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Rios KE, Alamneh Y, Werner LM, Leung C, Pavlovic R, Abu-Taleb R, Thanapaul RJRS, Lee S, Hull D, Czintos C, Su W, Getnet D, Antonic V, Bobrov AG. Optimization of a Lethal, Combat-Relevant Model of Sterile Inflammation in Mice for Drug Candidate Screening. Mil Med 2024; 189:694-701. [PMID: 39160880 DOI: 10.1093/milmed/usae233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/09/2024] [Accepted: 04/19/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Extensive trauma, commonly seen in wounded military Service Members, often leads to a severe sterile inflammation termed systemic inflammatory response syndrome (SIRS), which can progress to multiple organ dysfunction syndrome (MODS) and death. MODS is a serious threat to wounded Service Members, historically causing 10% of all deaths in trauma admissions at a forward deployed combat hospital. The importance of this problem will be exacerbated in large-scale combat operations, in which evacuation will be delayed and care of complex injuries at lower echelons of care may be prolonged. The main goal of this study was to optimize an existing mouse model of lethal SIRS/MODS as a therapeutic screening platform for the evaluation of immunomodulatory drugs. MATERIALS AND METHODS Male C57BL/6 mice were euthanized, and the bones and muscles were collected and blended into a paste termed tissue-bone matrix (TBX). The TBX at 12.5%-20% relative to body weight of each recipient mouse was implanted into subcutaneous pouches created on the dorsum of anesthetized animals. Mice were observed for clinical scores for up to 48 hours postimplantation and euthanized at the preset point of moribundity. To test effects of anesthetics on TBX-induced mortality, animals received isoflurane or ketamine/xylazine (K/X). In a separate set of studies, mice received TBX followed by intraperitoneal injection with 20 mg/kg or 40 mg/kg Eritoran or a placebo carrier. All Eritoran studies were performed in a blinded fashion. RESULTS We observed that K/X anesthesia significantly increased the lethality of the implanted TBX in comparison to inhaled anesthetics. Although all the mice anesthetized with isoflurane and implanted with 12.5% TBX survived for 24 hours, 60% of mice anesthetized with K/X were moribund by 24 hours postimplantation. To mimic more closely the timing of lethal SIRS/MODS following polytrauma in human patients, we extended observation to 48 hours. We performed TBX dose-response studies and found that as low as 15%, 17.5%, and 20% TBX caused moribundity/mortality in 50%, 80%, and 100% mice, respectively, over a 48-hour time period. With 17.5% TBX, we tested if moribundity/mortality could be rescued by anti-inflammatory drug Eritoran, a toll-like receptor 4 antagonist. Neither 20 mg/kg nor 40 mg/kg doses of Eritoran were found to be effective in this model. CONCLUSIONS We optimized a TBX mouse model of SIRS/MODS for the purpose of evaluating novel therapeutic interventions to prevent trauma-related pathophysiologies in wounded Service Members. Negative effects of K/X on lethality of TBX should be further evaluated, particularly in the light of widespread use of ketamine in treatment of pain. By mimicking muscle crush, bone fracture, and necrosis, the TBX model has pleiotropic effects on physiology and immunology that make it uniquely valuable as a screening tool for the evaluation of novel therapeutics against trauma-induced SIRS/MODS.
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Affiliation(s)
- Kariana E Rios
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830, USA
| | - Yonas Alamneh
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Lacie M Werner
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Clara Leung
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Radmila Pavlovic
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Rania Abu-Taleb
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Rex J R S Thanapaul
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
- NRC Research Associateship Programs, National Academies of Sciences, Engineering, and Medicine, Washington, DC 20001, USA
| | - Sunjoo Lee
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Dawn Hull
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Christine Czintos
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830, USA
| | - Wanwen Su
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Derese Getnet
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Vlado Antonic
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Alexander G Bobrov
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
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Schwab N, Jordana X, Monreal J, Garrido X, Soler J, Vega M, Brillas P, Galtés I. Ballistic long bone fracture pattern: an experimental study. Int J Legal Med 2024; 138:1685-1700. [PMID: 38376570 DOI: 10.1007/s00414-024-03191-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/09/2024] [Indexed: 02/21/2024]
Abstract
When dealing with badly preserved cadavers or skeletal human remains, the assessment of death circumstances remains challenging. When forensic evidence cannot be taken from the skin and soft tissue, the information may only be deduced from more resistant elements such as bone. Compared to cranial gunshot injuries, reliable data on ballistic long bone trauma remains scarce. This study aims to define ballistic fracture characteristics in human long bones. The shaft of 16 femurs and 13 humeri from body donors was perpendicularly shot with a 9-mm Luger full metal jacket bullet at an impact velocity of 360 m/s from a distance of 2 m. Some bones were embedded in Clear Ballistics Gel®, and some were shot without soft tissue simulant in order to better visualise the fracture propagation on the high-speed camera. The fractures were examined macroscopically and compared between the sample groups. We consistently found comminuted fractures with a stellate pattern. Fracture details were classified into entrance, exit and general characteristics. For some traits, we detected different occurrence values in the group comparison. The results indicate that some of the traits depend on bone properties such as shaft diameter, bone length and cortical thickness. The presence of ballistic gel also influenced some fracture traits, emphasising the relevance of soft tissue simulant in osseous gunshot experiments. This study revealed new insights in the detailed fracture pattern of human long bones. These may serve as guidelines for the identification and reconstruction of gunshot trauma in human long bones.
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Affiliation(s)
- Nathalie Schwab
- Biological Anthropology Unit, Department of Animal Biology, Plant Biology and Ecology, Faculty of Biosciences, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, 08193, Barcelona, Catalonia, Spain
- Forensic Anthropology Unit, Forensic Pathology Service, Catalonian Institute of Legal Medicine and Forensic Science (IMLCFC), Ciutat de La Justícia, Gran Via de Les Corts Catalanes, 111 Edifci G, 08075, Barcelona, Spain
| | - Xavier Jordana
- Biological Anthropology Unit, Department of Animal Biology, Plant Biology and Ecology, Faculty of Biosciences, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, 08193, Barcelona, Catalonia, Spain.
- Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IrisCC), Ctra. de Roda, 08500, Vic, Barcelona, Spain.
| | - Jordi Monreal
- Mossos d'Esquadra, Unitat Central de Balística I Traces Instrumentals, Av. de La Pau, 12, 08206, Sabadell, Barcelona, Spain
| | - Xavier Garrido
- Mossos d'Esquadra, Unitat Central de Balística I Traces Instrumentals, Av. de La Pau, 12, 08206, Sabadell, Barcelona, Spain
| | - Joan Soler
- Mossos d'Esquadra, Unitat Central de Balística I Traces Instrumentals, Av. de La Pau, 12, 08206, Sabadell, Barcelona, Spain
| | - Manel Vega
- Mossos d'Esquadra, Unitat Central de Balística I Traces Instrumentals, Av. de La Pau, 12, 08206, Sabadell, Barcelona, Spain
| | - Pedro Brillas
- Donor Center Barcelona Tissue Bank (BTB), Hospital Clínic de Barcelona, C/Villarroel 170, Escala 12 Planta 4, 08036, Barcelona, Spain
| | - Ignasi Galtés
- Forensic Anthropology Unit, Forensic Pathology Service, Catalonian Institute of Legal Medicine and Forensic Science (IMLCFC), Ciutat de La Justícia, Gran Via de Les Corts Catalanes, 111 Edifci G, 08075, Barcelona, Spain.
- Research Group of Biological Anthropology (GREAB), Biological Anthropology Unit, BABVE Department, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, 08193, Bellaterra, , Catalonia, Spain.
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Farhat T, Nahouli H, Hajjar M, Abdul-Sater Z, Kobeissi E, Menassa M, Chaya BF, Elamine A, El Sheikh WG, Tamim H, Hettiaratchy S, Abu-Sittah G. Characteristics of injuries during the 2006 Lebanon conflict: a three-center retrospective study of survivors, 16 years after the conflict. Front Public Health 2024; 12:1382514. [PMID: 38864014 PMCID: PMC11165059 DOI: 10.3389/fpubh.2024.1382514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/03/2024] [Indexed: 06/13/2024] Open
Abstract
Background Armed conflict injury is a growing public health concern, particularly in regions like the Middle East and North Africa (MENA). The protracted conflicts and political unrest in this region have led to a substantial number of injuries. Despite this, there is still limited understanding of the specific injury patterns stemming from conflicts, such as the 2006 Lebanon conflict. This study aimed to assess the characteristics and burdens of injuries resulting from this conflict, which occurred 16 years prior to this research. Methods This retrospective study analyzed data of individuals affected by the 2006 Lebanon conflict, across three tertiary care centers. Demographics, injuries, complications, injury management, and hospitalization expenses were extracted from medical records and analyzed using SPSS version 29.0. Categorical variables were presented as counts and proportions, and continuous variables as mean ± standard deviation (SD). Hospital comparisons utilized chi-square or Fisher's exact tests for categorical variables, and one-way ANOVAs for continuous variables. Analysis was conducted from September to November 2023. Results Across three hospitals, 341 patients were studied, comprising 73.6% males and 26.4% females. Among them, a notable proportion (57.3% males and 34.1% females) fell within the 18-39 age range. Children and adolescents under 18 years accounted for 15.9% of males and 25.9% of females. Blast-related injuries predominated, with 24.5% resulting from direct damage caused by explosive parts and 33.3% from blast wave forces. Extremity trauma occurred in 49.0% of patients, and head/neck trauma in 24.9%. Common injuries, including penetrating, musculoskeletal, and traumatic brain injuries affected 34.9%, 31.1, and 10.0% of patients, respectively. Wound repair, fracture treatment, and debridement were the most performed procedures on 15.5, 13.5 and 9.7% of the patients, respectively. The total cost of care was USD 692,711, largely covered by the Ministry of Public Health (95.9%). Conclusion Conflict-related injuries significantly contribute to the global burden of disease. Therefore, there is a pressing need to improve national guidelines to prioritize life-threatening cases and potential long-term disabilities. Furthermore, enhancing electronic registry systems to collect clinical data on injured patients is essential for conducting research and better understanding the needs of conflict casualties.
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Affiliation(s)
- Theresa Farhat
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Hasan Nahouli
- Division of Orthopedic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marwan Hajjar
- Division of Plastic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Zahi Abdul-Sater
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Elsa Kobeissi
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Marilyne Menassa
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Bachar F. Chaya
- Division of Plastic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ahmad Elamine
- Division of Plastic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Walaa G. El Sheikh
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Shehan Hettiaratchy
- Centre for Blast Injury Studies, Imperial College London, London, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
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Goldman SM, Eskridge SL, Franco SR, Dearth CL. Demographics and Comorbidities of United States Service Members with Combat-Related Lower Extremity Limb Salvage. J Clin Med 2023; 12:6879. [PMID: 37959344 PMCID: PMC10648071 DOI: 10.3390/jcm12216879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION This retrospective study describes the demographics and injury characteristics of a recently identified cohort of US Service members with combat-related lower extremity limb salvage (LS). METHODS US Service members with combat trauma were identified from the Expeditionary Medical Encounter Database and Military Health System Data Repository and stratified into primary amputation (PA), LS, and non-threatened limb trauma (NTLT) cohorts based on ICD-9 codes. Disparities in demographic factors and injury characteristics were investigated across cohorts and within the LS cohort based on limb retention outcome. RESULTS Cohort demographics varied by age but not by sex, branch, or rank. The mechanism of injury and injury characteristics were found to be different between the cohorts, with the LS cohort exhibiting more blast injuries and greater injury burden than their peers with NTLT. A sub-analysis of the LS population revealed more blast injuries and fewer gunshot wounds in those that underwent secondary amputation. Neither demographic factors nor total injury burden varied with limb retention outcome, despite slight disparities in AIS distribution within the LS cohort. CONCLUSIONS In accordance with historic dogma, the LS population presents high injury severity. Demographics and injury characteristics are largely invariant with respect to limb retention outcomes, despite secondary amputation being moderately more prevalent in LS patients with blast-induced injuries. Further study of this population is necessary to better understand the factors that impact the outcomes of LS in the Military Health System.
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Affiliation(s)
- Stephen M. Goldman
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | | | - Sarah R. Franco
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Christopher L. Dearth
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
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Holm E, Cook J, Porter K, Nelson A, Weishar R, Mallory T, Cantor A, Croft C, Liwag J, Harrington CJ, DesRosiers TT. A Quantitative and Qualitative Literature Analysis of the Orthopedic Surgeons' Experience: Reflecting on 20 Years in the Global War on Terror. Mil Med 2023; 188:2924-2931. [PMID: 35862000 DOI: 10.1093/milmed/usac219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/18/2022] [Accepted: 07/01/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION After over 20 years of war in the Middle East, orthopedic injuries have been among the most prevalent combat-related injuries, accounting for 14% of all surgical procedures at Role 2/3 (R2/R3) facilities according to the DoD Trauma Registry. To further delineate the role of the deployed orthopedic surgeon on the modern battlefield, a retrospective review was performed highlighting both quantitative and qualitative analysis factors associated with orthopedic surgical care during the war in the Middle East. METHODS A retrospective review was conducted of orthopedic surgeons in the Middle East from 2001 to 2021. A comprehensive literature search was conducted using the PubMed and Embase databases using a two-reviewer strategy. Articles were compiled and reviewed using Covidence. Inclusion criteria included journal articles focusing on orthopedic injuries sustained during the Global War on Terror (GWoT) in an adult U.S. Military population. In the event of a conflict, a third author would determine the relevance of the article. For the remaining articles, a full-text review was conducted to extract relevant predetermined quantitative data, and the Delphi consensus method was then utilized to highlight relevant qualitative themes. RESULTS The initial search yielded 1,226 potentially relevant articles. In all, 40 studies ultimately met the eligibility criteria. With the consultation of previously deployed orthopedic surgeons at the Walter Reed National Military Medical Center, a retrospective thematic analysis of the 40 studies revealed five themes encompassing the orthopedic surgeons experience throughout GWoT. These themes include unique mechanisms of orthopedic injury compared to previous war injuries due to novel weaponry, differences in interventions depending on R2 versus R3 locations, differences in injuries from those seen in civilian settings, the maintained emphasis on humanitarian aspect of an orthopedic surgeon's mission, and lastly relation of pre-deployment training to perceived deployed success of the orthopedic surgeons. From this extensive review, we found that explosive mechanisms of injury were greatly increased when compared to previous conflicts and were the etiology for the majority of orthopedic injuries sustained. With the increase of complex explosive injuries in the setting of improved body armor and overall survival, R2/3 facilities showed an increased demand for orthopedic intervention including debridement, amputations, and external fixation. Combat injuries sustained during the GWoT differ in the complications, management, and complexity when compared to civilian trauma. "Humanitarian" cases made up a significant number of operative cases for the deployed orthopedic surgeon. Lastly, heterogeneous training opportunities were available prior to deployment (fellowship, combat extremity surgical courses, and dedicated pre-deployment training), and the most commonly identified useful training was learning additional soft-tissue coverage techniques. CONCLUSION These major themes indicate an emphasis on pre-deployment training and the strategic positioning of orthopedic surgeons to reflect the changing landscape of musculoskeletal trauma care. Moving forward, these authors recommend analyzing the comfort and perceived capability of orthopedic surgeons in these unique military environments to best prepare for a changing operational format and the possibility of future peer-peer conflicts that will likely lead to a lack of medical evacuation and prolonged field care.
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Affiliation(s)
- Erik Holm
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - John Cook
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Kaitlin Porter
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew Nelson
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Robert Weishar
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Taylor Mallory
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Addison Cantor
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Caitlynn Croft
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jonah Liwag
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Colin J Harrington
- Department of Orthopedics, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Taylor T DesRosiers
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Combat Trauma Research Group U.S. Navy, USA
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Shakargy JD, Gendler S, Talmy T, Shushan G, Radomislensky I, Tsur AM, Almog O, Avital G, Benov A, Gelikas S. Blast Injury Patterns Among Israel Defense Forces Fatalities. Mil Med 2023; 188:e1788-e1794. [PMID: 36205252 DOI: 10.1093/milmed/usac280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/03/2022] [Accepted: 09/09/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The incidence of blast injuries on the battlefield has risen over the last several decades. In order to improve prevention and treatment, it is essential to understand the severity and bodily distribution of these injuries. This study aims to characterize blast injury patterns among IDF fatalities. MATERIALS AND METHODS This is a descriptive, retrospective study on postmortem reports of military-blast fatalities between the years 1982 and 2021. Body regions injured according to the Abbreviated Injury Scale (AIS) were described. The frequency of body region injury combinations was mapped, and the correlation between injured body regions was calculated using Pearson's coefficient. Analysis of a subgroup with a postmortem computed tomography (CT-PM) or autopsy was performed, describing severe (AIS ≥ 3) injury patterns. RESULTS Overall, 222 fatalities suffered from blast injury, with most injuries affecting the upper and lower extremities (63.7% and 66.5%, respectively), followed by the head (57.1%) and the thorax (56.6%). The median number of injured body regions was 4 (interquartile range, 2-5). The most frequent injury combinations were the upper and lower extremities (51%), the upper extremities and the thorax (45%), and the lower extremities and the thorax (41%). In all, 47/222 (21.2%) fatalities had a documented autopsy or CT-PM report. Among the fatalities with CT-PM or autopsy, the head (63.8%) and the thorax (57.4%) were most frequently severely injured (AIS ≥ 3). CONCLUSIONS Among blast fatalities in the military setting, the extremities were most commonly injured. However, data suggest that the head and thorax are more likely to sustain severe blast injuries resulting in mortality. Blast injuries in this cohort were characterized by concomitant involvement of several regions. Development of protective gear to minimize the multisystem injuries inflicted by blast injuries is warranted and should be focused on distinct types and anatomical distribution of severe blast injuries as reported in this study. LEVEL OF EVIDENCE Level III, Retrospective analysis.
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Affiliation(s)
- Josef Daniel Shakargy
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Sami Gendler
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Tomer Talmy
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem 91120, Israel
| | - Guy Shushan
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Ground forces Technology Unit, Tel-Hashomer, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Irina Radomislensky
- The Israel National Center for Trauma & Emergency Medicine Research, Gertner Institute of Epidemiology and Health Policy Research, Tel Aviv 5262000, Israel
| | - Avishai M Tsur
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Sheba Medical Center Hospital-Tel-Hashomer, Ramat Gan 5262000, Israel
| | - Ofer Almog
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem 91120, Israel
| | - Guy Avital
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Division of Anesthesia, Intensive Care & Pain Management, Tel-Aviv Sourasky Medical Center, Tel-Aviv 6423906, Israel
| | - Avi Benov
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
| | - Shaul Gelikas
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Sheba Medical Center Hospital-Tel-Hashomer, Ramat Gan 5262000, Israel
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Soft-armor Vest Effectiveness and Intrathoracic Biomechanics in Rodents Exposed to Primary Blast. Ann Biomed Eng 2023:10.1007/s10439-023-03174-5. [PMID: 36913085 DOI: 10.1007/s10439-023-03174-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/21/2023] [Indexed: 03/14/2023]
Abstract
The biomechanics and efficacy of personal protective equipment in mitigating injuries from blast overpressure remain unclear. The objectives of this study were to define intrathoracic pressures in response to blast wave (BW) exposure and biomechanically evaluate a soft-armor vest (SA) at diminishing these perturbations. Male Sprague-Dawley rats were instrumented with pressure sensors in the thorax and were exposed laterally to multiple exposures ranging from 33 to 108 kPa BW with SA and without SA. There were significant increases in rise time, peak negative pressure, and negative impulse in the thoracic cavity compared to the BW. Esophageal measurements were increased to a greater extent when compared to the carotid and the BW for all parameters (except positive impulse, which decreased). SA minimally altered the pressure parameters and energy content. This study establishes the relationship of external blast flow conditions and intra-body biomechanical responses in the thoracic cavity of rodents with and without SA.
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Gizatullin SK, Aliev ZS, Stanishevsky AV, Kristosturov AS, Davydov DV, Onnitsev IE. Treatment of gunshot wounds of the spine using full-endoscopic surgery: analysis of a small clinical series. HIRURGIÂ POZVONOČNIKA (SPINE SURGERY) 2022. [DOI: 10.14531/ss2022.4.77-85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective. To assess the effectiveness of the treatment of gunshot wounds of the spine using percutaneous full-endoscopic technique.Material and Methods. Three patients with gunshot shrapnel wounds of the spine were treated using percutaneous full endoscopy.Results. The patients underwent a removal of foreign bodies (metal fragments) at the cervical, thoracic and lumbosacral levels of the spine using percutaneous full endoscopic surgery. The operations were carried out without complications, with minimal additional trauma to soft tissues and the spinal motion segment. In all three cases, there was a positive dynamics in the form of regression of the pain syndrome. There were no infectious complications.Conclusion. The successful use of percutaneous full endoscopy in the surgical treatment of blind shrapnel wounds of the spine is shown. The results indicate the expediency of further research and development of this area to address the issue of introducing the technique into the routine practice of treating gunshot wounds both in peacetime in neurosurgical hospitals and centers of spinal neurosurgery, and in wartime at the stages of specialized care.
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Affiliation(s)
- Sh. Kh. Gizatullin
- Main Military Clinical Hospital n.a. N.N. Burdenko
3 Gospitalnaya sq., Moscow, 105094, Russia
| | - Z. Sh. Aliev
- Main Military Clinical Hospital n.a. N.N. Burdenko;
Military Hospital No. 426
3 Gospitalnaya sq., Moscow, 105094, Russia;
2 Nevskaya str., Samara, 443110, Russia
| | - A. V. Stanishevsky
- Main Military Clinical Hospital n.a. N.N. Burdenko
3 Gospitalnaya sq., Moscow, 105094, Russia
| | - A. S. Kristosturov
- Main Military Clinical Hospital n.a. N.N. Burdenko
3 Gospitalnaya sq., Moscow, 105094, Russia
| | - D. V. Davydov
- Main Military Clinical Hospital n.a. N.N. Burdenko
3 Gospitalnaya sq., Moscow, 105094, Russia
| | - I. E. Onnitsev
- Main Military Clinical Hospital n.a. N.N. Burdenko
3 Gospitalnaya sq., Moscow, 105094, Russia
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Chirvi S, Pahapill N, Yoganandan N, Curry W, Stemper B, Kleinberger M, Pintar FA. Calcaneus fracture pattern and severity: Role of local trabecular bone density. J Mech Behav Biomed Mater 2022; 134:105332. [DOI: 10.1016/j.jmbbm.2022.105332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 05/25/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
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10
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Bobrov AG, Getnet D, Swierczewski B, Jacobs A, Medina-Rojas M, Tyner S, Watters C, Antonic V. Evaluation of Pseudomonas aeruginosa pathogenesis and therapeutics in military-relevant animal infection models. APMIS 2021; 130:436-457. [PMID: 34132418 DOI: 10.1111/apm.13119] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/21/2021] [Indexed: 01/02/2023]
Abstract
Modern combat-related injuries are often associated with acute polytrauma. As a consequence of severe combat-related injuries, a dysregulated immune response results in serious infectious complications. The gram-negative bacterium Pseudomonas aeruginosa is an opportunistic pathogen that often causes life-threatening bloodstream, lung, bone, urinary tract, and wound infections following combat-related injuries. The rise in the number of multidrug-resistant P. aeruginosa strains has elevated its importance to civilian clinicians and military medicine. Development of novel therapeutics and treatment options for P. aeruginosa infections is urgently needed. During the process of drug discovery and therapeutic testing, in vivo testing in animal models is a critical step in the bench-to-bedside approach, and required for Food and Drug Administration approval. Here, we review current and past literature with a focus on combat injury-relevant animal models often used to understand infection development, the interplay between P. aeruginosa and the host, and evaluation of novel treatments. Specifically, this review focuses on the following animal infection models: wound, burn, bone, lung, urinary tract, foreign body, and sepsis.
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Affiliation(s)
- Alexander G Bobrov
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Derese Getnet
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Brett Swierczewski
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Anna Jacobs
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Maria Medina-Rojas
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Stuart Tyner
- US Army Medical Research and Development Command Military Infectious Diseases Research Program, Frederick, Maryland, USA
| | - Chase Watters
- Naval Medical Research Unit-3, Ghana Detachment, Accra, Ghana
| | - Vlado Antonic
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
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Tsur N, Benov A, Nadler R, Tsur AM, Glick Y, Radomislensky I, Abuhasira S, Mizrachi A, Chen J. Neck injuries - israel defense forces 20 years' experience. Injury 2021; 52:274-280. [PMID: 32972724 DOI: 10.1016/j.injury.2020.09.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 09/01/2020] [Accepted: 09/18/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Neck injuries are an important cause of combat mortality and morbidity. This study's objective was to examine the characteristics and causes of neck injuries among Israel Defense Forces (IDF) and emphasize the best treatment protocols for the advanced life support providers in the prehospital combat environment. METHODS The IDF Trauma Registry (IDF-TR) includes prehospital data regarding casualties treated by the IDF's medical forces. This study was a retrospective, observational study that included all casualties who were injured between January 2006 and December 2018. RESULTS Between January 2016 and December 2018, 3294 casualties were recorded. During the study period, 1% (41/3,394) of all injury casualties in the registry were isolated neck injuries compared to 94% (3185/3,394) without neck injury. 42% (14/41) percent of the neck casualties were classified as urgent compared to 26% (830/3185, P = 0.09) in the no neck group. The most frequent type of injury mechanism in the neck casualties was penetrating injury (54% 22/41), mostly due to shrapnel (68% 15/22). 60% of neck injured personnel were injured during the 2nd Lebanon War and Operation Protective Edge in high-intensity conflicts. As for life-saving interventions, advanced airway interventions were performed in 12% of neck injured group (5/41) compared to 3% (104/3185, P = 0.02) in the no neck group. We revealed that cricothyroidotomy was performed in almost 10% (4/41) of neck injured casualties compared to only 1% (19/3185, P<0.0001) in no neck casualties. As for damage control resuscitation, neck injury casualties received higher amounts of Fresh Dried Plasma 7% (3/41) Vs. 1% (32/3185, P = 0.02) and Tranexamic acid 15% (6/41) Vs. 4% (124/3185, P = 0.01) compared to non-neck casualties. CONCLUSIONS Military neck injuries are a significant cause of substantial disability and result in incompatibility with combat duties in previously healthy soldiers. Prompt medical care, especially urgent hemodynamic and airway management, is paramount in these injuries. Routine use of designated neck protection might lower the number of neck injuries, mitigate their severity, and even decrease mortality. LEVEL OF EVIDENCE Level III (Retrospective study with up to two negative criteria).
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Affiliation(s)
- Nir Tsur
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel; Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.
| | - Avi Benov
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel; Bar-Ilan University, Ramat Gan, Israel
| | - Roy Nadler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel; Department of General Surgery and Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avishai M Tsur
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Yuval Glick
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | | | | | - Aviram Mizrachi
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Chen
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
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Somasundaram K, Sherman D, Begeman P, Ciarelli T, McCarty SA, Kochkodan JJ, Demetropoulos CK, Cavanaugh JM. Mechanisms and timing of injury to the thoracic, lumbar and sacral spine in simulated underbody blast PMHS impact tests. J Mech Behav Biomed Mater 2020; 116:104271. [PMID: 33517100 DOI: 10.1016/j.jmbbm.2020.104271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 11/11/2020] [Accepted: 12/12/2020] [Indexed: 11/29/2022]
Abstract
During an underbody blast (UBB) event, mounted occupants are exposed to high rate loading of the spine via the pelvis. The objective of this study was to simulate UBB loading conditions and examine mechanisms of injury in the thoracic, lumbar and sacral spine. Fourteen instrumented, whole-body, postmortem human subject (PMHS) experiments were performed using the WSU-decelerative horizontal sled system. The specimens were positioned supine on a decelerative sled, which then impacted an energy absorbing system mounted to a concrete barrier. Variables included the peak velocity and time-to-peak velocity for seat and floor, and the presence or absence of personal protective equipment (PPE) and seat padding. Post-test CT scans and autopsies were performed to identify the presence and severity of injuries. Acceleration and angular rate data collected at vertebra T1, T5, T8, T12, and S1 were used to assess injury timing and mechanisms. Additionally, joint time-frequency analysis (JTFA) of the spinal Z acceleration of the sacrum and vertebrae was developed with the aim of verifying spinal fracture timing. Injuries observed in the spine were attributed to axial compression applied through the pelvis, together with flexion moment due to the offset in the center of gravity of the torso, and are consistent with UBB-induced combat injuries reported in the literature. The injury timing estimation techniques discussed in this study provide a time interval when the fractures are predicted to have occurred. Furthermore, this approach serves as an alternative to the estimation methods using acoustic sensors, force and acceleration traces, and strain gauges.
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Affiliation(s)
| | - Donald Sherman
- Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA
| | - Paul Begeman
- Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA
| | - Traci Ciarelli
- Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA
| | - Scott A McCarty
- Department of Orthopedic Surgery, Detroit Medical Center, Detroit, MI, USA
| | - James J Kochkodan
- Department of Orthopedic Surgery, Wayne State University School of Medicine, MI, USA
| | | | - John M Cavanaugh
- Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA.
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Qin H, Liu D, Chen S, Lyv M, Yang L, Bao Q, Zong Z. First-aid Training for Combatants Without Systematic Medical Education Experience on the Battlefield: Establishment and Evaluation of the Curriculum in China. Mil Med 2020; 185:e1822-e1828. [PMID: 32601667 DOI: 10.1093/milmed/usaa152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION For combatants without systematic medical education experience (CSMEE), it is necessary to participate in first-aid on the battlefield, but currently there is no effective training curriculum for CSMEE in Chinese military. MATERIALS AND METHODS A list of first-aid techniques based on expert consensus was formed, and then a curriculum was established according to the list. The effectiveness of the curriculum was further evaluated by comparing the scores among group A (the reserve officers trained by this curriculum), group B (the reserve officers in the military medical college trained by professional medic training system), and group C (the fresh officers trained by the Outline of Military Training and Assessment of Chinese military), through a 5-station assessment in a simulated battlefield environment, which included the following 5 techniques: tourniquet for massive extremities hemorrhage, thyrocricocentesis, thoracentesis, fixation of long bone fractures, and wound dressing with hemostatic bandage. RESULTS The training curriculum entitled "Implementation and Assessment Standards of First-aid Training for Combatants on the Battlefield" was established. The comparison of average scores in the 5-station assessment showed that group A had better scores than group C in tourniquet for massive extremity hemorrhage, thyrocricocentesis, and thoracentesis, with no significant differences compared with group B. Also, no significant difference between groups A and B in overall completion time and overall scores was observed, whereas an excellent candidate rate in overall score of group B was better than that of group A (87.4% vs. 80.9%, χ2 = 4.40, p = 0.036), and group A was better than group C (80.9% vs. 37.5%, χ2 = 62.01, p < 0.001). CONCLUSION The established training curriculum is indeed effective, which improved the CSMEE's first-aid capacity on the battlefield, and is equivalent to the level of medics.
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Affiliation(s)
- Hao Qin
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China.,Unit 77115 of the Chinese People's Liberation Army, Chengdu, Sichuan 611235, China
| | - Daocheng Liu
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Sixu Chen
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Mingrui Lyv
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China
| | - Lei Yang
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China
| | - Quanwei Bao
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Zhaowen Zong
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China.,Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
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Neurovascular Coupling in Special Operations Forces Combat Soldiers. Ann Biomed Eng 2020; 49:793-801. [PMID: 32944852 DOI: 10.1007/s10439-020-02604-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
The purpose of this study was to investigate how concussion history affects neurovascular coupling in Special Operations Forces (SOF) combat Soldiers. We studied 100 SOF combat Soldiers [age = 33.5 ± 4.3 years; height = 180.4 ± 6.0 cm; 55 (55.0%) with self-reported concussion history]. We employed transcranial Doppler (TCD) ultrasound to assess neurovascular coupling (NVC) via changes in posterior cerebral artery (PCA) velocity in response to a reading and a visual search task. Baseline TCD data were collected for 2 min. NVC was quantified by the percent change in overall PCA response curves. We employed linear mixed effect models using a linear spline with one knot to assess group differences in percent change observed in the PCA velocity response curves between SOF combat Soldiers with and without a concussion history. Baseline PCA velocity did not significantly differ (t98 = 1.28, p = 0.20) between those with and without concussion history. Relative PCA velocity response curves did not differ between those with and without a concussion history during the reading task (F1,98 = 0.80, p = 0.37) or the visual search task (F1,98 = 0.52, p = 0.47). When assessing only SOF combat Soldiers with a concussion history, differential response to task was significantly greater in those with 3 or more concussions (F1,4341 = 27.24, p < 0.0001) relative to those with 1-2 concussions. Despite no main effect of concussion history on neurovascular coupling response in SOF combat Soldiers, we observed a dose-response based on lifetime concussion incidence. While long-term neurophysiological effects associated with head impact and blast-related injury are currently unknown, assessing NVC response may provide further insight into cerebrovascular function and overall physiological health.
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Laserna AKC, Lai Y, Fang G, Ganapathy R, Atan MSBM, Lu J, Wu J, Uttamchandani M, Moochhala SM, Li SFY. Metabolic Profiling of a Porcine Combat Trauma-Injury Model Using NMR and Multi-Mode LC-MS Metabolomics-A Preliminary Study. Metabolites 2020; 10:metabo10090373. [PMID: 32948079 PMCID: PMC7570375 DOI: 10.3390/metabo10090373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 11/16/2022] Open
Abstract
Profiles of combat injuries worldwide have shown that penetrating trauma is one of the most common injuries sustained during battle. This is usually accompanied by severe bleeding or hemorrhage. If the soldier does not bleed to death, he may eventually succumb to complications arising from trauma hemorrhagic shock (THS). THS occurs when there is a deficiency of oxygen reaching the organs due to excessive blood loss. It can trigger massive metabolic derangements and an overwhelming inflammatory response, which can subsequently lead to the failure of organs and possibly death. A better understanding of the acute metabolic changes occurring after THS can help in the development of interventional strategies, as well as lead to the identification of potential biomarkers for rapid diagnosis of hemorrhagic shock and organ failure. In this preliminary study, a metabolomic approach using the complementary platforms of nuclear magnetic resonance (NMR) spectroscopy and liquid chromatography coupled with mass spectrometry (LC-MS) was used to determine the metabolic changes occurring in a porcine model of combat trauma injury comprising of penetrating trauma to a limb with hemorrhagic shock. Several metabolites associated with the acute-phase reaction, inflammation, energy depletion, oxidative stress, and possible renal dysfunction were identified to be significantly changed after a thirty-minute shock period.
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Affiliation(s)
- Anna Karen Carrasco Laserna
- Department of Chemistry, Faculty of Science, National University of Singapore, 3 Science Drive 3, Singapore 117543, Singapore; (A.K.C.L.); (G.F.); (M.U.)
| | - Yiyang Lai
- Defence Medical and Environmental Research Institute, DSO National Laboratories, 27 Medical Drive, Singapore 117510, Singapore; (Y.L.); (R.G.); (J.L.); (J.W.)
| | - Guihua Fang
- Department of Chemistry, Faculty of Science, National University of Singapore, 3 Science Drive 3, Singapore 117543, Singapore; (A.K.C.L.); (G.F.); (M.U.)
- Forensic Science Division, Health Services Authority, 11 Outram Road, Singapore 169078, Singapore
| | - Rajaseger Ganapathy
- Defence Medical and Environmental Research Institute, DSO National Laboratories, 27 Medical Drive, Singapore 117510, Singapore; (Y.L.); (R.G.); (J.L.); (J.W.)
| | | | - Jia Lu
- Defence Medical and Environmental Research Institute, DSO National Laboratories, 27 Medical Drive, Singapore 117510, Singapore; (Y.L.); (R.G.); (J.L.); (J.W.)
| | - Jian Wu
- Defence Medical and Environmental Research Institute, DSO National Laboratories, 27 Medical Drive, Singapore 117510, Singapore; (Y.L.); (R.G.); (J.L.); (J.W.)
| | - Mahesh Uttamchandani
- Department of Chemistry, Faculty of Science, National University of Singapore, 3 Science Drive 3, Singapore 117543, Singapore; (A.K.C.L.); (G.F.); (M.U.)
- Defence Medical and Environmental Research Institute, DSO National Laboratories, 27 Medical Drive, Singapore 117510, Singapore; (Y.L.); (R.G.); (J.L.); (J.W.)
| | - Shabbir M. Moochhala
- School of Applied Sciences, Temasek Polytechnic, 21 Tampines Ave 1, Singapore 529757, Singapore;
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Blk MD3, 16 Medical Drive, Singapore 117600, Singapore
- Correspondence: (S.M.M.); (S.F.Y.L.); Tel.: +65-6516-2681 (S.F.Y.L.)
| | - Sam Fong Yau Li
- Department of Chemistry, Faculty of Science, National University of Singapore, 3 Science Drive 3, Singapore 117543, Singapore; (A.K.C.L.); (G.F.); (M.U.)
- NUS Environmental Research Institute, National University of Singapore, T-Lab Building, 5A Engineering Drive 1, Singapore 117411, Singapore
- Correspondence: (S.M.M.); (S.F.Y.L.); Tel.: +65-6516-2681 (S.F.Y.L.)
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16
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Laparotomy Due to War-Related Penetrating Abdominal Trauma in Civilians: Experience From Syria 2011-2017. Disaster Med Public Health Prep 2020; 15:615-623. [PMID: 32489173 DOI: 10.1017/dmp.2020.77] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Penetrating abdominal trauma is one of the injuries that could affect civilians in wartime. This retrospective study investigates the commonly injured abdominal organs, and the impact of multiple injured organs on mortality. METHODS We reviewed the operating room (OR) logs of patients who presented to the surgical emergency department (SED) at Al-Mouwasat University Hospital with war-related abdominal penetrating trauma requiring exploratory laparotomy between April 1, 2011 and December 31, 2017. RESULTS Of 7826 patients with traumatic injuries, 898 patients (11.5%) required exploratory laparotomy. Of all patients who had an exploratory laparotomy (n = 898), 58 patients (6.5%) died in the perioperative period. Regarding complete laparotomies (n = 873 patients), small intestines, large intestines, and liver were the most commonly affected organs (36.4%, 33%, 22.9%, respectively). A total of 92 patients (10.2%) had negative laparotomy in which all the abdominal organs were not injured. The perioperative mortality rate (POMR) increased when more organs/organ systems were injured per patient reaching a peak at 3 organs/organ systems injuries with a POMR of 8.3%. POMR was highest in patients with musculoskeletal injuries (18.2%), followed by vascular injuries (11.8%), and liver injuries (7%). CONCLUSIONS The management of civilians' abdominal injuries remains a challenge for general and trauma surgeons, especially the civilian trauma team. The number and type of injured organs and their correlation with mortality should be considered during surgical management of penetrating abdominal injuries.
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17
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Wild H, Stewart BT, LeBoa C, Stave CD, Wren SM. Epidemiology of Injuries Sustained by Civilians and Local Combatants in Contemporary Armed Conflict: An Appeal for a Shared Trauma Registry Among Humanitarian Actors. World J Surg 2020; 44:1863-1873. [PMID: 32100067 PMCID: PMC7223167 DOI: 10.1007/s00268-020-05428-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Conflict-related injuries sustained by civilians and local combatants are poorly described, unlike injuries sustained by US, North Atlantic Treaty Organization, and coalition military personnel. An understanding of injury epidemiology in twenty-first century armed conflict is required to plan humanitarian trauma systems capable of responding to population needs. METHODS We conducted a systematic search of databases (e.g., PubMed, Embase, Web of Science, World Health Organization Catalog, Google Scholar) and grey literature repositories to identify records that described conflict-related injuries sustained by civilians and local combatants since 2001. RESULTS The search returned 3501 records. 49 reports representing conflicts in 18 countries were included in the analysis and described injuries of 58,578 patients. 79.3% of patients were male, and 34.7% were under age 18 years. Blast injury was the predominant mechanism (50.2%), and extremities were the most common anatomic region of injury (33.5%). The heterogeneity and lack of reporting of data elements prevented pooled analysis and limited the generalizability of the results. For example, data elements including measures of injury severity, resource utilization (ventilator support, transfusion, surgery), and outcomes other than mortality (disability, quality of life measures) were presented by fewer than 25% of reports. CONCLUSIONS Data describing the needs of civilians and local combatants injured during conflict are currently inadequate to inform the development of humanitarian trauma systems. To guide system-wide capacity building and quality improvement, we advocate for a humanitarian trauma registry with a minimum set of data elements.
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Affiliation(s)
- Hannah Wild
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Research and Prevention Center, Seattle, WA, USA
| | | | - Christopher D Stave
- Lane Medical Library, Stanford University School of Medicine, Stanford, CA, USA
| | - Sherry M Wren
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
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18
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Martin LKD, Mcbride LTJ, Unangst CA, Chisholm J. Prospective Study of Military Special Operations Medical Personnel and Lower Extremity Fracture Immobilization in an Austere Environment. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420916144. [PMID: 35097374 PMCID: PMC8697082 DOI: 10.1177/2473011420916144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Austere fracture immobilization equipment and techniques are often overlooked, with few studies critically evaluating the process. The purpose of this study was to evaluate current austere splinting techniques and equipment used for lower extremity fractures while field testing a new 1-step spray-on foam splint. Methods: This is a prospective analysis of austere splinting techniques. A cadaveric model with a distal third tibia-fibula fracture was used for testing. The specimens were placed in an austere environment and participants immobilized the injury with standard equipment (structural aluminum malleable [SAM] splint, 6-in. ACE wrap) while being critically evaluated. The specimens were also immobilized with a 1-step in-situ foam splint. Results: Twenty-one military Special Operations medical personnel participated. Each participant was observed and scored by a single orthopedic foot and ankle surgeon using a Likert scale based on 10 splinting criteria. Standard splinting resulted in an average score of 32.2 (range, 5-50), with significant deficiencies in fracture traction (1/5), fracture motion (2.9/5), protection of neurovascular structures (3/5), and soft tissue manipulation (3/5). The average time to completion was 203 seconds, with 1 splint failure. The spray-on foam splinting technique yielded a significantly higher score of 48.5 while completing the task significantly faster (68 seconds), with no failures. Conclusion: Special Operations medical personnel demonstrated success in immobilizing a complex fracture with standard techniques in a cadaveric model. However, testing demonstrated the inherent inability of the SAM splint to provide longitudinal traction while simultaneously allowing excessive fracture motion and potential injury to the soft tissues. In comparison, our spray-on foam proof of concept technique eliminated motion by allowing an in situ application with adequate rigidity. Clinical Relevance: This experiment included a likert scale to critically evaluate splinting techniques and equipment. It reliably tested standard splinting equipment and a 1-step in-situ foam splint for distal third tibia-fibula fractures.
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Azar A, Bhagavathula KB, Hogan J, Ouellet S, Satapathy S, Dennison CR. Protective Headgear Attenuates Forces on the Inner Table and Pressure in the Brain Parenchyma During Blast and Impact: An Experimental Study Using a Simulant-Based Surrogate Model of the Human Head. J Biomech Eng 2020; 142:041009. [PMID: 31539422 DOI: 10.1115/1.4044926] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Indexed: 07/25/2024]
Abstract
Military personnel sustain head and brain injuries as a result of ballistic, blast, and blunt impact threats. Combat helmets are meant to protect the heads of these personnel during injury events. Studies show peak kinematics and kinetics are attenuated using protective headgear during impacts; however, there is limited experimental biomechanical literature that examines whether or not helmets mitigate peak mechanics delivered to the head and brain during blast. While the mechanical links between blast and brain injury are not universally agreed upon, one hypothesis is that blast energy can be transmitted through the head and into the brain. These transmissions can lead to rapid skull flexure and elevated pressures in the cranial vault, and, therefore, may be relevant in determining injury likelihood. Therefore, it could be argued that assessing a helmet for the ability to mitigate mechanics may be an appropriate paradigm for assessing the potential protective benefits of helmets against blast. In this work, we use a surrogate model of the head and brain to assess whether or not helmets and eye protection can alter mechanical measures during both head-level face-on blast and high forehead blunt impact events. Measurements near the forehead suggest head protection can attenuate brain parenchyma pressures by as much as 49% during blast and 52% during impact, and forces on the inner table of the skull by as much as 80% during blast and 84% during impact, relative to an unprotected head.
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Affiliation(s)
- Austin Azar
- Biomedical Instrumentation Lab, Department of Mechanical Engineering, University of Alberta, Edmonton, AB T6G 1H9, Canada
| | | | - James Hogan
- Department of Mechanical Engineering, University of Alberta, Edmonton, AB T6G 1H9, Canada
| | - Simon Ouellet
- Weapons Effects and Protection Section, Defence R&D Valcartier Research Center, Quebec, QC G3J 1X5, Canada
| | - Sikhanda Satapathy
- Chief(A) with Impact Physics Branch, U.S. Army Research Labs, Aberdeen Proving Ground, Aberdeen, MD 21005-5066
| | - Christopher R Dennison
- Biomedical Instrumentation Lab, Department of Mechanical Engineering, University of Alberta, Edmonton, AB T6G 1H9, Canada
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Devasahayam RJ, Fabich RA, Tighe CA, Becker TE. Rare Use of Posterolateral Thoracotomy in an Austere Environment. Mil Med 2020; 185:530-531. [PMID: 31819958 DOI: 10.1093/milmed/usz300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/28/2019] [Accepted: 08/02/2019] [Indexed: 11/13/2022] Open
Abstract
A 25-year-old local national male presented to a split Forward Surgical Team after impalement of the posterior chest with a metal fragment. The patient was hemodynamically normal, but no imaging was available to determine the depth of penetration or the size of the internal portion of the fragment. This case represents a rare indication for posterolateral thoracotomy in an austere trauma setting.
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Affiliation(s)
| | - Robert A Fabich
- Department of Anesthesiology, Eisenhower Army Medical Center, 300 Hospital Rd, Fort Gordon, GA 30905
| | - Currie A Tighe
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave, JBLM, WA 98431
| | - Tyson E Becker
- Department of Trauma Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
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A novel model of blast induced traumatic brain injury caused by compressed gas produced sustained cognitive deficits in rats: involvement of phosphorylation of tau at the Thr205 epitope. Brain Res Bull 2020; 157:149-161. [PMID: 32044361 DOI: 10.1016/j.brainresbull.2020.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/05/2019] [Accepted: 02/04/2020] [Indexed: 12/13/2022]
Abstract
Improvised explosive devices (IEDs) represent the leading causes for casualties among civilians and soldiers in the present war (including counter-terrorism). Traumatic brain injury (TBI) caused by IEDs results in different degrees of impairment of cognition and behavior, but the exact brain pathophysiological mechanism following exposure to blast has not been clearly investigated. Here, we sought to establish a rat model of closed-head blast injury using compressed gas to deliver a single blast only to the brain without systemic injuries. The cognitive functions of these bTBI models were assessed by Morris Water Maze test (MWM test). The HE staining, flow cytometry, ELISA and Western Blotting were used to measure the effects of shock wave on general histology, regulatory T (Treg) cells percentage, inflammatory reactions, the expression and phosphorylation level of tau, respectively. In addition, the brain water content and 24 -h mortality were also assessed. As the distance from the blast source increased, the input pressure did not change, the overpressure decreased, and the mortality decreased. Receiver operating characteristic (ROC) curves for predicting 24 -h mortality using peak overpressure fits with the following areas under ROC curves: 0.833. In 2 weeks after blast injury, cognitive tests revealed significantly decreased performance at 20 cm distance from the blast (about 136.44 kPa) as demonstrated by increased escape latency in the acquisition phase, and decreased crossing numbers in the probe phase of MWM test. Interestingly, a single blast exposure (at 20 cm) lead to significantly increased tau phosphorylation at the Thr205 epitope but not at the Ser404 and Ser262 epitopes at 12 h, 24 h, 3d, and 7d after blast injury. Blast decreased the percentage of CD4+T cells, CD8+T cells, Treg cells and lymphocytes at different time points after blast injury, and blast increased the percentage of neutrophils at 12 h after blast injury and significantly increased IL-6 production at 12 h, 24 h and 3d after blast injury. In addition, blast lead to an increase of brain edema at 24 h and 3d after blast injury. However, no obvious alterations in brain gross pathology were found acutely in the blast-exposed rats. In conclusion, we established a rat model of simple craniocerebral blast injury characterized by impairment of cognitive function, Thr205 phosphorylation of tau, decreased Treg cells and increased inflammatory reactions and brain edema. We expect this model may help clarify the underlying mechanism after blast injury and possibly serve as a useful animal model in the development of novel therapeutic and diagnostic approaches.
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Abstract
Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.
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Somasundaram K, Zhang L, Sherman D, Begeman P, Lyu D, Cavanaugh J. Evaluating thoracolumbar spine response during simulated underbody blast impact using a total human body finite element model. J Mech Behav Biomed Mater 2019; 100:103398. [DOI: 10.1016/j.jmbbm.2019.103398] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/29/2019] [Accepted: 08/16/2019] [Indexed: 01/07/2023]
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Yaramothu C, Goodman AM, Alvarez TL. Epidemiology and Incidence of Pediatric Concussions in General Aspects of Life. Brain Sci 2019; 9:brainsci9100257. [PMID: 31569649 PMCID: PMC6827131 DOI: 10.3390/brainsci9100257] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 09/20/2019] [Accepted: 09/25/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Concussions are one of the most common head injuries acquired within the pediatric population. While sport-related concussions are well documented, concussions within other aspects of a child's life are not as well researched. The purpose of this study is to examine the incidence of a large pediatric concussion population in a broad range of daily activities. METHODS Patients' gender and nature of injury were extracted from 1408 medical records of patients who were diagnosed with a concussion at Saint Peter's Sports Medicine Institute. Statistical analyses were conducted for activities and environmental settings using chi-squared tests. RESULTS Concussions were most prevalent in organized sports (53.3%), followed by injuries within the following settings: school (16.5%), recreational (6.7%), motor vehicle collisions (6.6%), home (5.5%), and other (11.3%). Specifically, soccer (12.9%), school physical education (PE) class (10.6%), and football (9.8%) subcategories recorded the most incidences of concussion. For the PE class cohort (n = 149), significantly more females were diagnosed with a concussion compared to males (p < 0.001). CONCLUSIONS PE-related concussions had the second highest incidence rate after organized sports. A significant gender difference was observed in PE class. Awareness about concussions and methods to reduce the risk of concussion is suggested for PE classes.
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Affiliation(s)
- Chang Yaramothu
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ 07102, USA.
| | - Arlene M Goodman
- Saint Peter's Sports Medicine Institute, Saint Peter's University Hospital, Somerset, NJ 08873, USA.
| | - Tara L Alvarez
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ 07102, USA.
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Unrealized potential of the US military battlefield trauma system: DOW rate is higher in Iraq and Afghanistan than in Vietnam, but CFR and KIA rate are lower. J Trauma Acute Care Surg 2019; 85:S4-S12. [PMID: 29787556 DOI: 10.1097/ta.0000000000001969] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
LEVEL OF EVIDENCE Observational/retrospective/historic controls, level IV.
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Weppner J, Linsenmeyer M, Ide W. Military Blast-Related Traumatic Brain Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00241-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Wischik DL, Magny-Normilus C, Whittemore R. Risk Factors of Obesity in Veterans of Recent Conflicts: Need for Diabetes Prevention. Curr Diab Rep 2019; 19:70. [PMID: 31368008 PMCID: PMC7530827 DOI: 10.1007/s11892-019-1191-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW To identify factors associated with obesity in veterans of the recent, Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) war conflicts. RECENT FINDINGS Over 44% OEF/OIF/OND veterans are obese (BMI > 30 kg/m2), which exceeds the national obesity prevalence rate of 39% in people younger than 45. Obesity increases morbidity, risk for type 2 diabetes (T2D), and mortality as well as decreases quality of life. A scoping review method was used to identify factors associated with obesity in young veterans. Military exposures, such as multiple deployments and exposure to combat, contribute to challenges in re-integration to civilian life in all veterans. Factors that contribute to increased risk for obesity include changes in eating patterns/eating disorders, changes in physical activity, physical disability, and psychological comorbidity. These conditions can contribute to a rapid weight gain trajectory, changes in metabolism, and obesity. Young veterans face considerable challenges related to obesity risk. Further research is needed to better understand young veterans' experiences and health needs in order to adapt or expand existing programs and improve access, engagement, and metabolic outcomes in this vulnerable population.
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Affiliation(s)
| | | | - Robin Whittemore
- Yale School of Nursing, 400 West Campus Drive, Orange, CT, 06477, USA
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Stewart L, Shaikh F, Bradley W, Lu D, Blyth DM, Petfield JL, Whitman TJ, Krauss M, Greenberg L, Tribble DR. Combat-Related Extremity Wounds: Injury Factors Predicting Early Onset Infections. Mil Med 2019; 184:83-91. [PMID: 30901441 DOI: 10.1093/milmed/usy336] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/16/2018] [Indexed: 12/26/2022] Open
Abstract
We examined risk factors for combat-related extremity wound infections (CEWI) among U.S. military patients injured in Iraq and Afghanistan (2009-2012). Patients with ≥1 combat-related, open extremity wound admitted to a participating U.S. hospital (≤7 days postinjury) were retrospectively assessed. The population was classified based upon most severe injury (amputation, open fracture without amputation, or open soft-tissue injury defined as non-fracture/non-amputation wounds). Among 1271 eligible patients, 395 (31%) patients had ≥1 amputation, 457 (36%) had open fractures, and 419 (33%) had open soft-tissue wounds as their most severe injury, respectively. Among patients with traumatic amputations, 100 (47%) developed a CEWI compared to 66 (14%) and 12 (3%) patients with open fractures and open soft-tissue wounds, respectively. In a Cox proportional hazard analysis restricted to CEWIs ≤30 days postinjury among the traumatic amputation and open fracture groups, sustaining an amputation (hazard ratio: 1.79; 95% confidence interval: 1.25-2.56), blood transfusion ≤24 hours postinjury, improvised explosive device blast, first documented shock index ≥0.80, and >4 injury sites were independently associated with CEWI risk. The presence of a non-extremity infection at least 4 days prior to a CEWI diagnosis was associated with lower CEWI risk, suggesting impact of recent exposure to directed antimicrobial therapy. Further assessment of early clinical management will help to elucidate risk factor contribution. The wound classification system provides a comprehensive approach in assessment of injury and clinical factors for the risk and outcomes of an extremity wound infection.
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Affiliation(s)
- Laveta Stewart
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD
| | - William Bradley
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD.,Brooke Army Medical Center, 3551 Roger Brooke Drive #3600, JBSA Fort Sam Houston, TX
| | - Dan Lu
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD
| | - Dana M Blyth
- Brooke Army Medical Center, 3551 Roger Brooke Drive #3600, JBSA Fort Sam Houston, TX
| | | | - Timothy J Whitman
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD
| | | | | | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
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Farber SJ, Latham KP, Kantar RS, Perkins JN, Rodriguez ED. Reconstructing the Face of War. Mil Med 2019; 184:e236-e246. [DOI: 10.1093/milmed/usz103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/18/2019] [Indexed: 11/14/2022] Open
Abstract
AbstractIntroductionOngoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites.MethodsA case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images.ResultsFour patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed.ConclusionWhile the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients.
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Affiliation(s)
- Scott J Farber
- University of Texas Health Science Center San Antonio, Texas, Division of Plastic and Reconstructive Surgery, 7703 Floyd Curl Drive, MC 7844, San Antonio, TX
| | - Kerry P Latham
- Walter Reed National Military Medical Center Bethesda, MD, Division of Plastic Surgery, 4494 North Palmer Road, Bethesda, MD
| | - Rami S Kantar
- NYU Langone Health New York, NY, Hansjorg Wyss Department of Plastic Surgery, 307 E 33rd Street, New York, NY
| | - Jonathan N Perkins
- Walter Reed National Military Medical Center Bethesda, MD, Department of Otolaryngology-Head & Neck Surgery, 4494 North Palmer Road, Bethesda, MD
| | - Eduardo D Rodriguez
- NYU Langone Health New York, NY, Hansjorg Wyss Department of Plastic Surgery, 307 E 33rd Street, New York, NY
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Thompson KB, Krispinsky LT, Stark RJ. Late immune consequences of combat trauma: a review of trauma-related immune dysfunction and potential therapies. Mil Med Res 2019; 6:11. [PMID: 31014397 PMCID: PMC6480837 DOI: 10.1186/s40779-019-0202-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/07/2019] [Indexed: 12/29/2022] Open
Abstract
With improvements in personnel and vehicular body armor, robust casualty evacuation capabilities, and damage control resuscitation strategies, more combat casualties are surviving to reach higher levels of care throughout the casualty evacuation system. As such, medical centers are becoming more accustomed to managing the deleterious late consequences of combat trauma related to the dysregulation of the immune system. In this review, we aim to highlight these late consequences and identify areas for future research and therapeutic strategies. Trauma leads to the dysregulation of both the innate and adaptive immune responses, which places the injured at risk for several late consequences, including delayed wound healing, late onset sepsis and infection, multi-organ dysfunction syndrome, and acute respiratory distress syndrome, which are significant for their association with the increased morbidity and mortality of wounded personnel. The mechanisms by which these consequences develop are complex but include an imbalance of the immune system leading to robust inflammatory responses, triggered by the presence of damage-associated molecules and other immune-modifying agents following trauma. Treatment strategies to improve outcomes have been difficult to develop as the immunophenotype of injured personnel following trauma is variable, fluid and difficult to determine. As more information regarding the triggers that lead to immune dysfunction following trauma is elucidated, it may be possible to identify the immunophenotype of injured personnel and provide targeted treatments to reduce the late consequences of trauma, which are known to lead to significant morbidity and mortality.
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Affiliation(s)
- Kelly B Thompson
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, 2200 Children's Way, Nashville, TN, 37232, USA.
| | - Luke T Krispinsky
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Uniformed Services University, Naval Medical Center Portsmouth, Portsmouth, VA, 23708, USA
| | - Ryan J Stark
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, 2200 Children's Way, Nashville, TN, 37232, USA
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Neck Injuries: a Complex Problem in the Deployed Environment. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-0155-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Comparison of military and civilian burn patients admitted to a single center during 12 years of war. Burns 2019; 45:199-204. [DOI: 10.1016/j.burns.2018.08.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 08/14/2018] [Accepted: 08/17/2018] [Indexed: 11/17/2022]
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M.C.V. BS, Mustafa EM, Ferreira VRR, Sabino SB, Queiroz COV, Sbardellini BC, Sternieri GB, de Faria LAB, Filho IJZ, Braile DM. Approaches on the Major Predictors of Blood Transfusion in Cardiovascular Surgery: A Systematic Review. Health (London) 2019. [DOI: 10.4236/health.2019.114033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Hung PL, Hsu MH, Yu HR, Wu KLH, Wang FS. Thyroxin Protects White Matter from Hypoxic-Ischemic Insult in the Immature Sprague⁻Dawley Rat Brain by Regulating Periventricular White Matter and Cortex BDNF and CREB Pathways. Int J Mol Sci 2018; 19:ijms19092573. [PMID: 30158497 PMCID: PMC6164053 DOI: 10.3390/ijms19092573] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Periventricular white-matter (WM) injury is a prominent feature of brain injury in preterm infants. Thyroxin (T4) treatment reduces the severity of hypoxic-ischemic (HI)-mediated WM injury in the immature brain. This study aimed to delineate molecular events underlying T4 protection following periventricular WM injury in HI rats. Methods: Right common-carotid-artery ligation, followed by hypoxia, was performed on seven-day-old rat pups. The HI pups were injected with saline, or 0.2 or 1 mg/kg of T4 at 48–96 h postoperatively. Cortex and periventricular WM were dissected for real-time (RT)-quantitative polymerase chain reactions (PCRs), immunoblotting, and for immunofluorescence analysis of neurotrophins, myelin, oligodendrocyte precursors, and neointimal. Results: T4 significantly mitigated hypomyelination and oligodendrocyte death in HI pups, whereas angiogenesis of periventricular WM, observed using antiendothelium cell antibody (RECA-1) immunofluorescence and vascular endothelium growth factor (VEGF) immunoblotting, was not affected. T4 also increased the brain-derived neurotrophic factors (BDNFs), but not the nerve growth factor (NGF) expression of injured periventricular WM. However, phosphorylated extracellular signal regulated kinase (p-ERK) and phosphorylated cyclic adenosine monophosphate response element-binding protein (p-CREB) concentrations, but not the BDNF downstream pathway kinases, p38, c-Jun amino-terminal kinase (c-JNK), or Akt, were reduced in periventricular WM with T4 treatment. Notably, T4 administration significantly increased BDNF and phosphorylated CREB in the overlying cortex of the HI-induced injured cortex. Conclusion: Our findings reveal that T4 reversed BNDF signaling to attenuate HI-induced WM injury by activating ERK and CREB pathways in the cortex, but not directly in periventricular WM. This study offers molecular insight into the neuroprotective actions of T4 in HI-mediated WM injury in the immature brain.
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Affiliation(s)
- Pi-Lien Hung
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 33303, Taiwan.
| | - Mei-Hsin Hsu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 33303, Taiwan.
| | - Hong-Ren Yu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 33303, Taiwan.
| | - Kay L H Wu
- Center for Translational Research in Biomedical Sciences, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung 33303, Taiwan.
| | - Feng-Sheng Wang
- Core facility for Phenomics & Diagnostics, Department of Medical Research, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No123, Rd Ta-Pei, Niao-Song District, Kaohsiung 33303, Taiwan.
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Galvin JW, Thompson JC, Thompson AM, Parada SA, Eichinger JK, Dickens JF, Gillingham BL. A Guide to Understanding Reimbursement and Value-Based Care in the Military Health System. Mil Med 2018; 184:e205-e210. [DOI: 10.1093/milmed/usy206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/23/2018] [Accepted: 07/31/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joseph W Galvin
- Blanchfield Army Community Hospital, 650 Joel Drive, Fort Campbell, KY
| | - Joshua C Thompson
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD
| | - Amy M Thompson
- Walter Reed National Military Medical Center, 4494 North Palmer Road, Bethesda, MD
| | - Stephen A Parada
- Dwight D. Eisenhower Army Medical Center, 300 E Hospital Rd, Augusta, GA
| | - Josef K Eichinger
- Medical University of South Carolina, 171 Ashley Ave, Charleston, SC
| | - Jonathan F Dickens
- Walter Reed National Military Medical Center, 4494 North Palmer Road, Bethesda, MD
| | - Bruce L Gillingham
- Bureau of Medicine and Surgery, U.S. Navy, 7700 Arlington Blvd Falls Church, VA
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Borger van der Burg BLS, van Dongen TTCF, Morrison JJ, Hedeman Joosten PPA, DuBose JJ, Hörer TM, Hoencamp R. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg 2018; 44:535-550. [PMID: 29785654 PMCID: PMC6096615 DOI: 10.1007/s00068-018-0959-y] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 04/18/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die before hemorrhage control is achieved. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive surgical or endovascular repair. A systematic review was conducted for the current clinical use of REBOA in patients with hemodynamic instability and to discuss its potential role in improving prehospital and in-hospital outcome. METHODS Systematic review and meta-analysis (1900-2017) using MEDLINE, Cochrane, EMBASE, Web of Science and Central and Emcare using the keywords "aortic balloon occlusion", "aortic balloon tamponade", "REBOA", and "Resuscitative Endovascular Balloon Occlusion" in combination with hemorrhage control, hemorrhage, resuscitation, shock, ruptured abdominal or thoracic aorta, endovascular repair, and open repair. Original published studies on human subjects were considered. RESULTS A total of 490 studies were identified; 89 met criteria for inclusion. Of the 1436 patients, overall reported mortality was 49.2% (613/1246) with significant differences (p < 0.001) between clinical indications. Hemodynamic shock was evident in 79.3%, values between clinical indications showed significant difference (p < 0.001). REBOA was favored as treatment in trauma patients in terms of mortality. Pooled analysis demonstrated an increase in mean systolic pressure by almost 50 mmHg following REBOA use. CONCLUSION REBOA has been used in trauma patients and ruptured aortic aneurysm patients with improvement of hemodynamic parameters and outcomes for several decades. Formal, prospective study is warranted to clarify the role of this adjunct in all hemodynamic unstable patients.
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Affiliation(s)
| | - Thijs T. C. F. van Dongen
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
| | - J. J. Morrison
- R. Adam Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | | | - J. J. DuBose
- Division of Vascular Surgery, David Grant Medical Center, Travis AFB, California, USA
| | - T. M. Hörer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - R. Hoencamp
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
- Division of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Stemper BD, Chirvi S, Doan N, Baisden JL, Maiman DJ, Curry WH, Yoganandan N, Pintar FA, Paskoff G, Shender BS. Biomechanical tolerance of whole lumbar spines in straightened posture subjected to axial acceleration. J Orthop Res 2018; 36:1747-1756. [PMID: 29194745 DOI: 10.1002/jor.23826] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 11/29/2017] [Indexed: 02/04/2023]
Abstract
Quantification of biomechanical tolerance is necessary for injury prediction and protection of vehicular occupants. This study experimentally quantified lumbar spine axial tolerance during accelerative environments simulating a variety of military and civilian scenarios. Intact human lumbar spines (T12-L5) were dynamically loaded using a custom-built drop tower. Twenty-three specimens were tested at sub-failure and failure levels consisting of peak axial forces between 2.6 and 7.9 kN and corresponding peak accelerations between 7 and 57 g. Military aircraft ejection and helicopter crashes fall within these high axial acceleration ranges. Testing was stopped following injury detection. Both peak force and acceleration were significant (p < 0.0001) injury predictors. Injury probability curves using parametric survival analysis were created for peak acceleration and peak force. Fifty-percent probability of injury (95%CI) for force and acceleration were 4.5 (3.9-5.2 kN), and 16 (13-19 g). A majority of injuries affected the L1 spinal level. Peak axial forces and accelerations were greater for specimens that sustained multiple injuries or injuries at L2-L5 spinal levels. In general, force-based tolerance was consistent with previous shorter-segment lumbar spine testing (3-5 vertebrae), although studies incorporating isolated vertebral bodies reported higher tolerance attributable to a different injury mechanism involving structural failure of the cortical shell. This study identified novel outcomes with regard to injury patterns, wherein more violent exposures produced more injuries in the caudal lumbar spine. This caudal migration was likely attributable to increased injury tolerance at lower lumbar spinal levels and a faster inertial mass recruitment process for high rate load application. Published 2017. This article is a U.S. Government work and is in the public domain in the USA. J Orthop Res 36:1747-1756, 2018.
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Affiliation(s)
- Brian D Stemper
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, 5000 West National Avenue, Research 151, Milwaukee, Wisconsin, 53295.,Neuroscience Research, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Sajal Chirvi
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin.,Neuroscience Research, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Ninh Doan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin.,Neuroscience Research, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Jamie L Baisden
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin.,Neuroscience Research, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Dennis J Maiman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin.,Neuroscience Research, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - William H Curry
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin.,Neuroscience Research, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Narayan Yoganandan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin.,Neuroscience Research, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Frank A Pintar
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, 5000 West National Avenue, Research 151, Milwaukee, Wisconsin, 53295.,Neuroscience Research, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Glenn Paskoff
- Aircraft Division, Naval Air Warfare Center, Patuxent River, Maryland
| | - Barry S Shender
- Aircraft Division, Naval Air Warfare Center, Patuxent River, Maryland
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Benov A, Antebi B, Wenke JC, Batchinsky AI, Murray CK, Nachman D, Haim P, Tarif B, Glassberg E, Yitzhak A. Antibiotic Treatment – What Can Be Learned from Point of Injury Experience? Mil Med 2018; 183:466-471. [DOI: 10.1093/milmed/usx144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 01/06/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Avi Benov
- Israel Defense Forces, Medical Corps, Tel Hasomer, Ramat Gan 02718, Israel
- Department of Surgery “A”, Meir Medical Center, 59 Tesernikovski st, Kfar Saba and the Sackler School of Medicine, Tel-Aviv University, 4428164, Israel
| | - Ben Antebi
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3611, JBSA, Fort Sam Houston, TX 78234
| | - Joseph C Wenke
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3611, JBSA, Fort Sam Houston, TX 78234
| | - Andriy I Batchinsky
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3611, JBSA, Fort Sam Houston, TX 78234
| | - Clinton K Murray
- San Antonio Military Medical Center, 3551 Roger Brooke Dr, JBSA, Fort Sam Houston, TX 79219
| | - Dean Nachman
- Israel Defense Forces, Medical Corps, Tel Hasomer, Ramat Gan 02718, Israel
- Institute for Research in Military Medicine, The Hebrew University, Kiryt Hadassah, Jerusalem 91120, Israel
| | - Paran Haim
- Department of Surgery “A”, Meir Medical Center, 59 Tesernikovski st, Kfar Saba and the Sackler School of Medicine, Tel-Aviv University, 4428164, Israel
| | - Bader Tarif
- Israel Defense Forces, Medical Corps, Tel Hasomer, Ramat Gan 02718, Israel
- Department of Military Medicine, The Hebrew University, Kiryt Hadassah, Jerusalem 91120, Israel
| | - Elon Glassberg
- Israel Defense Forces, Medical Corps, Tel Hasomer, Ramat Gan 02718, Israel
| | - Avi Yitzhak
- Israel Defense Forces, Medical Corps, Tel Hasomer, Ramat Gan 02718, Israel
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Ordoñez CA, Manzano-Nunez R, Naranjo MP, Foianini E, Cevallos C, Londoño MA, Sanchez Ortiz AI, García AF, Moore EE. Casualties of peace: an analysis of casualties admitted to the intensive care unit during the negotiation of the comprehensive Colombian process of peace. World J Emerg Surg 2018; 13:2. [PMID: 29371879 PMCID: PMC5769432 DOI: 10.1186/s13017-017-0161-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/18/2017] [Indexed: 01/22/2023] Open
Abstract
Background After 52 years of war in 2012, the Colombian government began the negotiation of a process of peace, and by November 2012, a truce was agreed. We sought to analyze casualties who were admitted to the intensive care unit (ICU) before and during the period of the negotiation of the comprehensive Colombian process of peace. Methods Retrospective study of hostile casualties admitted to the ICU at a Level I trauma center from January 2011 to December 2016. Patients were subsequently divided into two groups: those seen before the declaration of the process of peace truce (November 2012) and those after (November 2012-December 2016). Patients were compared with respect to time periods. Results Four hundred forty-eight male patients were admitted to the emergency room. Of these, 94 required ICU care. Sixty-five casualties presented before the truce and 29 during the negotiation period. Median injury severity score was significantly higher before the truce. Furthermore, the odds of presenting with severe trauma (ISS > 15) were significantly higher before the truce (OR, 5.4; (95% CI, 2.0-14.2); p < 0.01). There was a gradual decrease in the admissions to the ICU, and the performance of medical and operative procedures during the period observed. Conclusion We describe a series of war casualties that required ICU care in a period of peace negotiation. Despite our limitations, our study presents a decline in the occurrence, severity, and consequences of war injuries probably as a result in part of the negotiation of the process of peace. The hysteresis of these results should only be interpreted for their implications in the understanding of the peace-health relationship and must not be overinterpreted and used for any political end.
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Affiliation(s)
- Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
- Department of Surgery, Universidad del Valle, Cali, Colombia
| | - Ramiro Manzano-Nunez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
- Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
| | - Maria Paula Naranjo
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
- Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
| | - Esteban Foianini
- Department of Surgery, Clinica Foianini, Santacruz de la Sierra, Bolivia
| | | | | | - Alvaro I. Sanchez Ortiz
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
- Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
| | - Alberto F. García
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
- Department of Surgery, Universidad del Valle, Cali, Colombia
| | - Ernest E. Moore
- Department of Surgery, Trauma Research Center, University of Colorado, Denver, CO USA
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Fievisohn E, Bailey Z, Guettler A, VandeVord P. Primary Blast Brain Injury Mechanisms: Current Knowledge, Limitations, and Future Directions. J Biomech Eng 2018; 140:2666247. [DOI: 10.1115/1.4038710] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Indexed: 12/18/2022]
Abstract
Mild blast traumatic brain injury (bTBI) accounts for the majority of brain injury in United States service members and other military personnel worldwide. The mechanisms of primary blast brain injury continue to be disputed with little evidence to support one or a combination of theories. The main hypotheses addressed in this review are blast wave transmission through the skull orifices, direct cranial transmission, skull flexure dynamics, thoracic surge, acceleration, and cavitation. Each possible mechanism is discussed using available literature with the goal of focusing research efforts to address the limitations and challenges that exist in blast injury research. Multiple mechanisms may contribute to the pathology of bTBI and could be dependent on magnitudes and orientation to blast exposure. Further focused biomechanical investigation with cadaver, in vivo, and finite element models would advance our knowledge of bTBI mechanisms. In addition, this understanding could guide future research and contribute to the greater goal of developing relevant injury criteria and mandates to protect our soldiers on the battlefield.
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Affiliation(s)
- Elizabeth Fievisohn
- Department of Biomedical Engineering and Mechanics, Virginia Tech, 440 Kelly Hall, 325 Stanger Street, Blacksburg, VA 24061 e-mail:
| | - Zachary Bailey
- Department of Biomedical Engineering and Mechanics, Virginia Tech, 440 Kelly Hall, 325 Stanger Street, Blacksburg, VA 24061 e-mail:
| | - Allison Guettler
- Department of Mechanical Engineering, Virginia Tech, 440 Kelly Hall, 325 Stanger Street, Blacksburg, VA 24061 e-mail:
| | - Pamela VandeVord
- Department of Biomedical Engineering and Mechanics, Virginia Tech, 317 Kelly Hall, 325 Stanger Street, Blacksburg, VA 24061; Salem Veterans Affairs Medical Center, Salam, VA 24153 e-mail:
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Ordoñez CA, Manzano Nunez R, Parra MW, Herrera JP, Naranjo MP, Escobar SS, Badiel M, Morales M, Cevallos C, Bayona JG, Sanchez AI, Puyana JC, García AF. Analysis of combat casualties admitted to the emergency department during the negotiation of the comprehensive Colombian process of peace. COLOMBIA MEDICA (CALI, COLOMBIA) 2017; 48:155-160. [PMID: 29662256 PMCID: PMC5896721 DOI: 10.25100/cm.v43i4.3389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aim: Our objective was to describe the variations in casualties admitted to the emergency department during the period of the negotiation of the comprehensive peace agreement in Colombia between 2011 and 2016. Methods: A retrospective study of all hostile military casualties managed at a regional Level I trauma center from January 2011 to December 2016. Patients were subsequently divided into two groups: those seen before the declaration of the process of peace truce (November 2012) and those after (negotiation period). Variables were compared with respect to periods Results: A total of 448 hostile casualties were registered. There was a gradual decline in the number of admissions to the emergency department during the negotiation period. The number of soldiers suffering blast and rifle injuries also decreased over this period. In 2012 there were nearly 150 hostile casualties' admissions to the ER. This number decreased to 84, 63, 32 and 6 in 2013, 2014, 2015 and 2016 respectively. Both, the proportion of patients with an ISS ≥9 and admitted to the intensive care unit were significantly higher in the period before peace negotiation. From August to December/2016 no admissions of war casualties were registered. Conclusion: We describe a series of soldiers wounded in combat that were admitted to the emergency department before and during the negotiation of the Colombian process of peace. Overall, we found a trend toward a decrease in the number of casualties admitted to the emergency department possibly in part, as a result of the period of peace negotiation.
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Affiliation(s)
- Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery. Fundación Valle del Lili. Cali, Colombia.,Universidad del Valle, Cali, Colombia
| | - Ramiro Manzano Nunez
- Division of Trauma and Acute Care Surgery. Fundación Valle del Lili. Cali, Colombia.,Clinical Research Center. Fundación Valle del Lili. Cali, Colombia
| | | | - Juan Pablo Herrera
- Department of Surgery, Brigham & Women's Hospital. Boston, Massachusetts. USA
| | | | | | | | | | | | - Juan G Bayona
- Clinical Research Center. Fundación Valle del Lili. Cali, Colombia
| | | | | | - Alberto F García
- Division of Trauma and Acute Care Surgery. Fundación Valle del Lili. Cali, Colombia.,Universidad del Valle, Cali, Colombia
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Lichtenberger JP, Kim AM, Fisher D, Tatum PS, Neubauer B, Peterson PG, Carter BW. Imaging of Combat-Related Thoracic Trauma – Review of Penetrating Trauma. Mil Med 2017. [DOI: 10.1093/milmed/usx034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- John P Lichtenberger
- Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Andrew M Kim
- Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Dane Fisher
- Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Peter S Tatum
- Rowan School of Osteopathic Medicine, 42 East Laurel Road, Stratford,NJ 08084
| | - Brian Neubauer
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda,MD 20814
| | - P Gabriel Peterson
- Department of Radiology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda,MD 20889
| | - Brett W Carter
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
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Heitkamp RA, Li P, Mende K, Demons ST, Tribble DR, Tyner SD. Association of Enterococcus spp. with Severe Combat Extremity Injury, Intensive Care, and Polymicrobial Wound Infection. Surg Infect (Larchmt) 2017; 19:95-103. [PMID: 29261091 DOI: 10.1089/sur.2017.157] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Combat-related extremity wound infections can complicate the recovery of injured military personnel. The Enterococcus genus contains both commensal and pathogenic bacteria found in many combat wounds. We describe the patient population susceptible to Enterococcus infection, the characteristics of Enterococcus spp. isolated from combat-related wounds, and the microbiological profile of Enterococcus-positive wounds. METHODS Patient and culture data were obtained from the Trauma Infectious Disease Outcomes Study. Subjects were divided into a case group with enterococcal extremity wound infections and a comparator group with wound infections caused by other micro-organisms. RESULTS Case and comparator subjects had similar patterns of injury and infection. Case subjects had higher Injury Severity Scores (33 vs. 30; p < 0.001), longer hospitalization at U.S. facilities (55 vs. 40 days; p = 0.004), and required more large-volume blood transfusions (>20 units) within 24 h post-injury (53% vs. 30%; p < 0.001). Approximately 60% of case subjects had three or more infections, and 91% had one or more polymicrobial infections, compared with 43% and 50%, respectively, in the comparator group. The thigh was the most common site of Enterococcus spp. isolation, contributing 50% of isolates. Enterococcus faecium was the predominant species isolated from case-group infections overall (66%), as well as in polymicrobial infections (74%). Frequent co-colonizing microbes in polymicrobial wound infections with Enterococcus were other ESKAPE pathogens (64%) (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae [and Escherichia coli], Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) and fungi (35%). CONCLUSIONS The specific pathogenicity of Enterococcus relative to other pathogens in polymicrobial wounds is unknown. Identifying strain-specific outcomes and investigating the interactions of Enterococcus strains with other wound pathogens could provide additional tools and strategies for infection mitigation in combat-related wounds.
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Affiliation(s)
- Rae A Heitkamp
- 1 Bacterial Diseases Branch, Walter Reed Army Institute of Research , Silver Spring, Maryland
| | - Ping Li
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,3 Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland
| | - Katrin Mende
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,3 Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland.,4 San Antonio Military Medical Center , Joint Base San Antonio, Fort Sam Houston, Texas
| | - Samandra T Demons
- 1 Bacterial Diseases Branch, Walter Reed Army Institute of Research , Silver Spring, Maryland
| | - David R Tribble
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Stuart D Tyner
- 1 Bacterial Diseases Branch, Walter Reed Army Institute of Research , Silver Spring, Maryland
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Occupational outcomes following combat-related gunshot injury: Cohort study. Int J Surg 2017; 48:286-290. [DOI: 10.1016/j.ijsu.2017.11.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/10/2017] [Accepted: 11/24/2017] [Indexed: 11/24/2022]
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Ausset S. Quelles sont les leçons récentes et quel est l’avenir de la médecine opérationnelle ? ANESTHESIE & REANIMATION 2017. [DOI: 10.1016/j.anrea.2017.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Exendin-4 attenuates blast traumatic brain injury induced cognitive impairments, losses of synaptophysin and in vitro TBI-induced hippocampal cellular degeneration. Sci Rep 2017. [PMID: 28623327 PMCID: PMC5473835 DOI: 10.1038/s41598-017-03792-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Mild blast traumatic brain injury (B-TBI) induced lasting cognitive impairments in novel object recognition and less severe deficits in Y-maze behaviors. B-TBI significantly reduced the levels of synaptophysin (SYP) protein staining in cortical (CTX) and hippocampal (HIPP) tissues. Treatment with exendin-4 (Ex-4) delivered by subcutaneous micro-osmotic pumps 48 hours prior to or 2 hours immediately after B-TBI prevented the induction of both cognitive deficits and B-TBI induced changes in SYP staining. The effects of a series of biaxial stretch injuries (BSI) on a neuronal derived cell line, HT22 cells, were assessed in an in vitro model of TBI. Biaxial stretch damage induced shrunken neurites and cell death. Treatment of HT22 cultures with Ex-4 (25 to 100 nM), prior to injury, attenuated the cytotoxic effects of BSI and preserved neurite length similar to sham treated cells. These data imply that treatment with Ex-4 may represent a viable option for the management of secondary events triggered by blast-induced, mild traumatic brain injury that is commonly observed in militarized zones.
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Abstract
INTRODUCTION The use of improvised explosive devices is a frequent method of insurgents to inflict harm on deployed military personnel. Consequently, lower extremity injuries make up the majority of combat related trauma. The wounding pattern of an explosion is not often encountered in a civilian population and can lead to substantial disability. It is therefore important to study the impact of these lower extremity injuries and their treatment (limb salvage versus amputation) on functional outcome and quality of life. PATIENTS AND METHODS All Dutch repatriated service members receiving treatment for wounds on the lower extremity sustained in the Afghan theater between august 2005 and August 2014, were invited to participate in this observational cohort study. We conducted a survey regarding their physical and mental health using the Short Form health survey 36, EuroQoL 6 dimensions and Lower Extremity Functional Scale questionnaires. Results were collated in a specifically designed electronic database combined with epidemiology and hospital statistics gathered from the archive of the Central Military Hospital. Statistical analyses were performed to identify differences between combat and non-combat related injuries and between limb salvage treatment and amputation. RESULTS In comparison with non-battle injury patients, battle casualties were significantly younger of age, sustained more severe injuries, needed more frequent operations and clinical rehabilitation. Their long-term outcome scores in areas concerning well-being, social and cognitive functioning, were significantly lower. Regarding treatment, amputees experienced higher physical well-being and less pain compared to those treated with limb salvage surgery. CONCLUSION Sustaining a combat injury to the lower extremity can lead to partial or permanent dysfunction. However, wounded service members, amputees included, are able to achieve high levels of activity and participation in society, proving a remarkable resilience. These long-term results demonstrate that amputation is not a failure for casualty and surgeon, and strengthen a life before limb (damage control surgery) mindset in the initial phase. For future research, we recommend the use of adequate coding and injury scoring systems to predict outcome and give insight in the attributes that are supportive for the resilience that is needed to cope with a serious battle injury.
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50
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Godfrey BW, Martin A, Chestovich PJ, Lee GH, Ingalls NK, Saldanha V. Patients with multiple traumatic amputations: An analysis of operation enduring freedom joint theatre trauma registry data. Injury 2017; 48:75-79. [PMID: 27592185 DOI: 10.1016/j.injury.2016.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 07/18/2016] [Accepted: 08/17/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Improvised Explosive Devices (IED) are the primary wounding mechanism for casualties in Operation Enduring Freedom. Patients can sustain devastating traumatic amputations, which are unlike injuries seen in the civilian trauma sector. This is a database analysis of the largest patient registry of multiple traumatic amputations. METHODS The Joint Theater Trauma Registry was queried for patients with a traumatic amputation from 2009 to 2012. Data obtained included the Injury Severity Score (ISS), Glasgow Coma Score (GCS), blood products, transfer from theatre, and complications including DVT, PE, infection (Acinetobacter and fungal), acute renal failure, and rhabdomyolysis. Comparisons were made between number of major amputations (1-4) and specific outcomes using χ2 and Pearson's rank test, and multivariable logistic regression was performed for 30-day survival. Significance was considered with p<0.05. RESULTS We identified 720 military personnel with at least one traumatic amputation: 494 single, 191 double, 32 triple, and 3 quad amputees. Average age was 24.3 years (18-46), median ISS 24 (9-66), and GCS 15 (3-15). Tranexamic acid (TXA) was administered in 164 patients (23%) and tourniquets were used in 575 (80%). Both TXA and tourniquet use increased with increasing number of amputations (p<0.001). Average transfusion requirements (in units) were packed red blood cells (PRBC) 18.6 (0-142), fresh frozen plasma (FFP) 17.3 (0-128), platelets 3.6 (0-26), and cryoprecipitate 5.6 (0-130). Transfusion of all blood products increased with the number of amputations (p<0.001). All complications tested increased with the number of amputations except Acinetobacter infection, coagulopathy, and compartment syndrome. Transfer to higher acuity facilities was achieved in 676 patients (94%). CONCLUSION Traumatic amputations from blast injuries require significant blood product transfusion, which increases with the number of amputations. Most complications also increase with the number of amputations. Despite high injury severity, 94% of traumatic amputation patients who are alive upon admission to a role II/III facility will survive to transfer to facilities with higher acuity care.
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Affiliation(s)
- Brandon W Godfrey
- Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States.
| | - Ashley Martin
- Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States
| | - Paul J Chestovich
- Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States
| | - Gordon H Lee
- Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States
| | - Nichole K Ingalls
- Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States
| | - Vilas Saldanha
- Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States
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