Understanding the drivers of patient satisfaction with home health care services: An empirical study of two care pathways

This research aims to empirically determine the drivers of patient satisfaction with home health care services and to develop an instrument for measuring patient satisfaction in this context. The empirical study focuses on insulin and respiratory assistance therapies. Two large patient samples of a private home care provider in France are surveyed. Two distinct, yet complementary, analytical procedures are performed to maximize the validity and reliability of the results. We identify four core concepts (interpersonal relationship, support and guidance, delivery of consumables, and equipment use) that play a key role in influencing patient satisfaction across the two therapies studied. The results also reveal that the relative role of each factor in driving overall patient satisfaction varies across these therapies, possibly due to differences in the characteristics of the therapies and related care services. Our empirical results enrich the existing literature, largely focused on hospital and primary care settings, by providing evidence to capture patient satisfaction drivers at the level of specificity required to account for the unique context of home care services. The article's main theoretical contribution is to establish, from the patient's perspective, a core set of drivers that determine patient satisfaction in the context of home health care services. The instrument provides practitioners and policy makers with a practical tool that supports them in achieving patient satisfaction and in understanding why and how such satisfaction is achieved. The suitability of the patient satisfaction instrument to other forms of home care services needs examining.

Nine years of surgical activity in the deployed French military role 2 medical treatment facility in Mali

INTRODUCTION

In January 2013, France launched a military operation in Mali, which ended in August 2022. This study aimed to analyse the global activity performed by a surgical team within the role 2 medical treatment facility (MTF) deployed in Gao during this period, in order to adapt medical battlefield support and combat casualty care teaching.

METHODS

A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. All patients operated on were included.

RESULTS

During this period, 1298 patients with a median age of 29 (range: 23-38) years were included. Among them, 229 (17.6%) underwent a combat-related trauma surgery (CRTS), 234 (18.0%) underwent a non-CRTS, 167 (12.9%) underwent a non-trauma-related surgery and 668 (51.5%) underwent a scheduled surgery in the context of medical supply to the population.Among the CRTS group, 195 (85.2%) patients underwent an orthopaedic procedure, 73 (31.8%) required a general surgery. Finally, 15 (6.6%) wounded required a specialised surgery.

CONCLUSIONS

In line with the activity described in the role 2 MTF deployed in other contemporary asymmetric conflicts, this activity is moderate, especially if only combat-related injuries are considered; medical support to the population occupied most of the surgical activity. For CRTS, most of the traumas are limb traumas. Other traumas are composed of various lesions, which are often life-threatening. This fact imposes the presence of an orthopaedic surgeon with the appropriate equipment, as well as a general surgeon with a wide range of skills, in asymmetric conflicts.

Treating osteoarticular infections in a Role 2 in Chad: a bacterial epidemiological study

INTRODUCTION

The treatment of osteoarticular infections in Africa is a medical and surgical challenge due to the difficulties in managing antibiotic therapy after the surgical procedure. The objectives of this study were to identify the types of bacteria in osteoarticular lesions in patients treated in Chad and to determine the spectrum of resistance encountered and the efficacy of available antibiotics.

MATERIAL AND METHODS

This is a retrospective study of all intraoperative osteoarticular and soft tissue samples taken in a French Role 2 Medical Treatment Facility of N'Djamena during surgery for chronic osteoarticular infections, in Chad, for 1 year.

RESULTS

A total of 160 bacterial strains were identified, with a predominance of Gram-negative bacillus (GNB) and staphylococcus infections. Among staphylococci, 80% were methicillin-sensitive streptococci which were generally multidrug-sensitive. Enterococci were resistant to third-generation cephalosporins, first-generation fluoroquinolones and gentamycin. Among GNB, there was a predominance of enterobacteria compared with non-fermenting GNB, of which 52% were multidrug-resistant and produced extended spectrum beta-lactamases (ESBL).

CONCLUSION

Staphylococcus aureus infections are most often sensitive to available antibiotics and therefore have better prognoses than infections caused by other bacteria. In contrast, in half of the cases of GNB, infections were caused by bacteria producing ESBL, thus posing the problem of multidrug-resistance, the risks of which are increased in precarious situations. Therefore, the type of bacteria appears to be a major prognostic factor in the treatment of osteoarticular infections in a Role 2 in Chad. This criterion will need to be considered before any treatment decisions are made.

Elective brachial plexus decompression in neurogenic thoracic outlet syndrome

We aimed to evaluate functional outcome following elective brachial plexus decompression by compressive fibrous band resection and limited on-demand bone abnormality resection in patients with neurogenic thoracic outlet syndrome (N-TOS). A retrospective continuous observational study was conducted in 17 patients (15 women and 2 men), with a mean age of 42 years, operated on between 2013 and 2021. Twenty brachial plexus decompressions were performed, for 13 objective and 7 subjective N-TOSs, including 3 recurrent N-TOSs. At last follow-up, outcomes were evaluated in terms of residual pain, paresthesia and hand motor deficit, plus patient-reported assessment and Quick-DASH functional scoring. No postoperative complications occurred. At a median follow-up of 12 months (range 6-48 months), complete pain relief and paresthesia resolution were found in 11/15 and 9/14 cases, respectively. All patients reported that their symptoms had improved. In contrast, hand muscle atrophy persisted in all cases (n = 11). Sensorimotor recovery seemed to be poorer and mean Quick-DASH score better in objective than subjective N-TOS patients. Elective brachial plexus decompression seemed to be a safe procedure, providing constant improvement in subjective symptoms related to lower trunk irritation. However, nerve release did not provide hand muscle recovery in patients with objective N-TOS. LEVEL OF EVIDENCE: IV.

Flow Marks in Injection Molding of PP

Flow marks in injection moulding is quite often encountered on different type of polymers. This defects is known as successive and periodic bright and dull bands oriented perpendicular to the flow direction. Their appearances meanly depend on processing and observation conditions. This study was lead on two industrial polypropylene polymers with a simplified polished rectangular mould geometry. We show that this defect appears during the filling stage and comes from a local change of morphological and molecular orientation along the filling direction on the surface. An instability of the flow front due to a limited sliding at the contact combined to the strong changed of molecular orientation before and after the stagnation point are invoked to explain this instability.

Wartime upper-extremity injuries in the Sahelian strip: Experience from a French Forward Surgical Team deployed in Mali

This study aimed to analyze upper-extremity combat-related injuries (CRIs) and non-combat-related injuries (NCRIs) treated in the French Forward Surgical Team currently deployed in Gao, Mali. A retrospective study was conducted using the French Military Health Service OpEX surgical database from February 2013 to March 2020. All patients operated on for upper-extremity injury were included: 224 patients, with a mean age of 28.15 years, for 249 upper-extremity injuries. Seventy-six (33.9%) sustained CRIs and 148 (66.1%) NCRIs. Multiple upper-extremity injuries and associated injuries were significantly more common in the CRI group. The majority of NCRIs involved the hand. Debridement and wound care was the most common procedure in both groups. External fixation and fasciotomy were significantly more frequent in the CRI group, and internal fracture fixation in the NCRI group. The overall number of procedures was significantly higher in the CRI group. Due to the high frequency of upper-extremity injury in current theaters of operations, deployed orthopedic surgeons should be trained in basic hand surgery so as to optimally manage both CRIs and NCRIs.

Simultaneous Determination of Neutron-Induced Fission and Radiative Capture Cross Sections from Decay Probabilities Obtained with a Surrogate Reaction

Reliable neutron-induced-reaction cross sections of unstable nuclei are essential for nuclear astrophysics and applications but their direct measurement is often impossible. The surrogate-reaction method is one of the most promising alternatives to access these cross sections. In this work, we successfully applied the surrogate-reaction method to infer for the first time both the neutron-induced fission and radiative capture cross sections of ^{239}Pu in a consistent manner from a single measurement. This was achieved by combining simultaneously measured fission and γ-emission probabilities for the ^{240}Pu(^{4}He,^{4}He^{'}) surrogate reaction with a calculation of the angular-momentum and parity distributions populated in this reaction. While other experiments measure the probabilities for some selected γ-ray transitions, we measure the γ-emission probability. This enlarges the applicability of the surrogate-reaction method.

Blast injury of the hand related to warfare explosive devices: experience from the French Military Health Service

INTRODUCTION

The objective was to report on the experience of the French Army Health Service in the management of blast injury of the hands related to warfare explosive devices.

METHODS

A retrospective study was conducted in the Percy Military Hospital (role 4 medical treatment facility) among French soldiers who presented with a combat-related blast injury of the hand between 2002 and 2018. The functional result was assessed by the disabilities of the arm, shoulder and hand (DASH) and the Orthotics and Prosthetics User Survey (OPUS, upper extremity functional status) scores. Proximal amputations (PAs) and distal amputations (DAs) were distinguished for the analysis.

RESULTS

Fifteen patients with a mean age of 31±8 years were included. They totalised 20 blasted hands. There were 16 traumatic amputations: 8 in each of the PA and DA groups. Twelve patients had additional injuries, four of which were polytraumatic. Skin closure time and flap use were higher in the DA group. Only one thumb reconstruction was performed. At a mean follow-up of 6.5±4 years, the number of amputees wearing a prosthesis was higher in the PA group. The mean DASH and OPUS scores were 35.5%±24.0% and 64.0%±19.0%, respectively, with no difference between the two groups.

CONCLUSION

The severity of hand blasts related to warfare explosive devices requires the systematic application of damage control surgery. PAs are frequent and secondary reconstruction options are limited. The functional result is poor and similar between proximal and distal amputees.

Evaluation of a fellowship abroad as part of the initial training of the French military surgeon

INTRODUCTION

Military surgery requires skills that in general cannot be easily learnt in civilian training. Participation in a fellowship abroad adapted to the particular operating conditions of the foreign deployment is one route that might secure the necessary supplementary training. We therefore assessed the relevance of such a fellowship in the preparedness of young military surgeons in their first deployment.

METHODS

This study included all active military surgeons who had completed a fellowship abroad during their initial training from 2004 to 2017 in Tchad or Senegal or Djibouti. The collection of data was performed using a questionnaire. The main judgement criterion was the rate of positive answers awarded to the relevance of this fellowship in the preparedness of respondents' first foreign deployment.

RESULTS

Sixty-nine of 73 surgeons answered. Sixty-one estimated the fellowship had allowed them to feel more operational during their first mission, with 83.61% rating this feeling as important. Also, 61 recommended the use of a fellowship for war surgery training. The grade assigned to the surgical benefit was 8.48/10.

CONCLUSION

A fellowship abroad permits one to become familiar with surgical practice under austere circumstances and the particularities of the surgical structures at the front. Current trainees' feedback confirms its relevance.

Preliminary results on the 233U α-ratio measurement at n_TOF

233U is the fissile nuclei in the Th-U fuel cycle with a particularily small neutron capture cross setion which is on average about one order of magnitude lower than its fission cross section. Hence, the measurement of the 233U(n, γ) cross section relies on a method to accurately distinguish between capture and fission γ-rays. A measurement of the 233U α-ratio has been performed at the n_TOF facility at CERN using a so-called fission tagging setup, coupling n_TOF 's Total Absorption Calorimeter with a novel fission chamber to tag the fission γ-rays. The experimental setup is described and essential parts of the analysis are discussed. Finally, a preliminary 233U α-ratio is presented.

Microvascular anastomosis using loupes and smartphone magnification: Experimental study for application to limited-resource environments

Finger revascularization has been performed without a microscope in limited-resource environments only when absolutely necessary. This experimental study sought to assess the feasibility of microvascular anastomosis in rats performed using loupes or smartphone magnification. Thirty rats were divided into three groups of 10 individuals according to the magnification method used: operating microscope (control group M), surgical loupes (group L) and smartphone (group S). The infrarenal aorta was dissected under a microscope, then anastomosed by interrupted sutures using the group-specific magnifying device. The main analytical criteria were vessel diameter, anastomosis duration, immediate flow patency (T0), patency after one hour (T1) and anastomosis quality. Anastomosis duration was comparable between groups M and L, but was twice as long in group S. The number of leaks at clamp removal was higher in group S. Patency rates at T0 and T1 were 100% in groups M and L, but were significantly lower in group S. The anastomosis quality was low in group L and poor in group S. Anastomosis of digital arteries using loupes is possible, but the resulting quality is lower than with a microscope. Current smartphones are not adequate for performslt ing microvascular repairs in a living model.

The state of microsurgical practice in French forward surgical facilities from 2003 to 2015

Microsurgery is an unusual procedure in the theatres of military operations. We sought to analyze the state of microsurgical practices in the French medical treatment facilities (MTFs) deployed around the world in the 21st century. A retrospective study was conducted among all patients who were operated on in French forward surgical facilities between 2003 and 2015. Those who underwent microsurgical procedures for nerve injury, vascular injury, or extremity reconstruction were included. Only early vascular results were assessed. Among the 2589 patients operated on for an extremity injury during the study period, 56 (2.1%) were included, with the group composed of 29 patients with isolated nerve injuries, 28 patients with nerve and arterial injuries, and two patients with isolated arterial injuries, mostly at the hand level. Nerve procedures predominantly consisted of direct suturing, although autografting and nerve transfers were also performed. Thirteen microvascular repairs were carried out, including nine cases of proximal or digital revascularization; revascularization was successful in six of the nine cases. These procedures were completed by orthopedic surgeons trained in microsurgery, mostly under loupes magnification. Routine nerve repair in the field seems to be specific to French MTFs. Salvage of amputated or devascularized fingers in the combat zone had never been reported before. Such emphasizes the need to train deployed orthopedic surgeons to perform microsurgical procedures and to equip all MTFs with basic microsurgical sets and magnification means.

Assessing the impact of a patient education programme on pressure ulcer prevention in patients with spinal cord injuries

OBJECTIVES

There is currently a low level of evidence for the impact of patient education on the management of patients with chronic neurological disease at risk of developing pressure ulcers. The objective of this study was to assess the impact of a patient education programme on pressure ulcer prevention in patients with chronic spinal cord injuries.

MATERIALS AND METHODS

This study included adult patients with any spinal cord injury, regardless of the cause. Participants attended 2 group workshops focusing on pressure ulcer prevention. Various clinical data were gathered during an initial individual interview and at 3, 6 and 12 months, along with rating scale values from the Hospital Anxiety and Depression Scale, Rosenberg self-esteem scale, Schwarzer self-efficacy scale, a quality of life scale (SF-36) and the revised Skin Management Needs Assessment Checklist (Revised SMnac), which was used as the primary endpoint.

RESULTS

Twenty patients were included in the study. The mean patient age was 52 years (SD: 9,8). Sixteen patients had traumatic spinal cord injuries, with a median injury duration of 234 months (IQR: 123-407). Seventy-five percent had had a pressure ulcer in the twelve months prior to the study. Patient education was shown to have a significant impact on skin management ability, with a highly significant increase in the overall revised SMnac score at 3 months. These results were stable over time, from 6 to 12 months. Six patients developed a pressure ulcer during the study (30%).

CONCLUSION

This study supports the hypothesis that a therapeutic educational program conducted at the chronic phase in spinal cord injured individuals has an impact.

Preliminary results on the 233U capture cross section and alpha ratio measured at n_TOF (CERN) with the fission tagging technique

233U is of key importance among the fissile nuclei in the Th-U fuel cycle. A particularity of 233U is its small neutron capture cross-section, which is on average about one order of magnitude lower than the fission cross-section. The accuracy in the measurement of the 233U capture cross-section depends crucially on an efficient capture-fission discrimination, thus a combined set-up of fission and γ-detectors is needed. A measurement of the 233U capture cross-section and capture-to-fission ratio was performed at the CERN n_TOF facility. The Total Absorption Calorimeter (TAC) of n_TOF was employed as γ-detector coupled with a novel compact ionization chamber as fission detector. A brief description of the experimental set-up will be given, and essential parts of the analysis procedure as well as the preliminary response of the set-up to capture are presented and discussed.

Metacarpal bone reconstruction by a cementless induced membrane technique

Gunshot wounds to the hand often produce complex injuries and large segmental bone defects. Bone reconstruction remains a challenge in this context. The induced membrane technique is a simple and effective procedure for reconstruction of segmental bone defects. The technique is straightforward but must be performed rigorously. Usually polymethylmethacrylate (PMMA) cement is required for the first stage of the surgery. We describe four cases of metacarpal bone reconstruction after gunshot wounds in a limited-resource setting. Two patients were treated using the induced membrane technique with a polypropylene syringe body instead of PMMA cement, which was unavailable in this situation. A thick membrane was observed 6 weeks after spacer implantation. Bone union was achieved in all cases.

Development of a Gaseous Proton-Recoil Detector for neutron flux measurements between 0.2 and 2 MeV neutron energy

Absolute measurements of neutron fluence are an essential prerequisite of neutron-induced cross section measurements, dosimetric investigations and neutron beam lines characterisation. Independent and precise neutron flux measurements can be performed with respect to the H(n,p) elastic cross section. However, the use of silicon proton recoil detectors is not straightforward below incident neutron energy of 1 MeV, due to a high background in the detected proton spectrum. A new gaseous proton-recoil detector has been designed to answer the challenge. The detector is described in details and results of the commissioning tests are presented.

Assessment of an anti-scale low-frequency electromagnetic field device on drinking water biofilms

Low intensity and very low-frequency electromagnetic fields (EMF) used for preventing scaling in water distribution systems were tested for the first time for their potential impact on drinking water biofilms. The assays were carried out in laboratory-scale flow-through reactors that mimic water distribution systems. The drinking water biofilms were not directly exposed to the core of the EMF generator and only subjected to waterborne electromagnetic waves. The density and chlorine susceptibility of nascent or mature biofilms grown under exposure to EMF were evaluated in soft and hard water. This EMF treatment was able to modify CaCO₃ crystallization but it did not significantly affect biofilms. Indeed, over all the tested conditions, there was no significant change in cell number, or in the integrity of the cells (membrane, culturability), and no measurable effect of chlorine on the biofilm.

The action of chemical and mechanical stresses on single and dual species biofilm removal of drinking water bacteria

The presence of biofilms in drinking water distribution systems (DWDS) is a global public health concern as they can harbor pathogenic microorganisms. Sodium hypochlorite (NaOCl) is the most commonly used disinfectant for microbial growth control in DWDS. However, its effect on biofilm removal is still unclear. This work aims to evaluate the effects of the combination of chemical (NaOCl) and mechanical stresses on the removal of single and dual species biofilms of two bacteria isolated from DWDS and considered opportunistic, Acinectobacter calcoaceticus and Stenotrophomonas maltophilia. A rotating cylinder reactor was successfully used for the first time in drinking water biofilm studies with polyvinyl chloride as substratum. The single and dual species biofilms presented different characteristics in terms of metabolic activity, mass, density, thickness and content of proteins and polysaccharides. Their complete removal was not achieved even when a high NaOCl concentrations and an increasing series of shear stresses (from 2 to 23Pa) were applied. In general, NaOCl pre-treatment did not improve the impact of mechanical stress on biofilm removal. Dual species biofilms were colonized mostly by S. maltophilia and were more susceptible to chemical and mechanical stresses than these single species. The most efficient treatment (93% biofilm removal) was the combination of NaOCl at 175mg·l^-1 with mechanical stress against dual species biofilms. Of concern was the high tolerance of S. maltophilia to chemical and mechanical stresses in both single and dual species biofilms. The overall results demonstrate the inefficacy of NaOCl on biofilm removal even when combined with high shear stresses.

Design of a rotating disk reactor to assess the colonization of biofilms by free-living amoebae under high shear rates

The present study was aimed at designing and optimizing a rotating disk reactor simulating high hydrodynamic shear rates (γ), which are representative of cooling circuits. The characteristics of the hydrodynamic conditions in the reactor and the complex approach used to engineer it are described. A 60 l tank was filled with freshwater containing free-living amoebae (FLA) and bacteria. Adhesion of the bacteria and formation of a biofilm on the stainless steel coupons were observed. FLA were able to establish in these biofilms under γ as high as 85,000 s^-1. Several physical mechanisms (convection, diffusion, sedimentation) could explain the accumulation of amoeboid cells on surfaces, but further research is required to fully understand and model the fine mechanisms governing such transport under γ similar to those encountered in the industrial environment. This technological advance may enable research into these topics.

Temporary fixation of limbs and pelvis

"Urgent, complete, definitive" treatment still today seems to be an appropriate attitude in many trauma cases. There are, however, several situations in which emergency definitive fixation is not the optimal strategy for all cases of fracture. Temporary fixation has a role to play in the orthopedic "trauma damage control" design comprising successive steps, as applied in multiple trauma, multiple fracture, severe multi-tissue limb lesions and soft-tissue lesions of unpredictable progression. The aim of this study is to define the strategies, indications, principles and limitations of temporary fixation in limb and pelvis fracture.

Studies of fission fragment yields via high-resolution γ-ray spectroscopy

Precise spectroscopic information on the fast neutron induced fission of the 238U(n,f) reaction was recently gained using a new technique which involved coupling of the Miniball high resolution y-ray spectrometer and the LICORNE directional neutron source. The experiment allowed measurement of the isotopic fission yields for around 40 even-even nuclei at an incident neutron energy of around 2 MeV where yield data are very sparse. In addition spectroscopic information on very neutron-rich fission products was obtained. Results were compared to models, both the JEFF-3.1.1 data base and the GEF code, and large discrepancies for the S1 fission mode in the Sn/Mo isotope pair were discovered. This suggests that current models are overestimating the role played by spherical shell effects in fast neutron induced fission. In late 2017 and 2018 the nu-ball hybrid spectrometer will be constructed at the IPN Orsay to perform further experimental investigations with directional neutrons coupled to a powerful hybrid Ge/LaBr3 detector array. This will open up new possibilities for measurements of fission yields for fast-neutron-induced fission using the spectroscopic technique and will be complimentary to other methods being developed.

The effect of chlorination and hydrodynamic shear stress on the persistence of bacteriophages associated with drinking water biofilms

AIMS

This work aimed to assess at pilot scale the effect of chlorination and water flushing on 2-month-old drinking water biofilms and, above all, on biofilm-associated F-specific RNA bacteriophages MS2, GA and Qβ.

METHODS AND RESULTS

Chlorination (4 mg l(-1) ) was applied first with a hydrodynamic shear stress of 1 Pa and second with an increase in hydrodynamic shear stress to 10 Pa. Despite a rapid decrease in the number of biofilm bacteria and associated phages, infectious phages were still detected on surfaces after completion of the 150 min cleaning procedure. The resulting sequence of phage removal was: GA > Qβ ≫ MS2.

CONCLUSIONS

The effect of chlorine on biofilm bacteria and biofilm-associated phages was limited to the upper layers of the biofilm and was not enhanced by an increase in hydrodynamic shear stress. A smaller decrease was observed for MS2 than for GA or Qβ after completion of the cleaning procedure.

SIGNIFICANCE AND IMPACT OF THE STUDY

The differences observed between the three phages suggest that the location of the viral particles in the biofilm, which is related to their surface properties, affects the efficiency of chlorine disinfection.

War-related extremity injuries in children: 89 cases managed in a combat support hospital in Afghanistan

BACKGROUND

Meeting paediatric needs is among the priorities of western healthcare providers working in Afghanistan.

HYPOTHESIS

Insufficient information is available on paediatric wartime injuries to the extremities. Our objective here was to describe these injuries and their management on the field.

MATERIALS AND METHODS

We retrospectively reviewed consecutive cases of injuries to the extremities in children (< 16 years of age) due to weapons and managed at the Kabul International Airport (KaIA) Combat Support Hospital between June 2009 and April 2013. We identified 89 patients with a mean age of 10.2 ± 3.5 years and a total of 137 elemental lesions.

RESULTS

Explosive devices accounted for most injuries (78.6%) and carried a significantly higher risk of multiple lesions. There were 54 bone lesions (traumatic amputations and fractures) and 83 soft-tissue lesions. The amputation rate was 18%. Presence of bone lesions was associated with a higher risk of injury to blood vessels and nerves. Of the 89 patients, four (4.5%) died and eight (9%) were transferred elsewhere. Of the 77 remaining patients, at last follow-up (median, one month; range, 0.1-16 months), 73 (95%) had achieved a full recovery (healed wound and/or fracture) or were recovering with no expectation that further surgery would be needed.

DISCUSSION

Despite the absence of paediatric surgeons, the combat support hospital provided appropriate care at the limb salvage and reconstruction phases. The highly specialised treatments needed to manage sequelae were very rarely provided. These treatments probably deserve to be developed in combat support hospitals.

Current issues with lower extremity amputations in a country at war: experience from the National Military Hospital of Kabul

PURPOSE

Management practices associated with war-related amputations in countries at war may be different from the recommendations of occidental Health Force Services due to the high numbers of wounded persons to treat in precarious conditions. This observational retrospective study documents the current management of local lower extremity amputees in Afghanistan. Surgical practices, with or without delayed primary closure (DPC), and prosthetic rehabilitation issues are analyzed.

METHODS

This retrospective study was conducted in the National Military Hospital (NMH) of Kabul from May 2011 to November 2011. Fifty-four Afghan patients who underwent a lower extremity combat-related amputation were included. Ten of them sustained a bilateral amputation.

RESULTS

Injuries were caused by improvised explosive devices (IEDs) or mines in 48 cases, bullets in three cases, and exploding shell fragments in three cases. Of the 64 amputations studied, 46 were open length preserving amputations and primary closure (PC) was applied in 18 cases. Patients were reviewed with a mean follow-up of 5.4 months (range 1-28 months). In the DPC group, secondary closure was performed with a mean time of 18.7 days (range 4-45 days) from injury. The proportion of infectious complications seemed to be higher in the PC group (5/18) than in the DPC group (3/46), but it was only a statistical trend (p = 0.1). Forty-three patients were not prosthetic fitted at the last follow-up.

CONCLUSION

This study supports the surgical strategy of a two-stage procedure for lower limb amputations in countries at war, but underlines the problems of late secondary closure and prosthetic fitting related to decreased sanitary conditions.

Drinking water biofilm cohesiveness changes under chlorination or hydrodynamic stress

Attempts at removal of drinking water biofilms rely on various preventive and curative strategies such as nutrient reduction in drinking water, disinfection or water flushing, which have demonstrated limited efficiency. The main reason for these failures is the cohesiveness of the biofilm driven by the physico-chemical properties of its exopolymeric matrix (EPS). Effective cleaning procedures should break up the matrix and/or change the elastic properties of bacterial biofilms. The aim of this study was to evaluate the change in the cohesive strength of two-month-old drinking water biofilms under increasing hydrodynamic shear stress τw (from ∼0.2 to ∼10 Pa) and shock chlorination (applied concentration at T0: 10 mg Cl2/L; 60 min contact time). Biofilm erosion (cell loss per unit surface area) and cohesiveness (changes in the detachment shear stress and cluster volumes measured by atomic force microscopy (AFM)) were studied. When rapidly increasing the hydrodynamic constraint, biofilm removal was found to be dependent on a dual process of erosion and coalescence of the biofilm clusters. Indeed, 56% of the biofilm cells were removed with, concomitantly, a decrease in the number of the 50-300 μm(3) clusters and an increase in the number of the smaller (i.e., <50 μm(3)) and larger (i.e., >600 μm(3)) ones. Moreover, AFM evidenced the strengthening of the biofilm structure along with the doubling of the number of contact points, NC, per cluster volume unit following the hydrodynamic disturbance. This suggests that the compactness of the biofilm exopolymers increases with hydrodynamic stress. Shock chlorination removed cells (-75%) from the biofilm while reducing the volume of biofilm clusters. Oxidation stress resulted in a decrease in the cohesive strength profile of the remaining drinking water biofilms linked to a reduction in the number of contact points within the biofilm network structure in particular for the largest biofilm cluster volumes (>200 μm(3)). Changes in the cohesive strength of drinking water biofilms subsequent to cleaning/disinfection operations call into question the effectiveness of cleaning-in-place procedures. The combined alternating use of oxidation and shear stress sequences needs to be investigated as it could be an important adjunct to improving biofilm removal/reduction procedures.

Wartime upper extremity injuries: experience from the Kabul International Airport combat support hospital

Few epidemiologic studies have been published about the surgical management of wartime upper extremity injuries (UEIs). The purpose of the present report was to analyze upper extremity combat-related injuries (CRIs) and non-combat related injuries (NCRIs) treated in the Kabul International Airport Combat Support Hospital. A retrospective study was conducted using the French surgical database OpEX (French military health service) from June 2009 to January 2013. During this period, 491 patients with a mean age of 28.7 ± 13 years were operated on because of an UEI. Among them, 244 (49.7%) sustained CRIs and 247 (50.3%) sustained NCRIs. A total number of 558 UEIs were analyzed. Multiple UEIs and associated injuries were significantly more common in the CRIs group. Debridement was the most common procedure in both groups. External fixator application, delayed primary closure and flap coverage were predominant in the CRIs group, as well as internal fracture fixation and tendon repair in the NCRIs group. The overall number of surgical episodes was significantly higher in the CRIs group. Due to the high frequency of UEIs in the theatres of operations, deployed orthopedic surgeons should be trained in basic hand surgery. Although the principles of CRIs treatment are well established, management of hand NCRIs remains controversial in this setting.

Management of the complications of traditional bone setting for upper extremity fractures: the experiences of a French Forward Surgical Team in Chad

The practice of traditional bone setting (TBS) in sub-Saharan Africa often leads to severe complications after upper extremity fracture. The purpose of this study was to evaluate the management of these complications by a French Forward Surgical Team deployed in Chad. An observational, prospective study was conducted over a six-month period between 2010 and 2011. During this period 28 patients were included. There were 20 males and 8 females with a mean age of 30.6 years (range 5-65 years). Thirteen patients (47%) had mal-union of their fracture, nine had non-union (32%), three children (10.5%) presented gangrene and three patients (10.5%) suffered from other complications. Fifteen (54%) patients did not undergo a corrective procedure either because it was not indicated or because they declined. Only 13 (46%) patients were operated on. Twelve of these patients were reviewed with a mean follow-up of 2.4 months. All of them were satisfied with conventional treatment. The infection seemed to be under control in every septic patient. Bone union could not be evaluated in most patients because of the short follow-up. Management of TBS complications is always challenging, even in a deployed Western medical treatment facility. Surgical expectations should be low because of the severity of the sequelae and the uncertainty of patient follow-up. Prevention remains the best treatment.

The psychotic mummified hand: an unusual hand injury complication

The authors report the case of a patient with psychotic symptoms secondary to a posttraumatic stress disorder following a work-related hand injury. The somatic presentation was a "mummified" hand neglected for several years in a splint without any care. The psychiatric analysis concluded that this was part of a delusion of persecution expressing a conflict against the patient's employer and insurance company. Surgical treatment was limited to a hand cleaning with hardware removal. Despite 3 years of antipsychotic medication the patient was still suffering from delusion and the hand remained neglected at the last follow-up.