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Osborne-Smith L, Swerdlow B. Emergency Operable Traumatic Pulmonary Injury at a Level 1 Trauma Center: A Retrospective Descriptive Study. Mil Med 2024:usae417. [PMID: 39298324 DOI: 10.1093/milmed/usae417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/29/2024] [Accepted: 08/21/2024] [Indexed: 09/21/2024] Open
Abstract
INTRODUCTION Despite the use of body armor, emergency operable pulmonary trauma (EOPT) remains a major cause of battlefield morbidity and mortality. While EOPT during military conflicts has some features that distinguish it from EOPT in civilian settings, the 2 occurrences demonstrate overall parallel findings related to presentation, management, and outcome. The goals of the present study were to provide a descriptive analysis of the nature of EOPT and its management at a level 1 trauma center and to determine the associations between EOPT patient demographics and/or patient management and outcome in order to better understand battlefield EOPT. MATERIALS AND METHODS This is a retrospective, descriptive analysis of EOPT at a level 1 trauma center during a recent 9-year period (2012-2020). The Oregon Health & Science University Trauma Registry was searched, and 106 patients met inclusion criteria for the study. Patients with primary cardiac trauma were excluded. Individual electronic medical records were reviewed to obtain descriptive data, and associations were evaluated for statistical significance. RESULTS In-hospital mortality in this cohort was 17.0%. The most common pulmonary injury associated with EOPT was unilateral diaphragmatic laceration (62.3%), and the most common single operation performed for EOPT was a laparotomy (71.7%) often involving diaphragmatic repair. In the remaining instances of EOPT, a thoracotomy (11.3%), a thoracotomy and a laparotomy (10.4%), or another surgery (6.6%) occurred. The primary indication for EOPT surgery was uncontrolled hemorrhage, and one-third of patients received massive transfusion. One-lung ventilation (OLV) was infrequently employed (8.5%). When OLV was used, it was equally likely to involve a single-lumen endotracheal tube (SLETT) with mainstem bronchus insertion, a SLETT with a bronchial blocker, or a double-lumen endotracheal tube. Time from EOPT to operating room arrival was inversely related to in-hospital mortality. Also, both initial in-hospital endotracheal intubation and low injury severity score were strongly associated with survival in the population studied. CONCLUSIONS The most common indication for EOPT surgery was uncontrolled hemorrhage. The most frequent operation performed for this EOPT cohort was a laparotomy for diaphragmatic repair. A total of 91.5% of EOPT surgery was performed without OLV, an unexpected finding. When OLV occurred, it was equally likely to involve an SLETT with mainstem bronchus insertion, an SLETT with bronchial blocker, or a double-lumen endotracheal tube. The most common indication for OLV was surgical exposure. More extensive injury (expressed as an injury severity score), preadmission endotracheal intubation, and a shorter time from EOPT to operating room arrival were associated with increased odds ratios for mortality. A better understanding of the nature of EOPT at a civilian level 1 trauma center can serve to identify conditions that are associated with more favorable outcomes for EOPT under battlefield conditions and thereby assist in both management decisions and to help prognosticate and triage severely injured patients in that setting.
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Affiliation(s)
- Lisa Osborne-Smith
- Nurse Anesthesia Program, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Barry Swerdlow
- Nurse Anesthesia Program, Oregon Health & Science University, Portland, OR 97239, USA
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van Dongen TTCF, Berendsen RR, de Jong FJM, Endert EL, van Hulst RA, Hoencamp R. Frostbite: a systematic review on freezing cold injuries in a military environment. BMJ Mil Health 2023:e002171. [PMID: 36750255 DOI: 10.1136/military-2022-002171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 12/27/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Military practice or deployment in extreme conditions includes risks, dangers and rare disorders. One of the challenges is frostbite; however, current literature does not provide an overview of this condition in a military context. This review aims to map the incidence, risk factors and outcome of frostbite in military casualties in the armed forces. METHODS A systematic literature search on frostbite (freezing cold injuries) in military settings from 1995 to the present was performed. A critical appraisal of the included articles was conducted. Data on incidence, risk factors, treatment and outcome were extracted. RESULTS Fourteen studies were included in our systematic review. Most studies of frostbite in a military setting were published nearly half a century ago. Frostbite incidence has declined from 7% to around 1% in armed forces in arctic regions but could be as high as 20% in small-scale arctic manoeuvres. Overall and military-specific risk factors for contracting frostbite were identified. CONCLUSION During inevitable arctic manoeuvres, frostbite is a frequently diagnosed injury in service members. Postfreezing symptoms often persist after severe frostbite injury, which decreases employability within the service. Over time, military practice has changed considerably, and modern protective materials have been introduced; therefore, re-evaluation and future study in the military field are appropriate, preferably with other North Atlantic Treaty Organization partners.
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Affiliation(s)
- T T C F van Dongen
- Defence Healthcare Organisation, Ministry of Defence, Utrecht, The Netherlands
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - R R Berendsen
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - F J M de Jong
- Dive Medical Centre, Royal Netherlands Navy, Den Helder, The Netherlands
| | - E L Endert
- Dive Medical Centre, Royal Netherlands Navy, Den Helder, The Netherlands
| | - R A van Hulst
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - R Hoencamp
- Defence Healthcare Organisation, Ministry of Defence, Utrecht, The Netherlands
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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3
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Vrancken SM, Borger van der Burg BL, DuBose JJ, Glaser JJ, Hörer TM, Hoencamp R. Advanced bleeding control in combat casualty care: An international, expert-based Delphi consensus. J Trauma Acute Care Surg 2022; 93:256-264. [PMID: 35067523 PMCID: PMC9323555 DOI: 10.1097/ta.0000000000003525] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/03/2021] [Accepted: 12/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hemorrhage from truncal and junctional injuries is responsible for the vast majority of potentially survivable deaths in combat casualties, causing most of its fatalities in the prehospital arena. Optimizing the deployment of the advanced bleeding control modalities required for the management of these injuries is essential to improve the survival of severely injured casualties. This study aimed to establish consensus on the optimal use and implementation of advanced bleeding control modalities in combat casualty care. METHODS A Delphi method consisting of three rounds was used. An international expert panel of military physicians was selected by the researchers to complete the Delphi surveys. Consensus was reached if 70% or greater of respondents agreed and if 70% or greater responded. RESULTS Thirty-two experts from 10 different nations commenced the process and reached consensus on which bleeding control modalities should be part of the standard equipment, that these modalities should be available at all levels of care, that only trained physicians should be allowed to apply invasive bleeding control modalities, but all medical and nonmedical personnel should be allowed to apply noninvasive bleeding control modalities, and on the training requirements for providers. Consensus was also reached on the necessity of international registries and guidelines, and on certain indications and contraindications for resuscitative endovascular balloon occlusion of the aorta (REBOA) in military environments. No consensus was reached on the role of a wound clamp in military settings and the indications for REBOA in patients with chest trauma, penetrating axillary injury or penetrating neck injury in combination with thoracoabdominal injuries. CONCLUSION Consensus was reached on the contents of a standard bleeding control toolbox, where it should be available, providers and training requirements, international registries and guidelines, and potential indications for REBOA in military environments.
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Affiliation(s)
- Suzanne M. Vrancken
- From the Department of Surgery (S.M.V., B.L.S.B.v.d.B., R.H.), Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit, Department of Surgery (S.M.V., R.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; R Adams Cowley Shock Trauma Center (J.J.D.), University of Maryland, Baltimore, Maryland; Naval Medical Research Unit San Antonio (J.J.G.), JBSA-Ft. Sam Houston, Texas; San Antonio Military Medical Center (J.J.G.), JBSA-Ft. Sam Houston, Texas; Department of Cardiothoracic and Vascular Surgery (T.M.H.), Faculty of Medicine and Health, Örebro University Hospital, Örebro University, Örebro, Sweden; Department of Surgery, Faculty of Medicine and Health (T.M.H.), Örebro University Hospital, Örebro University, Örebro, Sweden; Defense Healthcare Organization, Ministry of Defense (R.H.), Utrecht, the Netherlands; and Department of Surgery, Leiden University Medical Centre (R.H.), Leiden, the Netherlands
| | - Boudewijn L.S. Borger van der Burg
- From the Department of Surgery (S.M.V., B.L.S.B.v.d.B., R.H.), Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit, Department of Surgery (S.M.V., R.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; R Adams Cowley Shock Trauma Center (J.J.D.), University of Maryland, Baltimore, Maryland; Naval Medical Research Unit San Antonio (J.J.G.), JBSA-Ft. Sam Houston, Texas; San Antonio Military Medical Center (J.J.G.), JBSA-Ft. Sam Houston, Texas; Department of Cardiothoracic and Vascular Surgery (T.M.H.), Faculty of Medicine and Health, Örebro University Hospital, Örebro University, Örebro, Sweden; Department of Surgery, Faculty of Medicine and Health (T.M.H.), Örebro University Hospital, Örebro University, Örebro, Sweden; Defense Healthcare Organization, Ministry of Defense (R.H.), Utrecht, the Netherlands; and Department of Surgery, Leiden University Medical Centre (R.H.), Leiden, the Netherlands
| | - Joseph J. DuBose
- From the Department of Surgery (S.M.V., B.L.S.B.v.d.B., R.H.), Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit, Department of Surgery (S.M.V., R.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; R Adams Cowley Shock Trauma Center (J.J.D.), University of Maryland, Baltimore, Maryland; Naval Medical Research Unit San Antonio (J.J.G.), JBSA-Ft. Sam Houston, Texas; San Antonio Military Medical Center (J.J.G.), JBSA-Ft. Sam Houston, Texas; Department of Cardiothoracic and Vascular Surgery (T.M.H.), Faculty of Medicine and Health, Örebro University Hospital, Örebro University, Örebro, Sweden; Department of Surgery, Faculty of Medicine and Health (T.M.H.), Örebro University Hospital, Örebro University, Örebro, Sweden; Defense Healthcare Organization, Ministry of Defense (R.H.), Utrecht, the Netherlands; and Department of Surgery, Leiden University Medical Centre (R.H.), Leiden, the Netherlands
| | - Jacob J. Glaser
- From the Department of Surgery (S.M.V., B.L.S.B.v.d.B., R.H.), Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit, Department of Surgery (S.M.V., R.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; R Adams Cowley Shock Trauma Center (J.J.D.), University of Maryland, Baltimore, Maryland; Naval Medical Research Unit San Antonio (J.J.G.), JBSA-Ft. Sam Houston, Texas; San Antonio Military Medical Center (J.J.G.), JBSA-Ft. Sam Houston, Texas; Department of Cardiothoracic and Vascular Surgery (T.M.H.), Faculty of Medicine and Health, Örebro University Hospital, Örebro University, Örebro, Sweden; Department of Surgery, Faculty of Medicine and Health (T.M.H.), Örebro University Hospital, Örebro University, Örebro, Sweden; Defense Healthcare Organization, Ministry of Defense (R.H.), Utrecht, the Netherlands; and Department of Surgery, Leiden University Medical Centre (R.H.), Leiden, the Netherlands
| | - Tal M. Hörer
- From the Department of Surgery (S.M.V., B.L.S.B.v.d.B., R.H.), Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit, Department of Surgery (S.M.V., R.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; R Adams Cowley Shock Trauma Center (J.J.D.), University of Maryland, Baltimore, Maryland; Naval Medical Research Unit San Antonio (J.J.G.), JBSA-Ft. Sam Houston, Texas; San Antonio Military Medical Center (J.J.G.), JBSA-Ft. Sam Houston, Texas; Department of Cardiothoracic and Vascular Surgery (T.M.H.), Faculty of Medicine and Health, Örebro University Hospital, Örebro University, Örebro, Sweden; Department of Surgery, Faculty of Medicine and Health (T.M.H.), Örebro University Hospital, Örebro University, Örebro, Sweden; Defense Healthcare Organization, Ministry of Defense (R.H.), Utrecht, the Netherlands; and Department of Surgery, Leiden University Medical Centre (R.H.), Leiden, the Netherlands
| | - Rigo Hoencamp
- From the Department of Surgery (S.M.V., B.L.S.B.v.d.B., R.H.), Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit, Department of Surgery (S.M.V., R.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; R Adams Cowley Shock Trauma Center (J.J.D.), University of Maryland, Baltimore, Maryland; Naval Medical Research Unit San Antonio (J.J.G.), JBSA-Ft. Sam Houston, Texas; San Antonio Military Medical Center (J.J.G.), JBSA-Ft. Sam Houston, Texas; Department of Cardiothoracic and Vascular Surgery (T.M.H.), Faculty of Medicine and Health, Örebro University Hospital, Örebro University, Örebro, Sweden; Department of Surgery, Faculty of Medicine and Health (T.M.H.), Örebro University Hospital, Örebro University, Örebro, Sweden; Defense Healthcare Organization, Ministry of Defense (R.H.), Utrecht, the Netherlands; and Department of Surgery, Leiden University Medical Centre (R.H.), Leiden, the Netherlands
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Tribble DR, Spott MA, Shackleford SA, Gurney JM, Murray BCK. Department of Defense Trauma Registry Infectious Disease Module Impact on Clinical Practice. Mil Med 2022; 187:7-16. [PMID: 35512379 DOI: 10.1093/milmed/usac050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/03/2022] [Accepted: 02/14/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Joint Trauma System (JTS) is a DoD Center of Excellence for Military Health System trauma care delivery and the DoD's reference body for trauma care in accordance with National Defense Authorization Act for Fiscal Year 2017. Through the JTS, evidence-based clinical practice guidelines (CPGs) have been developed and subsequently refined to standardize and improve combat casualty care. Data are amassed through a single, centralized DoD Trauma Registry to support process improvement measures with specialty modules established as the registry evolved. Herein, we review the implementation of the JTS DoD Trauma Registry specialty Infectious Disease Module and the development of infection-related CPGs and summarize published findings on the subsequent impact of the Infectious Disease Module on combat casualty care clinical practice and guidelines. METHODS The DoD Trauma Registry Infectious Disease Module was developed in collaboration with the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious Disease Outcomes Study (TIDOS). Infection-related information (e.g., syndromes, antibiotic management, and microbiology) were collected from military personnel wounded during deployment June 1, 2009 through December 31, 2014 and medevac'd to Landstuhl Regional Medical Center in Germany before transitioning to participating military hospitals in the USA. RESULTS To support process improvements and reduce variation in practice patterns, data collected through the Infectious Disease Module have been utilized in TIDOS analyses focused on assessing compliance with post-trauma antibiotic prophylaxis recommendations detailed in JTS CPGs. Analyses examined compliance over three time periods: 6 months, one-year, and 5 years. The five-year analysis demonstrated significantly improved adherence to recommendations following the dissemination of the 2011 JTS CPG, particularly with open fractures (34% compliance compared to 73% in 2013-2014). Due to conflicting recommendations regarding use of expanded Gram-negative coverage with open fractures, infectious outcomes among patients with open fractures who received cefazolin or expanded Gram-negative coverage (cefazolin plus fluoroquinolones and/or aminoglycosides) were also examined in a TIDOS analysis. The lack of a difference in the proportion of osteomyelitis (8% in both groups) and the significantly greater recovery of Gram-negative organisms resistant to aminoglycosides or fluoroquinolones among patients who received expanded Gram-negative coverage supported JTS recommendations regarding the use of cefazolin with open fractures. Following recognition of the outbreak of invasive fungal wound infections (IFIs) among blast casualties injured in Afghanistan, the ID Module was refined to capture data (e.g., fungal culture and histopathology findings, wound necrosis, and antifungal management) needed for the TIDOS team to lead the DoD outbreak investigation. These data captured through the Infectious Disease Module provided support for the development of a JTS CPG for the prevention and management of IFIs, which was later refined based on subsequent TIDOS IFI analyses. CONCLUSIONS To improve combat casualty care outcomes and mitigate high-consequence infections in future conflicts, particularly in the event of prolonged field care, expansion, refinement, and a mechanism for sustainability of the DoD Trauma Registry Infectious Disease Module is needed to include real-time surveillance of infectious disease trends and outcomes.
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Affiliation(s)
- David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Mary Ann Spott
- Joint Trauma System, JBSA Fort Sam Houston, TX 78234, USA
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Lier H, Bernhard M, Knapp J, Buschmann C, Bretschneider I, Hossfeld B. [Approaches to pre-hospital bleeding management : Current overview on civilian emergency medicine]. Anaesthesist 2018; 66:867-878. [PMID: 28785773 DOI: 10.1007/s00101-017-0350-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Severe bleeding is a typical result of traumatic injuries. Hemorrhage is responsible for almost 50% of deaths within the first 6 h after trauma. Appropriate bleeding control and coagulation therapy depends on an integrated concept of local hemostasis by primary pressure with the hands, compression, and tourniquets accompanied by prevention of hypothermia, acidosis and hypocalcemia. Additionally, permissive hypotension is accepted for suitable patients and tranexamic acid should be administered early. Multiple publications prove that prehospital transfusion of blood products (e. g. red blood cells and plasma) and coagulation factors (e. g. fibrinogen) is feasible and safe, but only required for <5% of polytrauma patients in the civilian setting.
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Affiliation(s)
- H Lier
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Straße 62, 50937, Köln, Deutschland. .,Arbeitsgruppe "Taktische Medizin" des Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland.
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Arbeitsgruppe "Trauma- und Schockraummanagement" des Arbeitskreis Notfallmedizin, Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland
| | - J Knapp
- Klinik für Anästhesiologie und Schmerztherapie, Universitätsspital Bern, Bern, Schweiz.,Air Zermatt, Zermatt, Schweiz
| | - C Buschmann
- Institut für Rechtsmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - I Bretschneider
- Klinik für Anästhesiologie & Intensivmedizin, Bundeswehrkrankenhaus, Ulm, Deutschland
| | - B Hossfeld
- Klinik für Anästhesiologie & Intensivmedizin, Bundeswehrkrankenhaus, Ulm, Deutschland.,Arbeitsgruppe "Taktische Medizin" des Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland
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Vickers ML, Coorey CP, Milinovich GJ, Eriksson L, Assoum M, Reade MC. Bibliometric analysis of military trauma publications: 2000-2016. J ROY ARMY MED CORPS 2018; 164:142-149. [PMID: 29331949 DOI: 10.1136/jramc-2017-000858] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/05/2017] [Accepted: 12/06/2017] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Bibliometric tools can be used to identify the authors, topics and research institutions that have made the greatest impact in a field of medicine. The aim of this research was to analyse military trauma publications over the last 16 years of armed conflict in order to highlight the most important lessons that have translated into civilian practice and military doctrine as well as identify emerging areas of importance. METHODS A systematic search of research published between January 2000 and December 2016 was conducted using the Thompson Reuters Web of Science database. Both primary evidence and review publications were included. Results were categorised according to relevance and topic and the 30 most cited publications were reviewed in full. The h-index, impact factors, citation counts and citation analysis were used to evaluate results. RESULTS A plateau in the number of annual publications on military trauma was found, as was a shift away from publications on wound and mortality epidemiology to publications on traumatic brain injury (TBI), neurosurgery or blast injury to the head. Extensive collaboration networks exist between highly contributing authors and institutions, but less collaboration between authors from different countries. The USA produced the majority of recent publications, followed by the UK, Germany and Israel. CONCLUSIONS In recent years, the number of publications on TBI, neurosurgery or blast injury to the head has increased. It is likely that the lessons of recent conflicts will continue to influence civilian medical practice, particularly regarding the long-term effects of blast-related TBI.
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Affiliation(s)
- Mark L Vickers
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - C P Coorey
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - G J Milinovich
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - L Eriksson
- Herston Health Sciences Library, The University of Queensland, St Lucia, Queensland, Australia
| | - M Assoum
- Centre for Child Health Research, The University of Queensland, South Brisbane, Queensland, Australia
| | - M C Reade
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia.,Joint Health Command, Australian Defence Force, Canberra, Australia
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