Exploring the global health and defence engagement interface

Militaries have an important and inevitable role in global health and will interface with existing health systems on deployments. While the primary concern of militaries is not global health, there are clear, and increasingly frequent, circumstances when global health activities align with the interests of defence. Recognising this link between global health and security warrants thoughtful consideration and action where concerns affecting both intersect. In addition to providing medical support to military personnel on operations, advantageous effects can be achieved directly from military medical activities as part of Defence Engagement. While there are limitations and ethical boundaries to the role of militaries in global health, further training, research and conceptual development are warranted to optimise military medical activity at the intersection of security and global health to deliver advantageous effects. This paper forms part of a special issue of BMJ Military Health dedicated to Defence Engagement.

Understanding progressive tissue loss and wound burden in combat casualties: lessons learnt for future operational capability

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.

546 A Longitudinal Case History of Skin Cancer Presentations from One of the UK's Longest Surviving Renal Transplant Patients

Introduction

The immunosuppression required by solid-organ transplant patients not only increases their risk of severe infections but also pre-disposes them to post-transplant malignancy, with skin cancers being the most frequent type. We present a longitudinal history of skin cancers in a patient who received their kidney transplant as a child and has been on immunosuppression for 50 years.

Case Report

The patient developed renal failure at 12 years of age and received a living donor renal transplant in 1970. He developed his first skin cancer in 2004, 34 years later. To date he has had a total of 173 lesions excised of which 123 were a non-melanoma skin cancer (NMSC) (108 basal cell carcinomas (BCCs) and 15 squamous cell carcinomas (SCCs)). None of these lesions had any high-severity features such as poor differentiation or lymphovascular invasion. Numbers of BCCs have not varied, but numbers of SCCs, Bowen's disease and Actinic Keratoses have risen gradually over time.

Discussion

The patient developed his first skin cancer later than has typically been reported in transplant patients and has had a ratio of BCCs to SCCs more similar to the non-transplant population.

Conclusion

Whilst the patient has had a large number of NMSCs over time, a recognised association for those taking immunosuppressive medications, the types and nature of his lesions mirrored that of the non-transplant population, which could relate to the fact he received his transplant as a child.

O3: EVALUATION OF A 3D PRINTED BIO-ARTIFICIAL MUSCLE-ORGANOID FOR TRAUMA RESEARCH

Introduction

Organoid models serve as a robust platform for investigating injury and disease in vitro. Currently, representative models of injury are lacking to investigate the effects of traumatic damage to organs and tissues. Here we describe a three-dimensional in vitro model of high strain rate loading seen in traumatic blast injury.

Method

3D printing resins were tested for Young's Modulus & Poisson Ratio using a universal testing Organoids were then loaded into a 3D Printed bioreactor for high strain rate loading using a split Hopkinson pressure bar device. machine and digital image. Euler beam theory was used to evaluate post deflection. C2C12 myoblasts were seeded in fibrin hydrogels around 3D printed posts using a custom designed jig. High strain rate loading was applied to constructs, then qPCR & Fluorescent Live/Dead staining was utilised to demonstrate cell alignment and myotube formation.

Result

Young's modulus of Flexible resin was 11.51Mpa. Differentiated C2C12 myoblasts were capable of alignment between posts and expression of key markers of differentiation shown by qPCR & imaging. MYH5, MYH2 & MYH1 all had a > 1.5 old increase in expression compared to undifferentiated controls. Organoids were capable of survival in bioreactor casings for over 24 hours and were intact after application of high strain rate loading.

Conclusion

This work demonstrates the first use of a 3D printed organoid in vitro model to investigate high strain rate loading for trauma research. This organoid is capable of high throughput analysis to facilitate genomic and protein level expression analysis.

Take-home message

This work demonstrates the first use of a 3D printed organoid in vitro model to investigate high strain rate loading for trauma research.

Systematic review of the use of endo-luminal topical negative pressure in oesophageal leaks and perforations

Topical negative pressure is widely used in the management of superficial wounds. The use of this technology in the management of oesophageal perforations is becoming increasingly common. This systematic review aims to capture available evidence about its use in this setting. Medline and Embase were searched using MeSH terms and free text: esophageal perforation; esophageal injury; vacuum assisted closure; vacuum therapy device; esophagus; wounds penetrating; esophageal perforation; wound healing; negative pressure wound therapy. Searches were carried out between April and November 2015. Case series, cohort trials and controlled trials were included. Additional studies were found by hand searching reference lists. Eleven studies met the inclusion criteria with 180 patients. Nine of the studies were case series and two were retrospective comparisons of negative pressure with stents or clips. Healing of the perforation occurred in 163/179 patients and the overall mortality was 12.8%. Compared with published data on mortality from oesophageal perforation, the application of negative pressure appears to be beneficial. The studies are, however, limited to case series and retrospective cohort studies. The number of patients in each study is small and in the absence of randomized trials demonstrating a lack of bias firm conclusions cannot be made.

Management and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis

INTRODUCTION

Damage control laparotomy for trauma (DCL) entails immediate control of haemorrhage and contamination, temporary abdominal closure (TAC), a period of physiological stabilisation, then definitive repair of injuries. Although immediate primary fascial closure is desired, fascial retraction and visceral oedema may dictate an alternate approach. Our objectives were to systematically identify and compare methods for restoration of fascial continuity when primary closure is not possible following DCL for trauma, to simplify these into a standardised map, and describe the ideal measures of process and outcome for future studies.

METHODS

Cochrane, OVID (Medline, AMED, Embase, HMIC) and PubMed databases were accessed using terms: (traum*, damage control, abbreviated laparotomy, component separation, fascial traction, mesh closure, planned ventral hernia (PVH), and topical negative pressure (TNP)). Randomised Controlled Trials, Case Series and Cohort Studies reporting TAC and early definitive closure methods in trauma patients undergoing DCL were included. Outcomes were mortality, days to fascial closure, hospital length of stay, abdominal complications and delayed ventral herniation.

RESULTS

26 studies described and compared early definitive closure methods; delayed primary closure (DPC), component separation (CS) and mesh repair (MR), among patients with an open abdomen after DCL for trauma. A three phase map was developed to describe the temporal and sequential attributes of each technique. Significant heterogeneity in nomenclature, terminology, and reporting of outcomes was identified. Estimates for abdominal complications in DPC, MR and CS groups were 17%, 41% and 17% respectively, while estimates for mortality in DPC and MR groups were 6% and 0.5% (data heterogeneity and requirement of fixed and random effects models prevented significance assessment). Estimates for abdominal closure in the MR and DPC groups differed; 6.30 (95% CI=5.10-7.51), and 15.90 (95% CI=9.22-22.58) days respectively. Reporting poverty prevented subgroup estimate generation for ventral hernia and hospital length of stay.

CONCLUSION

Component separation or mesh repair may be valid alternatives to delayed primary closure following a trauma DCL. Comparisons were hampered by the lack of uniform reporting and bias. We propose a new system of standardised nomenclature and reporting for further investigation and management of the post-DCL open abdomen.

Development and implementation of the first national data quality standards for population-based birth defects surveillance programs in the United States

Background

Population-based birth defects surveillance is a core public health activity in the United States (U.S.); however, the lack of national data quality standards has limited the use of birth defects surveillance data across state programs. Development of national standards will facilitate data aggregation and utilization across birth defects surveillance programs in the U.S.

Methods

Based on national standards for other U.S. public health surveillance programs, existing National Birth Defects Prevention Network (NBDPN) guidelines for conducting birth defects surveillance, and information from birth defects surveillance programs regarding their current data quality practices, we developed 11 data quality measures that focused on data completeness (n = 5 measures), timeliness (n = 2), and accuracy (n = 4). For each measure, we established tri-level performance criteria (1 = rudimentary, 2 = essential, 3 = optimal). In January 2014, we sent birth defects surveillance programs in each state, District of Columbia, Puerto Rico, Centers for Disease Control and Prevention (CDC), and the U.S. Department of Defense Birth and Infant Health Registry an invitation to complete a self-administered NBDPN Standards Data Quality Assessment Tool. The completed forms were electronically submitted to the CDC for analyses.

Results

Of 47 eligible population-based surveillance programs, 45 submitted a completed assessment tool. Two of the 45 programs did not meet minimum inclusion criteria and were excluded; thus, the final analysis included information from 43 programs. Average scores for four of the five completeness performance measures were above level 2. Conversely, the average scores for both timeliness measures and three of the four accuracy measures were below level 2. Surveillance programs using an active case-finding approach scored higher than programs using passive case-finding approaches for the completeness and accuracy measures, whereas their average scores were lower for timeliness measures.

Conclusions

This initial, nation-wide assessment of data quality across U.S. population-based birth defects surveillance programs highlights areas for improvement. Using this information to identify strengths and weaknesses, the birth defects surveillance community, working through the NBDPN, can enhance and implement a consistent set of standards that can promote uniformity and enable surveillance programs to work towards improving the potential of these programs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2223-2) contains supplementary material, which is available to authorized users.

Predictive utility of cardiac ultrasound in traumatic cardiac arrest in a combat casualty

We report a case of traumatic cardiac arrest in a combat casualty who was resuscitated to return of spontaneous circulation despite asystole and no visible cardiac activity on initial ultrasound examination. This return of spontaneous circulation suggests that survival may be possible in traumatic cardiac arrest due to exsanguination, even when there is no demonstrable cardiac activity on ultrasound. Cardiac ultrasonography was performed for 10 s only. We suggest that cardiac ultrasonography should be performed for a minimum of 1 min during volume resuscitation. If absence of cardiac activity is confirmed once the heart is full, and there are no other signs of life (including pupillary reaction), then termination of resuscitation should be considered.

Birth defects data from population-based birth defects surveillance programs in the United States, 2007 to 2011: highlighting orofacial clefts

© 2014 The Authors Birth Defects Research Part A: Clinical and Molecular Teratology Published by Wiley Periodicals, Inc.

The association between race/ethnicity and major birth defects in the United States, 1999-2007

OBJECTIVES

We investigated the relationship between race/ethnicity and 27 major birth defects.

METHODS

We pooled data from 12 population-based birth defects surveillance systems in the United States that included 13.5 million live births (1 of 3 of US births) from 1999 to 2007. Using Poisson regression, we calculated prevalence estimates for each birth defect and 13 racial/ethnic groupings, along with crude and adjusted prevalence ratios (aPRs). Non-Hispanic Whites served as the referent group.

RESULTS

American Indians/Alaska Natives had a significantly higher and 50% or greater prevalence for 7 conditions (aPR = 3.97; 95% confidence interval [CI] = 2.89, 5.44 for anotia or microtia); aPRs of 1.5 to 2.1 for cleft lip, trisomy 18, and encephalocele, and lower, upper, and any limb deficiency). Cubans and Asians, especially Chinese and Asian Indians, had either significantly lower or similar prevalences of these defects compared with non-Hispanic Whites, with the exception of anotia or microtia among Chinese (aPR = 2.08; 95% CI = 1.30, 3.33) and Filipinos (aPR = 1.90; 95% CI = 1.10, 3.30) and tetralogy of Fallot among Vietnamese (aPR = 1.60; 95% CI = 1.11, 2.32).

CONCLUSIONS

This is the largest population-based study to our knowledge to systematically examine the prevalence of a range of major birth defects across many racial/ethnic groups, including Asian and Hispanic subgroups. The relatively high prevalence of birth defects in American Indians/Alaska Natives warrants further attention.

Multistate study of the epidemiology of clubfoot

BACKGROUND

Although clubfoot is a common birth defect, with a prevalence of approximately 1 per 1000 livebirths, the etiology of clubfoot remains largely unknown. Studies of the prevalence and risk factors for clubfoot in the United States have previously been limited to specific states. The purpose of this study was to pool data from several birth defects surveillance programs to better estimate the prevalence of clubfoot and investigate its risk factors.

METHODS

The 10 population-based birth defects surveillance programs that participated in this study ascertained 6139 cases of clubfoot from 2001 through 2005. A random sample of 10 controls per case, matched on year and state of birth, was selected from birth certificates. Data on infant and maternal risk factors were collected from birth certificates. Prevalence was calculated by pooling the state-specific data. Conditional logistic regression was used to investigate the association between risk factors and clubfoot.

RESULTS

The overall prevalence of clubfoot was 1.29 per 1000 livebirths; 1.38 among non-Hispanic whites, 1.30 among Hispanics, and 1.14 among non-Hispanic blacks or African Americans. Maternal age, parity, education, and marital status were significantly associated with clubfoot. Maternal smoking and diabetes also showed significant associations. Several of these observed associations were consistent between surveillance programs.

CONCLUSIONS

We estimated the prevalence of clubfoot using data from several birth defects programs, representing one-quarter of all births in the United States. Our findings underline the importance of birth defects surveillance programs and their utility in monitoring population-based prevalence and investigating risk factors.

[Modern concept for treatment of the female-to-male transsexual]

BACKGROUND

The experience of our multidisciplinary team in surgical treatment of female-to-male trans-sexualism is presented, and our treatment concepts described in detail. In addition, our preferred technique of neourethra formation using a prefabricated free fibula flap is described.

PATIENTS AND METHOD

From 1996 to 2003, thirty-four patients underwent gender reassignment surgery as a staged procedure. The neourethra was constructed using an anterior vaginal flap and the prefabricated free fibular flap.

RESULTS

There were four complete losses of the prefabricated fibular flap (11.7%). The neourethra stricture rate was 20.5% and the fistula formation rate was 14.7%. In 82.3% of the patients, the ability to micturate while standing was achieved.

CONCLUSION

This modern concept reduces the complication rate and improves the quality of patient outcome.

Using active medical record review and capture-recapture methods to investigate the prevalence of Down Syndrome among live-born infants in Colorado

BACKGROUND

In a 1994 comparison of Down Syndrome (DS) birth prevalence rates between 17 states (CDC '94), the average rate for the 17 states was 9.2 per 10,000 live-born infants. Colorado residents had the highest birth prevalence rate (12.3 per 10,000). We investigated the accuracy of this report.

METHODS

All children born to Colorado residents during 1989-1991 and reported to CRCSN as having DS went through an active medical record review to eliminate false-positive cases. To adjust for case underascertainment, we used capture-recapture methods to estimate the number of cases missed during surveillance activities. After eliminating false-positive cases and adjusting for case underascertainment, we estimated a new prevalence rate.

RESULTS

A total of 198 children born to Colorado residents during 1989-1991 were reported to CRCSN as having DS. Of these, 151 (76%) were definite cases, 25 (13%) were false-positive cases, and 22 (11%) were inconclusive. A log-linear capture-recapture model applied to the definite cases resulted in an estimate of three missing cases. Therefore, the estimated total number of definite DS cases in Colorado was 155 (95% CI = (153-160)) and the new prevalence rate for 1989-1991 was 9.6 per 10,000 live-born infants.

CONCLUSIONS

Identifying false-positive cases and applying capture-recapture methods can help identify problems with birth defects surveillance efforts and provide direction for improvements. In Colorado, these techniques identified a problem of false-positive and inconclusive reports of DS. Case underascertainment was discovered not to be a problem.

Knowledge and use of folic acid supplementation: a study of Colorado women whose pregnancies were affected by a fetal neural tube defect

OBJECTIVES

To determine whether women who have ha da pregnancy in which the fetus is affected by a neural tube defect (NTD) know of current folic acid recommendations; whether the recommendations are followed before or during the pregnancy associated with an NTD and subsequent pregnancies; and to insure that women who have had an NTD-affected pregnancy have access to proper information about NTDs and folic acid recommendations.

METHODS

Women living in Colorado who had a pregnancy in 1996 or 1997 in which the fetus had an NTD were interviewed in 1998 about their knowledge and use of folic acid supplementation.

RESULTS

Twenty-one of 42 eligible women were interviewed. All women first learned of the folic acid recommendations either during or after their affected pregnancy. Only 23.8% of the women took vitamins containing folic acid during the 1 to 3 months before becoming pregnant. None who had a subsequent pregnancy followed the recommendation to consume 4.0 mg/d of folic acid, beginning at least 1 month before conception. Women who had subsequent pregnancies became pregnant on average of 9 months after their affected pregnancy ended.

CONCLUSIONS

Most women who have an NTD-affected pregnancy are unaware of the national folic acid recommendations and do not follow these recommendations for subsequent pregnancies. However, such women are receptive to information about folic acid supplementation. Health care providers and public health officials should consider their role in assuring that education is provided in an effective and timely manner to women with NTD-affected pregnancies.

An infiltration technique for reduction mammaplasty: results in 192 consecutive breasts

The use of local anaesthetic infiltration with adrenaline is now considered safe in reduction mammaplasty. However, the technique of infiltration by those who support its use is often unclear. Any technique must take account of the neurovascular anatomy of the breast if it is to be effective. We propose the use of a large volume of dilute local anaesthetic (20 ml of 1% lignocaine and 1 mg of adrenaline made up to 400 ml with 0.9% saline) which is placed judiciously in the retroglandular space 15 minutes prior to surgery. The results in 96 consecutive patients (192 breasts) who had an inferior pedicle technique were analysed. The breast complication rate was 9.36% and the patient complication rate 19.79%. Postoperative blood loss ranged from 0 to 305 ml with a mean of 56.03 ml and a median of 50 ml. The described method could be considered a variation of the tumescent technique used in liposuction. The results is an almost bloodless dissection with minimal postoperative blood loss. It should be possible to dispense with the use of drains in most cases.

Surveillance for fetal alcohol syndrome in Colorado

The authors performed surveillance for fetal alcohol syndrome with an existing birth defects registry. Fetal alcohol syndrome cases were identified from multiple sources using passive surveillance and from two selected medical sites using enhanced surveillance. Between May 1992 and March 1994, a total of 173 cases were identified, and the medical records of the cases were reviewed to determine whether the cases met a surveillance case definition for fetal alcohol syndrome. Of these cases, 37 (21 percent) met either definite (28) or probable (9) criteria for fetal alcohol syndrome, 76 met possible criteria (44 percent), and 60 (35 percent) were defined as not fetal alcohol syndrome. Enhanced surveillance had the highest sensitivity for definite or probable cases, 31 of 37 (84 percent), followed by hospital discharge data, 14 of 37 (38 percent). The authors also compared birth certificate information for 22 definite or probable cases in children born between 1989 and 1992 to birth certificate information for all Colorado births for that period. The proportion of mothers of children with fetal alcohol syndrome was statistically significantly greater (as determined by exact binomial 95 percent confidence limits) than the proportion of all mothers for the following characteristics: black race (0.23 versus 0.05), unmarried (0.55 versus 0.22), not employed during pregnancy (0.86 versus 0.43), and started prenatal care in the third trimester (0.18 versus 0.04). Surveillance for fetal alcohol syndrome can be accomplished with an existing registry system in combination with additional case finding and verification activities. Through followup investigation of reported cases, data can be gathered on the mothers of children with fetal alcohol syndrome. These data could be used to target fetal alcohol syndrome prevention programs.