BACKGROUND: The mass gathering event (MGE) industry is growing globally, including in countries such as Canada. MGEs have been associated with a greater prevalence of injury and illness when compared with daily life events, despite most participants having few comorbidities. As such, adequate health, safety, and emergency medical planning is required. However, there is no single entity regulating these concerns for MGEs, resulting in the responsibility for health planning lying with event organizers. This study aims to compare the legislative requirements for MGE medical response systems in the 13 provinces and territories of Canada.
METHODS: This study is a cross-sectional descriptive analysis of Canadian legislation. Lists of publicly available legislative requirements were obtained by means of the emergency medical services directors and Health Ministries. Descriptive statistics were performed to compare legislation.
RESULTS: Of the 13 provinces and territories, 10 responded. For the missing 3, a law library review confirmed the absence of specific legislation. Most (n = 6; 60%) provinces and territories referred to provisions in their Public Health laws. Four confirmed that MGE medical response was a municipal or local concern to be addressed by the event organizers.
CONCLUSIONS: No provinces could list specific legislation guiding safety, health, and medical response for an MGE.

A moment magnitude (Mw) 7.5 earthquake (the Global IDentifire (GLIDE) number: # Q-2024-000001-JPN) struck the Noto Peninsula of Ishikawa Prefecture on 1 January 2024 at 16:10 (Japan Standard Time). The reversed fault, 150 km in length and subducting beneath the peninsula, resulted in maximum seismic intensity 7 shaking, triggered the tsunami, destroyed over 43 thousand buildings, and disrupted roads and lifelines. The disaster claimed 236 deaths, including 15 indirect disaster deaths as of Jan. 28, 2024. There were Disaster Base Hospitals (DBHs) in the region, which survived structurally but suffered from impaired functions and the surge of medical needs of affected people. The disaster medical system of Japan immediately responded and coordinated the hundreds of emergency medical teams (EMTs), i.e., the Japan Disaster Medical Assistance Team (DMAT), from all over the country. Tohoku University Hospital, which had the experience of the 2011 Great East Japan Earthquake (GEJE), joined the coordinated response, dispatching a chain of DMATs, which helped the medical and public health coordination in Wajima City. The medical and public health needs included injuries, non-communicable diseases, infectious diseases, mental health issues, and maternal and child health issues, which were similar in the affected communities in GEJE. Although the actual damage far exceeded expectations, the structural retrofitting and business continuity plans of DBHs and the coordinated response of the national disaster medical system enhanced the effectiveness of medical and public health response.

Earthquakes are natural disasters which can destroy the rural and urban infrastructure causing a high toll of injuries and death without advanced notice. We aim to review the prehospital medical management of earthquake crush injuries in the field. PubMed was searched using general terms including rhabdomyolysis, crush injury, and earthquake in English language without time restriction. Selected articles were critically evaluated by three experts in disaster medicine, emergency medicine, and critical care. The medical response to earthquakes includes: (1) search and rescue; (2) triage and initial stabilization; (3) definitive care; and (4) evacuation. Long-term, continuous pressure on muscles causes crush injury. Ischemia-reperfusion injury following the relieving of muscle compression may cause metabolic changes and rhabdomyolysis depending on the time of extrication. Sodium and water enter the cell causing cell swelling and hypovolemia, while potassium and myoglobin are released into the circulation. This may cause sudden cardiac arrest, acute extremity compartment syndrome, and acute kidney injury. Recognizing these conditions and treating them timely and properly in the field will save many patients. Majority of emergency physicians who have worked in the field of the recent Kahramanmaraş 2023, Turkey, earthquakes, have acknowledged their lack of knowledge and experience in managing earthquake crush injuries. We hope that this collective review will cover the essential knowledge needed for properly managing seriously crushed injured patients in the earthquake field.

BACKGROUND: Body fat composition is believed to be associated with the progression, medical response, and prognosis of inflammatory bowel disease (IBD). Hence, we conducted this study to explore if fat metrics were associated with the disease activity of severe IBD and the response to intravenous corticosteroids (IVCS).
METHODS: We included 69 patients with ulcerative colitis (UC) and 72 patients with Crohn\'s disease (CD) who had previously received IVCS during hospitalization. We quantified individual fat distribution using abdominal computed tomography slices. The correlations between fat parameters and disease activity were available with Spearman correlation analysis. The prediction model was developed using independent risk factors derived from multivariable logistic regression analysis. Model discrimination was evaluated leveraging the receiver operating characteristic curve. 1000 bootstrap resamples internally validated the model\'s prediction performance.
RESULTS: Notable differences in age, nutritional status, serum cytomegalovirus replication, stool condition, and extraintestinal involvement between UC and CD patients were observed. UC subjects who responded to IVCS had higher subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI), and mesorectal adipose tissue index (MATI) than non-responders. IVCS-responding CD individuals had lower VATI and mesenteric fat index (MFI) than non-responders. CD patients with a prolonged disease duration had a decreased SATI and an elevated MFI. VATI and MATI were reduced as UC clinically progressed, while more prominent clinical activity in CD correlated with increased VATI, MATI, and MFI. A high SATI indicated that patients with UC were more prone to be IVCS responders. For patients with CD, levels of VATI and MFI were negatively associated with effective IVCS treatment. The established models showed a discriminative accuracy of 0.834 [95% confidence interval (CI) 0.740-0.928] in the UC cohort and 0.871 (95% CI 0.793-0.949) in the CD cohort. Repeated samples supported the reliability of the developed models (AUCUC = 0.836, 95% CI 0.735-0.919; AUCCD = 0.876, 95% CI 0.785-0.946).
CONCLUSIONS: Human fat indexes represent novel imaging biomarkers for identifying IBD patients who respond to IVCS, thus building accelerated therapy regimens and avoiding the adverse effects of ineffective IVCS.

UNASSIGNED: Assembling an effective medical response for an overwhelming number of casualties has become a priority worldwide. Terrorist attacks have been part of the Colombian contemporaneous history. On February 7, 2003, a terrorist car bomb explosion occurred inside a private club in Bogotá, causing the largest number of casualties of all terrorist attacks for over 15 years. The present study analyses the hospital and prehospital responses to this mass casualty event by characterizing the patterns of injury, resource allocation, and outcome in a tertiary-level hospital where most of the casualties were treated.
UNASSIGNED: This is a retrospective chart review of the patients brought to a single hospital (La Clínica del Country), which was the nearest to the terrorist attack. Demographics, severity of injury, patterns of injury, prehospital care, and outcomes were determined from the hospital medical records and government registries.
UNASSIGNED: Of the 240 victims, 35 died at the explosion site (immediate mortality 17%). The 205 survivors were dispersed throughout the city, of whom 63 patients came to La Clínica del Country hospital. Most of these patients were evaluated only clinically and deemed not serious. The main mechanism of trauma was blunt (81.4%). The mean injury severity score (ISS) was 5.6 ± 8.3. Ten patients required emergent surgical intervention and 14 patients were admitted. The in-hospital mortality was 20%.
UNASSIGNED: This mass casualty event was a true test for the Colombian emergency medical system and disaster preparedness. The medical response and resource optimization resulted in an overall mortality rate similar to those observed in the recent European and North American bombings. Despite the limited resources, the continuous challenge of terrorist\'s attacks in Colombia made the country feel the need for training and preparing the healthcare professionals, allowing effective delivery of medical care.
UNASSIGNED: La organización de una respuesta médica efectiva a un número excesivo de víctimas de ataques terroristas se ha convertido en una prioridad en el mundo. Los ataques terroristas han sido parte de la historia colombiana contemporánea. El 7 de Febrero de 2003, un carro bomba explotó en el interior de un club privado en Bogotá, resultando en el ataque terrorista con mayor numero de víctimas durante los últimos 15 años. El objetivo de este estudio es determinar la respuesta del sistema pre y hospitalario a un ataque terrorista masivo, caracterizar los patrones de lesión, utilización de recursos y desenlaces en un hospital de primer nivel, donde la mayoría de las víctimas fueron atendidas.
UNASSIGNED: Este es un estudio retrospectivo de la revisión de 43 historias clínicas de 63 pacientes que fueron llevados al hospital privado más cercano después de un ataque terroristas. La información demográfica, la severidad, el patrón de las lesiones y los desenlaces fueron determinados a partir de las historias clínicas y los registros gubernamentales.
UNASSIGNED: Treinta y cinco personas murieron en la escena y 205 personas fueron lesionadas (mortalidad inmediata de 17%). 63 pacientes fueron transferidos a nuestros hospitales. La mayoría de los pacientes fueron valorados clínicamente y no tenían lesiones serias. El principal mecanismos de trauma fue cerrado. El promedio de ISS fue 5.6 ± 8.3. Diez pacientes requirieron intervenciones quirúrgicas de urgencia y 14 fueron admitidos al hospital. La mortalidad crítica fue de 20%.
UNASSIGNED: Este incidente fue un verdadero examen a nuestro sistema médico de emergencias y plan de desastres hospitalario. Nuestro sistema médico optimizó los recursos resultando en una mortalidad crítica similar a la de las bombas ocurridas en Europa y Norte América. El desafío permanente de confrontar los ataques terroristas en Colombia ha proporcionado entrenamiento y preparación para asegurar un cuidado médico efectivo, aun con recursos limitados.
UNASSIGNED: Ataque terrorista, Bomba, Evento con lesionados masivos, Respuesta medica.

BACKGROUND: Regarding the inconclusive results of previous investigations, this study aimed to determine the association between pathology, as a possible predictor, with remission outcomes, to know the role of pathology in the personalized decision making in acromegaly patients.
METHODS: A retrospective cohort study was performed on the consecutive surgeries for growth hormone (GH) producing pituitary adenomas from February 2015 to January 2021. Seventy-one patients were assessed for granulation patterns and prolactin co-expression as dual staining adenomas. The role of pathology and some other predictors on surgical remission was evaluated using logistic regression models.
RESULTS: Among 71 included patients, 34 (47.9%) patients had densely granulated (DG), 14 (19.7%) had sparsely granulated (SG), 23 (32.4%) had dual staining pituitary adenomas. The remission rate was about 62.5% in the patients with SG and DG adenomas named single staining and 52.2% in dual staining groups. Postoperative remission was 1.53-folds higher in the single staining adenomas than dual staining-one (non-significant). The remission rate was doubled in DG group compared to two other groups (non-significant). By adjusting different predictors, cavernous sinus invasion and one-day postoperative GH levels decreased remission rate by 91% (95% CI: 0.01-0.67; p = 0.015) and 64% (95% CI: 0.19-0.69; p < 0.001), respectively. Responses to the medications were not significantly different among three groups.
CONCLUSIONS: Various pathological subtypes of pituitary adenomas do not appear to have a predictive role in estimating remission outcomes. Cavernous sinus invasion followed by one-day postoperative GH is the strongest parameter to predict biochemical remission.

Post-operative myocardial infarctions (MI) are a challenging diagnosis due to the alterations in the presenting complaint compared to an acute MI. Patients may be asymptomatic due to their anesthetics and sedatives from their operation which may create clinical confusion. As such, there is an increased risk for delayed administration of reperfusion therapies in this patient population which has shown to increase morbidity and mortality. It is anticipated that the difficulty of recognizing a post-operative MI would be exacerbated for clinical clerks due to their lack of clinical experience and overstimulation. Fortunately, the use of simulation-based learning has been proven to be a useful teaching tool to help clinical clerks manage medical problems in a controlled environment. This technical report describes a simulation case designed to enhance the recognition and response to a post-operative MI by a third-year clinical clerk. In this scenario, a 56-year-old male accountant presents with shortness of breath while recovering in the orthopaedic ward 12 hours following a total knee replacement (TKR). The clinical clerks are expected to conduct an independent follow-up prior to finishing their shift during which the patient begins complaining of shortness of breath. The clerk is required to order an electrocardiogram (ECG) for further analysis which reveals an anterior ST-segment elevation. Once recognized, a request for the crash cart and patient handover to the senior physician are expected.

Our aims were to evaluate resources and the preparedness of the health care facilities to respond to mass burn injuries in Vietnam. A survey was conducted in 19 provincial and central/regional hospitals using a questionnaire. The contents of the survey included infrastructure, human resources, medical equipment for burn care, and preparedness of hospitals for mass burn injuries. Results indicated that a variety of burn care facilities were set up, from separate burn departments (42.1%) to burn units (15.8%) or burn beds (42.1%) inside trauma or surgical departments. Medical staff/burn bed ratio was .7 and nurse/physician ratio was 1.7, with 52.7% of nurses having more than 5 years\' experience. Infrastructure and medical equipment for burn facilities were limited, with just under half of the hospitals equipped with an air conditioner and heater. Bronchoscopy for diagnosis and management of inhalation injury was available in 6 (31.6%) hospitals. Few health facilities had a mechanical ventilator, fluid warmer, hemofiltration machine, burn theater, electro-dermatome or skin mesher. Only 26.3% hospitals had a plan for the management of mass burn injuries. A burn specialist was a member of the hospital\'s emergency medical team in 36.8% of the hospitals. Guidelines for burn emergency care were available in 63.2% hospitals. In the last 5 years, 21.1% of health facilities had conducted a drill for mass casualty incident management, but only 1 (5.3%) hospital had conducted a drill for MBI management. In conclusion, facilities, equipment, human resources for burn care and preparedness to manage mass burn injuries in Vietnam are still limited and need to be improved.
Nous avons étudié les capacités du système de santé vietnamien à répondre à un afflux massif de brûlés. Nous avons envoyé un questionnaire à 19 structures provinciales et régionales. Il portait sur les infrastructures, les moyens humains comme matériels, les structures de soins aux brûlés et la préparation à la prise en charge d’un afflux massif de brûlés. Nous avons repéré 3 types de structures de soins aux brûlés : CTB spécifiques (42,1%), unités (15,8%) ou lits (42,1%) pour brûlés dans des services de traumatologie ou de chirurgie. On recense 0,7 médecin par lit et 1,7 infirmière par médecin, 52,7% d’entre elles ayant au moins 5 ans d’expérience. Un peu moins de la moitiés des hôpitaux avaient des systèmes de chauffage ou de climatisation. Seuls 6 (31,6%) des hôpitaux disposaient d’un fibroscope, permettant de diagnostiquer et prendre en charge les inhalations de fumées. Peu de structures disposaient de ventilateurs, réchauffeurs de perfusion, dialyseurs, salle d’opération dédiée, dermatome électrique ou Meshgraft. Seuls 26,3% des hôpitaux avaient élaboré un plan catastrophe spécifique, 36,8% des structures ayant un brûlologue dans leur équipe d’urgences. Des référentiels de prise en charge en urgence existaient dans 62,3% des hôpitaux. 21,1% des hôpitaux avaient réalisé un exercice- catastrophe dans les 5 ans précédant l’étude mais 1 seul (5,3%) avait modélisé un afflux massif de brûlés. En conclusion, les infrastructures, le personnel et l’entraînement vis-à-vis d’un afflux massif de brûlés restent insuffisants au Viêt-Nam et doivent être améliorés.

Since the 1970s, terrorist bombings in subways have been frequently occurring worldwide. To cope with this threat and to provide medical response countermeasures, we analyzed the characteristics of subway bombing terrorist attacks and used the Haddon matrix to explore medical response strategies.
First, we analyzed 111 subway bombings from 1970 to 2017 recorded in the Global Terrorism Database to provide a reference for the strategy exploration. Then, we convened an expert panel to use the Haddon matrix to explore the medical response strategies to subway bombings.
In recent decades, at least one bombing attack occurs every 3 years. Summarized by the Haddon matrix, the influencing factors of medical responses to conventional subway bombings include the adequacy of first-aid kits and the medical evacuation equipment, the traffic conditions affecting the evacuation, the continuity and stability of communication, as well as the factors exclusively attributed to dirty bomb attacks in subways, such as ionizing radiation protection capabilities, the structure of the radiation sickness treatment network based on the subway lines, and the disposal of radioactive sewage. These factors form the basis of the strategy discussion.
Since subway bombings are long-term threats, it is necessary to have proper medical response preparation. Based on the Haddon matrix, we explored the medical response strategies for terrorist subway bombings, especially dirty bomb attacks. Haddon matrix can help policymakers systematically find the most important factors, which makes the preparations of the response more efficient.

BACKGROUND: The summit of Yosemite\'s Half Dome is reached using cable handrails for the final 146 m (480 ft). Access to these cables was restricted to users with permits in 2010. The authors aim to describe the impact of permitting on search and rescue (SAR) in the region of the park most affected by permitting.
METHODS: An observational study from 2005 to 2009 and 2011 to 2015 comparing the number of incidents, major incidents (exceeding $500), victims, and fatalities before and after permitting the use of cable handrails on Half Dome in the area above Little Yosemite Valley (LYV) and parkwide. Each year was analyzed separately with t tests and Mann-Whitney U tests. Data are presented as mean±SD.
RESULTS: The number of hikers in the study area was reduced by up to 66% by permitting. Above LYV from 2005 to 2009, there were 85 SAR incidents, 134 victims, 8 fatalities, 38 major incidents, and annual SAR costs of $44,582±28,972. From 2011 to 2015, the same area saw 54 SAR incidents, 156 victims, 4 fatalities, 35 major incidents, and annual SAR costs of $27,027±19,586. No parameter showed statistical significance. Parkwide SAR incidents decreased from 232 to 198 annual incidents (P=0.013) during the same time period, with parkwide mortality increasing from 8 to 12 deaths annually (P=0.045).
CONCLUSIONS: SAR incidents, victims, fatalities, or costs above LYV did not decrease after cable handrail permitting. Parkwide SAR activity decreased during the same intervals. This strongly suggests that overcrowding is not the key factor influencing safety on Half Dome. This discordant trend warrants close observation over 5 to 10 y.