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Overmann AL, Harrington CJ, Richards JT, Colantonio DT, Renninger CH, Stinner DJ, Forsberg JA. What is the Case Volume of Orthopaedic Trauma Surgeons in the Military Health System? An Assessment of Wartime Readiness and Skills Sustainment. Mil Med 2024:usae314. [PMID: 38900157 DOI: 10.1093/milmed/usae314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/27/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION Complex, high-energy extremity trauma secondary to explosive mechanisms has been increasingly common in modern warfare, accounting for a majority of combat wounds throughout the conflicts in Iraq and Afghanistan. Fellowship-trained orthopaedic trauma surgeons treated many of these complex injuries; however, as the number of casualties continue to decrease during a period of relative peace, a growing concern over maintaining military trauma readiness exists. METHODS The Military Health System Data Repository was queried for all Common Procedural Terminology (CPT) codes associated with 18 fellowship-trained orthopaedic trauma surgeons from 2013 to 2019. The codes were further analyzed and categorized based on common trauma subspecialty procedures such as fracture fixation of the pelvic ring, acetabulum, upper and lower extremity, peri-articular, and nonunion/malunion surgery. We used descriptive statistics to quantify both the average number of cases per surgeon per year in each of the subcategories and case volume among Military Treatment Facilities (MTFs) during the study period. RESULTS We identified 7,769 CPT codes for surgical procedures throughout the study period. The most common surgical procedures performed were: removal of implant (n = 836, 11%), knee arthroscopy (n = 507, 7%), and debridement of devitalized tissue (n = 345, 4%). The total trauma subspecialty procedural codes and average cases per surgeon per year were as follows: pelvic ring (n = 54, <1 case/year), acetabulum (n = 90, 1 case/year), upper extremity (n = 1,314, 15 cases/year), lower extremity (n = 2,286, 25 cases/year), peri-articular (n = 675, 8 cases/year), and nonunion/malunion (n = 288, 3 cases/year). San Antonio Military Medical Center (SAMMC) accounted for the most fracture-related CPT codes overall (35%), while all other MTFs contributed approximately 10% or less of all fracture-related codes. CONCLUSIONS These results highlight the lack of orthopaedic trauma volume at other MTFs outside of SAMMC, raising concern for maintaining military readiness during an inter-war period of relative peace. The DoD continues to make concerted efforts to maintain readiness through civilian partnerships and subsequently increase surgical case volume for military trauma surgeons. Future efforts should include an in-depth analysis of caseloads of military trauma surgeons providing care at both MTFs and civilian institutions to optimize preparedness in future conflicts.
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Affiliation(s)
- Archie L Overmann
- Orthopaedic Surgery, Eisenhower Army Medical Center, Fort Eisenhower, GA 30905, USA
- Orthopaedic Surgery, Medical College of Georgia, Augusta, GA 30912, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Colin J Harrington
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - John T Richards
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Orthopaedic Surgery, Naval Medical Center LeJeune, Camp Lejeune, NC 28547, USA
| | - Donald T Colantonio
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Orthopaedic Surgery, Keller Army Community Hospital, West Point, NY 10996, USA
| | - Christopher H Renninger
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Daniel J Stinner
- Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Orthopaedic Surgery, Blanchfield Army Community Hospital, Fort Campbell, TN 42223, USA
| | - Jonathan A Forsberg
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Doshi TL, Sandbrink F, Cohen SP. Postamputation limb pain in military personnel: separate but equal or separate and never equal? Pain 2024; 165:723-724. [PMID: 38112618 DOI: 10.1097/j.pain.0000000000003095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 12/21/2023]
Affiliation(s)
- Tina L Doshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Friedhelm Sandbrink
- Department of Neurology, Washington Veterans Affairs Medical Center, Washington, DC, United States
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Department of Neurology, George Washington University School of Medicine, Washington, DC, United States
| | - Steven P Cohen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, Physical Medicine and Rehabilitation and Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Department of Physical Medicine and Rehabilitation and Anesthesiology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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Mueller NN, Kim Y, Ocoko MYM, Dernelle P, Kale I, Patwa S, Hermoso AC, Chirra D, Capadona JR, Hess-Dunning A. Effects of Micromachining on Anti-oxidant Elution from a Mechanically-Adaptive Polymer. JOURNAL OF MICROMECHANICS AND MICROENGINEERING : STRUCTURES, DEVICES, AND SYSTEMS 2024; 34:10.1088/1361-6439/ad27f7. [PMID: 38586082 PMCID: PMC10996452 DOI: 10.1088/1361-6439/ad27f7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Intracortical microelectrodes (IMEs) can be used to restore motor and sensory function as a part of brain-computer interfaces in individuals with neuromusculoskeletal disorders. However, the neuroinflammatory response to IMEs can result in their premature failure, leading to reduced therapeutic efficacy. Mechanically-adaptive, resveratrol-eluting (MARE) neural probes target two mechanisms believed to contribute to the neuroinflammatory response by reducing the mechanical mismatch between the brain tissue and device, as well as locally delivering an antioxidant therapeutic. To create the mechanically-adaptive substrate, a dispersion, casting, and evaporation method is used, followed by a microfabrication process to integrate functional recording electrodes on the material. Resveratrol release experiments were completed to generate a resveratrol release profile and demonstrated that the MARE probes are capable of long-term controlled release. Additionally, our results showed that resveratrol can be degraded by laser-micromachining, an important consideration for future device fabrication. Finally, the electrodes were shown to have a suitable impedance for single-unit neural recording and could record single units in vivo.
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Affiliation(s)
- Natalie N Mueller
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Youjoung Kim
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Mali Ya Mungu Ocoko
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Peter Dernelle
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Ishani Kale
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Simran Patwa
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Anna Clarissa Hermoso
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Deeksha Chirra
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Jeffrey R Capadona
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Allison Hess-Dunning
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
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Tropf JG, Hoyt BW, Walsh SA, Gibson JA, Polfer EM, Souza JM, Potter BK. Long-Term Health Outcomes of Limb Salvage Compared with Amputation for Combat-Related Trauma. J Bone Joint Surg Am 2023; 105:1867-1874. [PMID: 37733907 DOI: 10.2106/jbjs.22.01284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND There are little long-term health data, particularly in terms of body composition and development of metabolic syndromes, to help surgeons to guide the decision between limb salvage and amputation in patients with limb-threatening trauma. The purpose of this study was to compare long-term health outcomes after high-energy lower-extremity trauma between patients who underwent attempted flap-based limb salvage or amputation. METHODS We performed a retrospective review of servicemembers with a minimum 10-year follow-up who underwent flap-based limb salvage followed by unilateral amputation or continued limb salvage after combat-related, lower-extremity trauma between 2005 and 2011. Patient demographic characteristics, injury characteristics, and health outcomes including body mass index (BMI) and development of metabolic disease (e.g., hyperlipidemia, hypertension, heart disease, and diabetes) were compared between treatment cohorts. Adjusted BMIs were calculated for the amputation cohort to account for lost surface area. We performed multivariable and propensity score analysis to determine the likelihood of developing obesity or metabolic disease. RESULTS In this study, 110 patients had available long-term follow-up (mean, 12.2 years) from the time of the injury. Fifty-six patients underwent limb salvage and 54 patients underwent unilateral amputation. There was no difference in preinjury BMI (p = 0.30). After adjusting for limb loss, the amputation cohort had a trend toward higher BMIs at ≥1 years after the injury, a higher rate of obesity, and a greater increase in BMI from baseline after the injury. The development of metabolic comorbidities was common after both amputation (23 [43%] of 54) and limb salvage (27 [48%] of 56). With the numbers available, we were unable to demonstrate a difference in risk for the development of hypertension, hyperlipidemia, diabetes, heart disease, or any comorbidity other than obesity (p > 0.05). CONCLUSIONS Amputations may be medically necessary and may decrease pain, improve mobility, and/or expedite return to activity compared with limb salvage after similar injuries. However, limb loss may negatively impact metabolic regulation and may contribute to a higher risk of obesity despite beneficial effects on mobility. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jordan G Tropf
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Benjamin W Hoyt
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Sarah A Walsh
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | | | - Jason M Souza
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Plastic and Reconstructive Surgery, Ohio State University, Columbus, Ohio
| | - Benjamin K Potter
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
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Hutaif M, Al Moaish A, Soliman M, Al-Fadliy A. The hidden toll of war: a comprehensive study of orthopedic injuries in Yemen. Confl Health 2023; 17:55. [PMID: 38037162 PMCID: PMC10691014 DOI: 10.1186/s13031-023-00551-8] [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: 06/18/2023] [Accepted: 11/01/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Yemen has been experiencing a protracted civil war and humanitarian crisis since 2015, which has resulted in many war-related injuries. However, there is a lack of data on the epidemiology, characteristics, and outcomes of these injuries, especially the orthopedic ones. This study aimed to describe the war-related orthopedic injuries in Yemen and their impact on the patients' health and function. METHODS This was a retrospective study based on medical records and trauma registries of 3930 patients who were admitted to three major trauma centers in Sana'a city with war-related orthopedic injuries from January 2015 to December 2020. We collected data on demographics, injury mechanisms, injury types and locations, surgical procedures, complications, mortality, and functional outcomes using the Musculoskeletal Function Assessment questionnaire. We used descriptive and inferential statistics to analyze the data and performed a logistic regression analysis to identify the factors associated with mortality. RESULTS Most of the patients were young males and civilians who suffered from complex and severe injuries involving multiple body regions, especially the lower extremities. The main mechanisms of injury were gunshot wounds, blast injuries, and landmine explosions. The patients required multiple surgical procedures and implants, and had high rates of complications and mortality. The most common complications were infection, nonunion, malunion, and amputation. The most common cause of death was sepsis. The functional outcomes were poor, as indicated by the high mean MFA score. The logistic regression analysis showed that older age, blast injuries, spine injuries, vascular injuries, and infection were significant predictors of mortality. CONCLUSION This study provides valuable information on the war-related orthopedic injuries in Yemen and their impact on the patients' health and function. It also identifies some areas for future research, such as exploring the risk factors for infection and nonunion/malunion, evaluating the effectiveness and cost-effectiveness of different surgical procedures and implants, assessing the long-term outcomes and quality of life of the patients, and developing novel strategies to enhance bone and soft-tissue healing.
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Affiliation(s)
- Mohammad Hutaif
- Sana'a University School of Medicine, Vice Dean, Sana'a, Yemen.
| | | | - Mosleh Soliman
- Sana'a University School of Medicine, Vice Dean, Sana'a, Yemen
| | - Anwar Al-Fadliy
- Sana'a University School of Medicine, Vice Dean, Sana'a, Yemen
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Staruch R, Naumann DN, Wordsworth M, Jeffery S, Rickard R. Understanding progressive tissue loss and wound burden in combat casualties: lessons learnt for future operational capability. BMJ Mil Health 2023:e002227. [PMID: 38053264 DOI: 10.1136/military-2022-002227] [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: 04/25/2023] [Accepted: 09/14/2023] [Indexed: 12/07/2023]
Abstract
Understanding tissue loss following injury is important due to its prevalence among the war-wounded and the impact it has on subsequent treatment and rehabilitation. Progressive tissue loss is a type of tissue loss that has complicated extremity injury in recent conflicts. It has resulted in more proximal residual limb lengths and has influenced rehabilitation. Quantifying wound burden in combat casualties remains a challenge due to poor quality of data sets that lack the capacity for detailed analysis. The aims of this article are to outline the current hurdles in attempting to quantify wound burden in combat casualties and to propose simple interventions to improve data capture for future analysis.
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Affiliation(s)
- Robert Staruch
- Department of Plastic & Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Department of Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - M Wordsworth
- Department of Burns and Plastic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - S Jeffery
- Department of Health Sciences, Aston University, Birmingham, UK
| | - R Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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7
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Drelich E, Tracz J, Cisowski A, Kowalik M, Figurski A, Kwacz M, Rządkowski W. Force prediction in the cylindrical grip for a model of hand prosthesis. Sci Rep 2023; 13:17205. [PMID: 37821502 PMCID: PMC10567731 DOI: 10.1038/s41598-023-43600-1] [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: 08/09/2022] [Accepted: 09/26/2023] [Indexed: 10/13/2023] Open
Abstract
The aim of this paper is to present an analytical method of calculating forces acting on the thumb, index, middle finger, and metacarpal part of a hand prosthesis in a cylindrical grip. This prehension pattern represents a common operation of grabbing and manipulating everyday life objects. The design process assumed that such a prosthesis would have 5 fully operating fingers and 18 total degrees of freedom: three for each finger including the thumb, and another three for the wrist. The assumed load was 1 kg and the diameter equaled 70 mm, representing a water bottle. The method was based on analytical mechanics and as opposed to experiments or numerical methods does not require many resources. The calculations involved solving a system with seven unknown forces using an equilibrium equation for forces and moments in all three axes. The resulting equations were presented in a matrix form and solved using MATLAB software. The validation of the method with an experiment using FSR sensors and comparing it to other reports showed differences in index and middle finger involvement. However, the total sum of forces was similar, therefore it is reasoned that the grip can be performed and the prediction was accurate for the thumb and metacarpal. When using the model, the friction coefficient must be chosen with a safe margin as it influences the grip force. The presented method can be used for other models and designs by inserting their dimensions into the equations and solving them numerically to obtain forces useful in mechatronics design.
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Affiliation(s)
- Ewelina Drelich
- Institute of Micromechanics and Photonics, Warsaw University of Technology, Św. Andrzeja Boboli 8, 02-525, Warsaw, Poland
| | - Jan Tracz
- Institute of Micromechanics and Photonics, Warsaw University of Technology, Św. Andrzeja Boboli 8, 02-525, Warsaw, Poland
- Institute of Aeronautics and Applied Mechanics, Warsaw University of Technology, Nowowiejska 24, 00-665, Warsaw, Poland
| | - Adam Cisowski
- Institute of Aeronautics and Applied Mechanics, Warsaw University of Technology, Nowowiejska 24, 00-665, Warsaw, Poland
| | - Michał Kowalik
- Institute of Aeronautics and Applied Mechanics, Warsaw University of Technology, Nowowiejska 24, 00-665, Warsaw, Poland
| | - Aleksy Figurski
- Institute of Aeronautics and Applied Mechanics, Warsaw University of Technology, Nowowiejska 24, 00-665, Warsaw, Poland
| | - Monika Kwacz
- Institute of Micromechanics and Photonics, Warsaw University of Technology, Św. Andrzeja Boboli 8, 02-525, Warsaw, Poland
| | - Witold Rządkowski
- Institute of Aeronautics and Applied Mechanics, Warsaw University of Technology, Nowowiejska 24, 00-665, Warsaw, Poland.
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Monaghan PG, Knight AD, Brinkerhoff SA, Harrison KD, Dearth CL, Hendershot BD, Sefton JM, Zabala M, Vazquez A, Shannon D, Crumbley D, Roper JA. Characterization of initial ankle-foot prosthesis prescription patterns in U.S. Service members following unilateral transtibial amputation. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1235693. [PMID: 37691914 PMCID: PMC10485831 DOI: 10.3389/fresc.2023.1235693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
Introduction The purpose of this study was to explore relationships between patient-specific characteristics and initial ankle-foot prosthesis prescription patterns among U.S. Service members with unilateral transtibial limb loss. Methods A retrospective review of health records identified 174 individuals with unilateral transtibial limb loss who received care at Walter Reed National Military Medical Center between 2001 and 2019. We examined patient-specific factors such as demographics, participant duty status at injury and amputation, amputation etiology, and timing between injury, amputation, and initial prescription. The type of first prescribed ankle-foot prosthesis was categorized as energy storing and return - nonarticulating, energy storing and return - articulating, or computer controlled. Results Sex, amputation etiology, time from injury to initial prescription, and time from amputation to initial prescription differed by type of initial ankle-foot prosthesis prescription. Service members with shorter intervals between injury-initial prescription and amputation-initial prescription, and those injured by combat blast, were more likely to receive a non-articulating device. Incorporating sex, time from injury-initial prescription, time from amputation-initial prescription, and amputation etiology as predictors of prosthesis type, we were able to correctly classify 72% of all first prostheses prescribed. Discussion Patient-specific characteristics such as sex, the time between injury-initial prescription, time from amputation-initial prescription and amputation etiology are essential characteristics that influence initial ankle-foot prosthesis prescription patterns in U.S. Service members.
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Affiliation(s)
| | - Ashley D. Knight
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, United States
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, United States
- Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | | | - Christopher L. Dearth
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, United States
- Department of Surgery, Uniformed Services University of the Health Sciences—Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Brad D. Hendershot
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, United States
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, United States
- Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Michael Zabala
- Department of Mechanical Engineering, Auburn University, Auburn, AL, United States
| | - Adan Vazquez
- School of Kinesiology, Auburn University, Auburn, AL, United States
- Department of Prosthetics and Orthotics, Alabama State University, Montgomery, AL, United States
| | - David Shannon
- Department of Educational Foundations, Leadership, and Technology, Auburn University, Auburn, AL, United States
| | - David Crumbley
- School of Nursing, Auburn University, Auburn, AL, United States
| | - Jaimie A. Roper
- School of Kinesiology, Auburn University, Auburn, AL, United States
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9
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Spain DR, Andrews AM, Crews SA, Khan JM. Males With Traumatic Lower Limb Loss Differ in Body Fat Distribution Compared to Those Without Limb Loss. Mil Med 2023; 188:e140-e144. [PMID: 34143209 DOI: 10.1093/milmed/usab237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/08/2021] [Accepted: 06/04/2021] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES The primary objective was to examine body fat composition in males with traumatic lower limb loss and a comparison group without limb loss. A secondary objective was to determine if there are differences in body fat composition by traumatic limb loss level. RESEARCH METHODS AND PROCEDURES Cross-sectional analyses of baseline in-person intake data was completed at a large military medical center. Data were collected from 2011 to 2020, and analysis was conducted in 2020. Participants (n = 89) included males who sustained traumatic lower limb loss (n = 50) and an age-matched comparison group without limb loss (n = 39). Mean age of participants was 36.0 ± 13.2 years. Main outcomes measured included age, height, body mass index, weight, body fat mass and percent, android fat mass and percent, gynoid fat mass and percent, and android/gynoid percent fat ratio. Differences between groups were assessed using t-tests or Mann-Whitney U tests. Differences between limb loss levels were assessed using one-way ANOVA or Wilcoxon signed-rank test. RESULTS Body fat percent (P = .001), gynoid fat percent (P = .010), android fat mass (P = .01), and percent (P = .02) were higher in the group with limb loss. There were no differences in body fat composition between limb loss levels (P > .05). CONCLUSION Males with traumatic lower limb loss had a higher body fat percent compared to those without limb loss. Given higher body fat composition in individuals with limb loss and the relationship between body fat composition and cardiovascular disease risk, including body composition analysis with clinical screening could identify changes and allow for early intervention.
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Affiliation(s)
- David R Spain
- Nutrition Services Department, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA.,U.S. Military-Baylor, Graduate Program of Nutrition, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA.,Nutrition Care Division, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Anne M Andrews
- Research Protections Office, National Institute of Standards and Technology, Gaithersburg, MD 20889, USA.,Department of Orthopaedics and Rehabilitation, and US Military-Baylor Graduate Program in Nutrition, Nutrition Services Department, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Sara A Crews
- U.S. Military-Baylor, Graduate Program of Nutrition, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA.,Nutrition Services Department, Darnall Army Medical Center, Fort Hood, TX 76544, USA
| | - Joetta M Khan
- Nutrition Services Department, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
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10
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Greising SM, Weiner JI, Garry DJ, Sachs DH, Garry MG. Human muscle in gene edited pigs for treatment of volumetric muscle loss. Front Genet 2022; 13:948496. [PMID: 35957684 PMCID: PMC9358139 DOI: 10.3389/fgene.2022.948496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022] Open
Abstract
Focusing on complex extremity trauma and volumetric muscle loss (VML) injuries, this review highlights: 1) the current pathophysiologic limitations of the injury sequela; 2) the gene editing strategy of the pig as a model that provides a novel treatment approach; 3) the notion that human skeletal muscle derived from gene edited, humanized pigs provides a groundbreaking treatment option; and 4) the impact of this technologic platform and how it will advance to far more multifaceted applications. This review seeks to shed insights on a novel treatment option using gene edited pigs as a platform which is necessary to overcome the clinical challenges and limitations in the field.
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Affiliation(s)
- Sarah M. Greising
- School of Kinesiology, University of Minnesota, Minneapolis, MN, United States
- *Correspondence: Sarah M. Greising, ; Mary G. Garry,
| | - Joshua I. Weiner
- Departments of Surgery, Columbia Center for Translations Immunology, College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Daniel J. Garry
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States
- Lillehei Heart Institute, University of Minnesota, Minneapolis, MN, United States
- NorthStar Genomics, Eagan, MN, United States
| | - David H. Sachs
- Departments of Surgery, Columbia Center for Translations Immunology, College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Mary G. Garry
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States
- Lillehei Heart Institute, University of Minnesota, Minneapolis, MN, United States
- NorthStar Genomics, Eagan, MN, United States
- *Correspondence: Sarah M. Greising, ; Mary G. Garry,
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Hering K, Fisher MWA, Dalton MK, Simpson AK, Ye J, Suneja N, Cooper Z, Koehlmoos TP, Schoenfeld AJ. Health-Care Utilization and Expenditures Associated with Long-Term Treatment After Combat and Non-Combat-Related Orthopaedic Trauma. J Bone Joint Surg Am 2022; 104:864-871. [PMID: 35142748 DOI: 10.2106/jbjs.21.01124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The long-term consequences of musculoskeletal trauma can be profound and can extend beyond the post-injury period. The surveillance of long-term expenditures among individuals who sustain orthopaedic trauma has been limited in prior work. We sought to compare the health-care requirements of active-duty individuals who sustained orthopaedic injuries in combat and non-combat (United States) environments using TRICARE claims data. METHODS We identified service members who sustained combat or non-combat musculoskeletal injuries between 2007 and 2011. Combat-injured personnel were matched to those in the non-combat-injured cohort on a 1:1 basis using biologic sex, year of the injury, Injury Severity Score (ISS), and age at the index hospitalization. Health-care utilization was surveyed through 2018. The total health-care expenditures over the post-injury period were the primary outcome. These were assessed as a total overall cost and then as costs adjusted per year of follow-up. We used negative binomial regression to identify the independent association between risk factors and health-care expenditures. RESULTS We identified 2,119 individuals who sustained combat-related orthopaedic trauma and 2,119 individuals who sustained non-combat injuries. The most common mechanism of injury within the combat-injured cohort was blast-related trauma (59%), and 418 individuals (20%) sustained an amputation. The total costs were $156,886 for the combat-injured group compared with $55,873 for the non-combat-injured group (p < 0.001). Combat-related orthopaedic injuries were associated with a 43% increase in health-care expenditures (incidence rate ratio, 1.43 [95% confidence interval, 1.19 to 1.73]). Severe ISS at presentation, ≥2 comorbidities, and amputations were also significantly associated with health-care utilization, as was junior enlisted rank, our proxy for socioeconomic status. CONCLUSIONS Health-care requirements and associated costs are substantial among service members sustaining combat and non-combat orthopaedic trauma. Given the sociodemographic characteristics of our cohort, we believe that these results are translatable to civilians who sustain similar types of musculoskeletal trauma.
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Affiliation(s)
| | - Miles W A Fisher
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jamie Ye
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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McDonald J, Liang SY, Li P, Stewart L, Tribble DR. DoD-VA Trauma Infection Research Collaboration. Mil Med 2022; 187:17-24. [PMID: 35512378 DOI: 10.1093/milmed/usab482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/28/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the aftermath of wars, there is a surge in the number of wounded service members who leave active duty and become eligible for healthcare through the Department of Veterans Affairs (VA). Collaborations between the Department of Defense (DoD) and VA are crucial to capture comprehensive data and further understand the long-term impact of battlefield trauma. We provide a summary of the development, methodology, and status of an effective collaboration between the Infectious Disease Clinical Research Program and the St. Louis VA Health Care System with the multicenter, observational Trauma Infectious Disease Outcomes Study (TIDOS), which examines the short- and long-term outcomes of deployment-related trauma. METHODS As part of TIDOS, wounded service members who transitioned to participating military hospitals in the United States (2009-2014) were given the opportunity to enroll in a prospective follow-up cohort study to continue to capture infection-related data after their hospital discharge. Enrollees in the TIDOS cohort who left military service and received health care through the VA also had the option of consenting to have relevant VA medical records abstracted and included with the study data. Infections considered to be complications resulting from the initial trauma were examined. RESULTS Among 1,336 TIDOS enrollees, 1,221 (91%) registered and received health care through the VA with 633 (47%) consenting to follow-up using VA records and comprising the TIDOS-VA cohort. Of the first 337 TIDOS-VA cohort enrollees, 38% were diagnosed with a new trauma-related infection following hospital discharge (median: 88 days; interquartile range: 18-351 days). Approximately 71% of the infections were identified through DoD sources (medical records and follow-up) and 29% were identified through VA electronic medical records, demonstrating the utility of DoD-VA collaborations. The TIDOS DoD-VA collaboration has also been utilized to assess intermediate and long-term consequences of specific injury patterns. Among 89 TIDOS-VA cohort enrollees with genitourinary trauma, 36% reported sexual dysfunction, 21% developed at least one urinary tract infection, 14% had urinary retention/incontinence, and 8% had urethral stricture. The rate of urinary tract infections was 0.05/patient-year during DoD follow-up time and 0.07/patient-year during VA follow-up time. CONCLUSIONS Wider capture of infection-related outcome data through the DoD-VA collaboration provided a clearer picture of the long-term infection burden resulting from deployment-related trauma. Planned analyses include assessment of osteomyelitis among combat casualties with amputations and/or open fractures, evaluation of mental health and social factors related to injury patterns, and examination of health care utilization and cost in relation to infectious disease burdens.
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Affiliation(s)
- Jay McDonald
- Infectious Diseases Section, Veterans Affairs St. Louis Health Care System, St. Louis, MO 63106, USA.,Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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13
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Rodriguez RCJ, Ganesan A, Shaikh F, Carson ML, Bradley W, Warkentien TE, Tribble DR. Combat-Related Invasive Fungal Wound Infections. Mil Med 2022; 187:34-41. [PMID: 35512377 DOI: 10.1093/milmed/usab074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION During Operation Enduring Freedom in Afghanistan, an outbreak of combat-related invasive fungal wound infections (IFIs) emerged among casualties with dismounted blast trauma and became a priority issue for the Military Health System. METHODS In 2011, the Trauma Infectious Disease Outcomes Study (TIDOS) team led the Department of Defense IFI outbreak investigation to describe characteristics of IFIs among combat casualties and provide recommendations related to management of the disease. To support the outbreak investigation, existing IFI definitions and classifications utilized for immunocompromised patients were modified for use in epidemiologic research in a trauma population. Following the conclusion of the outbreak investigation, multiple retrospective analyses using a population of 77 IFI patients (injured during June 2009 to August 2011) were conducted to evaluate IFI epidemiology, wound microbiology, and diagnostics to support refinement of Joint Trauma System (JTS) clinical practice guidelines. Following cessation of combat operations in Afghanistan, the TIDOS database was comprehensively reviewed to identify patients with laboratory evidence of a fungal infection and refine the IFI classification scheme to incorporate timing of laboratory fungal evidence and include categories that denote a high or low level of suspicion for IFI. The refined IFI classification scheme was utilized in a large-scale epidemiologic assessment of casualties injured over a 5.5-year period. RESULTS Among 720 combat casualties admitted to participating hospitals (2009-2014) who had histopathology and/or wound cultures collected, 94 (13%) met criteria for an IFI and 61 (8%) were classified as high suspicion of IFI. Risk factors for development of combat-related IFIs include sustaining a dismounted blast injury, experiencing a traumatic transfemoral amputation, and requiring resuscitation with large-volume (>20 units) blood transfusions. Moreover, TIDOS analyses demonstrated the adverse impact of IFIs on wound healing, particularly with order Mucorales. A polymerase chain reaction (PCR)-based assay to identify filamentous fungi and support earlier IFI diagnosis was also assessed using archived formalin-fixed, paraffin-embedded tissue specimens. Although the PCR-based assay had high specificity (99%), there was low sensitivity (63%); however, sensitivity improved to 83% in tissues collected from sites with angioinvasion. Data obtained from the initial IFI outbreak investigation (37 IFI patients) and subsequent TIDOS analyses (77 IFI patients) supported development and refinement of a JTS clinical practice guideline for the management of IFIs in war wounds. Furthermore, a local clinical practice guideline to screen for early tissue-based evidence of IFIs among blast casualties at the Landstuhl Regional Medical Center was critically evaluated through a TIDOS investigation, providing additional clinical practice support. Through a collaboration with the Uniformed Services University Surgical Critical Care Initiative, findings from TIDOS analyses were used to support development of a clinical decision support tool to facilitate early risk stratification. CONCLUSIONS Combat-related IFIs are a highly morbid complication following severe blast trauma and remain a threat for future modern warfare. Our findings have supported JTS clinical recommendations, refined IFI classification, and confirmed the utility of PCR-based assays as a complement to histopathology and/or culture to promote early diagnosis. Analyses underway or planned will add to the knowledge base of IFI epidemiology, diagnostics, prevention, and management.
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Affiliation(s)
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA.,Walter Reed National Military Medical Center, Bethesda, MD 20852, USA
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - William Bradley
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | | | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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14
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Petfield JL, Lewandowski LR, Stewart L, Murray CK, Tribble DR. IDCRP Combat-Related Extremity Wound Infection Research. Mil Med 2022; 187:25-33. [PMID: 35512376 DOI: 10.1093/milmed/usab065] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/02/2021] [Accepted: 02/09/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Extremity trauma is the most common battlefield injury, resulting in a high frequency of combat-related extremity wound infections (CEWIs). As these infections are associated with substantial morbidity and may impact wounded warriors long after initial hospitalization, CEWIs have been a focus of the Infectious Disease Clinical Research Program (IDCRP). Herein, we review findings of CEWI research conducted through the IDCRP and discuss future and ongoing analyses. METHODS Military personnel with deployment-related trauma sustained between 2009 and 2014 were examined in retrospective analyses through the observational Trauma Infectious Disease Outcomes Study (TIDOS). Characteristics of wounded warriors with ≥1 open extremity wound were assessed, focusing on injury patterns and infection risk factors. Through a separate trauma-associated osteomyelitis study, military personnel with combat-related open fractures of the long bones (tibia, femur, and upper extremity) sustained between 2003 and 2009 were examined to identify osteomyelitis risk factors. RESULTS Among 1,271 wounded warriors with ≥1 open extremity wound, 16% were diagnosed with a CEWI. When assessed by their most severe extremity injury (i.e., amputation, open fracture, or open soft-tissue wound), patients with amputations had the highest proportion of infections (47% of 212 patients with traumatic amputations). Factors related to injury pattern, mechanism, and severity were independent predictors of CEWIs during initial hospitalization. Having a non-extremity infection at least 4 days before CEWI diagnosis was associated with reduced likelihood of CEWI development. After hospital discharge, 28% of patients with extremity trauma had a new or recurrent CEWI during follow-up. Risk factors for the development of CEWIs during follow-up included injury pattern, having either a CEWI or other infection during initial hospitalization, and receipt of antipseudomonal penicillin for ≥7 days. A reduced likelihood for CEWIs during follow-up was associated with a hospitalization duration of 15-30 days. Under the retrospective osteomyelitis risk factor analysis, patients developing osteomyelitis had higher open fracture severity based on Gustilo-Anderson (GA) and the Orthopaedic Trauma Association classification schemes and more frequent traumatic amputations compared to open fracture patients without osteomyelitis. Recurrence of osteomyelitis was also common (28% of patients with open tibia fractures had a recurrent episode). Although osteomyelitis risk factors differed between the tibia, femur, and upper extremity groups, sustaining an amputation, use of antibiotic beads, and being injured in the earlier years of the study (before significant practice pattern changes) were consistent predictors. Other risk factors included GA fracture severity ≥IIIb, blast injuries, foreign body at fracture site (with/without orthopedic implant), moderate/severe muscle damage and/or necrosis, and moderate/severe skin/soft-tissue damage. For upper extremity open fractures, initial stabilization following evacuation from the combat zone was associated with a reduced likelihood of osteomyelitis. CONCLUSIONS Forthcoming studies will examine the effectiveness of common antibiotic regimens for managing extremity deep soft-tissue infections to improve clinical outcomes of combat casualties and support development of clinical practice guidelines for CEWI treatment. The long-term impact of extremity trauma and resultant infections will be further investigated through both Department of Defense and Veterans Affairs follow-up, as well as examination of the impact on comorbidities and mental health/social factors.
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Affiliation(s)
| | | | - Laveta Stewart
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Clinton K Murray
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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15
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Mende K, Akers KS, Tyner SD, Bennett JW, Simons MP, Blyth DM, Li P, Stewart L, Tribble DR. Multidrug-Resistant and Virulent Organisms Trauma Infections: Trauma Infectious Disease Outcomes Study Initiative. Mil Med 2022; 187:42-51. [PMID: 35512375 DOI: 10.1093/milmed/usab131] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION During the wars in Iraq and Afghanistan, increased incidence of multidrug-resistant (MDR) organisms, as well as polymicrobial wounds and infections, complicated the management of combat trauma-related infections. Multidrug resistance and wound microbiology are a research focus of the Trauma Infectious Disease Outcomes Study (TIDOS), an Infectious Disease Clinical Research Program, Uniformed Services University, research protocol. To conduct comprehensive microbiological research with the goal of improving the understanding of the complicated etiology of wound infections, the TIDOS MDR and Virulent Organisms Trauma Infections Initiative (MDR/VO Initiative) was established as a collaborative effort with the Brooke Army Medical Center, Naval Medical Research Center, U.S. Army Institute of Surgical Research, and Walter Reed Army Institute of Research. We provide a review of the TIDOS MDR/VO Initiative and summarize published findings. METHODS Antagonism and biofilm formation of commonly isolated wound bacteria (e.g., ESKAPE pathogens-Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.), antimicrobial susceptibility patterns, and clinical outcomes are being examined. Isolates collected from admission surveillance swabs, as part of infection control policy, and clinical infection workups were retained in the TIDOS Microbiological Repository and associated clinical data in the TIDOS database. RESULTS Over the TIDOS study period (June 2009 to December 2014), more than 8,300 colonizing and infecting isolates were collected from military personnel injured with nearly one-third of isolates classified as MDR. At admission to participating U.S. military hospitals, 12% of wounded warriors were colonized with MDR Gram-negative bacilli. Furthermore, 27% of 913 combat casualties with ≥1 infection during their trauma hospitalization had MDR Gram-negative bacterial infections. Among 335 confirmed combat-related extremity wound infections (2009-2012), 61% were polymicrobial and comprised various combinations of Gram-negative and Gram-positive bacteria, yeast, fungi, and anaerobes. Escherichia coli was the most common Gram-negative bacilli isolated from clinical workups, as well as the most common colonizing MDR secondary to extended-spectrum β-lactamase resistance. Assessment of 479 E. coli isolates collected from wounded warriors found 188 pulsed-field types (PFTs) from colonizing isolates and 54 PFTs from infecting isolates without significant overlap across combat theaters, military hospitals, and study years. A minority of patients with colonizing E. coli isolates developed subsequent infections with the same E. coli strain. Enterococcus spp. were most commonly isolated from polymicrobial wound infections (53% of 204 polymicrobial cultures). Patients with Enterococcus infections were severely injured with a high proportion of lower extremity amputations and genitourinary injuries. Approximately 65% of polymicrobial Enterococcus infections had other ESKAPE organisms isolated. As biofilms have been suggested as a cause of delayed wound healing, wound infections with persistent recovery of bacteria (isolates of same organism collected ≥14 days apart) and nonrecurrent bacterial isolates were assessed. Biofilm production was significantly associated with recurrent bacteria isolation (97% vs. 59% with nonrecurrent isolates; P < 0.001); however, further analysis is needed to confirm biofilm formation as a predictor of persistent wound infections. CONCLUSIONS The TIDOS MDR/VO Initiative provides comprehensive and detailed data of major microbial threats associated with combat-related wound infections to further the understanding of wound etiology and potentially identify infectious disease countermeasures, which may lead to improvements in combat casualty care.
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Affiliation(s)
- Katrin Mende
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA.,Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Kevin S Akers
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
| | - Stuart D Tyner
- Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Jason W Bennett
- Multidrug-Resistant Organisms Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Mark P Simons
- Naval Medical Research Center, Silver Spring, MD 20910, USA
| | - Dana M Blyth
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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16
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Rask DMG, Tansey KA, Osborn PM. Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System. Mil Med 2022; 188:usab534. [PMID: 34986247 DOI: 10.1093/milmed/usab534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/07/2021] [Accepted: 12/14/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). STUDY DESIGN All major amputations performed in military treatment facilities (MTF) for calendar years 2017-2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. RESULTS One thousand one hundred and eighty-four major amputations at 16 of the 49 military's inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. CONCLUSION This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military-civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.
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Affiliation(s)
- Dawn M G Rask
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Orthopaedic Surgery, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA
| | - Kimberly A Tansey
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Patrick M Osborn
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Orthopaedic Surgery, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA
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17
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Örgel M, Schwarze F, Graulich T, Krettek C, Weidemann F, Aschoff HH, Winkelmann M, Ranker A. Comparison of functional outcome and patient satisfaction between patients with socket prosthesis and patients treated with transcutaneous osseointegrated prosthetic systems (TOPS) after transfemoral amputation. Eur J Trauma Emerg Surg 2022; 48:4867-4876. [PMID: 35717545 PMCID: PMC9712408 DOI: 10.1007/s00068-022-02018-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/23/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE The aim of this retrospective analysis was to investigate and evaluate differences in functional outcome and satisfaction of patients treated with a TOPS and patients using socket prosthesis after transfemoral amputation. METHODS This retrospective comprehensive analysis included patients from a single hospital, and was conducted between February 2017 and December 2018. Overall n = 139 patients with prosthesis were included and divided into two comparable groups (socket- and TOPS group). Incomplete data sets were excluded. This led to n = 36 participants for the socket- and n = 33 for the TOPS group. Functional outcome and satisfaction were evaluated by Patient Reported Outcome Measures (PROMs). The used PROMs were: Questionnaire for Persons with a Transfemoral Amputation (Q-TFA), EQ5D-5L, Satisfaction with Prosthesis Questionnaire (SAT-PRO), Prosthesis Mobility Questionnaire (PMQ 2.0) and Functional Independence Measure (FIM). RESULTS Significant results in favor of TOPS patients were identified for the EQ-5D 5L (p = 0.004), Q-TFA (p = 0.000), SAT-PRO (p = 0.000) and PMQ 2.0 (p = 0.000). For FIM, no statistical significance was found (p = 0.318). CONCLUSION In this study, transfemoral amputees treated with an osseointegrated prosthetic attachment (TOPS) showed significantly higher scores for mobility and satisfaction. This demonstrates the high potential of TOPS in the prosthetic treatment of patients with transfemoral amputation with regard to their functional abilities in daily life.
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Affiliation(s)
- Marcus Örgel
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Frederik Schwarze
- Orthopedic, Trauma and Sportsmedicine Department, KRH Klinikum Agnes Karll Laatzen, Hildesheimer Straße 158, 30880 Laatzen, Germany
| | - Tilman Graulich
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Christian Krettek
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Friederike Weidemann
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Horst-Heinrich Aschoff
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Marcel Winkelmann
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Alexander Ranker
- Department of Physical Medicine and Rehabilitation, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Barth CA, Wladis A, Blake C, Bhandarkar P, Aebischer Perone S, O'Sullivan C. Retrospective observational study of characteristics of persons with amputations accessing International Committee of the Red Cross (ICRC) rehabilitation centres in five conflict and postconflict countries. BMJ Open 2021; 11:e049533. [PMID: 34853101 PMCID: PMC8638157 DOI: 10.1136/bmjopen-2021-049533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 11/05/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Limb amputation incidence is particularly high in fragile contexts due to conflict, accidents and poorly managed diabetes. The study aim was to analyse (1) demographic and amputation characteristics of persons with any type of acquired amputation (PwA) and (2) time between amputation and first access to rehabilitation in five conflict and postconflict countries. DESIGN A retrospective, observational study analysing differences in demographic and clinical factors and time to access rehabilitation between users with traumatic and non-traumatic amputations. SETTING Five countries with the highest numbers of PwA in the global International Committee of the Red Cross database (Afghanistan, Cambodia, Iraq, Myanmar, Sudan). Cleaned and merged data from 2009 to 2018 were aggregated by sex; age at amputation and registration; cause, combination and anatomical level of amputation(s); living environment. PARTICIPANTS All PwA newly attending rehabilitation. RESULTS Data for 28 446 individuals were included (4329 (15.2%) female). Most were traumatic amputations (73.4%, 208 90); of these, 48.6% (138 01) were conflict related. Average age at traumatic amputation for men and women was 26.9 and 24.1 years, respectively; for non-traumatic amputation it was 49.1 years and 45.9 years, respectively. Sex differences in age were statistically significant for traumatic and non-traumatic causes (p<0.001, p=0.003). Delay between amputation and rehabilitation was on average 8.2 years for those with traumatic amputation, significantly higher than an average 3 years for those with non-traumatic amputation (p<0.001). CONCLUSIONS Young age for traumatic and non-traumatic amputations indicates the devastating impact of war and fragile health systems on a society. Long delays between amputation and rehabilitation reveal the mismatch of needs and resources. For rehabilitation service providers in fragile settings, it is an enormous task to manage the diversity of PwA of various causes, age, sex and additional conditions. Improved collaboration between primary healthcare, surgical and rehabilitation services, a prioritisation of rehabilitation and increased resource provision are recommended to ensure adequate access to comprehensive rehabilitation care for PwA.
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Affiliation(s)
- Cornelia Anne Barth
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
- Cochrane Switzerland, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Andreas Wladis
- Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Catherine Blake
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Prashant Bhandarkar
- BARC Hospital, WHO collaborating centre for research in surgical needs in LMICs, Mumbai, India
- School of Health Systems Studies, Tata Institute of Social Sciences, Deonar, India
| | - Sigirya Aebischer Perone
- Health Unit, International Committee of the Red Cross, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Cliona O'Sullivan
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
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Panhelleux B, Shalhoub J, Silverman AK, McGregor AH. A review of through-knee amputation. Vascular 2021; 30:1149-1159. [PMID: 34844469 DOI: 10.1177/17085381211045183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Through-knee amputation is an umbrella term for several different surgical techniques, which may affect clinical and functional outcomes. This makes it hard to evaluate the benefits and need for a through-knee amputation approach. This article seeks to (1) determine the number of through-knee amputation performed compared with other major lower limb amputations in England over the past decade; (2) identify the theoretical concepts behind through-knee amputation surgical approaches and their potential effect on functional and clinical outcomes and (3) provide a platform for discussion and research on through-knee amputation and surgical outcomes. METHODS National Health Service Hospital Episodes Statistics were used to obtain recent numbers of major lower limb amputations in England. EMBASE and MEDLINE were searched using a systematic approach with predefined criteria for relevant literature on through-knee amputation surgery. RESULTS In the past decade, 4.6% of major lower limb amputations in England were through-knee amputations. Twenty-six articles presenting through-knee amputation surgical techniques met our criteria. These articles detailed three through-knee amputation surgical techniques: the classical approach, which keeps the femur intact and retains the patella; the Mazet technique, which shaves the femoral condyles into a box shape and the Gritti-Stokes technique, which divides the femur proximal to the level of the condyles and attaches the patella at the distal cut femur. CONCLUSIONS Through-knee amputation has persisted as a surgical approach over the past decade, with three core approaches identified. Studies reporting clinical, functional and biomechanical outcomes of through-knee amputation frequently fail to distinguish between the three distinct and differing approaches, making direct comparisons difficult. Future studies that compare through-knee amputation approaches to one another and to other amputation levels are needed.
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Affiliation(s)
- Brieuc Panhelleux
- Department of Surgery and Cancer, 4615Imperial College London, London, UK
| | - Joseph Shalhoub
- Department of Surgery and Cancer, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 4615Imperial College Healthcare NHS Trust, London, UK
| | - Anne K Silverman
- Department of Mechanical Engineering, 3557Colorado School of Mines Golden, CO, USA
| | - Alison H McGregor
- Department of Surgery and Cancer, 4615Imperial College London, London, UK
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20
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Hoyt BW, Nelson SY, Fay JG, Wade SM, Brooks DI, Potter BK. IDEO energy-storing orthosis: Effects on lower extremity function and preservation. Injury 2021; 52:3505-3510. [PMID: 34311958 DOI: 10.1016/j.injury.2021.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/14/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Intrepid Dynamic Exoskeletal Orthosis (IDEO) brace is a custom energy-storing orthosis design meant to improve gait, stability, and function after lower extremity injury or limb salvage. Early studies demonstrated the potential for the IDEO to improve functional performance, in conjunction with its paired return to run (RTR) rehabilitation program, compared to other brace types, and an impressively decreased rate of late amputation. The current study aimed to investigate these functional and revision outcomes from our institution to determine which patients may benefit most from IDEO bracing and what factors of the IDEO design and rehabilitation program are most important for improved outcomes after lower extremity trauma and/or loss of function. METHODS We performed a retrospective review of all patients treated with a IDEO style brace at a single military lower extremity trauma referral center between May 2003 and November 2017. We reviewed the medical records for initial diagnosis, post-orthotic rehabilitation program, IDEO use characteristics, pain, change in desire for amputation, and whether patient underwent eventual amputation. RESULTS We identified 213 patients with 222 lower extremities treated with IDEO brace. Of these, 76 limbs were treated for combat-related injuries. At one year follow-up, use status could not be determined for 37 extremities (16.7%). Of the 185 limbs with use data available, 116 (61.1%) continued regular brace use, and 37 (15.7%) reported intermittent use. Patients diagnosed with footdrop or weakness were more likely to continue use (OR 2.33, p=0.04), while patients with a previous fusion were less likely to continue use (OR 0.45, p=0.049). Undergoing any dedicated therapy increased chances of continued use (OR 3.37, p<0.001). At final follow-up, 16 patients (7.5%) underwent delayed lower extremity amputations following IDEO treatment. Overall, 27.2% of patients who initially desired amputation eventually underwent amputation despite IDEO brace use. Patients who underwent amputation reported higher pain levels (2 versus 5, p<0.001). DISCUSSION In select patients, the IDEO may decrease the desire for delayed amputation and permit higher levels of activity; however, its efficacy appears tied to the rehabilitative regimen, pain levels, and initial diagnosis. These findings should guide post-surgical extremity bracing prescriptions and expectations.
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Affiliation(s)
- Benjamin W Hoyt
- USU-WRNMMC Department of Surgery, Bethesda, MD, United States.
| | - Sarah Y Nelson
- USU-WRNMMC Department of Surgery, Bethesda, MD, United States
| | - Jeffrey G Fay
- Department of Orthotics and Prosthetics, WRNMMC, Bethesda, MD, United States
| | - Sean M Wade
- USU-WRNMMC Department of Surgery, Bethesda, MD, United States
| | - Daniel I Brooks
- Department of Research Programs, WRNMMC, Bethesda, MD, United States
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21
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Development of a magnetically aligned regenerative tissue-engineered electronic nerve interface for peripheral nerve applications. Biomaterials 2021; 279:121212. [PMID: 34717196 DOI: 10.1016/j.biomaterials.2021.121212] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 10/11/2021] [Accepted: 10/20/2021] [Indexed: 01/18/2023]
Abstract
Peripheral nerve injuries can be debilitating to motor and sensory function, with severe cases often resulting in complete limb amputation. Over the past two decades, prosthetic limb technology has rapidly advanced to provide users with crude motor control of up to 20° of freedom; however, the nerve-interfacing technology required to provide high movement selectivity has not progressed at the same rate. The work presented here focuses on the development of a magnetically aligned regenerative tissue-engineered electronic nerve interface (MARTEENI) that combines polyimide "threads" encapsulated within a magnetically aligned hydrogel scaffold. The technology exploits tissue-engineered strategies to address concerns over traditional peripheral nerve interfaces including poor axonal sampling through the nerve and rigid substrates. A magnetically templated hydrogel is used to physically support the polyimide threads while also promoting regeneration in close proximity to the electrode sites on the polyimide. This work demonstrates the utility of magnetic templating for use in tuning the mechanical properties of hydrogel scaffolds to match the stiffness of native nerve tissue while providing an aligned substrate for Schwann cell migration in vitro. MARTEENI devices were fabricated and implanted within a 5-mm-long rat sciatic-nerve transection model to assess regeneration at 6 and 12 weeks. MARTEENI devices do not disrupt tissue remodeling and show axon densities equivalent to fresh tissue controls around the polyimide substrates. Devices are observed to have attenuated foreign-body responses around the polyimide threads. It is expected that future studies with functional MARTEENI devices will be able to record and stimulate single axons with high selectivity and low stimulation regimes.
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22
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Development of overuse musculoskeletal conditions after combat-related upper limb amputation: a retrospective cohort study. J Hand Ther 2021; 36:66-73. [PMID: 34253405 DOI: 10.1016/j.jht.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 02/01/2021] [Accepted: 05/06/2021] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Retrospective cohort study INTRODUCTION: Service members who have sustained traumatic amputations are typically young and otherwise healthy. Beyond standard care, these individuals desire long, highly active, and relatively pain-free lifestyle, whether that is returning to active duty or transitioning to civilian life. Development of overuse musculoskeletal conditions could have a significant influence on quality of life for Service members with traumatic upper limb amputation. PURPOSE OF THE STUDY Compare one-year incidence of overuse musculoskeletal injuries in Service members with different levels of combat-related upper limb amputation to Service members with minor combat-related upper limb injuries. METHODS Service members with deployment-related upper limb injury (N = 519), 148 major upper limb amputation (55 with amputation at or above elbow, 93 with amputation below elbow) and 371 minor upper limb injury were included in the study. Outcomes of interest clinical diagnosis codes associated with overuse conditions of the upper limb, neck and upper back, lower limb, low back pain, and all regions combined, one year before and one year after injury. RESULTS Overall, the one-year incidence of developing at least one musculoskeletal overuse condition after upper limb amputation was between 60% and 65%. Service members with upper limb amputations were 2.7 to 4.7 times more likely to develop an overuse upper limb condition, 3.6 to 3.8 times more likely to develop a neck and upper back condition, 2.8 to 4.4 times more likely to develop a lower limb condition, and 3.3 to 3.9 times more likely to develop low back pain as compared those who sustained minor combat-related injuries. No significant differences in the odds of developing a musculoskeletal condition was found between the above elbow and below elbow amputation groups. CONCLUSIONS Incidence of secondary overuse conditions is elevated in Service members with upper limb amputation and warrants focused research efforts toward preventative and rehabilitative interventions.
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23
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Williams HE, Chapman CS, Pilarski PM, Vette AH, Hebert JS. Myoelectric prosthesis users and non-disabled individuals wearing a simulated prosthesis exhibit similar compensatory movement strategies. J Neuroeng Rehabil 2021; 18:72. [PMID: 33933105 PMCID: PMC8088043 DOI: 10.1186/s12984-021-00855-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background Research studies on upper limb prosthesis function often rely on the use of simulated myoelectric prostheses (attached to and operated by individuals with intact limbs), primarily to increase participant sample size. However, it is not known if these devices elicit the same movement strategies as myoelectric prostheses (operated by individuals with amputation). The objective of this study was to address the question of whether non-disabled individuals using simulated prostheses employ the same compensatory movements (measured by hand and upper body kinematics) as individuals who use actual myoelectric prostheses. Methods The upper limb movements of two participant groups were investigated: (1) twelve non-disabled individuals wearing a simulated prosthesis, and (2) three individuals with transradial amputation using their custom-fitted myoelectric devices. Motion capture was used for data collection while participants performed a standardized functional task. Performance metrics, hand movements, and upper body angular kinematics were calculated. For each participant group, these measures were compared to those from a normative baseline dataset. Each deviation from normative movement behaviour, by either participant group, indicated that compensatory movements were used during task performance. Results Results show that participants using either a simulated or actual myoelectric prosthesis exhibited similar deviations from normative behaviour in phase durations, hand velocities, hand trajectories, number of movement units, grip aperture plateaus, and trunk and shoulder ranges of motion. Conclusions This study suggests that the use of a simulated prosthetic device in upper limb research offers a reasonable approximation of compensatory movements employed by a low- to moderately-skilled transradial myoelectric prosthesis user.
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Affiliation(s)
- Heather E Williams
- Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| | - Craig S Chapman
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Patrick M Pilarski
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Albert H Vette
- Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Department of Mechanical Engineering, Faculty of Engineering, University of Alberta, Edmonton, AB, Canada.,Glenrose Rehabilitation Hospital, Alberta Health Services, Edmonton, AB, Canada
| | - Jacqueline S Hebert
- Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Glenrose Rehabilitation Hospital, Alberta Health Services, Edmonton, AB, Canada
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Melcer T, Walker J, Bhatnagar V, Richard E. Clinic Use at the Departments of Defense and Veterans Affairs Following Combat Related Amputations. Mil Med 2021; 185:e244-e253. [PMID: 31247095 DOI: 10.1093/milmed/usz149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/02/2019] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Little population-based research has described the transition from Department of Defense (DoD) to Department of Veterans Affairs (VA) healthcare following combat related amputations. The objectives were to describe (1) to what extent patients used either DoD only facilities, both DoD and VA facilities, or VA only facilities during the first 5 years postinjury, (2) which specific clinics were used and (3) clinic use among patients with different levels of amputation (upper versus lower), and among patients with early or late amputation. MATERIALS AND METHODS This was a retrospective analysis of health data extracted from the expeditionary medical encounter database (EMED) and national DoD and VA databases. Patients were 649 US service members who sustained a single major limb amputation following injuries in the Iraq and Afghanistan conflicts, 2001-2008. We compared yearly DoD and VA clinic use by patient groups with different levels of amputation (upper limb: above versus below elbow or lower limb: above versus below knee), different timing of amputation (early: within 90 days postinjury versus late: more than 90 days postinjury), military component (Active Duty versus National Guard/Reserve) and race (White versus Black). For all groups, we calculated the percentage of patients using: (1) DoD only, (2) both DoD and VA or 3) VA only clinics during each of postinjury years 1 through 5. We also calculated the percentage of patients who used specific clinics (e.g., social work, prosthetics, mental health) during each postinjury year. RESULTS During postinjury year 1, over 98% of patients used DoD only or both DoD and VA clinics. Most individuals (70% to 78%) used both DoD and VA clinics during postinjury year 1. Use of VA only clinics increased gradually between postinjury year 2 (15% to 30% of patient groups) and year 5 (75% to 88%). This gradual transition to use of VA only clinics was seen consistently across patient groups with different anatomical levels or timing of amputation, military component or race. Patients with lower levels of amputation (versus higher levels) and individuals with early amputations (versus late) transitioned earlier to VA only care. Overall, clinic use was high as 91% to 100% of all patient groups used one or more clinics (DoD or VA) during each of the first 5 years. For specific clinics, most patients used DoD facilities related to rehabilitation (physical therapy, prosthetics) or transitional care (social work) particularly during postinjury year 1. Use of most VA clinics studied (social work, primary care, prosthetics, mental health) showed a modest increase primarily after postinjury year 1 and remained stable through postinjury year 5. The results indicated apparent underuse of psychiatric/mental health and prosthetics between postinjury year 1 and 2. CONCLUSIONS The present study indicated a gradual transition from DoD to VA only healthcare which extended across 5 years following combat related amputations. Patients with lower levels of amputation or early amputation generally transitioned earlier to VA only healthcare. These results can inform medical planning to support a timely and clinically effective transition from DoD to VA healthcare.
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Affiliation(s)
- Ted Melcer
- Department of Medical Modeling, Simulation, and Mission Support, Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521
| | - Jay Walker
- Leidos Inc., 10260 Campus Point Dr, San Diego, CA 92121
| | - Vibha Bhatnagar
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161.,Department for Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093
| | - Erin Richard
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161.,Department for Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093
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Khorram-Manesh A, Goniewicz K, Burkle FM, Robinson Y. Review of Military Casualties in Modern Conflicts-The Re-emergence of Casualties From Armored Warfare. Mil Med 2021; 187:e313-e321. [PMID: 33742659 PMCID: PMC8963150 DOI: 10.1093/milmed/usab108] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/08/2021] [Indexed: 11/12/2022] Open
Abstract
Introduction The re-emergence of armored warfare in modern conflicts has resulted in a higher number of extremity injuries, burns, and brain injuries. Despite this dramatic increase, little is reported on the type of injuries caused and their management. This review summarizes the publicly available literature and reports on the rate and type of injuries related to armored warfare, their medical outcomes, and management limitations. Materials and Methods This rapid evidence review involves a systematic literature search, followed by a non-systematic literature review. The reason for choosing this approach was the inherent lack of quantitative outcome data in the literature to satisfy the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The study also used content analysis to study all peer-reviewed articles, focusing on similarities and differences in the findings necessary to formulate tentative results. The electronic search included PubMed, Scopus, and Web of Science, using the following search string: “Armored; Injuries; Mechanized; Morbidity; Mortality; War; Warfare”, alone or in combination. Results Modern conflicts are associated with higher number of extremity injuries, burns, and brain injuries among military casualties. Several publications claim that the characteristics of armored warfare and anticipated injuries in this type of warfare might require the far forward deployment of medical support supported by a reliable casualty evacuation chain. Still the quality of the available casualty data is low. Conclusions Because of the limited availability of reliable data or military trauma registries, up-to-date military casualty estimation remains a recognized knowledge gap, which needs to be addressed by armed forces worldwide. The future management of modern war casualties requires professional and well-trained staff in all levels, indicating a need for educational initiatives to provide both nurses and medics a greater proportion of medical care and management capabilities and responsibilities than in past conflicts.
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Affiliation(s)
- Amir Khorram-Manesh
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg 413 45, Sweden
- Department of Development and Research, Armed Forces Center for Defense Medicine, Västra Frölunda 426 76, Sweden
| | - Krzysztof Goniewicz
- Department of Aviation Security, Military University of Aviation, Dęblin 08-521, Poland
| | - Frederick M Burkle
- Harvard Humanitarian Initiative, T.H. Chan School of Public Health, Harvard University, Boston, MA 02115, USA
| | - Yohan Robinson
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg 413 45, Sweden
- Department of Development and Research, Armed Forces Center for Defense Medicine, Västra Frölunda 426 76, Sweden
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Incidence and demographic characteristics of Syrian Civil War-related amputations: A multi-center study. Turk J Phys Med Rehabil 2021; 67:48-55. [PMID: 33948543 PMCID: PMC8088804 DOI: 10.5606/tftrd.2021.5058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/18/2019] [Indexed: 11/21/2022] Open
Abstract
Objectives The aim of this study was to identify the causes, levels, and rates of amputations performed in civilians during the Syrian Civil War and to present epidemiological data of the amputees. Patients and methods Between August 2017 and February 2019, a total of 363 amputations of 307 amputees (266 males, 41 females; mean age 29.9±13.3 years; range, 6 to 86 years) were retrospectively analyzed in four prosthesis and orthosis centers managed by an international non-governmental organization and serving to individuals who experienced amputation during Syrian Civil War. Level, etiology, number of amputations and distribution of the amputations by years were investigated. Results Of the patients, 25.4% were under the age of 18 years. A total of 74% of all amputations were of the lower extremities. Transtibial and transfemoral amputations were the most common amputation levels. Of the amputees, 89.3% reported the cause of amputation as bombing. Conclusion Civil amputations during the Syrian Civil War are different from those in other civil wars due to the high rate of bombing-induced amputations and also the high rate of victims under the age of 18 years. Our study results show a high ratio of both lower and upper extremity amputations in these civilians.
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27
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Hynes C, Scullion L, Lawler C, Steel R, Boland P. The impact of in-service physical injury or illness on the mental health of military veterans. BMJ Mil Health 2021; 169:e51-e54. [PMID: 33664089 DOI: 10.1136/bmjmilitary-2020-001759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Each year approximately 2000 UK service personnel are medically discharged with physical and/or psychological injury or illness. While there is much research on both psychological injury and physical injury, the challenges of transition relating to the intersection between the two has received less attention. This article reports on the first phase of a 2-year funded study with the aim to understand the lived experiences of veterans who have been discharged from service with a physical injury or illness and the impacts of this on their mental health. METHODS Using a qualitative methodology, 22 veterans who had been discharged from service within the last 8 years were interviewed to identify key aspects of their experience of the transition process. RESULTS The article highlights two key themes: how some veterans adjusted to life with a physical injury or condition; and, the intersections that became apparent between physical injury and mental health. The challenges that veterans faced were shaped by the transition process and by the way in which the medical discharge process was conducted. CONCLUSIONS Consideration of improvements to the medical discharge process could influence better outcomes for those who have left with a physical injury or illness and later find themselves struggling with mental health issues.
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Affiliation(s)
- Celia Hynes
- School of Community Health & Midwifery, University of Central Lancashire, Preston, UK
| | - L Scullion
- Professor of Social Policy, Sustainable Housing & Urban Studies Unit (SHUSU), School of Health & Society, University of Salford, Salford, Greater Manchester, UK
| | - C Lawler
- Salford Social Prescribing Hub, SHUSU, School of Health & Society, University of Salford, Salford, Greater Manchester, UK
| | - R Steel
- School of Community Health & Midwifery, University of Central Lancashire, Preston, UK
| | - P Boland
- School of Community Health & Midwifery, University of Central Lancashire, Preston, UK
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Saunders D, Rose L. Regenerative rehabilitation of catastrophic extremity injury in military conflicts and a review of recent developmental efforts. Connect Tissue Res 2021; 62:83-98. [PMID: 32552156 DOI: 10.1080/03008207.2020.1776707] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIM OF THE REVIEW This review aims to describe the current state of regenerative rehabilitation of severe military extremity injuries, and promising new therapies on the horizon. DISCUSSION The nature of warfare is rapidly shifting with information operations, autonomous weapons, and the threat of full-scale peer adversary conflicts threatening to create contested environments with delayed medical evacuation to definitive care. More destructive weapons will lead to more devastating injuries, creating new challenges for limb repair and restoration. Current paradigms of delayed rehabilitation following initial stabilization, damage control surgery, and prolonged antibiotic therapy will need to shift. Advances in regenerative medicine technologies offer the possibility of treatment along the continuum of care. Regenerative rehabilitation will begin at the point of injury and require a holistic, organ-systems approach. CONCLUSIONS Both technological improvements and a rapidly advancing understanding of injury pathophysiology will contribute to improved limb-salvage outcomes, and shift the calculus away from early limb amputation.
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Affiliation(s)
- David Saunders
- US Army Medical Material Development Activity, Fort Detrick, MD , USA
| | - Lloyd Rose
- US Army Medical Material Development Activity, Fort Detrick, MD , USA
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29
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Breeze J, Bowley DM, Harrisson SE, Dye J, Neal C, Bell RS, Armonda RA, Beggs AD, DuBose J, Rickard RF, Powers DB. Survival after traumatic brain injury improves with deployment of neurosurgeons: a comparison of US and UK military treatment facilities during the Iraq and Afghanistan conflicts. J Neurol Neurosurg Psychiatry 2020; 91:359-365. [PMID: 32034113 PMCID: PMC7147183 DOI: 10.1136/jnnp-2019-321723] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/14/2019] [Accepted: 01/12/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is the most common cause of death on the modern battlefield. In recent conflicts in Iraq and Afghanistan, the US typically deployed neurosurgeons to medical treatment facilities (MTFs), while the UK did not. Our aim was to compare the incidence, TBI and treatment in US and UK-led military MTF to ascertain if differences in deployed trauma systems affected outcomes. METHODS The US and UK Combat Trauma Registries were scrutinised for patients with HI at deployed MTFs between March 2003 and October 2011. Registry datasets were adapted to stratify TBI using the Mayo Classification System for Traumatic Brain Injury Severity. An adjusted multiple logistic regression model was performed using fatality as the binomial dependent variable and treatment in a US-MTF or UK-MTF, surgical decompression, US military casualty and surgery performed by a neurosurgeon as independent variables. RESULTS 15 031 patients arrived alive at military MTF after TBI. Presence of a neurosurgeon was associated with increased odds of survival in casualties with moderate or severe TBI (p<0.0001, OR 2.71, 95% CI 2.34 to 4.73). High injury severity (Injury Severity Scores 25-75) was significantly associated with a lower survival (OR 4×104, 95% CI 1.61×104 to 110.6×104, p<0.001); however, having a neurosurgeon present still remained significantly positively associated with survival (OR 3.25, 95% CI 2.71 to 3.91, p<0.001). CONCLUSIONS Presence of neurosurgeons increased the likelihood of survival after TBI. We therefore recommend that the UK should deploy neurosurgeons to forward military MTF whenever possible in line with their US counterparts.
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Affiliation(s)
- John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Douglas M Bowley
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Stuart E Harrisson
- Department of Neurosurgery, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Justin Dye
- Department of Neurosurgery, Loma Linda University, Loma Linda, California, USA
| | - Christopher Neal
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Randy S Bell
- National Capital Neurosurgery Consortium, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University Medical Center, Washington, DC, USA
| | - Andrew D Beggs
- Surgical Research Laboratory, University of Birmingham, Birmingham, UK
| | - Jospeh DuBose
- Center for the Sustainment of Trauma and Readiness Skills, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - David Bryan Powers
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina, USA
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30
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Cancio JM, Orr A, Eskridge S, Shannon K, Mazzone B, Farrokhi S. Occupational Therapy Practice Patterns for Military Service Members With Upper Limb Amputation. Mil Med 2020; 185:444-450. [PMID: 31665420 DOI: 10.1093/milmed/usz341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Military Service Members (SMs) with upper limb (UL) amputation have unrestricted access to occupational therapy (OT) services. Identifying OT interventions used based on clinical rationale and patient needs can provide insight toward developing best practice guidelines. The purpose of this retrospective observational study was to identify preferred OT practice patterns for U.S. Military SMs treated in Military Treatment Facilities, who have sustained various levels of deployment-related UL amputation. METHODS The study sample was ascertained from the Expeditionary Medical Encounter Database housed at the Naval Health Research Center in San Diego, California. SMs with an immediate (within 24 hours of injury) deployment-related unilateral major UL amputation (partial hand and proximal), occurring between January 2001 and December 2014 were identified. SMs with concurrent major lower limb amputation (partial foot and proximal) were excluded. Frequency of OT outpatient visits and units of treatment received were quantified in 3-month increments during the first year after amputation and compared for individuals with above elbow (at or proximal to elbow joint) and below elbow (distal to the elbow joint including partial hand) amputation. This study was approved by the Naval Health Research Center Institutional Review Board. RESULTS A total of 29,878 encounters occurred during first year after amputation in 148 patients, who had sustained UL loss during the first year after amputation. Active treatments were included in 79.2% of all treatments, followed by manual therapy (13.7%) and modalities (13.5%). A higher number of OT encounters occurred in the above elbow amputation group-the first year of treatment with significantly higher mean number of treatments months 4 to12. A similar pattern in OT encounters was observed in the active therapy category with significantly higher mean number of treatments occurring in above elbow limb loss group in months 10 to 12. CONCLUSION Findings of the current study suggest SMs with UL amputation utilize OT services often within the first year after injury and those who have sustained amputation proximal to the elbow received more therapy visits than their below elbow counterparts during months 4 to 12. Prosthetic training, therapeutic activities, and therapeutic exercise can be expected to be the highest used active interventions in the first year following UL amputation. Further research is needed to determine details on types and frequency of therapy utilization and recommended therapy strategies.
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Affiliation(s)
- Jill M Cancio
- Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234.,Extremity Trauma and Amputation Center of Excellence, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | - Annemarie Orr
- Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | | | | | - Brittney Mazzone
- Extremity Trauma and Amputation Center of Excellence, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234.,Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Shawn Farrokhi
- Extremity Trauma and Amputation Center of Excellence, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234.,Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
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Stewart L, Li P, Blyth MDM, Campbell WR, Petfield JL, Krauss M, Greenberg L, Tribble DR. Antibiotic Practice Patterns for Extremity Wound Infections among Blast-Injured Subjects. Mil Med 2020; 185:628-636. [PMID: 32074316 DOI: 10.1093/milmed/usz211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 06/30/2019] [Accepted: 07/03/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION We examined antibiotic management of combat-related extremity wound infections (CEWI) among wounded U.S. military personnel (2009-2012). METHODS Patients were included if they sustained blast injuries, resulting in ≥1 open extremity wound, were admitted to participating U.S. hospitals, developed a CEWI (osteomyelitis or deep soft-tissue infections) within 30 days post-injury, and received ≥3 days of relevant antibiotic (s) for treatment. RESULTS Among 267 patients, 133 (50%) had only a CEWI, while 134 (50%) had a CEWI plus concomitant non-extremity infection. In the pre-diagnosis period (4-10 days prior to CEWI diagnosis), 95 (36%) patients started a new antibiotic with 28% of patients receiving ≥2 antibiotics. During CEWI diagnosis week (±3 days of diagnosis), 209 (78%) patients started a new antibiotic (71% with ≥2 antibiotics). In the week following diagnosis (4-10 days after CEWI diagnosis), 121 (45%) patients started a new antibiotic with 39% receiving ≥2 antibiotics. Restricting to ±7 days of CEWI diagnosis, patients commonly received two (35%) or three (27%) antibiotics with frequent combinations involving carbapenem, vancomycin, and fluoroquinolones. CONCLUSIONS Substantial variation in antibiotic prescribing patterns related to CEWIs warrants development of combat-related clinical practice guidelines beyond infection prevention, to include strategies to reduce the use of unnecessary antibiotics and improve stewardship.
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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 20814.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD 20817
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD 20817
| | - Maj Dana M Blyth
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Drive #3600, Fort Sam Houston, TX 78234
| | - Wesley R Campbell
- Infectious Disease Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889
| | | | - Margot Krauss
- Westat, 1600 Research Boulevard, Rockville, MD 20850
| | | | - 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 20814
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Mitchell SL, Hayda R, Chen AT, Carlini AR, Ficke JR, MacKenzie EJ. The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study: Outcomes of Amputation Compared with Limb Salvage Following Major Upper-Extremity Trauma. J Bone Joint Surg Am 2019; 101:1470-1478. [PMID: 31436655 PMCID: PMC7406140 DOI: 10.2106/jbjs.18.00970] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe upper-extremity injuries account for almost one-half of all extremity trauma in recent conflicts in the Global War on Terror. Few long-term outcomes studies address severe combat-related upper-extremity injuries. This study's objective was to describe long-term functional outcomes of amputation compared with those of limb salvage in Global War on Terror veterans who sustained severe upper-extremity injuries. Limb salvage was hypothesized to result in better arm and hand function scores, overall functional status, and quality of life, with similar pain interference. METHODS This retrospective cohort study utilized data from the Military Extremity Trauma Amputation/Limb Salvage (METALS) study for a subset of 155 individuals who sustained major upper-extremity injuries treated with amputation or limb salvage. Participants were interviewed by telephone 40 months after injury, assessing social support, personal habits, and patient-reported outcome instruments for function, activity, depression, pain, and posttraumatic stress. Outcomes were evaluated for participants with severe upper-extremity injuries and were compared with participants with concomitant severe, lower-extremity injury. The analysis of outcomes comparing limb salvage with amputation was restricted to the 137 participants with a unilateral upper-extremity injury because of the small number of patients with bilateral upper-extremity injuries (n = 18). RESULTS Overall, participants with upper-extremity injuries reported moderate to high levels of physical and psychosocial disability. Short Musculoskeletal Function Assessment (SMFA) scores were high across domains; 19.4% screened positive for posttraumatic stress disorder (PTSD), and 12.3% were positive for depression. Nonetheless, 63.6% of participants were working, were on active duty, or were attending school, and 38.7% of participants were involved in vigorous recreational activities. No significant differences in outcomes were observed between patients who underwent limb salvage and those who underwent amputation. CONCLUSIONS Severe, combat-related upper-extremity injuries result in diminished self-reported function and psychosocial health. Our results suggest that long-term outcomes are equivalent for those treated with amputation or limb salvage. Addressing or preventing PTSD, depression, chronic pain, and associated health habits may result in less disability burden in this population. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stuart L. Mitchell
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Roman Hayda
- Department of Orthopaedic Surgery, Brown University Warren Alpert School of Medicine, Providence, Rhode Island
| | - Andrew T. Chen
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anthony R. Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - James R. Ficke
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ellen J. MacKenzie
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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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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Abstract
BACKGROUND Alongside physical impairment, psychosocial health issues may arise after amputation, impacting quality of life. Traditional psychosocial care models provide services in a linear fashion, with limited supports upon discharge. A novel program entitled Amputees Unanimous is a 12-step program provided for amputees by amputees. OBJECTIVE To shape the final content of Amputees Unanimous by identifying personal beliefs and opinions of healthcare professionals and amputees. STUDY DESIGN Qualitative design utilizing a phenomenological approach. METHOD Five focus groups were held: four with amputees and one with healthcare providers. A phenomenological approach shaped the inquiry of the lived experience of limb loss in relation to the content of Amputees Unanimous. RESULTS Three themes emerged: (1) accepting limb loss, (2) peer inspiration, and (3) regaining prior level of function. CONCLUSION Limb loss may alter one's self-image, both physically and psychologically, having a profound effect on how an individual copes throughout his or her lifetime. The content and delivery format of Amputees Unanimous could be tested for effectiveness as a program tailored to facilitate coping after limb loss and to provide encouragement, support, and hope for the future of amputees. CLINICAL RELEVANCE A dynamic, amputee-led, mutual help program may provide individuals with limb loss a place for encouragement, support, and optimism for the future.
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Affiliation(s)
- Catrinna Amorelli
- 1 Specialty Care Services, Vilseck Army Health Clinic, Vilseck, Germany
| | - Kathleen Yancosek
- 2 Department of Rehabilitation Medicine, Center for the Intrepid, Brooke Army Medical Center, San Antonio, TX, USA
| | - Ruth Morris
- 3 University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Wendland TM, Seguin B, Duerr FM. Retrospective Multi-Center Analysis of Canine Socket Prostheses for Partial Limbs. Front Vet Sci 2019; 6:100. [PMID: 31024938 PMCID: PMC6460115 DOI: 10.3389/fvets.2019.00100] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/14/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Socket prostheses for treatment of distal limb pathology are becoming increasingly prevalent in veterinary medicine, however, limited objective data is available. Objectives of the present study were to retrospectively evaluate owner satisfaction, clinical outcomes, and prognostic factors associated with dogs receiving socket prostheses for partial limbs in a larger patient population. Materials and Methods: Client databases of a single prosthesis provider were reviewed to identify owners whose dogs had received a prosthetic device within the last 10 years. An online survey was developed to evaluate owner-reported outcomes. The survey inquired about anatomy of the residuum, concurrent disease, prosthesis use, rehabilitation, activity, complications, and owner satisfaction. Medical records and radiographs were requested from all participants. Radiographs were used to confirm level of amputation and evaluate for osseous complications. Survey responses were analyzed by assigning author-defined numeric scores defining clinical outcome and owner satisfaction. Results: One-hundred thirty-seven owners were contacted. The response rate was 50/137 (37%); 47 responses were analyzed. Forty-six of 47 owners reported positive satisfaction; 1/47 was displeased. Forty-two of 47 dogs were scored to have acceptable to full function; 5/47 had unacceptable clinical function using the author-defined scoring system. A 62% short-term complication rate and a 19% long-term complication rate were reported. Skin sores were the most common short and long-term complication. There was a significant correlation between both clinical outcome scores and owner satisfaction with days per week spent in the prosthesis. Additionally, clinical outcome scores and owner satisfaction significantly varied between dogs with different durations of prosthesis wear with a trend toward better outcomes associated with longer prosthesis wear. Radiographs were obtained for 23/47 dogs to further define level of defect. The most proximal level of defect was mid-radius for the forelimb and mid-tibia for the hind limb. There was no correlation between level of defect and either owner satisfaction or clinical outcome. Discussion/Conclusion: Results of this survey suggest a high degree of owner satisfaction despite substantial complication rates. Based on preliminary data, further evaluation of socket prostheses as a limb-sparing option for treatment of distal limb pathology should be considered. Prospective clinical trials with objective outcome measures are required to draw firm conclusions.
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Affiliation(s)
- Theresa M Wendland
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Bernard Seguin
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Felix M Duerr
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States
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Abstract
OBJECTIVES To identify the risk factors for osteomyelitis development in US military personnel with combat-related, open femur fractures? DESIGN Retrospective observational case-control study. SETTING US military regional hospital in Germany and tertiary care hospitals in United States (2003-2009). PATIENTS/PARTICIPANTS One hundred three patients with open femur fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Sixty-four patients with open femur fractures who did not meet osteomyelitis diagnostic criteria were included as controls. MAIN OUTCOME MEASUREMENTS The main outcome measurements were multivariable odds ratios (ORs) and 95% confidence interval (CI). RESULTS Among patients with surgical implants, osteomyelitis cases had significantly longer time to definitive orthopaedic surgery compared with controls (median: 21 vs. 13 days). Independent predictors for osteomyelitis risk were Gustilo-Anderson classification (transfemoral amputation OR: 19.3; CI: 3.0-123.0) and Orthopaedic Trauma Association Open Fracture Classification for muscle loss (OR: 5.7; CI: 1.3-25.1) and dead muscle (OR: 32.9; CI: 5.4-199.1). Being injured between 2003 and 2006, antibiotic bead use, and foreign body plus implant(s) at fracture site were also risk factors. CONCLUSIONS Patients with open femur fractures resulting in significant muscle damage have the highest osteomyelitis risk. Foreign body contamination was only significant when an implant was present. Increased risk with antibiotic bead use is likely a surrogate for clinical suspicion of contamination with complex wounds. The timeframe association is likely due to changing trauma system patterns around 2006-2007 (eg, increased negative pressure wound therapy, reduced high-pressure irrigation, decreased crystalloid use, and delayed definitive internal fixations). LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Melcer T, Walker J, Sechriest VF, Bhatnagar V, Richard E, Perez K, Galarneau M. A Retrospective Comparison of Five‐Year Health Outcomes Following Upper Limb Amputation and Serious Upper Limb Injury in the Iraq and Afghanistan Conflicts. PM R 2019; 11:577-589. [DOI: 10.1002/pmrj.12047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/17/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Ted Melcer
- Department of Medical Modeling, Simulation, and Mission SupportNaval Health Research Center, 140 Sylvester Road San Diego CA 92106‐3521
| | - Jay Walker
- Department of Medical Modeling, Simulation, and Mission Support Naval Health Research Center, Leidos San Diego CA
| | - Vernon Franklin Sechriest
- Department of Orthopedic Surgery, Minneapolis Veterans Affairs Hospital, Minneapolis VA Health Care System Minneapolis MN
| | - Vibha Bhatnagar
- VA San Diego Healthcare System San Diego CA
- Department for Family and Preventive MedicineUniversity of California San DiegoLa JollaCA
| | - Erin Richard
- VA San Diego Healthcare System San Diego CA
- Department for Family and Preventive MedicineUniversity of California San DiegoLa JollaCA
| | - Katheryne Perez
- Department of Medical Modeling, Simulation, and Mission Support Naval Health Research Center, Leidos San Diego CA
| | - Michael Galarneau
- Department of Medical Modeling, Simulation, and Mission SupportNaval Health Research Center San Diego CA
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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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Darter BJ, Hawley CE, Armstrong AJ, Avellone L, Wehman P. Factors Influencing Functional Outcomes and Return-to-Work After Amputation: A Review of the Literature. JOURNAL OF OCCUPATIONAL REHABILITATION 2018; 28:656-665. [PMID: 29397480 PMCID: PMC6076349 DOI: 10.1007/s10926-018-9757-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Purpose Amputation is a life changing event that can significantly impact an individual's physical and mental well-being. Our objective was to review literature exploring the impact of amputation upon a person's functioning and inclusion in the workplace. Methods Medline, CINAHL, and PsycINFO were searched using keywords related to amputation, employment and community reintegration. Eligible studies were published since 2000 and one of the following study designs: randomized controlled trial, non-randomized controlled trial, retrospective study, prospective study, concurrent cohort study, or cross sectional study. Studies for civilians with amputation as well as service members and Veterans with amputation were considered for inclusion. Results The search identified 995 articles, 25 of which met inclusion/exclusion criteria and were included in the review. While strong evidence for correlations and predictors of outcomes after amputation were limited, multiple factors were identified as contributing to physical functioning and employment after amputation. Conclusions Outcomes after amputation can vary widely with many potentially inter-related factors contributing. The factors identified may also serve to inform the development of interventions aiming to improve functional performance and reintegration after amputation. Furthermore, the review highlights the need for more high quality prospective studies.
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Affiliation(s)
- Benjamin J Darter
- Department of Physical Therapy, Virginia Commonwealth University, 1200 East Broad Street, Box 980224, Richmond, VA, 23298, USA.
- Department of Research, Hunter Holmes McGuire Veteran Affairs Medical Center, Richmond, VA, 23249, USA.
| | - Carolyn E Hawley
- Department of Rehabilitation Counseling, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Amy J Armstrong
- Department of Rehabilitation Counseling, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Lauren Avellone
- Rehabilitation Research and Training Center, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Paul Wehman
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, 23284, USA
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Tribble DR, Lewandowski LR, Potter BK, Petfield JL, Stinner DJ, Ganesan A, Krauss M, Murray CK. Osteomyelitis Risk Factors Related to Combat Trauma Open Tibia Fractures: A Case-Control Analysis. J Orthop Trauma 2018; 32:e344-e353. [PMID: 29878946 PMCID: PMC6103838 DOI: 10.1097/bot.0000000000001225] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We assessed osteomyelitis risk factors in US military personnel with combat-related open tibia fractures (2003-2009). METHODS Patients with open tibia fractures who met the diagnostic criteria of osteomyelitis were identified as cases using Military Health System data and verified through medical record review. Controls were patients with open tibia fractures who did not meet osteomyelitis criteria. The Gustilo-Andersen fracture classification scheme was modified to include transtibial amputations (TTAs) as the most severe level. Logistic regression multivariable odds ratios [ORs; 95% confidence intervals (CI)] were assessed. RESULTS A total of 130 tibia osteomyelitis cases and 85 controls were identified. Excluding patients with TTAs, osteomyelitis cases had significantly longer time to radiographic union compared with controls (median: 210 vs. 165 days). Blast injuries, antibiotic bead utilization, ≥ Gustilo-Andersen-IIIb fractures [highest risk with TTA (OR: 15.10; CI: 3.22-71.07)], and foreign body at the fracture site were significantly associated with developing osteomyelitis. In a separate model, the Orthopaedic Trauma Association Open Fracture Classification muscle variable was significant with increasing risk from muscle loss (OR: 5.62; CI: 2.21-14.25) to dead muscle (OR: 8.46; CI: 3.31-21.64). When TTAs were excluded, significant risk factors were similar and included sustaining an injury between 2003 and 2006. CONCLUSIONS Patients with severe blast trauma resulting in significant muscle damage are at the highest risk for osteomyelitis. The period association coincides with a time frame when several trauma system practice changes were initiated (eg, increased negative pressure wound therapy, decreased high-pressure irrigation, and reduced crystalloid use). LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David R. Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Louis R. Lewandowski
- Department of Surgery, Uniformed Services University - Walter Reed National Military Medical Center, Bethesda, MD
| | - Benjamin K. Potter
- Department of Surgery, Uniformed Services University - Walter Reed National Military Medical Center, Bethesda, MD
| | | | | | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD
- Infectious Disease, Walter Reed National Military Medical Center, Bethesda, MD
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Bethesda, MD
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Suresh MR, Chung KK, Schiller AM, Holley AB, Howard JT, Convertino VA. Unmasking the Hypovolemic Shock Continuum: The Compensatory Reserve. J Intensive Care Med 2018; 34:696-706. [PMID: 30068251 DOI: 10.1177/0885066618790537] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hypovolemic shock exists as a spectrum, with its early stages characterized by subtle pathophysiologic tissue insults and its late stages defined by multi-system organ dysfunction. The importance of timely detection of shock is well known, as early interventions improve mortality, while delays render these same interventions ineffective. However, detection is limited by the monitors, parameters, and vital signs that are traditionally used in the intensive care unit (ICU). Many parameters change minimally during the early stages, and when they finally become abnormal, hypovolemic shock has already occurred. The compensatory reserve (CR) is a parameter that represents a new paradigm for assessing physiologic status, as it comprises the sum total of compensatory mechanisms that maintain adequate perfusion to vital organs during hypovolemia. When these mechanisms are overwhelmed, hemodynamic instability and circulatory collapse will follow. Previous studies involving CR measurements demonstrated their utility in detecting central blood volume loss before hemodynamic parameters and vital signs changed. Measurements of the CR have also been used in clinical studies involving patients with traumatic injuries or bleeding, and the results from these studies have been promising. Moreover, these measurements can be made at the bedside, and they provide a real-time assessment of hemodynamic stability. Given the need for rapid diagnostics when treating critically ill patients, CR measurements would complement parameters that are currently being used. Consequently, the purpose of this article is to introduce a conceptual framework where the CR represents a new approach to monitoring critically ill patients. Within this framework, we present evidence to support the notion that the use of the CR could potentially improve the outcomes of ICU patients by alerting intensivists to impending hypovolemic shock before its onset.
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Affiliation(s)
- Mithun R Suresh
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Kevin K Chung
- 2 Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,3 Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Alicia M Schiller
- 4 Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Aaron B Holley
- 2 Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,3 Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeffrey T Howard
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Victor A Convertino
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
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Second Place: Dismounted complex blast injuries: patterns of remaining limb injuries in patients with single-limb lower extremity amputations. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Maddry JK, Perez CA, Mora AG, Lear JD, Savell SC, Bebarta VS. Impact of prehospital medical evacuation (MEDEVAC) transport time on combat mortality in patients with non-compressible torso injury and traumatic amputations: a retrospective study. Mil Med Res 2018; 5:22. [PMID: 29976254 PMCID: PMC6032797 DOI: 10.1186/s40779-018-0169-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In combat operations, patients with traumatic injuries require expeditious evacuation to improve survival. Studies have shown that long transport times are associated with increased morbidity and mortality. Limited data exist on the influence of transport time on patient outcomes with specific injury types. The objective of this study was to determine the impact of the duration of time from the initial request for medical evacuation to arrival at a medical treatment facility on morbidity and mortality in casualties with traumatic extremity amputation and non-compressible torso injury (NCTI). METHODS We completed a retrospective review of MEDEVAC patient care records for United States military personnel who sustained traumatic amputations and NCTI during Operation Enduring Freedom between January 2011 and March 2014. We grouped patients as traumatic amputation and NCTI (AMP+NCTI), traumatic amputation only (AMP), and neither AMP nor NCTI (Non-AMP/NCTI). Analysis was performed using chi-squared tests, Fisher's exact tests, Cochran-Armitage Trend tests, Shapiro-Wilks tests, Wilcoxon and Kruskal-Wallis techniques and Cox proportional hazards regression modeling. RESULTS We reviewed 1267 records, of which 669 had an injury severity score (ISS) of 10 or greater and were included in the analysis. In the study population, 15.5% sustained only amputation injuries (n=104, AMP only), 10.8% sustained amputation and NCTI (n=72, AMP+NCTI), and 73.7% did not sustain either an amputation or an NCTI (n=493, Non-AMP/NCTI). AMP+NCTI had the highest mortality (16.7%) with transport time greater than 60 min. While the AMP+NCTI group had decreasing survival with longer transport times, AMP and Non-AMP/NCTI did not exhibit the same trend. CONCLUSIONS A decreased transport time from the point of injury to a medical treatment facility was associated with decreased mortality in patients who suffered a combination of amputation injury and NCTI. No significant association between transport time and outcomes was found in patients who did not sustain NCTI. Priority for rapid evacuation of combat casualties should be given to those with NCTI.
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Affiliation(s)
- Joseph K Maddry
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA.,Department of Emergency Medicine, San Antonio Military Medical Center, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Crystal A Perez
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Alejandra G Mora
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Jill D Lear
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Shelia C Savell
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA.
| | - Vikhyat S Bebarta
- US Air Force En route Care Research Center 59th MDW/ST, Chief Scientist's Office -US Army Institute of Surgical research, JBSA Ft. Sam Houston, San Antonio, TX, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Tennent DJ, Polfer EM, Sgromolo NM, Krueger CA, Potter BK. Characterization of disability following traumatic through knee and transfemoral amputations. Injury 2018; 49:1193-1196. [PMID: 29606330 DOI: 10.1016/j.injury.2018.03.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/20/2018] [Accepted: 03/26/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study is to characterize through knee and transfemoral amputations following severe traumatic injuries. METHODS A retrospective review of all transfemoral and through knee amputations sustained by United States military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, inpatient medical records and the Physical Evaluation Board Liaison Offices were queried in order to obtain characteristics related to injury sustained, demographics, treatment, and disability/mental health outcome data. RESULTS A total of 1631 amputations in 1315 patients were identified. Of these there were 37 through knee and 296 were transfemoral amputations. Adequate records for detailed analysis were available on 140 and 25 transfemoral and through knee amputations respectively. There were no significant differences in demographic information, injury mechanism, initial injury severity score, or associated injuries, to include contralateral amputations. There was no significant difference in average disability rating (67.9% vs 78.3%, p = 0.46) or number of service members determined to be fully disabled (42.2% vs 28.6% p = 0.33) between the transfemoral and through knee amputation groups. Whereas there was no difference between groups preoperatively, the knee disarticulation group displayed a higher rate of mental health diagnoses post-amputation (96% vs 72%, p < 0.001) and a higher preponderance of anxiety related disorders than the transfemoral amputees (26.92% vs 12.96%, p = 0.0129). DISCUSSION/CONCLUSION Among this military amputee through knee and transfemoral amputees displayed similar physical disability profiles. However, the through knee amputees displayed a higher level of anxiety related disorders and mental health diagnosis overall. While we don't believe this relationship to be causal in nature, this finding reflects the importance of paying particular attention to mental health in the final disposition of traumatic lower extremity amputees.
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Affiliation(s)
- David J Tennent
- San Antonio Military Medical Center, Department of Orthopaedics, 3855 Roger Brooke Drive, Fort Sam Houston, TX 78234, United States.
| | - Elizabeth M Polfer
- William Beaumont Army Medical Center, Department of Orthopaedics, 5005 N Piedras St., El Paso, TX, 79920, United States.
| | - Nicole M Sgromolo
- San Antonio Military Medical Center, Department of Orthopaedics, 3855 Roger Brooke Drive, Fort Sam Houston, TX 78234, United States.
| | - Chad A Krueger
- Department of Orthopaedic Surgery and Rehabilitation, Womack Army Medical Center, Fort Bragg, NC, 28310, United States.
| | - Benjamin K Potter
- Walter Reed National Naval Military Medical Center, Department of Orthopaedics, WRNMMC 8901,Wisconsin Ave Fl America Building Bldg 19 2(nd), Bethesda, MD 20889, United States.
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Janssen EM, Benz HL, Tsai JH, Bridges JFP. Identifying and prioritizing concerns associated with prosthetic devices for use in a benefit-risk assessment: a mixed-methods approach. Expert Rev Med Devices 2018; 15:385-398. [DOI: 10.1080/17434440.2018.1470505] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Ellen M Janssen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Center of Excellence in Regulatory Science and Innovation, Baltimore, MD, USA
| | - Heather L Benz
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Jui-Hua Tsai
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John FP Bridges
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Center of Excellence in Regulatory Science and Innovation, Baltimore, MD, USA
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Inkellis E, Low EE, Langhammer C, Morshed S. Incidence and Characterization of Major Upper-Extremity Amputations in the National Trauma Data Bank. JB JS Open Access 2018; 3:e0038. [PMID: 30280131 PMCID: PMC6145564 DOI: 10.2106/jbjs.oa.17.00038] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background There are few recent data examining the epidemiology of severe upper-extremity trauma in non-military patients. We used the National Trauma Data Bank (NTDB) to investigate the epidemiology and descriptive characteristics of upper-extremity amputations in U.S. trauma centers. Methods We queried the 2009 to 2012 NTDB research datasets for patients undergoing major upper-extremity amputation and extracted characteristics of the patient population, injury distribution, and treating facilities. In addition, multivariable regression models were fit to identify correlates of reoperation, major in-hospital complications, duration of hospitalization, and in-hospital mortality. Results A total of 1,386 patients underwent a major upper-extremity amputation secondary to a trauma-related upper-extremity injury, representing 46 per 100,000 NTDB trauma admissions from 2009 to 2012. The most frequent definitive procedures performed were amputations through the humerus (35%), forearm (30%), and hand (14%). The average duration of hospitalization for all amputees was 17 days. Thirty-one percent of patients underwent at least 1 reoperation. The rate of reoperation was significantly higher at university-associated hospitals compared with nonteaching or community hospitals (p < 0.0001). Patients who had at least 1 reoperation stayed in the hospital approximately 7 days longer than patients who did not undergo reoperation. The Injury Severity Score, hospital teaching status, concomitant neurovascular injury, and occurrence of a complication were significantly associated with reoperation. Conclusions The present study provides an updated report on the epidemiology and characteristics of trauma-related major upper-extremity amputation in the U.S. civilian population. Additional work is necessary to assess the long-term outcomes following attempted upper-extremity salvage. The population-level data provided by the present study may help to inform the design and implementation of future studies on the optimum treatment for this survivable but life-altering injury.
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Affiliation(s)
- Elizabeth Inkellis
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Eric Edison Low
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Christopher Langhammer
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.,Orthopaedic Trauma Institute, San Francisco, California
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Streifel BC, Lundin JG, Sanders AM, Gold KA, Wilems TS, Williams SJ, Cosgriff‐Hernandez E, Wynne JH. Hemostatic and Absorbent PolyHIPE–Kaolin Composites for 3D Printable Wound Dressing Materials. Macromol Biosci 2018; 18:e1700414. [DOI: 10.1002/mabi.201700414] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/23/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Benjamin C. Streifel
- Chemistry Division Naval Research Laboratory 4555 Overlook Avenue SW Washington DC 20375 USA
| | - Jeffrey G. Lundin
- Chemistry Division Naval Research Laboratory 4555 Overlook Avenue SW Washington DC 20375 USA
| | - Allix M. Sanders
- National Cancer Institute/National Institutes of Health Frederick MD 21701 USA
| | - Karli A. Gold
- Department of Biomedical Engineering Texas A&M University College Station TX 77843 USA
| | - Thomas S. Wilems
- Department of Biomedical Engineering Texas A&M University College Station TX 77843 USA
| | - Sierra J. Williams
- Chemistry Division Naval Research Laboratory 4555 Overlook Avenue SW Washington DC 20375 USA
| | | | - James H. Wynne
- Chemistry Division Naval Research Laboratory 4555 Overlook Avenue SW Washington DC 20375 USA
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Williams MR, Herr H, D'Andrea S. Metabolic effects of using a variable impedance prosthetic knee. ACTA ACUST UNITED AC 2018; 53:1079-1088. [PMID: 28355031 DOI: 10.1682/jrrd.2015.04.0072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 12/17/2015] [Indexed: 11/05/2022]
Abstract
A transfemoral amputation has a significant effect on walking. Though current prosthetic knee options serve to restore mobility, as do purely passive devices, they do not fully restore nondisabled gait. Persons with transfemoral amputation incur a higher metabolic cost during walking than persons without amputation and as a result walk slower and for a shorter distance before tiring. An original variable-impedance transmission prosthetic knee (VI Knee) was tested with five study participants with unilateral transfemoral amputation at two steady-state walking speeds, one below and one above their preferred walking speed. While walking with the VI Knee, participants with shorter limbs showed a reduction in metabolic cost compared with their conventional C-Leg prosthesis, while those with longer limbs exhibited an increase. Though differences were observed between speeds, overall, the difference in metabolic cost (reduction or increase) was found to correlate significantly with rise in the center of mass, with those with shorter residual limbs exhibiting less overall lifting of the body during gait.
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Affiliation(s)
- Matthew R Williams
- Providence Department of Veterans Affairs Medical Center, Providence, RI.,Media Lab, Massachusetts Institute of Technology, Cambridge, MA
| | - Hugh Herr
- Providence Department of Veterans Affairs Medical Center, Providence, RI.,Media Lab, Massachusetts Institute of Technology, Cambridge, MA
| | - Susan D'Andrea
- Providence Department of Veterans Affairs Medical Center, Providence, RI.,Department of Orthopaedics, Brown University, Providence, RI
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Armstrong AJ, Hawley CE, Darter B, Sima AP, DiNardo J, Inge KJ. Operation Enduring Freedom and Operation Iraqi Freedom Veterans with amputation: An exploration of resilience, employment and individual characteristics. JOURNAL OF VOCATIONAL REHABILITATION 2018. [DOI: 10.3233/jvr-180923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Amy J. Armstrong
- Department of Rehabilitation Counseling, School of Allied Health Professions, Virginia Commonwealth University, Richmond, VA, USA
| | - Carolyn E. Hawley
- Department of Rehabilitation Counseling, School of Allied Health Professions, Virginia Commonwealth University, Richmond, VA, USA
| | - Benjamin Darter
- Department of Physical Therapy, School of Allied Health Professions, Virginia Commonwealth University, Richmond, VA, USA
| | - Adam P. Sima
- Department of Biostatistics, VCU School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Jason DiNardo
- Department of Biostatistics, VCU School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Katherine J. Inge
- Rehabilitation Research and Training Center (VCU-RRTC) on Employment of People with Physical Disabilities, Virginia Commonwealth University, Richmond, VA, USA
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