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It is generally recognized that voluntary family planning is essential for the lives and health of individuals in today’s world. What is less frequently acknowledged is that family planning has decreased the growth of human population over the past decades. Despite many wonderful advances since the industrial revolution, humans have caused massive deterioration of the natural world. Examples include climate disruption caused by the increase in greenhouse gases and the sixth mass extinction of species. Without modern, voluntary family planning, these negative effects would have been greater. This chapter recommends increased attention to the global public health benefits of family planning by reducing the numbers of unintended births and thus the number of people contributing to our environmental deterioration.

Introduction The COVID-19 pandemic has forced profound changes on many aspects of American healthcare delivery. Resource utilization and risk minimization have been the primary goals behind these shifts, and adaptations made to optimize public safety continue to affect patients. It is not known, however, how these changes have impacted burn patients. The aim of this study is to detect any effects the pandemic has had on this population by describing the incidence, nature, and short-term outcomes of patients treated by a single surgeon at a major burn center during the area’s shelter-in-place period. Methods A retrospective cohort study was performed using a database of one surgeon’s (RG) admissions and surgical procedures. All patients treated for acute burn injuries within the year following the announcement of COVID-associated shelter-in-place orders in the burn center’s area (March 2020-March 2021) were included. The control group consisted of the same surgeon’s patients treated in the prior year (March 2019-March 2020). All patients were included regardless of age. Patients treated for other conditions such as dermatologic issues or chronic burn sequelae were excluded. Delayed presentation was defined as an interval longer than 24 hours between injury and first medical encounter. Descriptive analyses were performed to compare the demographics, timing of presentation, treatment courses, and short-term outcomes between pre-pandemic and COVID period groups. Results 408 patients were included overall, with 227 admitted pre-COVID and 181 during the pandemic. The only significant difference in demographics between groups was a higher incidence of homelessness in the COVID group (7 vs 13%, p < 0.04). Delayed presentation was not significantly different between groups (15 vs 17%, p=0.75). We found no significant differences between groups in rates of cellulitis or sepsis at presentation (9 vs 10%, p=0.8; 5 vs 8%, p=0.32) or during admission (16 vs 18%, p=0.54; 5 vs 8%, p=0.32). The mean number of surgeries per patient was 2 in both groups. Rates of autografting (62 vs 56%, p=0.24), lengths of stay (16 vs 17 days, p=0.34), readmissions (2 vs 4%, p=0.11), and deaths (2 vs 2%, p=0.74) were also similar. There were several complicated cases of delayed care in the COVID group after burns were evaluated initially via telemedicine, including one patient who presented in septic shock, though this finding did not reach statistical significance. Conclusions Our results demonstrate that the pandemic did not have a significant impact on many key aspects of acute burn care in this cohort. Patients in the pandemic period did not delay treatment at a higher rate, and short-term outcomes were comparable overall between groups. Further studies will be useful in understanding the effect of the pandemic and telemedicine on burn care in a broader context.

The intervention of the U.S. Marines in Nicaragua in 1926 inspired opposition of two kinds, one against any U.S. intervention and the other specifically aligned with the Nicaraguan guerrillas under Augusto Sandino. These groups succeeded in having limits placed on the war but, by abandoning Sandino at a critical moment, set the stage for the creation of a new pro-U.S. Nicaraguan military that was able to seize power and control Nicaragua without the need for U.S. troops. The Somoza dictatorship was an unintended Nicaragua without the need for U.S. troops. The Somoza dictatorship was an unintended consequence of the organized opposition to U.S. intervention.

This article explores the creation of a nationalist identity in Nicaragua during the guerrilla war of Augusto Sandino against the occupying United States. The social base of Sandino was the mountain peasants of northern Nicaragua; a social sector usually described as unlikely to become the creators and carriers of a national identity. Yet by using a gendered and familial discourse, which described Nicaragua as the ‘madre patria’ (mother homeland) and the members as his army as brothers, Sandino was successful in activating strong nationalist feelings amongst his peasant followers. The article examines both Sandino's discourse, and how it was interpreted by his peasant followers. It is this attempt to bring their perspectives into the discussion that contributes to this new assessment of the construction of a national identity in Nicaragua.

Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN) is a rare and often fatal spectrum of mucocutaneous diseases usually attributable to severe adverse drug reactions. Burn units are referral centers for patients at the most extreme end of the disease continuum. Our burn center admits a much higher percentage of TEN (>30% BSA) cases than reported in most prior reviews. The purpose of this study was to analyze the diagnostic and prognostic value of variables collected on referred SJS/TEN patients. We retrospectively analyzed 94 patients admitted to our unit with a presumptive SJS/TEN diagnosis made in most cases by the referring center. Most of the diagnoses were clinical. Fifty of the 94 patients underwent biopsy when the clinical diagnosis was questionable. Of the 50 patients who underwent biopsy, 18 (36%) received an alternative diagnosis. Analysis was therefore limited to 76 patients, i.e. 44 patients felt to have firm clinical diagnoses plus 32 patients with diagnoses confirmed by biopsy. Mean age was 54.3 years (17-93) and overall gender ratio was 43 F vs. 33 M (56.6% vs. 43.4%). Mean LOS was 15.2 days (1-48) and overall mortality was 23.7% (18/76). Univariate analysis revealed percent body surface area (%BSA) did not show statistically significant association with mortality. Histopathological correlation for diagnosis is not standardized across institutions worldwide. Due to challenges in the diagnosis of SJS/TEN and the high incidence of error in clinical diagnosis, it is recommended that all patients with presumed SJS/TEN receive skin biopsies with H&E and direct immunofluorescence. We propose a diagnostic approach in order to address this need. Lack of association between %BSA and mortality suggests that all biopsy-proven SJS/TEN cases belong in specialty centers due to the unstable nature of the disease and risk for rapid progression.

A retrospective statistical analysis of orbital hypertelorism correction was performed by comparing the preoperative and postoperative intercanthal distances of these patients with published age-matched normal values. Forty-five patients who had undergone surgery over a 15-year period with an average follow-up of 5 years (6 months to 14 years) were evaluated. Comparison of age-normalized preoperative and postoperative intercanthal distances revealed a significant difference for orbital hypertelorism patients as a group (p0.0001), patients with clefts (p0.0001), patients with nasoencephalocele (p0.01), and patients with frontonasal dysplasia (p0.05), but not for those patients with craniofacial dysostosis (p0.20). Multiple analyses of variance revealed a significant interaction existing between the extent of preoperative deformity and the cause of hypertelorism for both the postoperative deformity and the total amount of correction achieved, but not for the type of surgery or for the age at which the surgery was performed.

Rigid fixation of the craniofacial skeleton has proven of great value in adult orthognathic and traumatic reconstructive surgical procedures. This technique has gained increased acceptance in the surgical treatment of infants and young children with congenital malformations, despite the fact that its effects on subsequent craniofacial growth are unknown. To examine this question, an experimental model using 25 young kittens was developed to compare rigid fixation with conventional wire fixation, with and without osteotomy. Our findings demonstrate a regional restriction of growth in the developing craniofacial skeleton when both wire and plate and screw fixation are utilized in concert with osteotomy. Further, a compensatory growth was observed in individual animals when plate fixation was utilized that was not seen in the wire-treated group. This suggests that there is a dynamic growth interaction between restriction and compensation in this setting.

Orbitofacial dermoids in the pediatric population represent a diverse group of lesions. Because of their variability in both clinical presentation and contiguous structure involvement, a thorough understanding of their surgical-pathologic anatomy is imperative. In this retrospective review of 84 lesions in 84 patients, we noted segregation of the lesions into three distinct subgroups: brow region dermoids, orbital region dermoids, and nasoglabellar dermoids. Further, we identified physical characteristics within each subgroup that appeared to direct diagnostic workup and subsequent surgical intervention. From this experience, a treatment algorithm was developed that gives the practitioner more precision in the management of these lesions.

With the development of increasingly sophisticated methods for the alteration of bony facial form consequent to age, it is imperative that the surgeon have a fundamental knowledge of the age-related changes the skeleton may undergo. To understand these changes better, a detailed anthropometric and histomorphic analysis of the craniofacial skeleton as a function of age was undertaken. The study consisted of a detailed craniometric analysis of 160 skulls selected randomly from a Caucasian population of skeletal remains totaling 1500 specimens. Additionally, a histologic analysis of the supraorbital ridge in a separate preserved cadaver population was performed. Although the results showed individual variation as expected, definite changes in craniofacial morphology were observed. These included (1) appreciable reduction of facial height, most marked in the maxilla and mandible, and strongly correlated with loss of teeth, (2) modest increase in facial width, (3) modest increase in facial depth, except in those regions associated with tooth loss, and (4) general coarsening of bony prominences. Histomorphic analysis demonstrated increasing porosity with age, more marked in the female population. Although these changes represent population trends, in any given patient, any or all of them may be present to varying degrees. Surgeons should be aware of these possibilities and consider selective alterations of the skeletal foundation, either separately or in concert with the overlying soft-tissue envelope, in order to optimize the results of surgery for the aging face.

Much attention has recently been focused on rigid fixation as a method of improving fracture healing. Whether such fixation, when applied to onlay grafting, improves graft take and volume is unknown. To examine this question, we compared survival of both endochondral and membranous grafts fixed rigidly and nonrigidly in areas of low motion (snout) and high motion (femur) in a rabbit model. Gross morphology, histologic analysis, and graft volume kinetics were evaluated. Findings demonstrate that in areas of high motion, the application of rigid fixation improves graft survival, whereas in a low-motion region, no differences in graft volume retention as a function of fixation were observed. Histologically, no differences with the method of fixation employed were seen, and similar revascularization patterns were noted. By kinetic analysis, rigid fixation appears to exert its most profound effect early in the postgraft period. Membranous bone grafts remain superior to endochondral grafts under all circumstances. From these studies, we conclude that rigid fixation is the method of choice in all circumstances where onlay bone grafts may be exposed to motion, shear, and torsional forces.

This article presents the rationale and methods used to employ hyperbaric oxygen (HBO) treatment for patients with burns at the Sherman Oaks Community Hospital. It is based upon an expanded concept of burn injury formation and healing. We believe that new knowledge of oxygen transport and storage in the tissues in the presence of HBO will alter our understanding of the process of wound healing and the application of HBO in treatment.

Despite all its complaints of layoffs and job loss due to environmental and occupational health and safety regulations, the business community has generated no data to substantiate its claims. EPA's survey, Economic Dislocation Early Warning System, identified 153 such closings in firms of 25 or more workers. During the period 1971-1981, 32,611 workers were alleged to have lost their jobs: an average of about 3200 workers a year in a workforce of about 100 million people (or 0.003 percent). The figures are exaggerated since environmental regulation may have been one of the least compelling reasons to suspend operations. In many cases obsolescence, declining sales, problems with raw materials and increased energy costs were much more important. Specific cases are cited. (JMT)

The Residency Program in Social Medicine at Montefiore Medical Center is a collaborative, integrated training program for primary care pediatricians, internists, and family physicians within one interdisciplinary organization. Since 1970 we have trained more than 200 physicians, prepared them for board certification in their specialty, emphasized the psychosocial aspects and social determinants of health and illness, and shared a faculty, curriculum, and commitment to provide medical care for inner-city, underserved populations. We discuss the program's history and curriculum, administrative and academic structure, shared "cross-track" faculty units (psychosocial; social medicine; and research, education, and evaluation), and graduates' practice outcomes. The interdisciplinary character of the Residency Program in Social Medicine helps physicians successfully serve the underserved and exemplifies that interdisciplinary medical education succeeds when interdisciplinary health care teams are organized for optimal patient care. Only the federal government has the perspective and power to foster more interdisciplinary collaboration and strengthen primary care education in a period of shrinking resources.

In this and the next issue we print some articles on alternative ways of funding political parties. He who pays the piper may not always get quite the tune he expects, but it is certainly in the public interest to consides that public funding of parties is possible, as well as controls of types of contribution and enforced publicity. We begin the symposium by reprinting from The Times of April 11, 1973, a characteristically provocative piece by the late Richard Crossman from his all too short-lived “Personal View Column”. We thank The Times for permission to reptint, and pay tribute to the memory of Crossman who was a member of the Board of THE POLITICAL QUARTERLY from 1939 to 1960.