Mass casualty events: what to do as the dust settles?

Care during mass casualty events (MCE) has improved during the last 15 years. Military and civilian collaboration has led to partnerships which augment the response to MCE. Much has been written about strategies to deliver care during an MCE, but there is little about how to transition back to normal operations after an event. A panel discussion entitled The Day(s) After: Lessons Learned from Trauma Team Management in the Aftermath of an Unexpected Mass Casualty Event at the 76th Annual American Association for the Surgery of Trauma meeting on September 13, 2017 brought together a cadre of military and civilian surgeons with experience in MCEs. The events described were the First Battle of Mogadishu (1993), the Second Battle of Fallujah (2004), the Bagram Detention Center Rocket Attack (2014), the Boston Marathon Bombing (2013), the Asiana Flight 214 Plane Crash (2013), the Baltimore Riots (2015), and the Orlando Pulse Night Club Shooting (2016). This article focuses on the lessons learned from military and civilian surgeons in the days after MCEs

How Good a Deal Was the Tobacco Settlement?: Assessing Payments to Massachusetts

We estimate the increment in Massachusetts Medicaid program costs attributable to smoking from December 20, 1991, to 1998. We describe how our methods improve upon earlier estimates of analogous costs at the national level. Current costs to the Massachusetts Medicaid program approximate the payments to Massachusetts under the tobacco settlement of November 1998. Whether these payments are viewed as appropriate compensation for Medicaid costs over time depends upon the rate of increase in future health care costs, the rate of decline in smoking, the proportion of smoking that should be attributed to the actions of the tobacco companies and the liklihood that state would have prevailed at trial. The costs to the Medicaid program are dwarfed by the internal costs to smokers themselves.

Chandra Observations of the Dwarf Nova WX Hyi in Quiescence

We report Chandra observations of the dwarf nova WX Hyi in quiescence. The X-ray spectrum displays strong and narrow emission lines of N, O, Mg, Ne, Si, S and Fe. The various ionization states implied by the lines suggest that the emission is produced within a flow spanning a wide temperature range, from T ~ 10^6 K to T >~ 10^8 K. Line diagnostics indicate that most of the radiation originates from a very dense region, with n ~ 10^{13}-10^{14} cm^{-3}. The Chandra data allow the first tests of specific models proposed in the literature for the X-ray emission in quiescent dwarf novae. We have computed the spectra for a set of models ranging from hot boundary layers, to hot settling flows solutions, to X-ray emitting coronae. WX Hyi differs from other dwarf novae observed at minimum in having much stronger low temperature lines, which prove difficult to fit with existing models, and possibly a very strong, broad O VII line, perhaps produced in a wind moving at a few x 10^3 km/s. The accretion rate inferred from the X-rays is lower than the value inferred from the UV. The presence of high-velocity mass ejection could account for this discrepancy while at the same time explaining the presence of the broad O VII line. If this interpretation is correct, it would provide the first detection of a wind from a dwarf nova in quiescence.Comment: accepted to ApJ; 19 pages, 3 figures, 1 tabl

Confocal laser scanning microscopy and three-dimensional reconstruction of cell clusters in serous fluids

Thick cell clusters are a common finding in reactive and malignant effusions. In order to arrive at a diagnosis, clusters are evaluated for certain cytomorphologic features including size, shape, smooth vs. scalloped borders, and three-dimensional (3-D) configuration. By conventional microscopy, the image of these clusters is often blurred due to limitations in resolution. Consequently, the exact internal structure and cellular arrangement within these clusters cannot be adequately determined. Utilizing confocal laser scanning microscopy (CLSM), we examined serous fluids from a variety of conditions. Cases included mesothelioma, adenocarcinoma, and papillary adenocarcinoma. Smears were stained with 0.01% ethidium bromide and 1% eosin Y, followed by analysis with an ACAS 570™ image analyzer (Meridian Instruments, Inc. Okemos, MI). Serial confocal fluorescence images were acquired, which allowed 3-D reconstruction of the clusters. Mesothelioma clusters (excluding those with obvious central collagen cores by light microscopy) appeared to be formed of the following configurations: 1) randomly coiled cords of cells, 2) small papillae encompassing central cores, and 3) tissue fragments with pseudoacinar formation. In contrast, adenocarcinomas had a more orderly pattern, with tightly cohesive cells and true acinar formation. Diagn. Cytopathol. 1997;17: 272–279. © 1997 Wiley-Liss, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/35303/1/7_ftp.pd

Chemical enrichment of the complex hot ISM of the Antennae Galaxies: II. Physical properties of the hot gas and supernova feedback

We investigate the physical properties of the interstellar medium (ISM) in the merging pair of galaxies known as The Antennae (NGC 4038/39), using the deep coadded ~411 ks Chandra ACIS-S data set. The method of analysis and some of the main results from the spectral analysis, such as metal abundances and their variations from ~0.2 to ~20-30 times solar, are described in Paper I (Baldi et al. submitted). In the present paper we investigate in detail the physics of the hot emitting gas, deriving measures for the hot-gas mass (~10^ M_sun), cooling times (10^7-10^8 yr), and pressure (3.5x10^-11-2.8x10^-10 dyne cm^-2). At least in one of the two nuclei (NGC 4038) the hot-gas pressure is significantly higher than the CO pressure, implying that shock waves may be driven into the CO clouds. Comparison of the metal abundances with the average stellar yields predicted by theoretical models of SN explosions points to SNe of Type II as the main contributors of metals to the hot ISM. There is no evidence of any correlation between radio-optical star-formation indicators and the measured metal abundances. Although due to uncertainties in the average gas density we cannot exclude that mixing may have played an important role, the short time required to produce the observed metal masses (<=2 Myr) suggests that the correlations are unlikely to have been destroyed by efficient mixing. More likely, a significant fraction of SN II ejecta may be in a cool phase, in grains, or escaping in hot winds. In each case, any such fraction of the ejecta would remain undetectable with soft X-ray observations.Comment: 29 pages, 6 figures, accepted by the Astrophysical Journa

The Far-Ultraviolet Spectrum and Short Timescale Variability of AM Herculis from Observations with the Hopkins Ultraviolet Telescope

Using the Hopkins Ultraviolet Telescope (HUT), we have obtained 850-1850 angstrom spectra of the magnetic cataclysmic variable star AM Her in the high state. These observations provide high time resolution spectra of AM Her in the FUV and sample much of the orbital period of the system. The spectra are not well-modelled in terms of simple white dwarf (WD) atmospheres, especially at wavelengths shortward of Lyman alpha. The continuum flux changes by a factor of 2 near the Lyman limit as a function of orbital phase; the peak fluxes are observed near magnetic phase 0.6 when the accreting pole of the WD is most clearly visible. The spectrum of the hotspot can be modelled in terms of a 100 000 K WD atmosphere covering 2% of the WD surface. The high time resolution of the HUT data allows an analysis of the short term variability and shows the UV luminosity to change by as much as 50% on timescales as short as 10 s. This rapid variability is shown to be inconsistent with the clumpy accretion model proposed to account for the soft X-ray excess in polars. We see an increase in narrow line emission during these flares when the heated face of the secondary is in view. The He II narrow line flux is partially eclipsed at secondary conjunction, implying that the inclination of the system is greater than 45 degrees. We also present results from models of the heated face of the secondary. These models show that reprocessing on the face of the secondary star of X-ray/EUV emission from the accretion region near the WD can account for the intensities and kinematics of most of the narrow line components observed.Comment: 19 pp., 12 fig., 3 tbl. To appear in The Astrophysical Journal. Also available at http://greeley.pha.jhu.edu/papers/amherpp.ps.g

Evaluation of a novel phantom for the quality assurance of a six-degree-of-freedom couch 3D-printed at multiple centres

This study aimed to validate a bespoke 3D-printed phantom for use in quality assurance (QA) of a 6 degrees-of-freedom (6DoF) treatment couch. A novel phantom design comprising a main body with internal cube structures, was fabricated at five centres using Polylactic Acid (PLA) material, with an additional phantom produced incorporating a PLA-stone hybrid material. Correctional setup shifts were determined using image registration by 3D-3D matching of high HU cube structures between obtained cone-beam computer tomography (CBCT) images to reference CTs, containing cubes with fabricated rotational offsets of 3.5°, 1.5° and −2.5° in rotation, pitch, and roll, respectively. Average rotational setup shifts were obtained for each phantom. The reproducibility of 3D-printing was probed by comparing the internal cube size as well as Hounsfield Units between each of the uniquely produced phantoms. For the five PLA phantoms, the average rot, pitch and roll correctional differences from the fabricated offsets were −0.3 ± 0.2°, −0.2 ± 0.5° and 0.2 ± 0.3° respectively, and for the PLA hybrid these differences were −0.09 ± 0.14°, 0.30 ± 0.00° and 0.03 ± 0.10°. There was found to be no statistically significant difference in average cube size between the five PLA printed phantoms, with the significant difference (P < 0.05) in HU of one phantom compared to the others attributed to setup choice and material density. This work demonstrated the capability producing a novel 3D-printed 6DoF couch QA phantom design, at multiple centres, with each unique model capable of sub-degree couch correction

Detached white dwarf main-sequence star binaries

We considered the formation of detached white dwarf main-sequence star (WDMS) binaries through seven evolutionary channels subdivided according to the evolutionary process that gives rise to the formation of the white dwarf or its helium-star progenitor: dynamically stable Roche-lobe overflow (Algol-type evolution), dynamically unstable Roche-lobe overflow (common-envelope evolution), or stellar winds (single star evolution). We examine the sensitivity of the population to changes in the amount of mass lost from the system during stable Roche-lobe overflow, the common-envelope ejection efficiency, and the initial mass ratio or initial secondary mass distribution. In the case of a flat initial mass ratio distribution, the local space density of WDMS binaries is of the order of 10^{-3}/pc^3. This number decreases to 10^{-4}/pc^3 when the initial mass ratio distribution is approximately proportional to the inverse of the initial mass ratio. More than 75% of the WDMS binary population stems from wide systems in which both components evolve as if they were single stars. The remaining part of the population is dominated by systems in which the white dwarf is formed in a common-envelope phase. The birthrate of WDMS binaries forming through a common-envelope phase is about 10 times larger than the birthrate of WDMS binaries forming through a stable Roche-lobe overflow phase. The ratio of the number of helium white dwarf systems to the number of carbon/oxygen or oxygen/neon/magnesium white dwarf systems derived from large samples of observed WDMS binaries by, e.g., future planet-search missions such as SuperWASP, COROT, and Kepler may furthermore constrain the common-envelope ejection efficiency.Comment: 22 pages, accepted for publication in A&

Attracting Manifold for a Viscous Topology Transition

An analytical method is developed describing the approach to a finite-time singularity associated with collapse of a narrow fluid layer in an unstable Hele-Shaw flow. Under the separation of time scales near a bifurcation point, a long-wavelength mode entrains higher-frequency modes, as described by a version of Hill's equation. In the slaved dynamics, the initial-value problem is solved explicitly, yielding the time and analytical structure of a singularity which is associated with the motion of zeroes in the complex plane. This suggests a general mechanism of singularity formation in this system.Comment: 4 pages, RevTeX, 3 ps figs included with text in uuencoded file, accepted in Phys. Rev. Let

Host Genetics Predict Clinical Deterioration in HCV-Related Cirrhosis

Single nucleotide polymorphisms (SNPs) in the epidermal growth factor (EGF, rs4444903), patatin-like phospholipase domain-containing protein 3 (PNPLA3, rs738409) genes, and near the interleukin-28B (IL28B, rs12979860) gene are linked to treatment response, fibrosis, and hepatocellular carcinoma (HCC) in chronic hepatitis C. Whether these SNPs independently or in combination predict clinical deterioration in hepatitis C virus (HCV)-related cirrhosis is unknown. We genotyped SNPs in EGF, PNPLA3, and IL28B from liver tissue from 169 patients with biopsy-proven HCV cirrhosis. We estimated risk of clinical deterioration, defined as development of ascites, encephalopathy, variceal hemorrhage, HCC, or liver-related death using Cox proportional hazards modeling. During a median follow-up of 6.6 years, 66 of 169 patients experienced clinical deterioration. EGF non-AA, PNPLA3 non-CC, and IL28B non-CC genotypes were each associated with increased risk of clinical deterioration in age, sex, and race-adjusted analysis. Only EGF non-AA genotype was independently associated with increased risk of clinical deterioration (hazard ratio [HR] 2.87; 95% confidence interval [CI] 1.31–6.25) after additionally adjusting for bilirubin, albumin, and platelets. Compared to subjects who had 0–1 unfavorable genotypes, the HR for clinical deterioration was 1.79 (95%CI 0.96–3.35) for 2 unfavorable genotypes and 4.03 (95%CI 2.13–7.62) for unfavorable genotypes for all three loci (Ptrend<0.0001). In conclusion, among HCV cirrhotics, EGF non-AA genotype is independently associated with increased risk for clinical deterioration. Specific PNPLA3 and IL28B genotypes also appear to be associated with clinical deterioration. These SNPs have potential to identify patients with HCV-related cirrhosis who require more intensive monitoring for decompensation or future therapies preventing disease progression