Expert Report of Thomas J. Sugrue

At the end of the twentieth century, the United States is a remarkably diverse society. It grows more diverse by the day, transformed by an enormous influx of immigrants from Latin America, the Caribbean, Africa, and Asia. In an increasingly global economy, Americans are coming into contact with others of different cultures to an extent seen only in times of world war. Yet amidst this diversity remains great division. When the young black academic W.E.B. DuBois looked out onto America in 1903, he memorably proclaimed that the problem of the twentieth century is the problem of the color line. Over the last one hundred years, that color line has shifted but not disappeared. The brutal regime of Jim Crow and lynching was vanquished by a remarkable grassroots movement for racial equality and civil rights. Overt expressions of racism are less common than they were a half century ago. Many nonwhite Americans, among them African Americans, Hispanics, and Native Americans, are better off than their forbears. Despite all of the gains of the past century, however, the burden of history still weighs heavily. Color lines still divide and separate Americans. Many Americans have managed diversity by avoiding it-by retreating into separate communities walled off by ignorance and distrust. In American public and private life, there are far too few opportunities to cross racial and ethnic barriers, to understand and appreciate differences, to learn from diversity rather than use it as an excuse for reproach and recrimination

An experimental study of bubble departure diameter in subcooled flow boiling including the effects of orientation angle, subcooling, mass flux, heat flux, and pressure

The effects of orientation angle, subcooling, heat flux, mass flux, and pressure on bubble departure diameter in the isolated bubble regime of subcooled flow boiling were studied by high-speed video in a two-phase flow loop that can accommodate a wide range of flow conditions. Specifically, the following ranges were explored: orientation angles of 0° (downward-facing horizontal), 30°, 45°, 60°, 90° (vertical), and 180° (upward-facing horizontal); mass flux values of 250, 300, 350, and 400 kg/m2 s, corresponding to Froude numbers between 0.42 and 1.06; pressures of 101 (atmospheric), 202, and 505 kPa; two values of the subcooling degrees (10 and 20 °C); and two heat fluxes (0.05 and 0.10 MW/m2). The combination of the test section design, high-speed video camera and LED lighting results in high accuracy (order of 20 μm) in the determination of the bubble departure diameter. The data indicate that the bubble departure diameter increases with increasing heat flux, decreasing mass flux, decreasing subcooling, and decreasing pressure. Also, the bubble departure diameter increases with decreasing orientation angle, i.e. the largest bubbles are found to detach from a downward-facing horizontal surface. The mechanistic bubble departure diameter model of Klausner et al. and its recent modification by Yun et al. were found to correctly predict all the observed parametric trends, but with large average errors and standard deviation: 65.5 ± 75.8% for Klausner's and 37.9 ± 51.2% for Yun's. Since the cube of the bubble departure diameter is used in subcooled flow boiling heat transfer models, such large errors are clearly unacceptable, and underscore the need for more accurate bubble departure diameter models.Douglas C. Spreng FundNuclear Energy Institut

Detroit's East Side Village Health Worker Partnership: Community-Based Lay Health Advisor Intervention in an Urban Area

In recent years, there have been few reports in the literature of interventions using a lay health advisor approach in an urban area. Consequently, little is known about how implementation of this type of community health worker model, which has been used extensively in rural areas, may differ in an urban area. This article describes the implementation of the East Side Village Health Worker Partnership, a lay health advisor intervention, in Detroit, Michigan, and notes how participatory action research methods and principles for community-based partnership research are being used to guide the intervention. Findings are presented on how the urban context is affecting the design and implementation of this intervention. Implications of the findings for health educators are also presented and include the utility of a participatory action research approach, the importance of considering the context and history of a community in designing a health education intervention, and the importance of recognizing and considering the differences between rural and urban settings when designing a health education intervention.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/67390/2/10.1177_109019819802500104.pd

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO)

Background: Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups. Methods: The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion. Recommendations: Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO. Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention. Discussion: This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited

Acute mesenteric ischemia : updated guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.Peer reviewe

The open abdomen in trauma and non-trauma patients : WSES guidelines

Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a "planned second-look" laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.Peer reviewe