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The field of humanitarian assistance advanced spectacularly over the last half of the twentieth century. Prolonged high-mortality crises common in the Cold War era have become rare, corresponding with an increase in international spending, a healthier world, and the politicization of humanitarian assistance. This has created a completely new environment for relief workers in the twenty-first century. This new environment requires an emphasis on chronic diseases, urban settings, and people displaced within their own country. The relative importance of natural disasters has also resulted in a new set of skills deemed essential for humanitarian relief. The concepts of disaster preparedness, risk management, and disaster recovery have become central to the humanitarian endeavour and often these responsibilities fall on the shoulders of host governments. This chapter reviews the new environment in which humanitarian relief exists, the dominant emerging themes, and some of the promising technical advances.

Normally, the upper airway adds heat and moisture to inspired air. When dry medical gases bypass the upper airway via an endotracheal tube, the normal heat and moisture exchange function is compromised. This function may be replaced in two ways. First, heat and humidity can be actively added with a heated humidifier; second, and more commonly, heat and moisture may be passively retained using a heat and moisture exchanger (HME).The upper airway also filters and expels particles, including bacteria and viruses, from inspired gas. The anesthesiologist is responsible for minimizing the risk of infection from inhaled microorganisms. The use of HME filters (HMEFs) protects patients from inhaled microorganisms and also protects the anesthesia breathing system from the patient.

We developed a pictorial atlas of 52 scanning electron microscope (SEM) images of hairs found on 12 mammalian game species commonly found in the South African lowveld. Guard hairs were taken from the dorsoscapular, scapular, sternal, or axillary regions of each animal; and bristle hairs, if present, were collected from the manes of animals of each species. These images, along with other diagnostic features of hairs, can be used as an identification system. Such a system is useful for ecological studies where identifying animal remains is necessary.

Background: Ventilator-associated pneumonia is the most common intensive care unit (ICU)-acquired infection, yet accurate diagnosis remains difficult, leading to overuse of antibiotics. Low concentrations of IL-1β and IL-8 in bronchoalveolar lavage fluid have been validated as effective markers for exclusion of ventilator-associated pneumonia. The VAPrapid2 trial aimed to determine whether measurement of bronchoalveolar lavage fluid IL-1β and IL-8 could effectively and safely improve antibiotic stewardship in patients with clinically suspected ventilator-associated pneumonia.Methods: VAPrapid2 was a multicentre, randomised controlled trial in patients admitted to 24 ICUs from 17 National Health Service hospital trusts across England, Scotland, and Northern Ireland. Patients were screened for eligibility and included if they were 18 years or older, intubated and mechanically ventilated for at least 48 h, and had suspected ventilator-associated pneumonia. Patients were randomly assigned (1:1) to biomarker-guided recommendation on antibiotics (intervention group) or routine use of antibiotics (control group) using a web-based randomisation service hosted by Newcastle Clinical Trials Unit. Patients were randomised using randomly permuted blocks of size four and six and stratified by site, with allocation concealment. Clinicians were masked to patient assignment for an initial period until biomarker results were reported. Bronchoalveolar lavage was done in all patients, with concentrations of IL-1β and IL-8 rapidly determined in bronchoalveolar lavage fluid from patients randomised to the biomarker-based antibiotic recommendation group. If concentrations were below a previously validated cutoff, clinicians were advised that ventilator-associated pneumonia was unlikely and to consider discontinuing antibiotics. Patients in the routine use of antibiotics group received antibiotics according to usual practice at sites. Microbiology was done on bronchoalveolar lavage fluid from all patients and ventilator-associated pneumonia was confirmed by at least 104 colony forming units per mL of bronchoalveolar lavage fluid. The primary outcome was the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage. Data were analysed on an intention-to-treat basis, with an additional per-protocol analysis that excluded patients randomly assigned to the intervention group who defaulted to routine use of antibiotics because of failure to return an adequate biomarker result. An embedded process evaluation assessed factors influencing trial adoption, recruitment, and decision making. This study is registered with ISRCTN, ISRCTN65937227, and ClinicalTrials.gov, NCT01972425.Findings: Between Nov 6, 2013, and Sept 13, 2016, 360 patients were screened for inclusion in the study. 146 patients were ineligible, leaving 214 who were recruited to the study. Four patients were excluded before randomisation, meaning that 210 patients were randomly assigned to biomarker-guided recommendation on antibiotics (n=104) or routine use of antibiotics (n=106). One patient in the biomarker-guided recommendation group was withdrawn by the clinical team before bronchoscopy and so was excluded from the intention-to-treat analysis. We found no significant difference in the primary outcome of the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage in the intention-to-treat analysis (p=0·58). Bronchoalveolar lavage was associated with a small and transient increase in oxygen requirements. Established prescribing practices, reluctance for bronchoalveolar lavage, and dependence on a chain of trial-related procedures emerged as factors that impaired trial processes.Interpretation: Antibiotic use remains high in patients with suspected ventilator-associated pneumonia. Antibiotic stewardship was not improved by a rapid, highly sensitive rule-out test. Prescribing culture, rather than poor test performance, might explain this absence of effect.Funding: UK Department of Health and the Wellcome Trust.

Little is known about undergraduate teaching in critical care unit (CrCU) and many undergraduate curricula lack placements in CrCU.To describe how our CrCU succeeded in developing a novel placement for Year 3 undergraduate medical students.Particular emphasis was placed on a robust timetable incorporating a variety of activities, a dedicated and thorough induction, and a mix of teaching methods such as formal and informal, consultant-led, and skills. Services allied to CrCU were also utilized.Our new firm has exceeded all expectations and, based on student feedback, received the "Firm of the Year" award for several years in succession. It now serves as a model of undergraduate teaching in our hospital.Educationalists and intensivists should work together to unlock the full potential of this rich learning environment. Professional societies in critical care medicine should take the opportunity to develop more interest in undergraduate medical education.

Border deaths are a result of dynamics involving diverse actors, and can be interpreted and represented in various ways. Critical voices from civil society (including academia) hold states responsible for making safe journeys impossible for large parts of the world population. Meanwhile, policy-makers argue that border deaths demonstrate the need for restrictive border policies. Statistics are widely (mis)used to support different readings of border deaths. However, the way data is collected, analysed, and disseminated remains largely unquestioned. Similarly, little is known about how bodies are treated, and about the different ways in which the dead - also including the missing and the unidentified - are mourned by familiars and strangers. New concepts and perspectives contribute to highlighting the political nature of border deaths and finding ways to move forward. The chapters of this collection, co-authored by researchers and practitioners, provide the first interdisciplinary overview of this contested field.

This chapter provides guidance for clinicians who are working in low-resource settings when there is a suspicion of Ebola virus disease. Recognizing the recent surge in Ebola cases in West Africa, and the possibility of further presentations, this chapter outlines the basic measures that medical staff should follow, including whom to alert if there is a suspected Ebola case. There are also some basic measures the staff can take while waiting for trained personnel to arrive.

Background: Percutaneous tracheosotmies are commonly performed in intensive care to expedite weaning from mechanical ventilation especially following major trauma, acquired brain injury or severe respiratory failure. Often patients are discharged from the intensive care unit (ICU) to a ward environment with no specialist follow up Aim: To evaluate the effectiveness of a multi-disciplinary tracheostomy team (MDT) at reducing the total length of hospital stay and improving decannulation rates in tracheostomy patients once discharged from ICU Method: The team consisted of a Consultant, Physiotherapist, Speech and Language Therapist, a Head & Neck Specialist Nurse and a Critical Care Outreach Nurse. The team met weekly on the neurosurgery and respiratory wards and may prescribe treatments or therapies, offer advice to ward staff or carry out interventions. Audit data was gathered for 6 months preceding the establishment of the team and during the 6 month pilot period. Result: Based on around 62 patients being discharged to neurosurgical and respiratory wards per year, the permanent introduction of a Trust Tracheostomy MDT has the potential to reduce the time patients spend with a temporary tracheostomy in situ by 50% and in patient bed use by 911 days per year. Conclusion: A Tracheostomy MDT is an essential service to ensure timely decannulation as well as reducing hospital length of stay and improving overall outcome.

We here report the responses of African bush elephants (Loxodonta africana) to a crude approximation of the honeybee alarm pheromone blend. We show that the elephants had an avoidance response to the semiochemical blend. The use of honeybee alarm pheromones to manage elephant movements in a non-invasive manner, using natural cues to which elephants may have an evolved response, holds potential for development of new options for an integrated system for elephant movement management and protection.

Background This article reports on the use of the ‘neighborhood method’ to measure the prevalence and basic characteristics of children who became separated from their parents or usual caregivers subsequent to an attack by the M23 militia group in North Kivu, Democratic Republic of the Congo. Methods A two-stage household cluster survey was conducted in 522 households in North Kivu in August 2014. Heads of households were asked about separated children in their household, as well as the households of their two closest neighbors. Separation was tracked in terms of children who arrived into the households after the M23 attacks and children who departed from the households after the recall event without their parent(s) or usual caregiver. For a subset of 44 neighbor pairs, respondents were asked to report on the same household to assess inter-rater reliability. Data about primary respondents and their neighbors were assessed to determine whether the neighborhood method was a comparable, reliable and efficient alternative to a traditional household survey about separated children. Results The prevalence of separated children who arrived was 8.52 % [95 % CI: 6.75–10.75] in primary households and 4.46 % [95 % CI: 3.60–5.52] in neighbors’ households (p-value = 0.0000). The prevalence of separated children who departed was 4.98 % [95 % CI: 3.45–7.19] in primary households and 3.19 % [95 % CI: 2.27–4.48] in neighbors’ households (p-value = 0.0110). Kappa coefficients for the neighbor pairs indicated fair to moderate agreement for most demographic variables, but agreement was generally higher for variables related to current characteristics of the households than for variables describing the household in the past, especially before the M23 attack. Compared to a traditional household survey with similar power, the neighborhood method reduced data collection time by 50 % and lowered costs by 36 %. Conclusion This pilot showed that, for measuring separated children in North Kivu, the results from neighbor households significantly underestimated the prevalence of separation when compared to data collected from respondents directly. Reliability was mixed. Although the neighborhood method did not yield valid results in this setting, given the potential the method holds to save scarce resources in humanitarian settings, additional pilots to refine and evaluate its validity and reliability in settings with shorter recall periods are recommended.

Despite taking every precaution while treating patients with Ebola in Guinea, Craig Spencer was hospitalized with Ebola last October. Rather than being welcomed home as a humanitarian, he was vilified even as his liver was failing and his fiancee was quarantined.

Background: Excessive use of empirical antibiotics is common in critically ill patients. Rapid biomarker-based exclusion of infection may improve antibiotic stewardship in ventilator-acquired pneumonia (VAP). However, successful validation of the usefulness of potential markers in this setting is exceptionally rare.Objectives: We sought to validate the capacity for specific host inflammatory mediators to exclude pneumonia in patients with suspected VAP. Methods: A prospective, multicentre, validation study of patients with suspected VAP was conducted in 12 intensive care units. VAP was confirmed following bronchoscopy by culture of a potential pathogen in bronchoalveolar lavage fluid (BALF) at >104 colony forming units per millilitre (cfu/mL). Interleukin-1 beta (IL-1β), IL-8, matrix metalloproteinase-8 (MMP-8), MMP-9 and human neutrophil elastase (HNE) were quantified in BALF. Diagnostic utility was determined for biomarkers individually and in combination. Results: Paired BALF culture and biomarker results were available for 150 patients. 53 patients (35%) had VAP and 97 (65%) patients formed the non-VAP group. All biomarkers were significantly higher in the VAP group (pConclusions: Low BALF IL-1β in combination with IL-8 confidently excludes VAP and could form a rapid biomarker-based rule-out test, with the potential to improve antibiotic stewardship.

We report the case of a 63-year-old man who suffered a witnessed pulseless electrical activity cardiac arrest on presentation to the emergency department. Despite a profound post-arrest acidosis (pH 6.48) he went on to make an unexpectedly good recovery. He was treated for metformin-associated lactic acidosis (MALA) and septic shock, although the origin of the sepsis was never confirmed. We discuss the growing evidence against the existence of MALA as a lone diagnosis and the aetiology of post-cardiac arrest metabolic acidosis.

The upper airway extends from the nose to the major bronchi. It fulfils two major functions; firstly it humidifies and heats inspired gas. Secondly it filters and expels particles via the muco-ciliary elevator. The upper airway provides the alveoli with relatively warm, moist, particle-free gas.

Public health officials are currently supporting adult male circumcision as a public health policy to minimize the transmission of HIV during intercourse. Estimates indicate that more than 3 million lives could be saved in sub-Saharan Africa alone if the procedure becomes widely used. Complications including infection and accidental cutting/amputation of the glans during traditional circumcision ceremonies can lead to permanent injury or death. A low cost, adjustable (one-size-fits-most), culturally appropriate adult male circumcision tool was designed for use in traditional circumcision ceremonies. A surgical procedure for using the device has also been defined, which can be performed in either a clinical or nonclinical setting.

The current study examines the effects of supervisor-to-subordinate expression of gratitude on subordinate engagement, perceived supervisor support, and turnover intentions. The intention of the gr...

As evidenced by the publication of three meta-analyses in 2013, the importance of collective turnover is garnering increasing attention. While each of these meta-analyses delivers a unique and sign...

To understand whether postprandial extracellular Ca2+(Cao2+) changes were related to intestinal epithelial homeostasis, we performed array analysis on extracellular calcium-sensing receptor (CaSR)-expressing colonic myofibroblasts (18Co cells) and observed increases in bone morphogenetic protein (BMP)-2 transcripts. The present experiments demonstrated that regulated secretion of BMP-2 occurs in response to CaSR activation of these cells and revealed a new property of BMP-2 on the intestinal barrier. Activation by Cao2+, spermine, GdCl3, or neomycin sulfate of 18Co cells or primary isolates of myofibroblasts from the normal human colon stimulated both the synthesis (RT-PCR) and secretion (ELISA) of BMP-2. Transient transfection with short interfering RNA against CaSR completely inhibited BMP-2 secretion. Transient transfection with dominant negative CaSR (R185Q) increased the EC50of Cao2+(5.7 vs. 2.3 mM). Upregulation of BMP-2 transcript and secretion occurring within 3 h of CaSR activation was prevented by actinomycin D. CaSR-mediated BMP-2 synthesis and secretion required phosphatidylinositol 3-kinase activation (as assessed by phospho-Akt generation). Exogenous BMP-2 and conditioned medium from CaSR-stimulated 18Co cells accelerated restitution in wounded postconfluent Caco-2 cells. Exogenous BMP-2 and conditioned medium from CaSR-stimulated 18Co cells increased the transepithelial resistance of low- and high-resistance T-84 epithelial monolayers. CaSR stimulation of T-84 epithelia and colonic myofibroblasts downregulated the BMP family antagonist Noggin, as assessed by RT-PCR and Western blot analysis. Together, our data suggest that the CaSR mediates the effective concentration of BMP-2 in the intestine, which leads to enhanced repair and barrier development.

Maspin, a serine protease inhibitor (serpin), can suppress tumor growth and metastasis in vivo and tumor cell motility and invasion in vitro. This may occur through maspin-mediated inhibition of pericellular proteolysis. In a recent report, we provided evidence that maspin may also suppress tumor progression by enhancing cellular sensitivity to apoptotic stimuli. To our knowledge, maspin is the only proapoptotic serpin among all of the serpins implicated thus far in apoptosis regulation. The goal of the present study is to identify the specific target molecule(s), the modification of which by maspin renders tumor cells sensitive to chemotherapeutic agents. Our cellular, molecular, and biochemical studies demonstrate an essential role of Bax in the proapoptotic effect of maspin. First, Bax was up-regulated in maspin-transfected prostate and breast tumor cells, whereas the levels of other Bcl-2 family members including Bcl-2, Bcl-xl, and Bak remained unchanged. Second, on apoptosis induction, a greater amount of Bax was translocated from cytosol to mitochondria in maspin-transfected cells. After treatment with a Bax-silencing small interfering RNA, maspin-transfected cells became significantly more resistant to drug-induced apoptosis. Consistently, the release of cytochrome c and Smac/DIABLO from mitochondria was more responsive to apoptosis stimuli in maspin-transfected cells than in the mock-transfected cells. Third, the apoptosis induction of maspin-transfected cells was associated with increased activation of both caspase-8 and caspase-9. However, a caspase-9-specific inhibitor blocked the sensitization effect of maspin in a dose-dependent and time-dependent manner, demonstrating a rate-limiting role for caspase-9. In line with the central role of the Bax-mediated mitochondrial apoptotic pathway, maspin sensitized the apoptotic response of breast and prostate carcinoma cells to various drugs, ranging from death ligands to endoplasmic reticulum stress. The link between maspin and Bax up-regulation explains the loss of maspin-expressing tumor cells in invasive breast and prostate carcinomas. Our data reveal a novel mechanism for tumor suppressive maspin and suggest that maspin may be used as a modifier for apoptosis-based cancer therapy.

This paper describes a 21-year-old man who presented to the emergency department with a knife wound to his buttock. He had a witnessed cardiac arrest with pulseless electrical activity in hospital as a result of further haemorrhage. His post-resuscitation arterial blood gas revealed a severe lactic acidosis (pH 6.61, lactate 22.0 mmol/l). Despite poor expectations he went on to make a full neurological recovery. To the authors' knowledge, he had the fourth-lowest pH for a cardiac arrest survivor with normal neurology. Severe lactic acidosis occurs post cardiac arrest due to imbalance between cellular oxygen supply and demand. Severe lactic acidosis is associated with hypoxic brain injury but has a low specificity in its prediction. The case illustrates that, especially in younger adults, severe lactic acidosis may be a poor predictor of outcome if it reflects a period of relative hypoperfusion preceding cardiac arrest.

Immunologic studies were performed on 5 patients with pigeon breeders' disease. Intradermal injection of pigeon serum produced an immediate wheal-and-flare reaction within 15 minutes and a secondary Arthus-type reaction within 4 to 8 hours. Immunofluorescent studies of the secondary reaction site showed IgG, C3, and C4 in 2 patients. Patients' sera produced multiple precipitin bands with pigeon serum when reacted by double diffusion in gel. IgG antibody isolated from each of the patients' serum formed precipitating immune complexes that fixed large amounts of complement (C4) when added to fresh human serum. Peripheral blood lymphocytes from 4 of the 5 patients produced macrophage migration inhibitory factor (MIF) when challenged with dilute pigeon serum. These studies are the first to show complement fixing antibodies and macrophage MIF production by lymphocytes from patients with hypersensitivity lung disease and suggest that both humoral and cellular immunity may be important in the pathogenesis of these disorders.

When lymphocyte-macrophage suspensions from sensitized animals are preincubated with specific antigen for 24 or more h, the following results are observed. (i) In a standard capillary macrophage migration test, there is complete inhibition of migration. (ii) When the preincubated cell suspension is mixed in varying proportions with a similar suspension from nonsensitized animals and a macrophage migration test is performed, there is no linear relationship between the degree of inhibition of migration and the proportion of sensitized lymphocytes initially present. Inhibition thus appears to be an “all-or-none” effect. (iii) In spite of the second observation, increasing periods of preincubation with antigen result in increasing inhibition. (iv) These results suggest the existence of a complex amplifying mechanism operating within the early period of exposure to antigen. (v) To test the possibility that cell proliferation contributes to this amplification, cells from sensitized guinea pigs were irradiated with a dose of 1,000 rads prior to preincubation with antigen. Despite this dose, which virtually abolishes cell division in other systems, no diminution whatever in the amplification of inhibition was observed. These results suggest the existence of an early phase of increased production of migratory inhibition factor that is not dependent on cell division but that may be related to “recruitment” of nonsensitized lymphocytes.