Concept and evaluation of the German War Surgery Course - Einsatzchirurgie-Kurs der Bundeswehr

INTRODUCTION

Military surgeons must be prepared to care for severe and complex life-threatening injuries rarely seen in the civilian setting. Typical civilian training and practice do not provide adequate exposure to the broad set of surgical skills required. The German Bundeswehr Medical Service has developed and refined the War Surgery Course (WSC) to meet this training gap. This article describes the recent experience with this readiness curriculum.

METHODS

Run annually since 1998, WSC consists nowadays of 5 days with 20 theoretical modules. Four sessions with standardised practical skills training use a live tissue porcine model, and the recently added cadaver-based Advanced Surgical Skills for Exposure in Trauma course. Sixteen military surgeons who participated in the WSC in January 2016 completed a survey of their self-rated readiness for 114 predefined emergency skills before and after completion, and provided an overall evaluation of the course.

RESULTS

Self-assessed readiness improved significantly over baseline for all areas covered in both the practical skills and theoretical knowledge portions of the WSC curriculum. Additionally, all participants rated the course as important and universally recommended it to other military surgeons preparing for missions.

CONCLUSIONS

The WSC course format was well received and perceived by learners as a valuable readiness platform. Ongoing evaluation of this course will enable data-driven evolution to ensure a maximum learning benefit for participants. With the increasing multinational nature of modern military missions, surgeons' training should follow international standards. Continuing evolution of military surgical training courses should further encourage the sharing and adoption of best educational practices.

Expression of matrix-metalloproteinases and their inhibitors in the wounds of diabetic and non-diabetic patients

AIMS/HYPOTHESIS

The molecular factors that cause an acute wound in diabetic patients to become chronic have not yet been established. Wound healing is known to require a balance between the accumulation of collagenous and non-collagenous extracellular matrix components and their remodelling by matrix metalloproteinases (MMPs) and the tissue inhibitors of metalloproteinases (TIMPs). Our aim was to assess if the concentrations of MMPs and TIMPs were different between acute and chronic wounds in diabetic patients by analysing biopsy samples.

METHODS

A 5 mm punch biopsy was taken from 20 diabetic foot ulcers of patients before initiating treatment and from traumatic wounds of 12 non-diabetic patients 2 days after injury. The concentrations of MMP-1, MMP-2(pro), MMP-2(active), MMP-8, MMP-9 and TIMP-2 were measured in detergent extracts of the biopsy homogenates using ELISAs and gelatin-zymography.

RESULTS

The concentration of MMP-1 was increased 65-fold in biopsies of diabetic foot ulcers compared with the concentrations measured in biopsies of traumatic wounds. Similarly, MMP-2(pro) were increased threefold, sixfold for MMP-2(active), twofold for MMP-8 and 14-fold for MMP-9 compared to average concentrations in biopsies of traumatic wounds. Furthermore, the expression of TIMP-2 was reduced twofold in diabetic wounds compared with lesions of non-diabetic patients.

CONCLUSION/INTERPRETATION

The combination of increased concentrations of MMPs with decreased concentrations of TIMP-2 in chronic diabetic foot ulcers compared with healing wounds in normal patients suggests that the increased proteolytic environment contributes to the failure of diabetic wounds to heal. New treatment strategies for healing chronic diabetic foot ulcers could be directed towards reducing concentrations of MMPs and increasing levels of TIMPs.

Three-dimensional aspects of caloric nystagmus in humans: II. Caloric-induced torsional deviation

The oculomotor response to caloric stimulation was recorded using video-oculography (VOG), yielding measures of eye rotation about all three orthogonal axes. During an ongoing caloric nystagmus response, a slow torsional deviation of the eye in the direction of the slow phase of the torsional component of nystagmus was observed. The effect appeared to be systematically influenced by the gravitoinertial force employed during a centrifuge study (see Part I, this issue), and was observed in all tested subjects. Furthermore, in subsequent laboratory tests warm and cold irrigations elicited opposite responses, as did stimulation to right and left ears. Testing in the supine and prone positions, however, did not lead to a reversal of direction, as is the case with the horizontal, vertical and torsional nystagmus components as such. The rate of torsional deviation was of the order of 0.05 degrees/s, well below the physiological transduction range of the cupular organs. Testing with a torsional optokinetic stimulus produced only the expected OK nystagmus without any slow deviation. This would argue against a central vestibular integratory, or oculomotor origin for the phenomenon. It is proposed that this caloric-induced, torsional deviation is of peripheral otolithic origin, most likely elicited by way of direct thermal stimulation to the hair cells of the utricular maculae.