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Medical surge events require effective coordination between multiple partners. Unfortunately, the information technology (IT) systems currently used for information-sharing by emergency responders and managers in the United States are insufficient to coordinate with health care providers, particularly during large-scale regional incidents. The numerous innovations adopted for the COVID-19 response and continuing advances in IT systems for emergency management and health care information-sharing suggest a more promising future. This article describes: (1) several IT systems and data platforms currently used for information-sharing, operational coordination, patient tracking, and resource-sharing between emergency management and health care providers at the regional level in the US; and (2) barriers and opportunities for using these systems and platforms to improve regional health care information-sharing and coordination during a large-scale medical surge event. The article concludes with a statement about the need for a comprehensive landscape analysis of the component systems in this IT ecosystem.

The definitive care component of the National Disaster Medical System (NDMS) may not be able to effectively manage tens of thousands of casualties resulting from a catastrophic disaster incident or overseas conflict. To address this potential national security threat, Congress authorized the US Secretary of Defense to conduct the NDMS Pilot Program to improve the interoperability, special capabilities, and patient capacity of the NDMS. The pilot's first phase was the Military-Civilian NDMS Interoperability Study, designed to identify broad themes to direct further NDMS research. Researchers conducted a series of facilitated discussions with 49 key NDMS federal and civilian (private sector) stakeholders to identify and assess weaknesses and opportunities for improving the NDMS. After qualitative analysis, 6 critical themes emerged: (1) coordination, collaboration, and communication between federal and private sector NDMS partners; (2) funding and incentives for improved surge capacity and preparedness for NDMS partners; (3) staffing capacity and competencies for government and private NDMS partners; (4) surge capacity, especially at private sector healthcare facilities; (5) training, education, and exercises and knowledge sharing between federal and private sector NDMS partners; and (6) metrics, benchmarks, and modeling for NDMS partners to track their NDMS-related capabilities and performance. These findings provide a roadmap for federal-level changes and additional operations research to strengthen the NDMS definitive care system, particularly in the areas of policy and legislation, operational coordination, and funding.

Background: Health care disparities exist between demographic groups with stroke. We examined whether patients of particular ethnicity or income levels experienced reduced access to or delays in receiving stroke care., Methods: We studied all admissions for ischemic stroke in the Nationwide Inpatient Sample (NIS) database between 2002 and 2008. We used statistical models to determine whether median income or race were associated with intravenous (i.v.) thrombolysis treatment, in-hospital mortality, discharge disposition, hospital charges, and LOS in high- or low-volume hospitals., Results: There were a total of 477,474 patients with ischemic stroke: 10,781 (2.3%) received i.v. thrombolysis, and 380,400 (79.7%) were treated in high-volume hospitals. Race (P < .0001) and median income (P < .001) were significant predictors of receiving i.v. thrombolysis, and minorities and low-income patients were less likely to receive i.v. thrombolysis. Median income was a predictor of access to high-volume hospitals (P < .0001), with wealthier patients more likely to be treated in high-volume hospitals, which had lower mortality rates (P = .0002). Patients in high-volume hospitals were 1.84 times more likely to receive i.v. thrombolysis (P < .0001)., Conclusions: African Americans, Hispanics, and low median income patients are less likely to receive i.v. thrombolysis for ischemic stroke. Low median income patients are less likely to be treated at high-volume hospitals. High-volume hospitals have lower mortality rates and a higher likelihood of treating patients with i.v. thrombolysis. There is evidence for an influence of socioeconomic status and racial disparity in the treatment of ischemic stroke., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background and Importance: Cavernous malformations of the brainstem are a dilemma in terms of deciding when to operate, and they remain difficult to access surgically. We present a novel approach for the resection of a brainstem cavernous malformation., Clinical Presentation: A 59-year-old woman presented with a 1-month history of intermittent dysarthria, right facial weakness, and left arm and leg weakness. A magnetic resonance image revealed a 2-cm mass in the pons with blood products of differing ages, consistent with a cavernous malformation. We discussed with her the risks of surgical resection and conservative management. She decided to pursue conservative management. Two weeks later, she returned to the emergency room with diplopia and left-sided hemiplegia. Acute hemorrhage within the right pons was seen. She then chose to undergo surgical resection., Conclusion: The patient underwent an endoscopic transnasal approach for resection of a pontine cavernous malformation. Image guidance was used to identify key anatomic landmarks. A gross total resection was achieved without new neurological deficits. With physical and occupational therapy, the patient developed antigravity strength in her left upper and lower extremities before discharge. At her 4-week follow-up, she was ambulating independently with the assistance of a cane. We report the successful gross total resection of a pontine cavernous malformation via an endoscopic transnasal approach. This patient had improvement in neurological symptoms after surgical resection with minimal surgical morbidity. Technologic advances in endoscopic skull base approaches have provided access to lesions of the skull base previously requiring more invasive approaches.

Objective: Cerebral vasospasm is a major source of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). A variety of therapies have been utilized to prevent or treat vasospasm. Despite the large number of clinical trials, few randomized controlled trials (RCTs) of sufficient quality have been published. We review the RCTs and meta-analyses in the literature regarding the treatment and prevention of cerebral vasospasm following aneurysmal SAH., Methods: A literature search of MEDLINE, the Cochrane Controlled Trials Registry, and the National Institutes of Health/National Library of Medicine clinical trials registry was performed in January 2010 using predefined search terms. These trials were critically reviewed and categorized based on therapeutic modality., Results: Forty-four RCTs and 9 meta-analyses met the search criteria. Significant findings from these trials were analyzed. The results of this study were as follows: nimodipine demonstrated benefit following aneurysmal SAH; other calcium channel blockers, including nicardipine, do not provide unequivocal benefit; triple-H therapy, fasudil, transluminal balloon angioplasty, thrombolytics, endothelin receptor antagonists, magnesium, statins, and miscellaneous therapies such as free radical scavengers and antifibrinolytics require additional study. Tirilazad is ineffective., Conclusions: There are many possible successful treatment options for preventing vasospasm, delayed ischemic neurologic deficits, and poor neurologic outcome following aneurysmal subarachnoid hemorrhage; however, further multicenter RCTs need to be performed to determine if there is a significant benefit from their use. Nimodipine is the only treatment that provided a significant benefit across multiple studies., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Cerebral vasospasm and delayed cerebral ischemia account for significant morbidity and mortality after aneurysmal subarachnoid hemorrhage. While most patients are managed with triple-H therapy, endovascular treatments have been used when triple-H treatment cannot be used or is ineffective. An electronic literature search was conducted to identify English language articles published through October 2010 that addressed endovascular management of vasospasm. A total of 49 articles were identified, addressing endovascular treatment timing, intra-arterial treatments, and balloon angioplasty. Most of the available studies investigated intra-arterial papaverine or balloon angioplasty. Both have generally been shown to successfully treat vasospasm and improve neurological condition, with no clear benefit from one treatment compared with another. There are reports of complications with both therapies including vessel rupture during angioplasty, intracranial hypertension, and possible neurotoxicity associated with papaverine. Limited data are available evaluating nicardipine or verapamil, with positive benefits reported with nicardipine and inconsistent benefits with verapamil.

Background: Nonvestibular schwannomas are uncommon tumors of the brain often treated by surgical resection. Surgery may be associated with high morbidity., Objective: We present a series of nonvestibular schwannomas treated with linear accelerator radiosurgery during a 19-year period., Methods: This is a retrospective analysis of patients who underwent treatment of nonvestibular schwannomas at the University of Florida with linear accelerator radiosurgery between August 1989 and February 2008. Forty-nine patients underwent treatment during the study period, and 6 were lost to follow up. The mean age was 51 years (range, 17-82 years), 39% had previous surgical resection, and 67% presented with preradiosurgery cranial nerve deficits. There were 25 trigeminal, 18 jugular foramen, 2 facial, 2 oculomotor, 1 hypoglossal, and 1 high cervical schwannomas. The median tumor volume was 5.3 mL (range, 0.3-24.5 mL), treated with a median dose of 1250 cGy (range, 1000-1500 cGy). Study endpoints were actuarial local tumor control and neurological outcome., Results: Forty-three patients were available for a median follow-up of 37 months (range, 6-210 months). Actuarial local tumor control was 97% at 1 year, 91% at 4.5 years, and 83% at 5 years. There were 4 new cranial nerve deficits (9%) including facial numbness (2 patients), anesthesia dolorosa (1 patient), and facial weakness (1 patient). Thirty-nine percent had documented clinical and/or symptomatic improvement. There were no other morbidity and no mortality with treatment., Conclusion: Radiosurgery for nonvestibular schwannomas offers good actuarial local tumor control and has superior morbidity compared with surgical resection. This is the largest linear accelerator radiosurgical series, and the second largest radiosurgical series reported to date.

Objective: Isolated neurosarcoidosis without evidence of extracranial manifestation continues to be a rare phenomenon. This case report and others in the literature demonstrate the difficulty in making the diagnosis of isolated neurosarcoidosis, as it may be indistinguishable from other pathologies on radiographic and laboratory studies. This case report and review of the literature will emphasize the need for clinical suspicion for neurosarcoidosis in patients with intrasellar lesions and the appropriate clinical history., Case History: A 37-year-old female presented with visual field changes and a headache unresponsive to nonsteroidal anti-inflammatory medications. A history of Bell's palsy, hypothyroidism, and a history of sarcoidosis in the patient's father were noted. Imaging revealed an intrasellar mass resembling a pituitary macroadenoma. Routine neuroendocrine laboratory studies were consistent with hypopituitarism, and all other standard laboratory tests were normal. An endonasal transsphenoidal resection of the intrasellar lesion was done. The tissue was inconsistent with a typical adenoma. Intraoperative pathology reported non-caseating granulomatous disease. Based on the patient's history and intraoperative pathology she was diagnosed with neurosarcoidosis, which was confirmed by final pathologic analysis. Minimal debulking was performed to decompress the optic chiasm. The patient was then placed on corticosteroids and methotrexate and responded well to medical therapy., Conclusion: If isolated neurosarcoidosis is diagnosed early it will save a costly and invasive work-up. Radiographic and laboratory studies may aid in diagnosis but no studies are pathognomonic. Neurosarcoidosis is diagnosed by a combination of imaging, diagnostic tests, and good clinical suspicion.

Objective: In this paper, the authors review the results of a single-center experience using linear accelerator (LINAC) radiosurgery for the treatment of cavernous sinus meningiomas., Methods: This is a retrospective analysis with a median follow-up of 50 months. All patients were treated on an outpatient basis. Fifty-five patients were treated and 6 patients were lost to follow-up. Changes in preradiosurgery cranial nerve deficits and symptoms as well as actuarial local tumor control were evaluated., Results: The actuarial local tumor control was 100% at 5 years and 98% at 10 years. One patient had enlargement of tumor. Sixty-five percent had improvement in preradiosurgery cranial nerve deficits, 31% were unchanged and 1 patient (3.5%) was worse. Only 1 patient developed a new neurologic deficit., Conclusions: This is the largest LINAC radiosurgery experience for cavernous sinus meningiomas reported to date. Radiosurgery appears to offer greatly superior tumor control and much lower morbidity than surgical resection of cavernous sinus meningiomas., ((c) 2009 S. Karger AG, Basel.)

Between 1999 and 2002, the effect of mid-season doramectin treatments on the level of resistance in pyrethroid-resistant horn fly populations was examined at three separate Louisiana State University Agricultural Center research stations. The cattle were treated with pyrethroid ear tags in all years at all farms, and each farm received a mid-season doramectin treatment in 1 year. The number of weeks of control at Red River was 11 weeks higher in the year following the mid-season treatment of doramectin. At Macon Ridge, the number of weeks of control was 2 weeks higher in the year following the doramectin treatment. No change was observed at St. Joseph. The LC50s for fly populations tested at Macon Ridge and St. Joseph were found to increase for pyrethroids from the spring populations to the fall populations between 2000 and 2002. The LC50s for fly populations at Red River followed the same trends except in 2000, the year when the doramectin treatment was administered. Flies collected pre and post-treatment each year from St. Joseph and Red River were assayed for two alleles (kdr and skdr) associated with target site resistance to pyrethroids. Flies collected pretreatment at Macon Ridge in 1999 also were assayed for the kdr and skdr, and this population of flies had a frequency of 85.6% R-kdr alleles. At St. Joseph and Red River there was a general decline in the frequency of homozygous susceptible skdr (SS-skdr) and homozygous susceptible kdr (SS-kdr) individuals, as well as a general increase in homozygous resistant skdr (RR-skdr) and homozygous resistant kdr (RR-kdr) individuals, during the 4-year study. At both sites, the frequency of R-kdr alleles increased significantly in flies collected in the fall compared to flies collected in the spring with the exception of Red River in 2000, when dormacetin was applied. The frequency of the R-kdr alleles was significantly higher in flies collected in the fall compared to flies collected in the spring in the following year at both sites in two out of three comparisons. The frequency of R-skdr alleles was significantly lower in fly populations tested in the spring compared to fly populations tested in the fall at both farms in years when doramectin was not applied but there were no differences in the years when doramectin was applied. The frequency of R-skdr alleles was significantly higher in fly populations tested in the fall compared to in the spring the following year during all three comparisons at Red River and in one of three comparisons at St. Joseph.

The whole-cell patch-clamp technique was used to examine the effects of retigabine, a novel anticonvulsant drug, on the electroresponsive properties of individual neurons as well as on neurotransmission between monosynaptically connected pairs of cultured mouse cortical neurons. Consistent with its known action on potassium channels, retigabine significantly hyperpolarized the resting membrane potentials of the neurons, decreased input resistance, and decreased the number of action potentials generated by direct current injection. In addition, retigabine potentiated inhibitory postsynaptic currents (IPSCs) mediated by activation of gamma-aminobutyric acid(A) (GABA(A)) receptors. IPSC peak amplitude, 90-to-10% decay time, weighted decay time constant, slow decay time constant, and, consequently, the total charge transfer were all significantly enhanced by retigabine in a dose-dependent manner. This effect was limited to IPSCs; retigabine had no significant effect on excitatory postsynaptic currents (EPSCs) mediated by activation of non-N-methyl-D-aspartate ionotropic glutamate receptors. A form of short-term presynaptic plasticity, paired-pulse depression, was not altered by retigabine, suggesting that its effect on IPSCs is primarily postsynaptic. Consistent with the hypothesis that retigabine increases inhibitory neurotransmission via a direct action on the GABA(A) receptor, the peak amplitudes, 90-to-10% decay times, and total charge transfer of spontaneous miniature IPSCs were also significantly increased. Therefore, retigabine potently reduces excitability in neural circuits via a synergistic combination of mechanisms.

Bertha Pappenheim ("Anna O,") was treated for hysteria by Josef Breuer when she was a young adult. As a mature adult she became a leading social worker, writer, and feminist activist in the German Jewish community. This article examines her therapy with Breuer, her own struggle for recovery, and some links between her earlier and later life, in particular the lack of intimate relationships in her life and her work against the victimization of women. Throughout the article psychoanalytic interpretations, social history, and feminist analyses are integrated to provide a contextualized examination of Pappenheim's life.