Hydrogen sulfide poisoning: review of 5 years' experience.

The workforce of Alberta, a province rich in fossil fuel, faces an increasing risk of exposure to hydrogen sulfide (H2S). Basic knowledge of the population exposed during the years 1969 to 1973 inclusive was accumulated to identify the immediate medical and management problems. Data were recorded from three sources of records: the Workers'' Compensation Board of Alberta, the Alberta Hospital Services Commission and the provincial coroner''s office. There were 221 cases of exposure to H2S. The overall mortality was 6%; 5% of victims were dead on arrival at hospital. Admission to hospital was required for 65% of the victims arriving at a hospital emergency room (78% of the 221). Acute problems were coma, dysequilibrium and respiratory insufficiency with pulmonary edema. Increased attention to cardiopulmonary resuscitation at the exposure site and during transportation to hospital is necessary to reduce the mortality from H2S exposure. No long-term adverse effects were apparent in the survivors.     

Acute Myocardial Infarction in Doncaster. II—Delays in Admission and Survival

The speed of admission of patients with suspected acute myocardial infarction was observed over a period of 12 months during which a “no refusal” coronary care scheme was functioning, with emphasis on minimizing delay. During the same period the duration of survival of cases diagnosed as coronary thrombosis by the coroner''s pathologist was measured. Comparison of the two series shows that 75% to 80% of the coroner''s cases had died before the median time of notification of the general practitioner by those patients referred to hospital.We argue that the provision of mobile coronary care on request from general practitioners is unlikely to have an appreciable effect in preventing deaths from acute myocardial infarction outside hospital.     

Death certification and epidemiological research. Medical Services Study Group of the Royal College of Physicians of London.

The cause of death shown on 191 death certificates was compared with the cause indicated by the hospital case notes, the consultants'' opinions, and the necropsy findings. All 191 deaths occurred among medical hospital patients aged under 50. In 39 cases there was a major discrepancy between the two sources over the cause of death and in another 54 ther was a minor but epidemiologically important difference. Death certificates are not primarily intended for epidemiological research, but researchers often rely on them. This and other studies have shown, however, that death certificates are often inaccurate records of the cause of death--even coroner''s certificates issued after a coroner''s necropsy. The accuracy of death certificates might be improved if coroners consulted clinicians more closely and if senior hospital staff completed hospital death certificates.     

Antibiotics: no panacea.

Indicator conditions were used to evaluate the quality of 686 episodes of care provided in two emergency departments and in five family physicians'' offices. Overall, the care was considered adequate in 53% of the emergency department cases and in 40% of the cases dealt with in family physicians'' offices, the difference being significant (P less than 0.01). Referrals were very common in both settings, and when quality was assessed solely on the basis of the care actually given by the primary-care providers the difference between the two settings disappeared. Half the observed deficiencies in care related to failure to document the findings from history-taking and physical examination. From these and earlier findings we conclude that the emergency department can be an appropriate setting for the care of nontraumatic illness.     

Clinicians and the coronial system: ability of clinicians to recognise reportable deaths.

OBJECTIVE--To assess the ability of clinicians to recognise deaths which require referral to the coroner. DESIGN--Postal questionnaire consisting of 16 fictitious case histories, 14 of which contained a clear indication for referral to the coroner. SETTING--Large teaching hospital. Coroner''s office. SUBJECTS--200 clinicians from general medical and surgical firms and senior staff of the local coroner''s office (two coroner''s officers and the two deputy coroners). MAIN OUTCOME MEASURES--Number of correct assessments on questionnaire. RESULTS--The mean recognition score for the clinicians was 9.11 (range 3-14) with no difference between the clinical grades. All of the coroner''s senior staff recorded maximum recognition scores of 16. CONCLUSIONS--The study highlights several features of the coronial system which are poorly understood by clinicians and provides the basis for an initiative to improve the medicolegal education of all clinicians.     

Can more efficient use be made of x ray examinations in the accident and emergency department?

Increasing workloads in our radiology department prompted a study of casualty officers'' use of x ray examinations, of which there were 5463 in the period. While casualty officers were in post referrals for x ray examination did not become more selective, but skills in interpreting films improved. Overall, 4.9% of trauma radiographs were misinterpreted, but this fell from 7.1% to 2.9% during tenure of post. One in four errors was clinically important. Clinical guidelines for selective radiography produced a significant and sustained reduction in the number of x ray examinations requested by the department. Analysis of one common injury indicated that the quality of patient care was not adversely affected. The number of x ray examinations carried out in the accident and emergency department can be reduced by using guidelines, and this does not compromise the quality of patient care. Appreciable savings may be made in patients'' waiting times and radiodiagnostic expenditure.     

556例多发伤患者的急诊救治临床分析

目的探讨多发伤患者的救治策略。方法回顾分析我科2000年1月至2008年5月急诊抢救的556例多发伤患者的临床资料。结果 16例患者经抢救无效死亡,死亡率2.88%;其余患者均经紧急抢救及行必要实验室检查,病情稳定,好转率达97.12%。平均抢救时间为(1.37±1.05)h。结论强化多发伤的急诊科早期救治,树立创伤急救"黄金1 h"观念,是提高多发伤患者生存率及降低死亡率的关键。     

Contrasting influences of stormflow and baseflow pathways on nitrogen and phosphorus export from an urban watershed

Eutrophication of urban surface waters from excess nitrogen (N) and phosphorus (P) inputs remains a major issue in water quality management. Although much research has focused on understanding loading of nutrients from storm events, there has been little research to understand the contribution of baseflow, the water moving through storm drains between rainfall events. We investigated the relative contributions of baseflow versus stormflow for loading of water and nutrients (various forms of N and P) by the storm drain network in six urban sub-watersheds in St. Paul, MN, USA. Across sites, baseflow made substantial contributions to warm season (May–October) water yields (27–66 % across sites), total N yields (31–68 %), and total P yields (7–32 %). These results show that while P was predominantly delivered by stormflow, N loading was similar between baseflow and stormflow. We found that baseflow was dominated by groundwater inputs, likely caused by interception of shallow groundwater by storm drains, but also that variability in N and P among sites was related in part to the connectivity of the storm drains to upstream lakes and wetlands in some watersheds. The substantial loading by groundwater-dominated baseflow, especially for N, implies that N management may require a broader focus on N source reduction, perhaps through improved land management, in order to prevent contamination of shallow groundwater via infiltration.     

A general practitioner in an ophthalmology accident and emergency department.

After a short period of intensive training, a general practitioner successfully replaced a senior house officer (SHO) in the accident and emergency department of an eye hospital on one morning a week for a year. An unbiased observer compared the performance of the general practitioner after one year with that of a full-time SHO who had had 17 months'' experience; their performances were about equal. Although a sessional general practitioner costs about 28% more than an SHO, the real cost is much less because undue length of service as an SHO or change to another specialty (because of the SHO surplus) delays achievement of a permanent grade. Continuity is a great advantage of the general practitioner. Replacement of some SHOs by general practitioners would reduce the surplus of SHOs with poor promotion prospects. The commonest diagnoses were Meibomian cysts (18%), corneal foreign bodies (20%), corneal abrasions (12%), and conjunctivitis (8%).     

The effects of the 2009 dust storm on emergency admissions to a hospital in Brisbane, Australia

In September 2009 an enormous dust storm swept across eastern Australia. Dust is potentially hazardous to health as it interferes with breathing, and previous dust storms have been linked to increased risks of asthma and even death. We examined whether the 2009 Australian dust storm changed the volume or characteristics of emergency admissions to hospital. We used an observational study design, using time series analyses to examine changes in the number of admissions, and case-only analyses to examine changes in the characteristics of admissions. The admission data were from the Prince Charles Hospital, Brisbane, between 1 January 2009 and 31 October 2009. There was a 39% increase in emergency admissions associated with the storm (95% confidence interval: 5, 81%), which lasted for just 1 day. The health effects of the storm could not be detected using particulate matter levels. We found no significant change in the characteristics of admissions during the storm; specifically, there was no increase in respiratory admissions. The dust storm had a short-lived impact on emergency hospital admissions. This may be because the public took effective avoidance measures, or because the dust was simply not toxic, being composed mainly of soil. Emergency departments should be prepared for a short-term increase in admissions during dust storms.     

Bicycle-related injuries: a survey in a pediatric emergency department.

The number of bicycle-related injuries has risen significantly with the increased popularity of bicycle riding in Canada. The risk of injury is highest among children. To assess the magnitude of the problem and to identify the contributing factors we used a questionnaire, injury reports and patient charts to survey bicycle-related injuries among children brought to the emergency department of the Children''s Hospital of Eastern Ontario, Ottawa, between May 1 and Sept. 30, 1988. The questionnaire was completed for 517 (91%) of the 568 children; 70% were boys, and the mean age was 9.4 years. Only 2% of the patients had been wearing a helmet at the time of injury, although 13% claimed to own one for cycling. Over 60% of the accidents were attributable to carelessness or poor bicycle control; mechanical failure and environmental hazards were minor factors. Over 80% of the injuries occurred within a kilometre of the child''s home. Of the 97 children admitted to hospital 49% had head and skull injuries and 40% had limb fractures. Bicycle-related injuries represented 14.8% of all nonwinter (Apr. 1 to Oct. 31) trauma admissions among children 5 years or older. Our results further document bicycle-related injuries as an important childhood problem and underscore the need for improved safety measures.     

Effect of NHS reforms on general practitioners' referral patterns.

OBJECTIVE--To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the implementation of the NHS reforms in April 1991. DESIGN--Prospective collection of data on general practitioners'' referrals to specialist outpatient clinics between June 1990 and March 1992 and detailed comparison of two time periods: October 1990 to March 1991 (phase 1) and October 1991 to March 1992 (phase 2). SETTING--10 fundholding practices and six non-fundholding practices in the Oxford region. SUBJECTS--Patients referred to consultant outpatient clinics. RESULTS--After implementation of the NHS reforms there was no change in the proportion of referrals from the two groups of practices which crossed district boundaries. Both groups of practices increased their referral rates in phase 2 of the study, the fundholders from 107.3 per 1000 patients per annum (95% confidence interval 106 to 109) to 111.4 (110 to 113) and the non-fundholders from 95.0 (93 to 97) to 112.0 (110 to 114). In phase 2 there was no difference in overall standardised referral rates between fundholders and non-fundholders. Just over 20% of referrals went to private clinics in phase 1. By phase 2 this proportion had reduced by 2.2% (1.0% to 3.4%) among the fundholders and by 2.7% (1.2% to 4.2%) among the non-fundholders. CONCLUSIONS--Referral patterns among fundholders and non-fundholders were strikingly similar after the implementation of the NHS reforms. There was no evidence that fundholding was encouraging a shift from specialist to general practice care or that budgetary pressures were affecting general practitioners'' referral behaviour.     

Direct and Indirect Effects of Fire on Eastern Box Turtles

Prescribed fire is an increasingly important management tool for eastern deciduous forests, but relativity little is known about the direct effects of fire on the eastern box turtle (Terrapene carolina carolina). We used very high frequency (VHF) transmitters to monitor mortality, movement, and spatial ecology of 118 box turtles in response to 17 prescribed fires across 4 seasons and 3 sites in east Tennessee, USA, during 2016–2018. Annual survival of box turtles that experienced a prescribed fire event was lower (0.87 ± 0.04 [SE]) than turtles that did not (0.98 ± 0.01) and was negatively correlated with fire intensity, fire temperature the turtle experienced, and litter depth. All prescribed fire-related mortalities occurred during the early (Apr–May, n = 5) or late growing season (Sep–Oct, n = 1). Fourteen percent of box turtles we captured exhibited damage to their carapace from previous fire events. Box turtles that survived prescribed fires were in microsites that did not burn, moved to unburned areas during the fire, or burrowed following ignition. Home range size was similar before and after burns and sinuosity of movements did not differ in burned or unburned areas. Our results indicate that though box turtles are susceptible to prescribed fire during their active season, they have behavioral and physical traits that reduce the direct effects of prescribed fire. Prescribed fire practitioners should be aware of the risks of fire, particularly during the active season. We suggest managers consider altering prescribed fire intensity, seasonality, and firing pattern to minimize risk of direct effects where box turtles are of concern. © 2020 The Wildlife Society.     

Reproductive phenology,growth and primary production of Phyllariopsis purpurascens (Phyllariaceae,Phaeophyta) from the Straits of Gibraltar

Two populations of Phyllariopsis purpurascens from the Straits of Gibraltar area were investigated during 1990 and 1991. This area has very strong currents (～2·5 m s^-1 at spring tide). The first sporophytes (less than 0·5 cm in length) were observed in April; they disappeared after the first storm period in October. The estimated number of spores produced in an unilocular sporangium was 64. The fertility period started in May and continued until October, but the maximum sorus surface area (27%) was reached in September. The maximum sporangial density was 1476±236 mm^-2. The slow development of fertility and its correlation with the seasonal increase in temperature suggest that sporangial development is controlled by temperature and not by photoperiod. The drag effect produced by the strong currents (at spring tides and storm periods) is sufficient to break adult plants (with 0·01 m² in surface intercepting the current). At the beginning of the sporophytic production cycle (210 days), the meristematic zone produces more tissue for blade growth than for stipe growth. Holdfast growth occurs in the first 3 months. The mortality was 90% for sporophytes 0–10 cm in length, and decreased to ～50% in adult plants. One cohort in the cycle has been identified. The net primary production (calculated by the graphic model of Allen) was 0·04 g dry weight m^-2·day^-1 from April to October (210 days). The production is among the lowest values estimated for seaweeds.     

Quantifying the direct fire threat to a critically endangered arboreal marsupial using biophysical,mechanistic modelling

Historically unprecedented areas of forest habitat have been impacted by fire, as climate change and other anthropogenic disturbances drive increases in fire burned area and severity. Although 88% of Australia's [threatened] land mammals are threatened by inappropriate fire regimes, calculations of animal mortality resulting from specific events have been impeded by knowledge gaps relating to both the direct (first-order) and long-term (second-order) effects of fire on different species. This study addresses the need for a quantified, mechanistic understanding of first-order effects, presenting an extension of the Fire Research and Modelling Environment (FRaME) to allow prediction of species-specific mortality. FRaME is demonstrated and tested here by replicating an incident in which a prescribed burn caused 77% mortality of a population of the critically endangered ngwayir (Pseudocheirus occidentalis, Pseudocheiridae). FRaME correctly predicted heavy mortality (62–79%) arising from partial and full-thickness burns and asphyxiation due to burns in the respiratory tract. Mortality varied with animal fire-avoidance strategies (p < 0.001) and the thickness of tree hollow walls (r = −0.95, p < 0.001). Although management guidelines specified low intensity fire, mortality had no significant relationship with Byram intensity and larger flames due to ‘torching’ were most frequent when fire spread was slowest. FRaME modelling predicted that individuals would be impacted by temperatures exceeding 500°C for several minutes. Fire management that is premised on discredited notions of fire behaviour and overly simple models can lead to catastrophic management outcomes such as those documented here. FRaME addresses this need by providing a platform to account for heterogeneous fire behaviour as well as animal behaviour and habitat quality, calculating fire risk to fauna and guiding management that maximizes safe habitat.     

Retrospective study of 1000 deaths from injury in England and Wales

One thousand consecutive deaths from injury in 11 coroner''s districts in England and Wales were reviewed by four independent assessors, who studied necropsy reports to identify deaths in hospital that might have been preventable. Of 514 patients admitted to hospital alive, 102 deaths (20%) were judged by all four assessors to have been potentially preventable. When those cases in which three out of four assessors considered that the death was preventable were added the total rose to 170 (33%). Nearly two thirds of all non-central nervous system deaths were judged to have been preventable. The median age of the 170 patients whose deaths were preventable was 41, and the mean Injury Severity Score was 29. Further analysis suggested that the preventable deaths were principally the result of failure to stop bleeding and prevent hypoxia and the absence of, or delay in, surgical treatment.The results closely parallel those from similar studies from the United States and suggest that there are serious deficiencies in the services for managing severe injury in England and Wales. Debate is needed now on how to correct these deficiencies. In particular, the place of trauma centres must be considered.     

Effects of prescribed burning on leaves and flowering of Quercus garryana

Many woodland understories are managed with prescribed fire. While prescribed burns intended to manipulate understory vegetation and fuels usually do not cause excessive tree mortality, sublethal canopy damage may occur and can affect tree vigor and reproductive output. We monitored Quercus garryana trees in western Washington, USA with multiple canopy thermocouples during three prescribed burns. Peak temperatures recorded in tree canopies ranged from 36 to 649°C. We assessed leaf damage immediately after burning, and flower, leaf and acorn production in the following year in the vicinity of each thermocouple. Leaf scorch first occurred with peak thermocouple temperatures around 45°C, was variable up to 75°C, but above 75°C all leaves were killed. Buds, including their reproductive and leaf organs were more resistant to heat damage than leaves, but leaf scorch had predictive value in forecasting bud organ damage. Staminate and pistillate inflorescences and acorn production per bud decreased and bud mortality increased with maximum thermocouple temperature. In two burns where the highest peak temperatures reached 137°C, there was no difference in leaf production between burned and control plots in the spring following burning. However, no staminate or pistillate inflorescences were produced when thermocouple peak temperatures went above 55 or 68°C, respectively. While heat damage to bud organs was detected, production of reproductive organs was also curtailed at temperatures lower than could reasonably be attributed to heat damage. Thus, it is probable that some other fire-related factor, possibly smoke, was also involved.     

Should we abandon Kielland's forceps?

To assess the risks associated with the use of Kielland''s forceps 2708 consecutive deliveries were studied prospectively and the neonatal outcome related to the mode of delivery. Of the 1191 primigravidas, 279 (23.4%) underwent instrumental delivery, of whom 65 (5.5%) were delivered with Kielland''s forceps. There was no difference in early neonatal outcome (as judged by Apgar scores, intubations, and admission to the special care baby unit) between these babies and those delivered normally or by non-rotational forceps, but a higher proportion of the 127 (10.7%) delivered by emergency caesarean section were compromised. Of the 1517 multigravid patients, only 57 (3.8%) underwent instrumental delivery, 15 (1.0%) by Kielland''s forceps. Among these babies, also, the outcome was no worse than for those delivered normally, but the babies delivered by caesarean section showed a greatly increased incidence of low Apgar scores, intubations, and admission to the special care baby unit. There were no stillbirths or neonatal deaths among babies delivered by Kielland''s forceps, nor were there any cases of severe birth trauma or of obvious neonatal morbidity.