan) with the HD live silhouette mode for diagnosing complete molar pregnancy in the first trimester and differentiating it from missed abortion with hydropic degeneration. In the case of a complete mole, color Doppler sonography showed numerous vesicles without blood vessels, whereas HDliveFlow with the HD live silhouette mode clearly depicted these vesicles forming a mass with the clear demarcation of its edges and showed no blood flow inside the mass. In contrast to the hydropic abortion, which appeared as some vesicles with many blood vessels around them on color Doppler sonography, HDliveFlow with the HD live silhouette mode showed some vesicles embedded within the abundant blood vessels. The spatial relationship between the vesicles and surrounding highly vascularized uterus could be shown on HDliveFlow with the HD live silhouette mode. This technique might be beneficial as an additional diagnostic tool along with conventional color/power Doppler sonography, and it facilitates the early discrimination of these cases in the first trimester of pregnancy.



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Klippel-Trenaunay Syndrome: Need for Careful Clinical Classification

Klippel-Trénaunay syndrome (KTS) is a rare congenital malformation characterized by a triad of clinical presentations: (1) capillary malformations manifesting as a "port wine stain"; (2) limb hypertrophy; and (3) venous varicosities. It is distinguished from Parkes-Weber syndrome by the absence of substantial arteriovenous shunting. Due to the clinical implications of an arteriovenous fistula, differentiation between the two syndromes is important, as the prognosis and treatment greatly differ. We present a series of 5 cases of suspected KTS, while emphasizing the difficulties in distinguishing KTS from Parkes-Weber syndrome without diagnostic imaging and underscoring the importance of accurately classifying patients with the appropriate syndrome.



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Contrast-Enhanced Sonographic Characteristics of Hepatic Inflammatory Pseudotumors

A hepatic inflammatory pseudotumor, which can be misdiagnosed as a malignant tumor, is a relatively uncommon tumor with nonspecific imaging manifestations. As a new diagnostic technique, contrast-enhanced sonography has become increasingly important in the diagnosis of liver focal lesions. Here we present 3 cases of histologically confirmed hepatic inflammatory pseudotumors diagnosed with contrast-enhanced sonography. "Fast-in and centrifugal-out" may be a characteristic contrast-enhanced sonographic enhancement pattern in the diagnosis of hepatic inflammatory pseudotumors, which needs confirmation in further studies.



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Louisiana floods: How a USAR task force responded to social media inquiries

By Catherine R. Counts and Ruel Douvillier

During the week in mid-August that saw seven trillion gallons of rain fall on southern Louisiana, the Louisiana Task Force 1 Urban Search and Rescue Team (LATF-1) received over half a dozen requests for aid or information via Facebook Messenger.

Given that more than 20,000 people were rescued from rising flood waters over the course of that same week, half a dozen requests may seem like a drop of rain in the ocean, but to those individuals, LATF-1 was a governmental entity that could help, and in many cases, it was the only one responding via social media. 

Calls for help or information
We were activated on August 13th and deployed on August 14th for water-based search and rescue missions, joining the hundreds, if not thousands, of other boats filling Louisiana's flooded roadways to make sure our neighbors were not trapped by the rising waters. That mission evolved into a search and recovery mission as the week progressed. 

After the first message was received LATF-1 leadership made the decision to respond to all messages as they were received. Since we only ever received second hand information from worried families and friends we had no way of knowing the accuracy or reliability of the information we were passing on. We passed each call for assistance on anyway, directly to the Operations Section Chief of the Incident Management Team. 

We thanked the messenger with a text response and let them know we had forwarded the request to the "appropriate authorities." In all cases we received a reply message of thanks, and sometimes even an update once the flood victims had been rescued. 

Although the Facebook Safety Check was activated during the flooding, given the large geographic area, varying timelines of the flooding and a lack of data coverage in the effected areas, it was a less than reliable source for accurate information on an individual's safety.

In some cases, we had no way of knowing whether or not we played any part in the rescue of these individuals, while in others we were informed of the victim's rescue before the Incident Management Team could even deploy a response team. But we do know that we played a role in the trust that the citizens of Louisiana place in governmental agencies. In that moment, they felt their voice had been heard. 

Armchair responders
Given past false alarms we try to intentionally delay alerting social media about our deployments until they are already underway. However, in this case, a real deployment happened and we didn't tell our followers until four days in to the response phase. 

Once we posted something, most Facebook page fans simply liked or shared the post, with a select few sending comments of prayer and well wishes.

To our surprise, we did receive one comment to the effect of "what took you so long?" This comment likely mirrored the growing frustration with the lack of national media coverage surrounding the flooding.

Rather than delete the comment or block the commenter we choose to respond as diplomatically as possible. Simply stating that we had been deployed since the weekend prior and had been unable to post an update.

The comment was almost instantly deleted by its author. 

When being diplomatic doesn't work
As a search and rescue team we are first and foremost responsible for the care of people. Although we have a canine team, many of whom were also deployed, we only assist with an animal rescue should we encounter one in the course of regular operations. We are not trained, nor expected, to seek out rescues geared towards pets, livestock, or other four-legged living beings. 

But not everyone knows that. 

Once the waters started to recede, two individuals reached out, both attempting to rescue the same group of neglected dogs. Although the dogs weren't in a flooded area, it was obvious they needed help, and these women had taken the initiative — independent of one another — to provide food and water while seeking out an organization that could formally take on the animals. 

That's when they found us. And for the next two days we messaged back and forth, explaining that we worked within a structured response system and couldn't "break ranks" to rescue these dogs. At times their frustration with our inability to assist was so apparent they asked for the name of the Operations Section Chief, something we weren't able to provide. 

It took a phone call from one of our canine handlers explaining our model of response as well as recommending a number of animal groups conducting rescues in the area to reach a mutual understanding that we weren't the appropriate group. The concerned individuals thanked us for the information and never contacted us again. 

A week later we determined that the dogs had been rescued by the original messenger and personally transported to a nearby no-kill shelter. No official rescue groups, animal or human, had been involved in their care. 

Lessons learned
Our USAR task force is extremely lucky to have an overwhelmingly supportive group of social media followers. Not only do they include our first responders and their family members, but also strangers from every corner of the globe. That level of support was mirrored during this recent activation from most, if not every, follower. 

However, given the similarities that this disaster shared with Hurricane Katrina, both in scope and size, as well as a lack of national media attention and a polarized political response, many of the negative emotions we were facing weren't necessarily directed at us.

But that doesn't mean we shouldn't have been prepared to respond. Because the last thing we want to do is discourage any requests for help. 

We now know that managing our Facebook page during this activation would have been significantly less stressful had we incorporated the following:

  • Designate one person to handle all social media responses and postings.
  • Ensure that no personal contact information is available on the public page.
  • Pre-identify contact information that the public can use to request aid.
  • Alert our followers to an activation within 24 hours.
  • Have an automatic response to Facebook messages.
  • Pre-script responses for requests for aid, with the next steps delineated depending on the type of request received.
  • Develop a mechanism for determining the timeliness of a second-hand request for aid to avoid any false alarms. 

As demonstrated by the thousands of private citizens, better as known as the Cajun Navy, that deployed their boats into the flood waters looking to help with rescues, the people of Louisiana are more than willing to step into action when they feel that the government isn't doing enough. But a lack of responsiveness on social media should never be deemed as the reason why they feel the need to launch out on their own. 

We are proud to have been active on social media during the recent flooding and we will continue to improve our utilization of this modern day communication platform to reflect our recent experiences. We owe it to those individuals we have sworn to serve.  

About the authors:
Ruel Douvillier spent 20 years in the Army, serving as a medic, infantryman and paratrooper. He spent five years as a paramedic with New Orleans Emergency Medical Services, and 14 years with the New Orleans Fire Department, most of that time with their heavy technical rescue squads. He has also served with private ambulance services and volunteer and combination fire departments. He has extensive experience as an instructor. Ruel is presently the Task Force Leader of the State and Regional USAR team, Louisiana Task Force 1 and the Operations Manager for SAR Specialists, an emergency response training company.

Catherine R. Counts is a doctoral candidate in the department of Global Health Management and Policy at Tulane University School of Public Health and Tropical Medicine where she also previously earned her Master of Health Administration. Counts has research interests in domestic health care policy, quality and patient safety, organizational culture and prehospital emergency medicine. She is a member of AcademyHealth, Academy of Management, the National Association of EMS Physicians, and National Association of EMTs. In her spare time, Counts serves as one of the Canine Managers of the State and Regional USAR team, Louisiana Task Force 1.



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Louisiana floods: How a USAR task force responded to social media inquiries

By Catherine R. Counts and Ruel Douvillier

During the week in mid-August that saw seven trillion gallons of rain fall on southern Louisiana, the Louisiana Task Force 1 Urban Search and Rescue Team (LATF-1) received over half a dozen requests for aid or information via Facebook Messenger.

Given that more than 20,000 people were rescued from rising flood waters over the course of that same week, half a dozen requests may seem like a drop of rain in the ocean, but to those individuals, LATF-1 was a governmental entity that could help, and in many cases, it was the only one responding via social media.

Calls for help or information
We were activated on August 13th and deployed on August 14th for water-based search and rescue missions, joining the hundreds, if not thousands, of other boats filling Louisiana's flooded roadways to make sure our neighbors were not trapped by the rising waters. That mission evolved into a search and recovery mission as the week progressed.

After the first message was received LATF-1 leadership made the decision to respond to all messages as they were received. Since we only ever received second hand information from worried families and friends we had no way of knowing the accuracy or reliability of the information we were passing on. We passed each call for assistance on anyway, directly to the Operations Section Chief of the Incident Management Team.

We thanked the messenger with a text response and let them know we had forwarded the request to the "appropriate authorities." In all cases we received a reply message of thanks, and sometimes even an update once the flood victims had been rescued.

Although the Facebook Safety Check was activated during the flooding, given the large geographic area, varying timelines of the flooding and a lack of data coverage in the effected areas, it was a less than reliable source for accurate information on an individual's safety.

In some cases, we had no way of knowing whether or not we played any part in the rescue of these individuals, while in others we were informed of the victim's rescue before the Incident Management Team could even deploy a response team. But we do know that we played a role in the trust that the citizens of Louisiana place in governmental agencies. In that moment, they felt their voice had been heard.

Armchair responders
Given past false alarms we try to intentionally delay alerting social media about our deployments until they are already underway. However, in this case, a real deployment happened and we didn't tell our followers until four days in to the response phase.

Once we posted something, most Facebook page fans simply liked or shared the post, with a select few sending comments of prayer and well wishes.

To our surprise, we did receive one comment to the effect of "what took you so long"" This comment likely mirrored the growing frustration with the lack of national media coverage surrounding the flooding.

Rather than delete the comment or block the commenter we choose to respond as diplomatically as possible. Simply stating that we had been deployed since the weekend prior and had been unable to post an update.

The comment was almost instantly deleted by its author.

When being diplomatic doesn't work
As a search and rescue team we are first and foremost responsible for the care of people. Although we have a canine team, many of whom were also deployed, we only assist with an animal rescue should we encounter one in the course of regular operations. We are not trained, nor expected, to seek out rescues geared towards pets, livestock, or other four-legged living beings.

But not everyone knows that.

Once the waters started to recede, two individuals reached out, both attempting to rescue the same group of neglected dogs. Although the dogs weren't in a flooded area, it was obvious they needed help, and these women had taken the initiative — independent of one another — to provide food and water while seeking out an organization that could formally take on the animals.

That's when they found us. And for the next two days we messaged back and forth, explaining that we worked within a structured response system and couldn't "break ranks" to rescue these dogs. At times their frustration with our inability to assist was so apparent they asked for the name of the Operations Section Chief, something we weren't able to provide.

It took a phone call from one of our canine handlers explaining our model of response as well as recommending a number of animal groups conducting rescues in the area to reach a mutual understanding that we weren't the appropriate group. The concerned individuals thanked us for the information and never contacted us again.

A week later we determined that the dogs had been rescued by the original messenger and personally transported to a nearby no-kill shelter. No official rescue groups, animal or human, had been involved in their care.

Lessons learned
Our USAR task force is extremely lucky to have an overwhelmingly supportive group of social media followers. Not only do they include our first responders and their family members, but also strangers from every corner of the globe. That level of support was mirrored during this recent activation from most, if not every, follower.

However, given the similarities that this disaster shared with Hurricane Katrina, both in scope and size, as well as a lack of national media attention and a polarized political response, many of the negative emotions we were facing weren't necessarily directed at us.

But that doesn't mean we shouldn't have been prepared to respond. Because the last thing we want to do is discourage any requests for help.

We now know that managing our Facebook page during this activation would have been significantly less stressful had we incorporated the following:

  • Designate one person to handle all social media responses and postings.
  • Ensure that no personal contact information is available on the public page.
  • Pre-identify contact information that the public can use to request aid.
  • Alert our followers to an activation within 24 hours.
  • Have an automatic response to Facebook messages.
  • Pre-script responses for requests for aid, with the next steps delineated depending on the type of request received.
  • Develop a mechanism for determining the timeliness of a second-hand request for aid to avoid any false alarms.

As demonstrated by the thousands of private citizens, better as known as the Cajun Navy, that deployed their boats into the flood waters looking to help with rescues, the people of Louisiana are more than willing to step into action when they feel that the government isn't doing enough. But a lack of responsiveness on social media should never be deemed as the reason why they feel the need to launch out on their own.

We are proud to have been active on social media during the recent flooding and we will continue to improve our utilization of this modern day communication platform to reflect our recent experiences. We owe it to those individuals we have sworn to serve.

About the authors:
Ruel Douvillier spent 20 years in the Army, serving as a medic, infantryman and paratrooper. He spent five years as a paramedic with New Orleans Emergency Medical Services, and 14 years with the New Orleans Fire Department, most of that time with their heavy technical rescue squads. He has also served with private ambulance services and volunteer and combination fire departments. He has extensive experience as an instructor. Ruel is presently the Task Force Leader of the State and Regional USAR team, Louisiana Task Force 1 and the Operations Manager for SAR Specialists, an emergency response training company.

Catherine R. Counts is a doctoral candidate in the department of Global Health Management and Policy at Tulane University School of Public Health and Tropical Medicine where she also previously earned her Master of Health Administration. Counts has research interests in domestic health care policy, quality and patient safety, organizational culture and prehospital emergency medicine. She is a member of AcademyHealth, Academy of Management, the National Association of EMS Physicians, and National Association of EMTs. In her spare time, Counts serves as one of the Canine Managers of the State and Regional USAR team, Louisiana Task Force 1.



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