Demographics, Stone Characteristic, and Treatment of Urinary Calculi at the 47th Combat Support Hospital during the First 6 Months of Operation Iraqi Freedom

There are few publications describing urolithiasis in deployed military personnel. Renal colic was the most common urologic indication for air evacuation from the 47th Combat Support Hospital during the first 6 months of Operation Iraqi Freedom and we describe our observations and experience herein. Institutional review board approval was obtained to create a database of patients presenting to the 47th Combat Support Hospital with urolithiasis. Patient demographics, stone characteristic, imaging modality, urinalysis results, treatment course, and outcomes were evaluated for 182 patients. Sixty percent of patients qualified for conservative treatment and spontaneous stone passage was documented in 28%. We conclude that conservative therapy is safe and appropriate initial treatment for the majority of deployed personnel with urinary calculi, however, many patients were lost to follow-up. No patient treated conservatively required admission for sepsis, azotemia, or other serious stone-related complication.

Outcome and impact of mental disorders in primary care at 5 years

OBJECTIVE

To assess 5-year mental disorder recognition rates and determine the natural history of mental disorders in primary care.

METHODS

A prospective cohort of adults presenting to a primary care walk-in clinic with a physical symptom were evaluated at baseline (n = 500) and at 5 years (n = 387) for mental disorders with the Primary Care Evaluation of Mental Disorders (PRIME-MD). Additional measures included functional status (Medical Outcomes Study SF-6; MOS-SF6), Patient Health Questionnaire-15, Satisfaction (Rand-9), unmet expectations, and symptom outcome. Patients self-reported whether their disorder was diagnosed or treated at the 5-year follow-up.

RESULTS

At baseline, 29% of patients had a mental disorder (major depression: 8.4%, minor depression 10.4%, Panic disorder 1.4%, generalized anxiety disorder 2%, anxiety not otherwise specified (NOS) 11.4%); of these patients, 26% had more than one mental disorder. Over 5 years, 33% were recognized. Threshold disorders were more likely to be recognized (major depression 56%, panic 100%, generalized anxiety disorder 88%) than subthreshold disorders (minor depression 20%, anxiety NOS 25%). Correlates of recognition included having a threshold or multiple disorders; recognition was associated with greater likelihood of persistence. Most patients with subthreshold disorders at baseline had no disorder at 5 years and few progressed to threshold disorders (minor to major depression 12%, anxiety NOS to generalized anxiety or panic 8%).

CONCLUSIONS

Mental disorders are common and their recognition and treatment remain low. Subthreshold disorders have a better prognosis. Patients with threshold or multiple disorders, worse functioning or persistence of their disorder were more likely to be diagnosed.

Descriptive summary of patients seen at the surgical companies during Operation Iraqi Freedom-1

The Navy-Marine Corps Combat Trauma Registry is a data repository summarizing information from data sets describing injuries sustained and treatments administered to casualties from the point of injury to rehabilitation. Among the medical facilities contributing data to the Combat Trauma Registry during Operation Iraqi Freedom were the Marine Corps forward surgical companies. The surgical companies offer resuscitative surgery, medical treatment, and temporary holding facilities, in addition to preparing patients for evacuation. This article reviews the types of patients admitted and treatments provided at the surgical companies during the major combat period of Operation Iraqi Freedom. The surgical companies saw an average of 15 to 17 patients per day during this period. Less than 20% of the U.S. casualties seen were wounded in action. In contrast, >75% of the enemy prisoner of war presentations were for battle injuries. Less than 15% of the patients were held at the facilities for >24 hours.

A review of one year of British Armed Forces mental health hospital admissions

OBJECTIVES

The paper provides a review of one year of military Mental Health (MH) hospital admissions. This includes an exploration into demographic trends, differences in clinical opinion and how information gained is used to improve the service and ensure appropriate, cost effective care in the optimum environment.

METHODS

The sample group is entitled military MH hospital admissions from 1 April 2005 to 31 March 2006. Data was collected on questionnaires with SPSS used for the management and analysis of the quantitative data, with the information exposed to descriptive and inferential statistical analysis.

RESULTS

There were 344 admissions. The paper contains a detailed review of a number of variables. Depression was the most common diagnosis resulting in 112 (33%) hospital admissions and Post Traumatic Stress Disorder accounted for 23 (7%). There were statistically significant differences that may be attributable to gender with more women admitted with depression and more men with alcohol related disorders. The average length of stay was 21 days, with 48% of patients discharged within 3 weeks. 45% of all returns included significant events reporting that highlighted written evidence of good and poor practice.

CONCLUSION

This study is part of an extensive monitoring programme of military MH hospital admissions. Depression is the most common MH problem leading to hospital admission. The results indicate that Service-personnel have access to a highly responsive service that provides brief assessment and treatment within a safe therapeutic environment. 45% of returns included significant event information that resulted in policy changes, leading to improved patient care and a better interface with the NHS. Bench-marking, both internally between military Departments of Community Mental Health and externally have improved visibility and self awareness leading to better GP induction programmes, PHC educational seminars and the establishment of MH web-pages. The Armed Forces need an effective MH service that is accessible, readily available, non-stigmatised and which positively advocates a duty of care. The results highlight the importance of further studies regarding depression to ensure that the Armed Forces are in a better position to maximise the use of MH resources.

Pediatric trauma: experience of a combat support hospital in Iraq

BACKGROUND/PURPOSE

The mission of the combat support hospital (CSH) is to evaluate and treat combatants injured during war operations. The 31st CSH in Balad and Baghdad, Iraq, during Operation Iraqi Freedom 2 also treated many injured civilians, including children. The purpose of this article is to report the experience of the 31st CSH treating pediatric trauma patients.

METHODS

A retrospective review of a comprehensive patient database collected in theater was conducted.

RESULTS

From January 1 to December 31, 2004, we treated 99 patients 17 years and younger. The average age of these patients was 10.6 years. Nine died of their wounds. The mean injury severity score was 11.6. Forty-one sustained gunshot wounds, 13 acquired fragment wounds (55% penetrating), and 22 were injured by improvised explosive devices (22%). Seventy-three patients required a total of 191 operations: 18 celiotomies, 8 craniotomies, 23 skeletal fixations, and 75 wound washout/debridements, among others. Predictors of mortality included admission Glasgow Coma Score less than 4 and admission pH less than 7.1.

CONCLUSIONS

The primary mission of the CSH in theater remains unchanged, but its role is evolving. With this study, we can begin to understand the needs of wounded children in urban conflict and help guide training and resource allocation in the future.

Summary of the 2004-2005 influenza season in the U.S. Army Europe

Influenza and other respiratory infections, the most common cause of acute infectious disease in U.S adults, are also the leading cause of outpatient illness and a major cause of infectious disease hospitalization in U.S. military personnel. Although respiratory disease control is improved, epidemics continue to occur, and respiratory disease in military trainees continues to exceed that in U.S. civilian adults. Overall, Department of Defense utilization of the trivalent inactivated vaccine was much lower than anticipated during the 2004-2005 season. The slow start to the 2004-2005 influenza season resulted in a low demand for influenza immunization by the medically high-risk beneficiary population of the Department of Defense. Surveillance for influenza during the 2004-2005 season in U.S. Army Europe reached unprecedented heights, testing and confirming more cases than in any previous year.

Attendances at a Field Hospital emergency department during operations in Iraq November 2003 to March 2004(Operation Telic III)

OBJECTIVE

This study investigated the types of presentations; time lines and disposal of patients from the international, local and military community in Southern Iraq.

METHODS

All presentations to the Emergency Department (ED) were clinically and demographically coded and entered onto an electronic database.

RESULTS

During the period studied the emergency department dealt with 1455 new presentations of which 75% were UK Armed Forces personnel.

CONCLUSIONS

This represented a busy period in the field hospitals time in Iraq and offered valuable training to emergency medicine trainees in an unusual environment.

Key transmission parameters of an institutional outbreak during the 1918 influenza pandemic estimated by mathematical modelling

AIM

To estimate the key transmission parameters associated with an outbreak of pandemic influenza in an institutional setting (New Zealand 1918).

METHODS

Historical morbidity and mortality data were obtained from the report of the medical officer for a large military camp. A susceptible-exposed-infectious-recovered epidemiological model was solved numerically to find a range of best-fit estimates for key epidemic parameters and an incidence curve. Mortality data were subsequently modelled by performing a convolution of incidence distribution with a best-fit incidence-mortality lag distribution.

RESULTS

Basic reproduction number (R0) values for three possible scenarios ranged between 1.3, and 3.1, and corresponding average latent period and infectious period estimates ranged between 0.7 and 1.3 days, and 0.2 and 0.3 days respectively. The mean and median best-estimate incidence-mortality lag periods were 6.9 and 6.6 days respectively. This delay is consistent with secondary bacterial pneumonia being a relatively important cause of death in this predominantly young male population.

CONCLUSION

These R0 estimates are broadly consistent with others made for the 1918 influenza pandemic and are not particularly large relative to some other infectious diseases. This finding suggests that if a novel influenza strain of similar virulence emerged then it could potentially be controlled through the prompt use of major public health measures.

Injuries and Illnesses among Armor Brigade Soldiers during Operational Training

This study describes injury and illness rates and some risk factors among soldiers from an armor division during a rotation at the National Training Center (Fort Irwin, California). Soldiers from a brigade of the 1st Cavalry Division were involved in a 5-week training exercise at the National Training Center. Health care visits were systematically recorded by the unit medics. Of 4,101 men and 413 women who participated in the exercise, 504 soldiers (409 men and 95 women) sought medical care at the main support medical clinic or Weed Army Community Hospital. The rates of injury and illness visits were 1.2% and 0.6% per week for men and 2.3% and 2.2% per week for women, respectively. Women had twice the risk of an injury and 3.5 times the risk of an illness, compared with men. Compared with other branches, combat service support soldiers had higher rates of injuries and illnesses. Enlisted soldiers of lower rank (E1-E4) experienced higher injury and illness rates than did noncommissioned officers and commissioned officers. Musculoskeletal injuries, environmental conditions, and dermatological conditions accounted for most visits.

Evacuation Times of Civilians and Soldiers Wounded during the War in Croatia

OBJECTIVE

The goal of this study was to estimate the mean time needed for evacuation of wounded persons from the site of injury to a medical institution.

METHODS

A database that includes medical and demographic data for persons treated in Croatian hospitals during the 1991-1995 war in Croatia was used.

RESULTS

A total of 61.11% of wounded persons was evacuated within 1 hour. The mean evacuation time was 2.26 hours, and times for civilians and army units did not vary significantly. After wounded patients were admitted to medical institutions, the chances of survival were 98.36%.

CONCLUSION

Because the wartime medical system in Croatia depended on army units for transport and on civilian medical institutions for medical procedures and later care, we conclude that the integrated model of medical care led to short evacuation times, with no significant differences between soldiers and civilians or soldiers on the two sides.

Assessment of breastfeeding practices and reasons for success in a military community hospital

The authors' objectives were (1) to assess factors associated with breastfeeding rates in the early postpartum period and (2) to assess factors contributing to successful breastfeeding among an active-duty and military-dependent population. In September 2002, a baseline breastfeeding survey was administered to women presenting for infant or postpartum care in a military health care facility. A lactation service was then established, and between May and September 2004, a cross-sectional survey was subsequently conducted. Surveys assessed demographics, breastfeeding history and practices, and perceived reasons for success and discontinuation. A total of 934 surveys were collected. Ninety-two percent of women initiated breastfeeding. Eighty-five percent were breastfeeding at 1 week. The rate was 67.0% at 6 weeks and 61.7% at 6 months. Prior breastfeeding experience predicted continued breast-feeding at 6 weeks (OR 2.04); higher education level predicted breastfeeding at 6 months (OR 2.55). Breastfeeding rates increased after the establishment of a lactation service.

Comparing the Population Health Impacts of Medical Conditions Using Routinely Collected Health Care Utilization Data: Nature and Sources of Variability

Prevention activities are designed and resourced based on perceptions of the relative population health impacts of various conditions. We examined the nature and variability of rankings of "conditions" based on how they are defined and how their population health impacts are measured. The first listed diagnosis from all hospitalizations and ambulatory visits of U.S. service members during 2002 was used to rank conditions (as defined by two standard classification systems) using five different measures of population health impacts. Less than 10% of all conditions accounted for more than one-half of total population health impact, regardless of how conditions were defined or impacts measured. However, specific conditions with the largest impacts varied depending on the classification system and impact measure. Four groups of related conditions--acute musculoskeletal injuries, pregnancy-related conditions, respiratory infections, and mental disorders (including substance abuse)--accounted for disproportionately large impacts regardless of the measure. The identification of conditions with the largest population health impacts depends on the nature and degree of aggregation in defining conditions and the measure of impact. The findings are relevant to prevention planning and resourcing.

Admission physiology criteria after injury on the battlefield predict medical resource utilization and patient mortality

BACKGROUND

Medical resources and resource allocation including operating room and blood utilization are of prime importance in the modern combat environment. We hypothesized that easily measurable admission physiologic criteria and injury site as well as injury severity calculated after diagnostic evaluation or surgical intervention, would be strongly correlated with resource utilization and in theater mortality outcomes.

METHODS

We retrospectively reviewed the Joint Theater Trauma Registry for all battlefield casualties presenting to surgical component facilities during Operation Iraqi Freedom from January to July 2004. Data were collected from the composite population of 1,127 battlefield casualty patients with respect to demographics, mechanism, presentation physiology (blood pressure, heart rate, temperature), base deficit, admission hematocrit, Glasgow Coma Score (GCS), Injury Severity Score (ISS), operating room utilization, blood transfusion, and mortality. Univariate and multivariate analyses were conducted to determine the degree to which admission physiology and injury severity correlated with blood utilization, necessity for operation, and acute mortality.

RESULTS

Univariate analysis demonstrated a significant (p < 0.05) association between hypothermia (T < 34 degrees C) and the subsequent requirement for operation and mortality. In addition, the outcome variable total blood product utilization was significantly correlated with base deficit (r = 0.61), admission hematocrit (r = 0.51), temperature (r = 0.47), and ISS (r = 0.54). Using multiple logistic regression techniques, blood pressure, GCS, and ISS together demonstrated a significant association (p < 0.05) with mortality (area under ROC curve = 95%). Multiple linear regression established that blood pressure, heart rate, temperature, hematocrit, and ISS had a collective significant effect (p < 0.05) on total blood product utilization explaining 67% of the variance in this outcome variable.

CONCLUSION

Admission physiology and injury characteristics demonstrate a strong capacity to predict resource utilization in the contemporary battlefield environment. In the future, such predictive yield could potentially have significant implications for triage and medical logistics in the resource constrained environment of war and potentially in mass casualty and disaster incidents in the civilian trauma setting which will likely have mechanistic similarity with war related injury.

First psychiatric hospitalizations in the US military: the National Collaborative Study of Early Psychosis and Suicide (NCSEPS)

BACKGROUND

Military samples provide an excellent context to systematically ascertain hospitalization for severe psychiatric disorders. The National Collaborative Study of Early Psychosis and Suicide (NCSEPS), a collaborative study of psychiatric disorders in the US Armed Forces, estimated rates of first hospitalization in the military for three psychiatric disorders: bipolar disorder (BD), major depressive disorder (MDD) and schizophrenia.

METHOD

First hospitalizations for BD, MDD and schizophrenia were ascertained from military records for active duty personnel between 1992 and 1996. Rates were estimated as dynamic incidence (using all military personnel on active duty at the midpoint of each year as the denominator) and cohort incidence (using all military personnel aged 18-25 entering active duty between 1992 and 1996 to estimate person-years at risk).

RESULTS

For all three disorders, 8723 hospitalizations were observed in 8,120,136 person-years for a rate of 10.7/10,000 [95% confidence interval (CI) 10.5-11.0]. The rate for BD was 2.0 (95% CI 1.9-2.1), for MDD, 7.2 (95% CI 7.0-7.3), and for schizophrenia, 1.6 (95% CI 1.5-1.7). Rates for BD and MDD were greater in females than in males [for BD, rate ratio (RR) 2.0, 95% CI 1.7-2.2; for MDD, RR 2.9, 95% CI 2.7-3.1], but no sex difference was found for schizophrenia. Blacks had lower rates than whites of BD (RR 0.8, 95% CI 0.7-0.9) and MDD (RR 0.8, 95% CI 0.8-0.9), but a higher rate of schizophrenia (RR 1.5, 95% CI 1.3-1.7).

CONCLUSIONS

This study underscores the human and financial burden that psychiatric disorders place on the US Armed Forces.

Children Treated at an Expeditionary Military Hospital in Iraq

OBJECTIVE

To describe the treatment of children at an expeditionary military hospital in wartime Iraq.

DESIGN

Descriptive, retrospective study.

SETTING

The 332nd Air Force Theater Hospital in Balad, Iraq, January 1, 2004, to May 31, 2005.

PATIENTS

All 85 children (of 1626 total patients) evaluated and treated at the hospital during the study period.

INTERVENTIONS

Indicated surgical procedures performed on children.

MAIN OUTCOME MEASURES

Age, sex, diagnosis, injury, operations, and complications for children during the study period.

RESULTS

The 85 children (age range, 1 day to 17 years; mean, 8 years) represented 5.2% of all patients. Thirty-four (61%) of the 56 children for whom sex was recorded were male. Injury was the diagnosis for 48 children (56%). Of these, the cause was fragmentation wound in 25 children (52%), penetrating trauma in 11 (23%), burn in 9 (19%), and blunt trauma in 3 (6%). The site of injury was the lower extremity in 18 children (38%), head in 11 (23%), upper extremity in 8 (17%), abdomen in 8 (17%), and chest in 3 (6%). Nontraumatic conditions had congenital, infectious, gastrointestinal, and neoplastic causes. During the study, 134 operations were performed on 63 children. There were 5 deaths.

CONCLUSIONS

Expeditionary military hospitals will encounter both injured and noninjured children seeking medical care. To optimize the care of these children, it will be necessary to provide the proper personnel, training, and equipment.

Patients Presenting with Birth Plans in a Military Tertiary Care Hospital: A Descriptive Study of Plans and Outcomes

OBJECTIVES

This study evaluates what type of patient prepares a birth plan, identifies common requests made, and determines how closely these are followed during labor.

METHODS

Patients who were admitted in labor with birth plans during a 3.5-year period were identified. Birth plans were analyzed, and common requests were recorded. Delivery records were reviewed, and outcomes were recorded. This study was approved by the hospital institutional review board.

RESULTS

Sixty-seven birth plans with delivery outcomes were available for review. The mean maternal age was 31 years, the median parity was 0, and 70% of patients had a college degree. The most common requests were to walk during labor (84%), to avoid episiotomy (82%), and to have no epidural (62%). Seventy-five percent of patients had spontaneous vaginal deliveries, and 19% had cesarean sections; the epidural use rate was 59%.

CONCLUSIONS

Patients with birth plans were generally older and well-educated and, despite plans to avoid an epidural, most patients changed their minds.

The prevalence of admission for sarcoma in the military health system during 2002-2003

The etiology of sarcomas is not clear. Environmental exposures have been implicated as potential agents in the development of some sarcomas, but more research is needed. The military health system (MHS) may be able to provide population-based information regarding sarcomas. Discharge diagnoses for bone sarcoma and soft tissue sarcoma were searched within a large administrative database maintained by the U.S. military. There were > 200 cases of bone sarcoma and > 300 cases of soft tissue sarcoma during the 2-year study period of 2002-2003. The crude prevalence of admission for bone sarcoma within the MHS was 1.2 cases per 100,000 per year. The crude prevalence of admission for soft tissue sarcoma was 1.7 cases per 100,000 per year. These statistics suggest that the MHS may be used to test hypotheses regarding sarcoma epidemiological features, especially for studies that concern military-related exposures. However, nearly 70% of the military beneficiaries who were sarcoma patients were admitted to civilian hospitals, as opposed to military treatment facilities. Therefore, population-based studies of sarcoma patients in the MHS should seek means to capture data for patients who are treated outside military facilities. The database used for this study may provide important information regarding these patients. In addition, military health care planners may use the information from this study to develop referral strategies within the MHS.

Comparison between civilian burns and combat burns from Operation Iraqi Freedom and Operation Enduring Freedom

OBJECTIVE

To assess outcome differences between locally burned civilians and military personnel burned in a distant combat zone treated in the same facility.

SUMMARY BACKGROUND DATA

The United States Army Institute of Surgical Research (USAISR) Burn Center serves as a referral center for civilians and is the sole center for significant burns in military personnel. We made the hypothesis that outcomes for military personnel burned in the current conflict in Iraq and Afghanistan would be poorer because of delays to definitive treatment, other associated injury, and distance of evacuation.

METHODS

We reviewed the civilian and military records of patients treated at the USAISR from the outset of hostilities in Iraq in April 2003 to May 2005. Demographics, injury data, mortality, and clinical outcomes were compared.

RESULTS

: We cared for 751 patients during this time period, 273 of whom were military (36%). Military injuries occurred in a younger population (41 +/- 19 vs. 26 +/- 7 years for civilian and military respectively, P < 0.0001) with a longer time from injury to burn center arrival (1 +/- 5 days vs. 6 +/- 5, P < 0.0001), a higher Injury Severity Score (ISS 5 +/- 8 vs. 9 +/- 11, P < 0.0001), and a higher incidence of inhalation injury (8% vs. 13%, P = 0.024). Total burn size did not differ. Mortality was 7.1% in the civilian and 3.8% in the military group (P = 0.076). When civilians outside the age range of the military cohort were excluded, civilian mortality was 5.0%, which did not differ from the military group (P = 0.57). Total body surface area (TBSA) burned, age > or =40 years, presence of inhalation injury, and ventilator days were found to be important predictors of mortality by stepwise regression, and were used in a final predictive model with the area under receiver operator characteristic curve of 0.97 for both populations considered together. No significant effect of either group was identified during development.

CONCLUSIONS

Mortality does not differ between civilians evacuated locally and military personnel injured in distant austere environments treated at the same center.

Operation Enduring Freedom: the 48th Combat Support Hospital in Afghanistan

OBJECTIVE

To examine the experience of the 48th Combat Support Hospital (CSH) while deployed to Afghanistan, with an emphasis on trauma care.

MATERIALS AND METHODS

Before redeployment, a retrospective review was performed on the medical records of all patients treated at the 48th CSH from December 6, 2002 through June 7, 2003.

RESULTS

During the 6-month period, 10,679 patients were evaluated and/or treated. There were 477 hospital admissions (adults, 387; children, 90; trauma, 204) and 634 operating room procedures. The most common mechanisms of injury were land mines/unexploded ordinance (74 = 36%) and gunshot wounds (41 = 20%). Extremities were the most common site. A total of 358 cases was performed on 168 trauma patients (mean, 2 cases per patient; range, 1-12). There were 63 complications in 40 trauma patients and 11 patients died.

CONCLUSIONS

The 48th CSH supported military and humanitarian operations with an ongoing process of re-evaluation, adaptation, and medical education that resulted in low morbidity and mortality rates.

Wounding patterns for U.S. Marines and sailors during Operation Iraqi Freedom, major combat phase

This investigation examined the wounds incurred by 279 U.S. Navy-Marine personnel (97% Marines and 3% sailors) identified as wounded in action during Operation Iraqi Freedom, from March 23 through April 30, 2003. The goal was to assess the potential impact of each causative agent by comparing the differences in anatomical locations, types of injuries caused, and medical specialists needed to treat the casualties. The overall average number of diagnoses per patient was 2.2, and the overall average number of anatomical locations was 1.6. The causative agents were classified into six major categories, i.e., small arms, explosive munitions, motor vehicle accidents, falls, weaponry accidents, and other/unknown. Explosive munitions and small arms accounted for approximately three of four combat-related injuries. Upper and lower extremities accounted for approximately 70% of all injuries, a percentage consistent for battlefield injuries since World War II.

Echelons of Care and the Management of Wartime Vascular Injury: A Report From the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq

The objective of this report is to provide a contemporary in-theater account on the systematic management of wartime vascular injury. Included are strategies at each echelon of care that affect the treatment of these injuries. In addition, the aim of this report is to present a modern wartime vascular registry describing rates and distribution of injury in what is now a mature military conflict. A 15-month review (September 1, 2004 through December 1, 2005) from the central level III echelon facility in Iraq (332nd EMDG/Air Force Theater Hospital) presented by the in-theater Consultants for Vascular Surgery. During this period 13 460 casualties were treated at or evacuated through our location, 3096 (23%) with battle-related injuries. Vascular injuries comprised 6.6% (N = 209) of battle-related trauma in the following distribution: extremity 79% (n = 166), neck 13% (n = 27), thoracoabdominal 8% (n = 16). Three levels (formerly echelons) of care are active in theater each with strategies that affect vascular injury management: Level 1: use of commercial tourniquets; level 2: use of temporary vascular shunts as damage control adjuncts; and level 3: definitive repair of arterial and venous injuries in theater using autologous vein. Evacuation patterns and the position of the Air Force Theater Hospital have allowed the formation of a contemporary wartime vascular registry. The rate of vascular injury appears increased compared to that of Vietnam with extremity injuries most prevalent. Effective strategies are in place at each of 3 levels of care that affect the management of vascular injury.

[Main military-and-clinical hospital in the system of medical support of the Russian Federation's Armed Forces]

Burdenko N.N. MMCH is the main hospital, a scientific-and-methodological center of medical service concerning prophylaxis-and-treatment spheres, the main clinical base of the State istitute of increasing doctors' qualification of RF MD and a military-and-medical faculty of the Moscow medical academy by Sechenov I.M. The hospital has the greatest experience of treatment of the wounded, sick and injured in all wars and armed conflicts with the participation of the Russian army. In the hospital's staff there is a unique flying surgical-and-reanimation laboratory "Skalpel" for urgent evacuation of the wounded from armed conflicts' centers. Almost all types of high technology medical care are provided in the hospital. About 6500 of the wounded and the sick obtain such treatment every year; 70-80% of the sick having treatment in the hospital are from the group of the most severe and complex patients. The hospital has the highest scientific and methodological level among hospitals of the Russian Federation's Armed Forces: 48 doctors and 141 candidates of medical science, those include 21 professors and 12 docents. It is the main base for new medical equipment and drugs testing to the interest of all medical service of the RF AF.

Modelling the utility of body temperature readings from primary care consults for SARS surveillance in an army medical centre

INTRODUCTION

There is interest in surveillance systems for outbreak detection at stages where clinical presentation would still be undifferentiated. Such systems focus on detecting clusters of syndromes in excess of baseline levels, which may indicate an outbreak. We model the detection limits of a potential system based on primary care consults for the detection of an outbreak of severe acute respiratory syndrome (SARS).

MATERIALS AND METHODS

Data from an averaged-sized medical centre were extracted from the Patient Care Enhancement System (PACES) [the electronic medical records system serving the Singapore Armed Forces (SAF)]. Thresholds were set to 3 or more cases presenting with particular syndromes and a temperature reading of >or=38oC (T >or=38). Monte Carlo simulation was used to insert simulated SARS outbreaks of various sizes onto the background incidence of febrile cases, accounting for distribution of SARS incubation period, delay from onset to first consult, and likelihood of presenting with T >or=38 to the SAF medical centre.

RESULTS

Valid temperature data was available for 2,012 out of 2,305 eligible syndromic consults (87.2%). T >or=38 was observed in 166 consults (8.3%). Simulated outbreaks would peak 7 days after exposure, but, on average, signals at their peak would consist of 10.9% of entire outbreak size. Under baseline assumptions, the system has a higher than 90% chance of detecting an outbreak only with 20 or more cases.

CONCLUSIONS

Surveillance based on clusters of cases with T >or=38 helps reduce background noise in primary care data, but the major limitation of such systems is that they are still only able to confidently detect large outbreaks.