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Home > List Archives

trauma-list Digest, Vol 94, Issue 5

B.D.D. van Loo B.D.vanLoo at amc.uva.nl
Tue May 3 22:06:09 BST 2011


Radiology/X-rays of Sherpa's ?
Not exactly trauma related but... I was recently travelling through the Nepal Himalaya and was fascinated by the Sherpa's and the amount of luggage/equipment they often carry on their backs. It would be interesting to see some X-rays of their back/spine. Does anybody know where to find this on the www. ?
Thx.
Benedikt Van Loo
nurse anesthetist
Academic Medical Center Amsterdam 

----- Original Message -----
From: trauma-list-request at trauma.org
Date: Monday, April 25, 2011 7:56 pm
Subject: trauma-list Digest, Vol 94, Issue 5
To: trauma-list at trauma.org


> Send trauma-list mailing list submissions to
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>  than "Re: Contents of trauma-list digest..."
>  
>  
>  Today's Topics:
>  
>     1. RE: New definition of severe trauma; ISS issue
>        (Phyllis.Uribe at HealthONEcares.com)
>     2. from Gen Surg News Feb 2011 (Robert Smith)
>     3. RE: from Gen Surg News Feb 2011 (Gross, Ronald)
>     4. Re: New definition of severe trauma? (Karim Brohi)
>     5. Trauma CT (Dave Napoliello)
>     6. level I activation (Shawn Ballard)
>     7. Skype android problems (Krin135 at aol.com)
>     8. Check out Skype for Android Flaw Puts User Information at
>        Risk |	Blogs | ITBu (Krin135 at aol.com)
>     9. Appendecitis (rm khattar)
>    10. (Off topic) Civil War soldiers photographs of wounds (S Schecter)
>    11. Using MLP's for PM ICU coverage (Todd Kelly, M.D.)
>    12. Re: Using MLP's for PM ICU coverage (Ante ?ori?)
>    13. Re: Using MLP's for PM ICU coverage (JORGE RAMIREZ ARCE)
>    14. trauma List (rm khattar)
>    15. RE: trauma List (Doc Holiday)
>    16. RE: trauma List (Kate Warren)
>    17. Re: trauma List (Krin135 at aol.com)
>    18. Re: trauma List (karan botsford)
>    19. RE: Using MLP's for PM ICU coverage (Seastrom, David, W)
>  
>  
>  ----------------------------------------------------------------------
>  
>  Message: 1
>  Date: Wed, 13 Apr 2011 18:04:18 -0500
>  From: <Phyllis.Uribe at HealthONEcares.com>
>  Subject: RE: New definition of severe trauma; ISS issue
>  To: <trauma-list at trauma.org>
>  Message-ID:
>  	<8854EFD20061C549B7A44E3E280BB7D2D12C61F3DA at FWDCWPMSGCMS05.hca.corpad.net>
>  	
>  Content-Type: text/plain; charset="iso-8859-1"
>  
>  Another confounding factor with using ISS is that different 
> facilities and systems use different iterations of the AIS scoring 
> tool; many injuries are scored lower in the current version than in 
> past version, making head-to-head comparison difficult.
>  
>  Phyllis Uribe MS RN 
>  Trauma Program Supervisor 
>  Swedish Medical Center Trauma Service 
>  Level I Trauma Center 
>  office: 499 E. Hampden #380 
>  Englewood, CO 80113 
>  ? 
>  ph:? 303-788-5082
>  cell: 303-594-8808
>  fax: 303-788-6928 
>  phyllis.uribe at healthonecares.com 
>  www.swedishhospital.com 
>  ? 
>  ? 
>  
>  -----Original Message-----
>  From: Heim Schoettker Katharina [mailto:Catherine.Heim at chuv.ch] 
>  Sent: Wednesday, April 13, 2011 2:52 PM
>  To: trauma-list at trauma.org
>  Subject: New definition of severe trauma?
>  
>  Is anybody using ISS > 20 as definition of severe trauma? Health-care 
> politicians want Swiss-hospitals  to use ISS > 20 rather than > 15 for 
> definition of severe trauma. Is anybody aware of scientific arguments 
> for that?
>  Thanks
>  Cat
>  
>  
>  
>  ------------------------------
>  
>  Message: 2
>  Date: Thu, 14 Apr 2011 13:30:41 -0400
>  From: Robert Smith <rfsmithmd at comcast.net>
>  Subject: from Gen Surg News Feb 2011
>  To: "Trauma-List \[TRAUMA.ORG\]" <trauma-list at trauma.org>
>  Message-ID: <DC66FBF9-DD37-4800-AA2C-CA10C683C13D at comcast.net>
>  Content-Type: text/plain;	charset=windows-1252
>  
>  Written by Dr. Lazar Greenfield, President Elect of the American 
> College of Surgeons.
>  
>  One of the legends of St. Valentine says that he was a priest 
> arrested by Roman Emperor Claudius II for secretly performing 
> marriages. Claudius wanted to enlarge his army and believed that 
> married men did not make good soldiers, rather like Halsted?s feelings 
> about surgical residents. But Valentine?s Day is about love, and if 
> you remember a romantic gut feeling when you met your significant 
> other, it might have a physiological basis.
>  
>  It has long been known that Drosophila raised on starch media are 
> more likely to mate with other starch-raised flies, whereas those fed 
> maltose have similar preferences. In a study published online in the 
> November issue of the Proceedings of the National Academy of Sciences, 
> investigators explored the mechanism for this preference by treating 
> flies with antibiotics to sterilize the gut and saw the preferences 
> disappear (Proc. Nad. Acad. Sci. U.S.A. 2010 Nov. 1).
>  
>  In cultures of untreated flies, the bacterium  L. plantarum was more 
> common in those on starch, and sure enough, when L. plantarum was 
> returned to the sterile groups, the mating preference returned. The 
> best explanation for this is revealed in the significant differences 
> in their sex pheromones. These experiments also support the hologenome 
> theory of evolution wherein the unit of natural selection is the 
> ?holobiont,? or combination of organism and its microorganisms, that 
> determines mating preferences.
>  
>  Mating gets more interesting when you have an organism that can 
> choose between sexual and asexual reproduction, like the rotifer. 
> Biologists say that it?s more advantageous for a rotifer to remain 
> asexual and pass 100% of its genetic information to the next 
> generation. But if the environment changes, rotifers must adapt 
> quickly in order to survive and reproduce with new gene combinations 
> that have an advantage over existing genotypes. So in this new 
> situation, the stressed rotifers, all of which are female, begin 
> sending messages to each other to produce males for the switch to 
> sexual reproduction (Nature 2010 Oct. 13). You can draw your own 
> inference about males not being needed until there?s trouble in the environment.
>  
>  As far as humans are concerned, you may think you know all about 
> sexual signals, but you?d be surprised by new findings. It?s been 
> known since the 1990s that heterosexual women living together 
> synchronize their menstrual cycles because of pheromones, but when a 
> study of lesbians showed that they do not synchronize, the researchers 
> suspected that semen played a role. In fact, they found ingredients in 
> semen that include mood enhancers like estrone, cortisol, prolactin, 
> oxytocin, and serotonin; a sleep enhancer, melatonin; and of course, 
> sperm, which makes up only 1%-5%. Delivering these compounds into the 
> richly vascularized vagina also turns out to have major salutary 
> effects for the recipient. Female college students having unprotected 
> sex were significantly less depressed than were those whose partners 
> used condoms (Arch. Sex. Behav. 2002;31:289-93). Their better moods 
> were not just a feature of promiscuity, because women using condoms 
> were just as depressed as those practi
>   cing total abstinence. The benefits of semen contact also were seen 
> in fewer suicide attempts and better performance on cognition tests.
>  
>  So there?s a deeper bond between men and women than St. Valentine 
> would have suspected, and now we know there?s a better gift for that 
> day than chocolates.
>  
>  One of the legends of St. Valentine says that he was a priest 
> arrested by Roman Emperor Claudius II for secretly performing 
> marriages. Claudius wanted to enlarge his army and believed that 
> married men did not make good soldiers, rather like Halsted?s feelings 
> about surgical residents. But Valentine?s Day is about love, and if 
> you remember a romantic gut feeling when you met your significant 
> other, it might have a physiological basis.
>  
>  It has long been known that Drosophila raised on starch media are 
> more likely to mate with other starch-raised flies, whereas those fed 
> maltose have similar preferences. In a study published online in the 
> November issue of the Proceedings of the National Academy of Sciences, 
> investigators explored the mechanism for this preference by treating 
> flies with antibiotics to sterilize the gut and saw the preferences 
> disappear (Proc. Nad. Acad. Sci. U.S.A. 2010 Nov. 1).
>  
>  In cultures of untreated flies, the bacterium  L. plantarum was more 
> common in those on starch, and sure enough, when L. plantarum was 
> returned to the sterile groups, the mating preference returned. The 
> best explanation for this is revealed in the significant differences 
> in their sex pheromones. These experiments also support the hologenome 
> theory of evolution wherein the unit of natural selection is the 
> ?holobiont,? or combination of organism and its microorganisms, that 
> determines mating preferences.
>  
>  Mating gets more interesting when you have an organism that can 
> choose between sexual and asexual reproduction, like the rotifer. 
> Biologists say that it?s more advantageous for a rotifer to remain 
> asexual and pass 100% of its genetic information to the next 
> generation. But if the environment changes, rotifers must adapt 
> quickly in order to survive and reproduce with new gene combinations 
> that have an advantage over existing genotypes. So in this new 
> situation, the stressed rotifers, all of which are female, begin 
> sending messages to each other to produce males for the switch to 
> sexual reproduction (Nature 2010 Oct. 13). You can draw your own 
> inference about males not being needed until there?s trouble in the environment.
>  
>  As far as humans are concerned, you may think you know all about 
> sexual signals, but you?d be surprised by new findings. It?s been 
> known since the 1990s that heterosexual women living together 
> synchronize their menstrual cycles because of pheromones, but when a 
> study of lesbians showed that they do not synchronize, the researchers 
> suspected that semen played a role. In fact, they found ingredients in 
> semen that include mood enhancers like estrone, cortisol, prolactin, 
> oxytocin, and serotonin; a sleep enhancer, melatonin; and of course, 
> sperm, which makes up only 1%-5%. Delivering these compounds into the 
> richly vascularized vagina also turns out to have major salutary 
> effects for the recipient. Female college students having unprotected 
> sex were significantly less depressed than were those whose partners 
> used condoms (Arch. Sex. Behav. 2002;31:289-93). Their better moods 
> were not just a feature of promiscuity, because women using condoms 
> were just as depressed as those practi
>   cing total abstinence. The benefits of semen contact also were seen 
> in fewer suicide attempts and better performance on cognition tests.
>  
>  So there?s a deeper bond between men and women than St. Valentine 
> would have suspected, and now we know there?s a better gift for that 
> day than chocolates.
>  
>  Reposted in Retraction Watch with many comments worth looking at  :  
> http://retractionwatch.wordpress.com/2011/04/06/forget-chocolate-on-valentines-day-try-semen-says-surgery-news-editor-retraction-resignation-follow/
>  
>  
>  Dr. Shanda Blackmon asks about the ACS response at Southwestern 
> Surgical:  http://youtu.be/CqD48vqCRUU
>  
>  
>  ------------------------------
>  
>  Message: 3
>  Date: Fri, 15 Apr 2011 00:46:06 -0400
>  From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
>  Subject: RE: from Gen Surg News Feb 2011
>  To: "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
>  Message-ID:
>  	<FD2BE6867A90F543AAD02E429F878633014F2A8A605C at bhsexc11.bhs.org>
>  Content-Type: text/plain; charset="us-ascii"
>  
>  NO COMMENT!
>  
>  
>  -----Original Message-----
>  From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert Smith
>  Sent: Thursday, April 14, 2011 1:31 PM
>  To: Trauma-List [TRAUMA.ORG]
>  Subject: from Gen Surg News Feb 2011
>  
>  Written by Dr. Lazar Greenfield, President Elect of the American 
> College of Surgeons.
>  
>  One of the legends of St. Valentine says that he was a priest 
> arrested by Roman Emperor Claudius II for secretly performing 
> marriages. Claudius wanted to enlarge his army and believed that 
> married men did not make good soldiers, rather like Halsted's feelings 
> about surgical residents. But Valentine's Day is about love, and if 
> you remember a romantic gut feeling when you met your significant 
> other, it might have a physiological basis.
>  
>  It has long been known that Drosophila raised on starch media are 
> more likely to mate with other starch-raised flies, whereas those fed 
> maltose have similar preferences. In a study published online in the 
> November issue of the Proceedings of the National Academy of Sciences, 
> investigators explored the mechanism for this preference by treating 
> flies with antibiotics to sterilize the gut and saw the preferences 
> disappear (Proc. Nad. Acad. Sci. U.S.A. 2010 Nov. 1).
>  
>  In cultures of untreated flies, the bacterium  L. plantarum was more 
> common in those on starch, and sure enough, when L. plantarum was 
> returned to the sterile groups, the mating preference returned. The 
> best explanation for this is revealed in the significant differences 
> in their sex pheromones. These experiments also support the hologenome 
> theory of evolution wherein the unit of natural selection is the 
> "holobiont," or combination of organism and its microorganisms, that 
> determines mating preferences.
>  
>  Mating gets more interesting when you have an organism that can 
> choose between sexual and asexual reproduction, like the rotifer. 
> Biologists say that it's more advantageous for a rotifer to remain 
> asexual and pass 100% of its genetic information to the next 
> generation. But if the environment changes, rotifers must adapt 
> quickly in order to survive and reproduce with new gene combinations 
> that have an advantage over existing genotypes. So in this new 
> situation, the stressed rotifers, all of which are female, begin 
> sending messages to each other to produce males for the switch to 
> sexual reproduction (Nature 2010 Oct. 13). You can draw your own 
> inference about males not being needed until there's trouble in the environment.
>  
>  As far as humans are concerned, you may think you know all about 
> sexual signals, but you'd be surprised by new findings. It's been 
> known since the 1990s that heterosexual women living together 
> synchronize their menstrual cycles because of pheromones, but when a 
> study of lesbians showed that they do not synchronize, the researchers 
> suspected that semen played a role. In fact, they found ingredients in 
> semen that include mood enhancers like estrone, cortisol, prolactin, 
> oxytocin, and serotonin; a sleep enhancer, melatonin; and of course, 
> sperm, which makes up only 1%-5%. Delivering these compounds into the 
> richly vascularized vagina also turns out to have major salutary 
> effects for the recipient. Female college students having unprotected 
> sex were significantly less depressed than were those whose partners 
> used condoms (Arch. Sex. Behav. 2002;31:289-93). Their better moods 
> were not just a feature of promiscuity, because women using condoms 
> were just as depressed as those practi
>   cing total abstinence. The benefits of semen contact also were seen 
> in fewer suicide attempts and better performance on cognition tests.
>  
>  So there's a deeper bond between men and women than St. Valentine 
> would have suspected, and now we know there's a better gift for that 
> day than chocolates.
>  
>  One of the legends of St. Valentine says that he was a priest 
> arrested by Roman Emperor Claudius II for secretly performing 
> marriages. Claudius wanted to enlarge his army and believed that 
> married men did not make good soldiers, rather like Halsted's feelings 
> about surgical residents. But Valentine's Day is about love, and if 
> you remember a romantic gut feeling when you met your significant 
> other, it might have a physiological basis.
>  
>  It has long been known that Drosophila raised on starch media are 
> more likely to mate with other starch-raised flies, whereas those fed 
> maltose have similar preferences. In a study published online in the 
> November issue of the Proceedings of the National Academy of Sciences, 
> investigators explored the mechanism for this preference by treating 
> flies with antibiotics to sterilize the gut and saw the preferences 
> disappear (Proc. Nad. Acad. Sci. U.S.A. 2010 Nov. 1).
>  
>  In cultures of untreated flies, the bacterium  L. plantarum was more 
> common in those on starch, and sure enough, when L. plantarum was 
> returned to the sterile groups, the mating preference returned. The 
> best explanation for this is revealed in the significant differences 
> in their sex pheromones. These experiments also support the hologenome 
> theory of evolution wherein the unit of natural selection is the 
> "holobiont," or combination of organism and its microorganisms, that 
> determines mating preferences.
>  
>  Mating gets more interesting when you have an organism that can 
> choose between sexual and asexual reproduction, like the rotifer. 
> Biologists say that it's more advantageous for a rotifer to remain 
> asexual and pass 100% of its genetic information to the next 
> generation. But if the environment changes, rotifers must adapt 
> quickly in order to survive and reproduce with new gene combinations 
> that have an advantage over existing genotypes. So in this new 
> situation, the stressed rotifers, all of which are female, begin 
> sending messages to each other to produce males for the switch to 
> sexual reproduction (Nature 2010 Oct. 13). You can draw your own 
> inference about males not being needed until there's trouble in the environment.
>  
>  As far as humans are concerned, you may think you know all about 
> sexual signals, but you'd be surprised by new findings. It's been 
> known since the 1990s that heterosexual women living together 
> synchronize their menstrual cycles because of pheromones, but when a 
> study of lesbians showed that they do not synchronize, the researchers 
> suspected that semen played a role. In fact, they found ingredients in 
> semen that include mood enhancers like estrone, cortisol, prolactin, 
> oxytocin, and serotonin; a sleep enhancer, melatonin; and of course, 
> sperm, which makes up only 1%-5%. Delivering these compounds into the 
> richly vascularized vagina also turns out to have major salutary 
> effects for the recipient. Female college students having unprotected 
> sex were significantly less depressed than were those whose partners 
> used condoms (Arch. Sex. Behav. 2002;31:289-93). Their better moods 
> were not just a feature of promiscuity, because women using condoms 
> were just as depressed as those practi
>   cing total abstinence. The benefits of semen contact also were seen 
> in fewer suicide attempts and better performance on cognition tests.
>  
>  So there's a deeper bond between men and women than St. Valentine 
> would have suspected, and now we know there's a better gift for that 
> day than chocolates.
>  
>  Reposted in Retraction Watch with many comments worth looking at  :  
> http://retractionwatch.wordpress.com/2011/04/06/forget-chocolate-on-valentines-day-try-semen-says-surgery-news-editor-retraction-resignation-follow/
>  
>  
>  Dr. Shanda Blackmon asks about the ACS response at Southwestern 
> Surgical:  http://youtu.be/CqD48vqCRUU
>  --
>  trauma-list : TRAUMA.ORG
>  To change your settings or unsubscribe visit:
>  http://www.trauma.org/index.php?/community/
>  
>  ----------------------------------------------------------------------
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>   
>  
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>  
>  
>  ------------------------------
>  
>  Message: 4
>  Date: Fri, 15 Apr 2011 23:47:20 +0100
>  From: Karim Brohi <karimbrohi at gmail.com>
>  Subject: Re: New definition of severe trauma?
>  To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
>  Message-ID: <BANLkTima+sDdjyNpS7e6cKYA5eafA3QTSA at mail.gmail.com>
>  Content-Type: text/plain; charset=ISO-8859-1
>  
>  I don't know of any studies that have ever used ISS>20 as a threshold
>  so I'm not sure where this specific value came from, but I do
>  understand the motivation.  As ISS>15 mortality has fallen over the
>  years, it is becoming increasingly difficult to use this group to
>  identify where improvements in process of care or novel therapeutics
>  can improve a mortality endpoint.  However this still represents a
>  large an important group of patients and we probably need to look at
>  non-mortality outcomes in this group to really evaluate how we deliver
>  care.  So I would not jettison the ISS>15 definition of severe trauma.
>   (In fact the ISS 9-15 group are also important but often overlooked)
>  
>  However there is logic in analysing a more severely injured cohort,
>  and the logical step up for ISS is 25 and above (ISS>24), which we
>  have defined as 'Critically Injured' in a previous paper
>  (http://www.ncbi.nlm.nih.gov/pubmed/20013932) as have others.  (25
>  being AIS 5 squared as a step up from 16 being AIS 4 squared).  These
>  are the group where you can more readily see a mortality impact of
>  improvements in care delivery etc.
>  
>  Karim
>  
>  On Wed, Apr 13, 2011 at 23:53, Zsolt J. Balogh
>  <Zsolt.Balogh at hnehealth.nsw.gov.au> wrote:
>  >
>  >
>  > Professor Zsolt J. Balogh, MD, PhD, FRACS
>  > Director of Trauma, John Hunter Hospital and Hunter New England 
> Area Health Service
>  > Discipline Head of Traumatology, University of Newcastle
>  > Newcastle, NSW
>  > AUSTRALIA
>  > Tel: +61 2 49214259
>  > Fax: +61 2 49214274
>  > E-mail: zsolt.balogh at hnehealth.nsw.gov.au
>  >
>  >
>  >
>  >
>  > -----Original Message-----
>  > From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Charlene M Morris
>  > Sent: Thursday, 14 April 2011 8:55 AM
>  > To: Trauma-List [TRAUMA.ORG]
>  > Subject: Re: New definition of severe trauma?
>  >
>  > can link to the article be posted, please?
>  >
>  > cmm
>  >
>  > On Wed, Apr 13, 2011 at 6:41 PM, Zsolt J. Balogh <
>  > Zsolt.Balogh at hnehealth.nsw.gov.au> wrote:
>  >
>  >> Dear Cat,
>  >>
>  >> Please look at our article on the "definition of Polytrauma". Best 
> Regards,
>  >> Zsolt Balogh
>  >>
>  >>
>  >>
>  >> Professor Zsolt J. Balogh, MD, PhD, FRACS
>  >> Director of Trauma, John Hunter Hospital and Hunter New England 
> Area Health
>  >> Service
>  >> Discipline Head of Traumatology, University of Newcastle
>  >> Newcastle, NSW
>  >> AUSTRALIA
>  >> Tel: +61 2 49214259
>  >> Fax: +61 2 49214274
>  >> E-mail: zsolt.balogh at hnehealth.nsw.gov.au
>  >>
>  >>
>  >>
>  >>
>  >> -----Original Message-----
>  >> From: trauma-list-bounces at trauma.org [mailto:
>  >> trauma-list-bounces at trauma.org] On Behalf Of Heim Schoettker Katharina
>  >> Sent: Thursday, 14 April 2011 6:52 AM
>  >> To: trauma-list at trauma.org
>  >> Subject: New definition of severe trauma?
>  >>
>  >> Is anybody using ISS > 20 as definition of severe trauma? Health-care
>  >> politicians want Swiss-hospitals ?to use ISS > 20 rather than > 15 
> for
>  >> definition of severe trauma. Is anybody aware of scientific 
> arguments for
>  >> that?
>  >> Thanks
>  >> Cat
>  >> --
>  >> trauma-list : TRAUMA.ORG <
>  >> To change your settings or unsubscribe visit:
>  >> http://www.trauma.org/index.php?/community/
>  >> --
>  >> trauma-list : TRAUMA.ORG <
>  >> To change your settings or unsubscribe visit:
>  >> http://www.trauma.org/index.php?/community/
>  >>
>  >
>  >
>  >
>  > --
>  > THE best person for the job is the one who knows what to do at that 
> given
>  > moment and is THERE, regardless of position, age or gender.
>  > --cmm
>  > --
>  > trauma-list : TRAUMA.ORG
>  > To change your settings or unsubscribe visit:
>  > http://www.trauma.org/index.php?/community/
>  >
>  > --
>  > trauma-list : TRAUMA.ORG
>  > To change your settings or unsubscribe visit:
>  > http://www.trauma.org/index.php?/community/
>  >
>  
>  
>  ------------------------------
>  
>  Message: 5
>  Date: Fri, 15 Apr 2011 19:31:40 -0400
>  From: Dave Napoliello <nappio at aol.com>
>  Subject: Trauma CT
>  To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
>  Message-ID: <2jnryt5k16jbxy206avtj2ih.1302910129713 at email.android.com>
>  Content-Type: text/plain; charset=utf-8
>  
>  I was just informed my community hospital obtains non~contrasted 
> trauma CT's.  Am I missing something?  Shouldn't a trauma ct have iv 
> contrast to look for vascular injury or organ extravisation?dn
>  
>  Sent from my Verizon Wireless Phone
>  
>  Karim Brohi <karimbrohi at gmail.com> wrote:
>  
>  >I don't know of any studies that have ever used ISS>20 as a threshold
>  >so I'm not sure where this specific value came from, but I do
>  >understand the motivation.  As ISS>15 mortality has fallen over the
>  >years, it is becoming increasingly difficult to use this group to
>  >identify where improvements in process of care or novel therapeutics
>  >can improve a mortality endpoint.  However this still represents a
>  >large an important group of patients and we probably need to look at
>  >non-mortality outcomes in this group to really evaluate how we deliver
>  >care.  So I would not jettison the ISS>15 definition of severe trauma.
>  > (In fact the ISS 9-15 group are also important but often overlooked)
>  >
>  >However there is logic in analysing a more severely injured cohort,
>  >and the logical step up for ISS is 25 and above (ISS>24), which we
>  >have defined as 'Critically Injured' in a previous paper
>  >(http://www.ncbi.nlm.nih.gov/pubmed/20013932) as have others.  (25
>  >being AIS 5 squared as a step up from 16 being AIS 4 squared).  These
>  >are the group where you can more readily see a mortality impact of
>  >improvements in care delivery etc.
>  >
>  >Karim
>  >
>  >On Wed, Apr 13, 2011 at 23:53, Zsolt J. Balogh
>  ><Zsolt.Balogh at hnehealth.nsw.gov.au> wrote:
>  >>
>  >>
>  >> Professor Zsolt J. Balogh, MD, PhD, FRACS
>  >> Director of Trauma, John Hunter Hospital and Hunter New England 
> Area Health Service
>  >> Discipline Head of Traumatology, University of Newcastle
>  >> Newcastle, NSW
>  >> AUSTRALIA
>  >> Tel: +61 2 49214259
>  >> Fax: +61 2 49214274
>  >> E-mail: zsolt.balogh at hnehealth.nsw.gov.au
>  >>
>  >>
>  >>
>  >>
>  >> -----Original Message-----
>  >> From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Charlene M Morris
>  >> Sent: Thursday, 14 April 2011 8:55 AM
>  >> To: Trauma-List [TRAUMA.ORG]
>  >> Subject: Re: New definition of severe trauma?
>  >>
>  >> can link to the article be posted, please?
>  >>
>  >> cmm
>  >>
>  >> On Wed, Apr 13, 2011 at 6:41 PM, Zsolt J. Balogh <
>  >> Zsolt.Balogh at hnehealth.nsw.gov.au> wrote:
>  >>
>  >>> Dear Cat,
>  >>>
>  >>> Please look at our article on the "definition of Polytrauma". 
> Best Regards,
>  >>> Zsolt Balogh
>  >>>
>  >>>
>  >>>
>  >>> Professor Zsolt J. Balogh, MD, PhD, FRACS
>  >>> Director of Trauma, John Hunter Hospital and Hunter New England 
> Area Health
>  >>> Service
>  >>> Discipline Head of Traumatology, University of Newcastle
>  >>> Newcastle, NSW
>  >>> AUSTRALIA
>  >>> Tel: +61 2 49214259
>  >>> Fax: +61 2 49214274
>  >>> E-mail: zsolt.balogh at hnehealth.nsw.gov.au
>  >>>
>  >>>
>  >>>
>  >>>
>  >>> -----Original Message-----
>  >>> From: trauma-list-bounces at trauma.org [mailto:
>  >>> trauma-list-bounces at trauma.org] On Behalf Of Heim Schoettker Katharina
>  >>> Sent: Thursday, 14 April 2011 6:52 AM
>  >>> To: trauma-list at trauma.org
>  >>> Subject: New definition of severe trauma?
>  >>>
>  >>> Is anybody using ISS > 20 as definition of severe trauma? Health-care
>  >>> politicians want Swiss-hospitals ?to use ISS > 20 rather than > 
> 15 for
>  >>> definition of severe trauma. Is anybody aware of scientific 
> arguments for
>  >>> that?
>  >>> Thanks
>  >>> Cat
>  >>> --
>  >>> trauma-list : TRAUMA.ORG <
>  >>> To change your settings or unsubscribe visit:
>  >>> http://www.trauma.org/index.php?/community/
>  >>> --
>  >>> trauma-list : TRAUMA.ORG <
>  >>> To change your settings or unsubscribe visit:
>  >>> http://www.trauma.org/index.php?/community/
>  >>>
>  >>
>  >>
>  >>
>  >> --
>  >> THE best person for the job is the one who knows what to do at 
> that given
>  >> moment and is THERE, regardless of position, age or gender.
>  >> --cmm
>  >> --
>  >> trauma-list : TRAUMA.ORG
>  >> To change your settings or unsubscribe visit:
>  >> http://www.trauma.org/index.php?/community/
>  >>
>  >> --
>  >> trauma-list : TRAUMA.ORG
>  >> To change your settings or unsubscribe visit:
>  >> http://www.trauma.org/index.php?/community/
>  >>
>  >--
>  >trauma-list : TRAUMA.ORG
>  >To change your settings or unsubscribe visit:
>  >http://www.trauma.org/index.php?/community/
>  
>  ------------------------------
>  
>  Message: 6
>  Date: Tue, 19 Apr 2011 10:27:45 -0500
>  From: "Shawn Ballard" <sballard at WNJ.ORG>
>  Subject: level I activation
>  To: <trauma-list at trauma.org>
>  Message-ID:
>  	<864481E5A1EFC947B19A0A4AA35E095204BC42BF at EXCHANGESVR.Internal.wnj.bz>
>  Content-Type: text/plain;	charset="us-ascii"
>  
>  I know the ACS is specific on arrival time for trauma surgeons for a
>  level I (high-level response). Are their guidelines or requirements for
>  the response of other team members. For example ED staff respond
>  immediately and support services respond within 10 minutes.
>  
>   
>  
>  Also are the response times for level II and level III activation
>  hospital specific?
>  
>   
>  
>   
>  
>   
>  
>  
>  
>  ------------------------------
>  
>  Message: 7
>  Date: Tue, 19 Apr 2011 13:09:58 EDT
>  From: Krin135 at aol.com
>  Subject: Skype android problems
>  To: ccm-l at list.pitt.edu, trauma-list at trauma.org
>  Message-ID: <26adb.253237b3.3adf1be6 at aol.com>
>  Content-Type: text/plain; charset="US-ASCII"
>  
>  considering the number of folks on these lists that use Skype, and 
> probably 
>   have Android type phones, I thought that this was pertinent:
>   
>  http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2011-May/_http://www.itbusinessedge.com/cm/blogs/bentley/skype-for-android-flaw-puts-
>  user-information-at-risk/?cs=46554&utm_source=itbe&utm_medium=email&utm_camp
>  aign=dye&nr=dye_ 
>  (http://www.itbusinessedge.com/cm/blogs/bentley/skype-for-android-flaw-puts-user-information-at-risk/?cs=46554&utm_source=itbe&utm_medi
>  um=email&utm_campaign=dye&nr=dye) 
>   
>  ck
>  
>  
>  ------------------------------
>  
>  Message: 8
>  Date: Tue, 19 Apr 2011 13:55:28 EDT
>  From: Krin135 at aol.com
>  Subject: Check out Skype for Android Flaw Puts User Information at
>  	Risk |	Blogs | ITBu
>  To: trauma-list at trauma.org, ccm-l at list.pitt.edu
>  Message-ID: <293c1.3da504b8.3adf2690 at aol.com>
>  Content-Type: text/plain; charset="US-ASCII"
>  
>  _Click  here: Skype for Android Flaw Puts User Information at Risk | 
> Blogs 
>  |  ITBusinessEdge.com_ 
>  (http://www.itbusinessedge.com/cm/blogs/bentley/skype-for-android-flaw-puts-user-information-at-risk/?cs=46554&utm_source=itbe&utm
>  _medium=email&utm_campaign=dye&nr=dye)  
>   
>  at the request of one of the list members, a shorter link to the blog 
> in  
>  question.
>   
>  ck
>  
>  
>  ------------------------------
>  
>  Message: 9
>  Date: Wed, 20 Apr 2011 13:58:08 +0530 (IST)
>  From: rm khattar <dr_rm_khattar at yahoo.co.in>
>  Subject: Appendecitis
>  To: trauma-list at trauma.org
>  Cc: ccm-l at list.pitt.edu
>  Message-ID: <81517.20264.qm at web95207.mail.in2.yahoo.com>
>  Content-Type: text/plain; charset=utf-8
>  
>  Recently I read an article suggesting incidence of appendicitis is 
> falling in Finland. Another article said, has appendicitis become a 
> medical illness? 
>  I have following observations to make regarding appendicitis in my 
> surgical practice of 25 years.
>  1.Incidence of appendicitis is falling in India too,due to improved 
> public health measures,subsequently less viral infections of the 
> gut,and probably less chances of inflammation of lymphoid follicles at 
> entry of appendicular lummen and subsequently less apendicitis.
>  2.Rate of appendicectomy is falling due to early initiation of 
> antibiotics of high generation in all abdominal pain ,subsequently 
> many milder forms of appendicitis is nipped in the bud.
>  3.Incidence of perforated and gangrenous appendicitis is also falling 
> due to same logic.Hardly any patient goes into septic shock due to appendicitis.
>  4.Many more cases of mild catarrhal inflammation of appendix  leading 
> to reccurrent RIF pain are seen getting treated with antibiotics each 
> time.
>  5.Studies have shown appendicectomy no more remains a middle of the 
> night operation,it can safely wait till next morning.
>  6.Hardly any appendicectomy is done without CT corroboration.
>  7.Lap appendicectomy has still not become gold standard for appendix 
> removal.
>  8.There is increasing questioning regarding Interval appendicectomy 
> ,since as much as 50 percent of appendecitis treated with antibiotics 
> may not have pain again.
>  R.M.Khattar Delhi India   
>  
>  
>  ------------------------------
>  
>  Message: 10
>  Date: Wed, 20 Apr 2011 15:48:52 -0400
>  From: S Schecter <schecters at gmail.com>
>  Subject: (Off topic) Civil War soldiers photographs of wounds
>  To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>
>  Message-ID: <BANLkTimwd1w66Rxp_gK6JFawViBpRG3cCw at mail.gmail.com>
>  Content-Type: text/plain; charset=ISO-8859-1
>  
>  Some of the photos of the soldiers are not wearing clothes in case filters
>  are in place.
>  
>  http://www.flickr.com/photos/medicalmuseum/with/5610191881/
>  
>  
>  ------------------------------
>  
>  Message: 11
>  Date: Thu, 21 Apr 2011 09:51:49 -0500
>  From: "Todd Kelly, M.D." <tkellymd at msn.com>
>  Subject: Using MLP's for PM ICU coverage
>  To: trauma-list at trauma.org
>  Message-ID: <BLU0-SMTP188447D8158BB01531AAC40CF920 at phx.gbl>
>  Content-Type: text/plain; charset="utf-8"
>  
>  Are any of you using Mid-level providers without an intensivist (NP 
> or ACNP) to provide in-house night coverage for your ICU's?  If so, 
> how many beds are they covering?
>  
>  ------------------------------
>  
>  Message: 12
>  Date: Fri, 22 Apr 2011 12:46:28 -0500
>  From: Ante ?ori? <ante.coric85 at gmail.com>
>  Subject: Re: Using MLP's for PM ICU coverage
>  To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
>  Message-ID: <BANLkTingJXRwrcd-d0dAHpd2PJeugmxohg at mail.gmail.com>
>  Content-Type: text/plain; charset=ISO-8859-1
>  
>  We don't use non physician staff for coverage, on most instances
>  intensivist in house or anasthetist (those with 5yrs residency
>  programme)
>  
>  2011/4/21, Todd Kelly, M.D. <tkellymd at msn.com>:
>  > Are any of you using Mid-level providers without an intensivist (NP 
> or ACNP)
>  > to provide in-house night coverage for your ICU's?  If so, how many 
> beds are
>  > they covering?
>  > --
>  > trauma-list : TRAUMA.ORG
>  > To change your settings or unsubscribe visit:
>  > http://www.trauma.org/index.php?/community/
>  >
>  
>  
>  ------------------------------
>  
>  Message: 13
>  Date: Sat, 23 Apr 2011 10:03:10 -0600
>  From: JORGE RAMIREZ ARCE <ramfons at racsa.co.cr>
>  Subject: Re: Using MLP's for PM ICU coverage
>  To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
>  Message-ID: <7540c01a39bd0.4db2a3de at racsa.co.cr>
>  Content-Type: text/plain; charset="us-ascii"
>  
>  An HTML attachment was scrubbed...
>  URL: <
>  
>  ------------------------------
>  
>  Message: 14
>  Date: Sun, 24 Apr 2011 14:24:10 +0530 (IST)
>  From: rm khattar <dr_rm_khattar at yahoo.co.in>
>  Subject: trauma List
>  To: trauma-list at trauma.org
>  Message-ID: <27214.69926.qm at web95203.mail.in2.yahoo.com>
>  Content-Type: text/plain; charset=utf-8
>  
>  What has happenened to trauma list? Are there no contributions or I 
> am 
>  unsubscribed?
>  R.M.Khattar
>  Delhi India
>  
>  
>  ------------------------------
>  
>  Message: 15
>  Date: Sun, 24 Apr 2011 08:59:42 +0000
>  From: Doc Holiday <drydok at hotmail.com>
>  Subject: RE: trauma List
>  To: ".Trauma List" <trauma-list at trauma.org>
>  Message-ID: <SNT104-W60543B700EE706873105FDC0970 at phx.gbl>
>  Content-Type: text/plain; charset="utf-8"
>  
>  
>  From: dr_rm_khattar at yahoo.co.in
>  > What has happenened to trauma list? Are there no contributions or I 
> am unsubscribed?
>  
>  --> Not sure what you mean?
>   
>  The item below came just yesterday:
>   
>   
>   
>  
>  Re: Using MLP's for PM ICU coverage?
>  
>   JORGE RAMIREZ ARCE 
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  ramfons at racsa.co.cr
>  
>  
>   
>  To Trauma-List [TRAUMA.ORG]
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  From:
>  trauma-list-bounces at trauma.org on behalf of JORGE RAMIREZ ARCE 
> (ramfons at racsa.co.cr) 
>  
>  Sent:
>  23 April 2011 16:05:47
>  
>  To: 
>  Trauma-List [TRAUMA.ORG] (trauma-list at trauma.org)
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  We use senior residents in anesthesiology for coverae and an 
> intensivist is on-call. Tiny unit 6 bed, but covering also recovery 
> room. (hope to grow in the near future???)
>  
>  
>  Jorge Ramirez-Arce, MD
>  Chief SICU.
>  Hospital "Dr. Rafael Angel Calderon Guardia"
>  San Jos?, Costa Rica
>  
>  El 22/04/11, Ante ?ori? <ante.coric85 at gmail.com> escribi?:            
>                                    
>  
>  ------------------------------
>  
>  Message: 16
>  Date: Sun, 24 Apr 2011 02:40:03 -0700
>  From: "Kate Warren" <traumadocs at cox.net>
>  Subject: RE: trauma List
>  To: "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
>  Message-ID: <001b01cc0263$96a86d20$c3f94760$@net>
>  Content-Type: text/plain;	charset="UTF-8"
>  
>   The list is up, maybe it is quiet due to the holiday weekend.
>  
>  -----Original Message-----
>  From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Doc Holiday
>  Sent: Sunday, April 24, 2011 2:00 AM
>  To: .Trauma List
>  Subject: RE: trauma List
>  
>  
>  From: dr_rm_khattar at yahoo.co.in
>  > What has happenened to trauma list? Are there no contributions or I 
> am unsubscribed?
>  
>  --> Not sure what you mean?
>   
>  The item below came just yesterday:
>   
>   
>   
>  
>  Re: Using MLP's for PM ICU coverage?
>  
>   JORGE RAMIREZ ARCE 
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  ramfons at racsa.co.cr
>  
>  
>   
>  To Trauma-List [TRAUMA.ORG]
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  From:
>  trauma-list-bounces at trauma.org on behalf of JORGE RAMIREZ ARCE 
> (ramfons at racsa.co.cr) 
>  
>  Sent:
>  23 April 2011 16:05:47
>  
>  To: 
>  Trauma-List [TRAUMA.ORG] (trauma-list at trauma.org)
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  We use senior residents in anesthesiology for coverae and an 
> intensivist is on-call. Tiny unit 6 bed, but covering also recovery 
> room. (hope to grow in the near future???)
>  
>  
>  Jorge Ramirez-Arce, MD
>  Chief SICU.
>  Hospital "Dr. Rafael Angel Calderon Guardia"
>  San Jos?, Costa Rica
>  
>  El 22/04/11, Ante ?ori? <ante.coric85 at gmail.com> escribi?:            
>                                    
>  --
>  trauma-list : TRAUMA.ORG
>  To change your settings or unsubscribe visit:
>  http://www.trauma.org/index.php?/community/
>   
>  
>  __________ Information from ESET Smart Security, version of virus 
> signature database 6066 (20110423) __________
>  
>  The message was checked by ESET Smart Security.
>  
>  http://www.eset.com
>   
>  
>  
>  
>  ------------------------------
>  
>  Message: 17
>  Date: Sun, 24 Apr 2011 07:30:37 EDT
>  From: Krin135 at aol.com
>  Subject: Re: trauma List
>  To: trauma-list at trauma.org
>  Message-ID: <81ca4.3fdc21c3.3ae563dd at aol.com>
>  Content-Type: text/plain; charset="US-ASCII"
>  
>  your message came through here.
>   
>  I figured folks were still recovering from the trip to Las Vegas.
>   
>  ck
>   
>   
>  In a message dated 04/24/11 03:54:28 Central Daylight Time,  
>  dr_rm_khattar at yahoo.co.in writes:
>  
>  What has  happenened to trauma list? Are there no contributions or I 
> am  
>  unsubscribed?
>  R.M.Khattar
>  Delhi India
>  --
>  trauma-list :  TRAUMA.ORG
>  To change your settings or unsubscribe  visit:
>  http://www.trauma.org/index.php?/community/
>  
>  
>  
>  ------------------------------
>  
>  Message: 18
>  Date: Mon, 25 Apr 2011 16:10:40 +0100 (BST)
>  From: karan botsford <karanbotsford at btinternet.com>
>  Subject: Re: trauma List
>  To: "Trauma-List \[TRAUMA.ORG\]" <trauma-list at trauma.org>
>  Message-ID: <454818.34176.qm at web87012.mail.ird.yahoo.com>
>  Content-Type: text/plain; charset=utf-8
>  
>  
>  
>  
>  
>  
>  ________________________________
>  From: Kate Warren <traumadocs at cox.net>
>  To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
>  Sent: Sunday, 24 April, 2011 10:40:03
>  Subject: RE: trauma List
>  
>  The list is up, maybe it is quiet due to the holiday weekend.
>  
>  -----Original Message-----
>  From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] On 
>  Behalf Of Doc Holiday
>  Sent: Sunday, April 24, 2011 2:00 AM
>  To: .Trauma List
>  Subject: RE: trauma List
>  
>  
>  From: dr_rm_khattar at yahoo.co.in
>  > What has happenened to trauma list? Are there no contributions or I 
> am 
>  >unsubscribed?
>  
>  --> Not sure what you mean?
>  
>  The item below came just yesterday:
>  
>  
>  
>  
>  Re: Using MLP's for PM ICU coverage?
>  
>  JORGE RAMIREZ ARCE 
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  ramfons at racsa.co.cr
>  
>  
>  
>  To Trauma-List [TRAUMA.ORG]
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  From:
>  trauma-list-bounces at trauma.org on behalf of JORGE RAMIREZ ARCE 
>  (ramfons at racsa.co.cr) 
>  
>  
>  Sent:
>  23 April 2011 16:05:47
>  
>  To: 
>  Trauma-List [TRAUMA.ORG] (trauma-list at trauma.org)
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  
>  We use senior residents in anesthesiology for coverae and an 
> intensivist is 
>  on-call. Tiny unit 6 bed, but covering also recovery room. (hope to 
> grow in the 
>  near future???)
>  
>  
>  Jorge Ramirez-Arce, MD
>  Chief SICU.
>  Hospital "Dr. Rafael Angel Calderon Guardia"
>  San Jos?, Costa Rica
>  
>  El 22/04/11, Ante ?ori? <ante.coric85 at gmail.com> escribi?: ??? ??? 
> ??? ? ??? ??? 
>  ? 
>  
>  --
>  trauma-list : TRAUMA.ORG
>  To change your settings or unsubscribe visit:
>  http://www.trauma.org/index.php?/community/
>  
>  
>  __________ Information from ESET Smart Security, version of virus 
> signature 
>  database 6066 (20110423) __________
>  
>  The message was checked by ESET Smart Security.
>  
>  http://www.eset.com
>  
>  
>  --
>  trauma-list : TRAUMA.ORG
>  To change your settings or unsubscribe visit:
>  http://www.trauma.org/index.php?/community/
>  
>  ------------------------------
>  
>  Message: 19
>  Date: Mon, 25 Apr 2011 12:52:59 -0500
>  From: "Seastrom, David, W" <dwseastrom at cmh.edu>
>  Subject: RE: Using MLP's for PM ICU coverage
>  To: "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
>  Message-ID:
>  	<69A64F7AFB8EA64482FF3FE076B278540FC3EE97 at CMHMAIL0.CMH.Internal>
>  Content-Type: text/plain; charset="utf-8"
>  
>  We have T/SCC fellows that are in-house 24/7, but we also have staff 
> intensivist that are in-house 24/7.  We use NP?s that round through 
> the ICU, but they are always see by the fellow or staff.
>  
>  David Seastrom RN, BSN, EMT-I
>  Trauma Injury Prevention / Outreach
>  Education Coordinator
>  The Children's Mercy Hospitals & Clinics
>  Kansas City, MO.  64108
>  Office:  816-983-6917
>  Fax:  816-234-3821
>  Pager:  816-458-4995
>  E-Mail:  dwseastrom at cmh.edu<
>  
>  [cid:image001.jpg at 01CC0347.B4709460]
>  
>  From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of JORGE RAMIREZ ARCE
>  Sent: Saturday, April 23, 2011 11:03 AM
>  To: Trauma-List [TRAUMA.ORG]
>  Subject: Re: Using MLP's for PM ICU coverage
>  
>  We use senior residents in anesthesiology for coverae and an 
> intensivist is on-call. Tiny unit 6 bed, but covering also recovery 
> room. (hope to grow in the near future???)
>  
>  Jorge Ramirez-Arce, MD
>  Chief SICU.
>  Hospital "Dr. Rafael Angel Calderon Guardia"
>  San Jos?, Costa Rica
>  El 22/04/11, Ante ?ori? <ante.coric85 at gmail.com> escribi?:
>  We don't use non physician staff for coverage, on most instances
>  intensivist in house or anasthetist (those with 5yrs residency
>  programme)
>  
>  2011/4/21, Todd Kelly, M.D. <tkellymd at msn.com>:
>  > Are any of you using Mid-level providers without an intensivist (NP 
> or ACNP)
>  > to provide in-house night coverage for your ICU's?  If so, how many 
> beds are
>  > they covering?
>  > --
>  > trauma-list : TRAUMA.ORG
>  > To change your settings or unsubscribe visit:
>  > http://www.trauma.org/index.php?/community/
>  >
>  --
>  trauma-list : TRAUMA.ORG
>  To change your settings or unsubscribe visit:
>  http://www.trauma.org/index.php?/community/
>  -------------- next part --------------
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>  
>  ------------------------------
>  
>  --
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