Antibiotic resistance among bacteria isolated from war-wounded patients at the Weapon Traumatology Training Center of the International Committee of the Red Cross from 2016 to 2019: a secondary analysis of WHONET surveillance data.

BACKGROUND: A substantial body of evidence has recently emphasized the risks associated with antibiotic resistance (ABR) in conflicts in the Middle East. War-related, and more specifically weapon-related wounds can be an important breeding ground for multidrug resistant (MDR) organisms. However, the majority of available evidence comes from the military literature focused on risks and patterns of ABR in infections from combat-related injuries among military personnel. The overall aim of this study is to contribute to the scarce existing evidence on the burden of ABR among patients, including civilians with war-related wounds in the Middle East, in order to help inform the revision of empirical antibiotic prophylaxis and treatment protocols adopted in these settings. The primary objectives of this study are to: 1) describe the microbiology and the corresponding resistance profiles of the clinically relevant bacteria most commonly isolated from skin, soft tissue and bone biopsies in patients admitted to the WTTC; and 2) describe the association of the identified bacteria and corresponding resistance profiles with sociodemographic and specimen characteristics. METHODS: We retrospectively evaluated the antibiograms of all consecutive, non-duplicate isolates from samples taken from patients admitted to the ICRC WTTC between 2016 and 2019, limited to skin and soft tissue samples and bone biopsies. We collected data on socio-demographic characteristics from patient files and data on specimens from the WHONET database. We ran univariate and multivariable logistic regression models to test the association between bacterial and resistance profiles with sociodemographic and specimen characteristics. RESULTS: Patients who were admitted with war-related trauma to the ICRC reconstructive surgical project in Tripoli, Lebanon, from 2016 to 2019, presented with high proportion of MDR in the samples taken from skin and soft tissues and bones, particularly Enterobacterales (44.6%), MRSA (44.6%) and P. aeruginosa (7.6%). The multivariable analysis shows that the odds of MDR isolates were higher in Iraqi patients (compared to Syrian patients) and in Enterobacterales isolates (compared to S. aureus isolates). CONCLUSIONS: Our findings stress the importance of regularly screening patients who present with complex war-related injuries for colonization with MDR bacteria, and of ensuring an antibiotic-sensitivity testing-guided antimicrobial therapeutic approach.

Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan.

BACKGROUND: Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared. METHODS: We performed a cohort study using routinely collected data from 457 consecutive Syrian civilians that received surgical treatment for acute conflict-related injuries during 2014-2016 at a Jordanian hospital supported by Médecins Sans Frontières. We defined wound infection as clinical signs of infection verified by a positive culture. We used logistic regression models to evaluate infection-related differences in outcome and resource consumption. RESULTS: Wound infection was verified in 49/457 (11%) patients. Multidrug-resistance (MDR) was detected in 36/49 (73%) of patients with infection. Among patients with infection, 11/49 (22%) were amputated, compared to 37/408 (9%) without infection, crude relative risk = 2.62 (95% confidence interval 1.42-4.81). Infected patients needed 12 surgeries on average, compared to five in non-infected patients (p < .00001). Mean length of stay was 77 days for patients with infection, and 35 days for patients without infection (p = .000001). CONCLUSIONS: Among Syrian civilians, infected conflict-related wounds had a high prevalence of MDR bacteria. Wound infection was associated with poor outcomes and high resource consumption. These results could guide the development of antibiotic protocols and adaptations of surgical management to improve care for wound infections in conflict-related injuries. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02744144 ). Registered April 13, 2016. Retrospectively registered.

Pilot study for detection of early changes in tissue associated with heterotopic ossification: moving toward clinical use of Raman spectroscopy.

Over 60% of combat-wounded patients develop heterotopic ossification (HO). Nearly 33% of them require surgical excision for symptomatic lesions, a procedure that is both fraught with complications and can delay or regress functional rehabilitation. Relative medical contraindications limit widespread use of conventional means of primary prophylaxis, such as nonspecific nonsteroidal anti-inflammatory medications and radiotherapy. Better methods for risk stratification are needed to both mitigate the risk of current means of primary prophylaxis as well as to evaluate novel preventive strategies currently in development. We asked whether Raman spectral changes, measured ex vivo, could be associated with histologic evidence of the earliest signs of HO formation and substance P (SP) expression in tissue biopsies from the wounds of combat casualties. In this pilot study, we compared normal muscle tissue, injured muscle tissue, very early HO lesions (< 16 d post-injury), early HO lesions (> 16 d post-injury) and mature HO lesions. The Raman spectra of these tissues demonstrate clear differences in the Amide I and III spectral regions of HO lesions compared to normal tissue, denoted by changes in the Amide I band center (p < 0.01) and the 1340/1270 cm(-1) (p < 0.05) band area and band height ratios. SP expression in the HO lesions appears to peak between 16 and 30 d post-injury, as determined by SP immunohistochemistry of corresponding tissue sections, potentially indicating optimal timing for administration of therapeutics. Raman spectroscopy may therefore prove a useful, non-invasive and early diagnostic modality to detect HO formation before it becomes evident either clinically or radiographically.

The impact of armed conflict on the development and global spread of antibiotic resistance: a systematic review.

BACKGROUND: Scant data are available on the link between armed conflicts and the development and spread of antimicrobial resistance. OBJECTIVES: We performed a systematic review with the aim to summarize the available data on the prevalence and features of antibiotic resistance and the causes of antibiotic resistance development during armed conflicts in the 21st century. METHODS: Data sources: PubMed and SCOPUS databases were searched from 1 January 2000 to 30 November 2023. STUDY ELIGIBILITY CRITERIA: Original articles reporting data on armed conflicts and antimicrobial resistance were included in this systematic review. No attempt was made to obtain information from unpublished studies. No language restriction was applied. Methods of data synthesis: Both quantitative and qualitative information were summarized by means of textual descriptions. PARTICIPANTS: Patients or soldiers deployed in armed conflict zones. TESTS: culture-dependent antibiotic sensitivity testing or molecular detection of the genetic determinants of antibiotic resistance after a confirmed diagnosis of bacterial infection. Assessment of risk of bias: To evaluate the quality of the included studies, we adapted the tool recommended by the Joanna Briggs Institute. RESULTS: Thirty-four studies were identified, published between November 2004 and November 2023. The quality of included studies was high and medium in 47% and 53% of the studies, respectively. The included studies reported high infection and colonization rates of multidrug-resistant bacteria. Studies performed during the Eastern Ukraine conflict reported high rates of New Delhi metallo-ß-lactamase producers. DISCUSSION: Our findings confirm that wars lead to a large pool of multidrug-resistant infections that could potentially spread. Infection control in healthcare facilities in conflict zones and proper antimicrobial stewardship are crucial.

The kinesthetic diagnosis in a homeric item of pathological heartbeat: An overview in the history of ancient greek medicine.

The Iliad, by the Greek poet Homer, is a precious mine of examples of war traumatology. In the specific case of spear wounds in the chest, the death of the Trojan warrior Alcathous is particularly interesting from the point of view of the history of medicine and the evolution of cardiology and knowledge of the heart at the time of ancient Greece. In particular this paper aims to evidence and reconstruct the main anatomical and physiological knowledge of the heart at that time. Indeed, a historical-linguistic analysis of the Greek text prompts some reflections and thoughts on the heartbeat in pathological conditions and on the function of the heart as a hematopoietic organ. Furthermore, Homer's account is a critical text that highlights the relevance of the use of the senses in the ancient description of nosological pictures and it allows us an interesting and suggestive approach to reconstruction from the historical and historiographical point of view.

Civilian war victims in Afghanistan: five-year report from the Kabul EMERGENCY NGO hospital.

BACKGROUND: Afghanistan has been plagued by war for more than 30 years, but little is known about the civilian cost of such a long-lasting conflict. In particular, the incidence of war injuries among civilians has largely been under-reported. EMERGENCY NGO's Surgical Centre for War Victims has been operating in Kabul since 2001, providing care free of charge to anyone injured in war. The primary aim of our study is to describe the population of patients admitted to our hospital in Kabul. METHODS: This is a 5-year retrospective analysis of all recorded hospital admissions at EMERGENCY NGO's hospital in Kabul, Afghanistan, from 1 January 2017 to 31 December 2021. RESULTS: During the study period, 16,053 patients were admitted. Of these, 85.7% were male and 17.5% were under 14 years old. The proportion of male patients increased progressively with the age ranges (from 63.4 to 89.0%). Bullet wounds were the most frequent kind of injury (55.6%), followed by shell, stab and mine wounds (32.2%, 8.3% and 3.9% respectively). Only 5.8% of patients arrived at our hospital within the "golden hour" following injury. No significant reduction in the hospitalization trend was observed over the study period. The overall in-hospital mortality rate was 4.41%, which bore no correlation to the number of admissions. CONCLUSIONS: This study provides for the first time epidemiology of war-related injuries in a hospital located in a place of long-standing conflict.

Case report: Azithromycin-meropenem combination therapy as a low-cost approach to combat PDR gram-negative infections of war wounds in Ukraine.

Antimicrobial resistance recognised as a major global health problem and it poses a significant challenge in conflict zones, such as the Russia-Ukraine war. This case study focuses on a 32-year-old soldier who sustained combat-related injuries, including extensive wound infections caused by multidrug-resistant and pan-resistant bacteria and was successfully treated with azithromycin-meropenem combination therapy. The emergence of pan-resistant bacteria, particularly a pandrug-resistant strain of Pseudomonas aeruginosa, highlights the severity of the problem and the limited treatment options available. Additionally, the financial burden posed by reserve antibiotics further complicates the management of these infections. The case study demonstrates the effectiveness of including azithromycin-meropenem combination therapy in the treatment regimen, which resulted in improvements in the patient's condition and the eradication of the resistant strains. The findings underscore the need for effective antimicrobial stewardship, infection control measures, and alternative treatment strategies to combat antimicrobial resistance in conflict zones.

Three-Dimensional Modeling of the Structural Microenvironment in Post-Traumatic War Wounds.

BACKGROUND: The development of post-traumatic heterotopic ossification (HO) is a common, undesirable sequela in patients with high-energy (war-related) extremity injuries. While inflammatory and osteoinductive signaling pathways are known to be involved in the development and progression of post-traumatic HO, features of the structural microenvironment within which the ectopic bone begins to form remain poorly understood. Thus, increasing our knowledge of molecular and structural changes within the healing wound may help elucidate the pathogenesis of post-traumatic HO and aid in the development of specific treatment and/or prevention strategies. METHODS: In this study, we performed high-resolution microscopy and biochemical analysis of tissues obtained from traumatic war wounds to characterize changes in the structural microenvironment. In addition, using an electrospinning approach, we modeled this microenvironment to reconstitute a three-dimensional type I collagen scaffold with non-woven, randomly oriented nanofibers where we evaluated the performance of primary mesenchymal progenitor cells. RESULTS: We found that traumatic war wounds are characterized by a disorganized, densely fibrotic collagen I matrix that influences progenitor cells adhesion, proliferation and osteogenic differentiation potential. CONCLUSION: Altogether, these results suggest that the structural microenvironment present in traumatic war wounds has the potential to contribute to the development of post-traumatic HO. Our findings may support novel treatment strategies directed towards modifying the structural microenvironment after traumatic injury.

A letter from Alexis Carrel concerning the preantibiotic treatment of war wounds: The Carrel-Dakin solution.

The morbidity and mortality of soldiers injured during the First World War stemmed in large part from infections of battle wounds. Preventing and treating such infections was a major challenge for the medical corps. Alexis Carrel, a French-American surgeon, advocated irrigating open wounds with a hypochlorite solution (the Carrel-Dakin solution) to prevent the growth of bacteria contaminating them. His method of treatment was complicated and time consuming and was not well followed by surgeons who doubted the necessity of such an exacting protocol. In 1917, Carrel wrote a letter to an American colonel overseeing U.S. medical personnel soliciting his support in training American medical personnel in the proper use of the Carrel-Dakin solution. This letter was the stimulus for recalling here the opposition encountered by both Carrel and Joseph Lister, his predecessor in the aseptic-antiseptic treatment of open wounds, and for noting the conflicting views of contemporary surgeons over surgical sepsis.

The Israeli Defense Forces Point of Injury Antimicrobial Treatment Protocol - A New Protocol and Review of the Literature.

INTRODUCTION: Combat wound infection is a common and serious complication, leading to significant morbidity and mortality. In 2005, a point of injury antimicrobial protocol was published by the Israel Defense Forces, in which Moxifloxacin was chosen. During 2016-2017, a revision of this protocol was performed and concluded with the publication of an updated protocol. The purpose of this report is to present this process and the revised protocol, together with a review of the literature. METHODS: We searched "Medline" and "Google Scholar" for studies dealing with antimicrobial prophylaxis in trauma, for militaries' point of injury antimicrobial protocol protocols and for established surgical antimicrobial prophylaxis protocols. RESULTS: Point of injury antimicrobial protocol is aimed at preventing early infection and its complications. The choice of Moxifloxacin for this purpose may not be optimal since Moxifloxacin spectrum might be overly broad, there is scant evidence supporting it for this indication, and the available preparation does not meet distinctive technical requirements. Contrarily, Ceftriaxone seemed to have suitable microbiological, pharmacological and technical features. CONCLUSION: Point of injury antimicrobial protocol should be used especially when evacuation and definitive surgical treatment are delayed. According to present scientific data and operational needs, Ceftriaxone was chosen for most penetrating injuries, with Metronidazole addition for penetrating abdominal and cranial trauma.

Injury patterns and causes of death in 953 patients with penetrating abdominal war wounds in a civilian independent non-governmental organization hospital in Lashkargah, Afghanistan.

Background: Management of penetrating abdominal war injuries centers upon triage, echeloned care, and damage control. A civilian hospital based in a war zone can rarely rely upon these principles because it normally has limited resources and lacks rapid medical evacuation. We designed this study to describe organ injury patterns and factors related to mortality in patients with penetrating abdominal war injuries in a civilian hospital in an active war zone in Afghanistan, examine how these findings differ from those in a typical military setting, and evaluate how they might improve patients' care. Methods: We reviewed the records of all patients admitted at the Lashkargah "Emergency" hospital with penetrating abdominal injuries treated from January 2006 to December 2016. Demographic and clinical data were recorded; univariate and multivariate analyses were used to identify variables significantly associated with death. Results: We treated 953 patients for penetrating abdominal injury. The population was mainly civilian (12.1% women and 21% under 14). Mean age was 23 years, and patients with blast injuries were younger than in the other groups. The mechanism of injury was bullet injury in 589 patients, shell injury in 246, stab wound in 97, and mine injury in 21. The most frequent abdominal lesion was small bowel injury (46.3%). Small and large bowel injuries were the most frequent in the blast groups, stomach injury in stab wounds. Overall mortality was 12.8%. Variables significantly associated with death were age > 34 years, mine and bullet injury, length of stay, time since injury > 5 h, injury severity score > 17, and associated injuries. Conclusions: Epidemiology and patterns of injury in a civilian hospital differ from those reported in a typical military setting. Our population is mainly civilian with a significant number of women and patients under 14 years. BI are more frequent than blast injuries, and gastrointestinal injuries are more common than injuries to solid organs. In this austere setting, surgeons need to acquire a wide range of skills from multiple surgical specialties. These findings might guide trauma and general surgeons treating penetrating abdominal war wounds to achieve better care and outcome.

Wartime Soft Tissue Coverage Techniques for the Deployed Surgeon.

BACKGROUND: Since the start of the conflict in the Middle East in 2001, military orthopedic surgeons have faced complex orthopedic injuries including high-energy soft tissue wounds, traumatic amputations, and open fractures. Although orthopedic surgeons are well trained in the management of osseous injuries, the treatment of soft tissue injuries can be technically challenging and unfamiliar. Early washout, debridement of devitalized tissue, external fixation of bony injuries, and antibiotic therapy remain the foundation of early wound management. However, these unique extremity injuries have no standard plan of care, and definitive treatment options continue to evolve. The following report highlights the typical cases seen in the wartime setting and offers possible solutions for the associated soft tissue injuries. METHODS: A single orthopedic surgeon at a Role 3 combat support hospital performed all cases in this series. This study is a report of the cases that the orthopedic surgeon encountered while deployed and the various techniques that can be used to manage the complex wounds seen in a deployed setting. FINDINGS: Twelve patients were included in this report and the data are shown. Of the 12 patients, 6 were injured by an improvised explosive device (IED), 4 were injured by a high-velocity gunshot wound (HVGSW), 1 was injured by a gunshot wound (GSW), and 1 was injured in an auto versus pedestrian motor vehicle crash. The wound sizes ranged from 10 to 300 cm2. All patients required more than one irrigation and debridement before wound closure. There was a successful outcome in 11 of the 12 patients. The only patient without a known successful outcome was lost to follow up. Six patients were treated with split thickness skin graft (STSG) alone. Four patients were treated with STSG plus an additional means of coverage. One patient was treated with a random flap and one patient was treated with a full thickness skin graft. Integra was used in two of the patients. Each of the patients in whom integra was used had exposed bone and had a successful outcome with respect to tissue coverage. DISCUSSION: This study details different soft tissue coverage techniques that must be learned and possibly employed by the deployed surgeon. Limitations of this study include its retrospective nature and the selected sampling of cases. At initial presentation, the management of war wounds secondary to high-velocity gunshot wounds and improvised explosive devices can be quite daunting. Adhering to firm surgical principles of thorough and meticulous debridement is the foundation of later soft tissue reconstructive options. Once the tissue is deemed clear of infection and contamination, there are myriad treatment options utilizing flaps, synthetic materials, and skin grafting. These are relatively straightforward techniques that the general orthopedic surgeon can utilize while deployed in a combat setting. In the end, it is critical for deployed surgeons to learn multiple techniques to provide definitive soft tissue coverage in a wartime theater.

"Reality rarely looks like the guidelines": a qualitative study of the challenges hospital-based physicians encounter in war wound management.

BACKGROUND: Globally, armed conflict is a major contributor to mortality and morbidity. The treatment of war-associated injuries is largely experience-based. Evidence is weak due to difficulty in conducting medical research in war settings. A qualitative method could provide insight into the specific challenges associated with providing health care to injured civilians. The aim of this study was to explore the challenges hospital-based physicians encounter in war wound management, focusing on surgical intervention and antibiotic use. METHODS: Semi-structured, face-to-face interviews were conducted with physicians at a Jordanian hospital supported by Médecins Sans Frontières. The interviews were recorded, transcribed verbatim and analysed using content analysis with an inductive and deductive approach. RESULTS: We found that challenges in war wound management primarily relate to protocol adherence. Protocols for the management of acute war wounds were adhered to on areas that could be considered commonly agreed principles of war wound surgery, such as the use of wound debridement and the evaluation of the systemic condition of the patient before initiating antibiotic treatment. We identified limitations imposed on the physicians that complicate or even hinder protocol adherence. Additionally, we identified factors associated with conscious deviations from the protocols. CONCLUSIONS: We conclude that adherence to established protocols around the management of acute war wounds is difficult. We present aspects that may be considered when establishing clinical projects in similar contexts. The knowledge gained by this study could provide insights for the development of protocols or guidelines for wound management and antibiotic use in an unstable setting, such as a hospital in close proximity to armed conflict. We suggest the use of a grounded theory approach to further study the discrepancy between guideline recommendations and actual practice.

Injuries due to Landmine Blast Referred to Shahid Motahhary Hospital, Iran.

BACKGROUND: The health system faced a new problem of an increasing number of civilian victims of landmine explosions at the end of Iran-Iraq war. METHODS: In a descriptive survey from 1998 to 2004, data was collected retrospectively from medical records of Shahid Motahhary Hospital, Urmia University of Medical Sciences, Iran. RESULT: The study covered 156 victims. 80% of the casualties were civilians of which 95% were male. Injuries led to amputation in 73.3% of the victims. The mortality rate was 3.8%. Blood transfusions was given to 93 (62%) victims. There were 52.6% pattern I, 14.6% pattern II and 32.6% pattern III injuries according to International Committee of the Red Cross (ICRC) classification. CONCLUSION: Mine awareness programs should be conducted amongst civilians who live in high-risk areas. Improved health infrastructure with trained personals for emergency care and early transfer of the casualties would reduce morbidity and mortality. Studies are required to understand the social and public health consequences of this problem.

Bacterial flora of combat wounds from eastern Ukraine and time-specified changes of bacterial recovery during treatment in Ukrainian military hospital.

BACKGROUND: Microbiology of modern war wounds is unique for each military conflict. Climatic and geographical features of the theater of war, contemporary warfare as well as wound management affect the microbial flora of wounds. This study was designed to determine time-specific microbial flora of combat wounds of upper and lower extremities obtained during the war in eastern Ukraine. METHODS: The patients enrolled in study had combat wounds of upper or lower extremities which were treated in the Military Medical Clinical Center of Central Region. The wounds were swab-cultured and measured at each surgical debridement. The recovered microorganisms were identified and their antimicrobial resistance profiles were evaluated by disc diffusion method. RESULTS: Forty-nine patients with battle-field wounds were enrolled in the study from July to November 2014; all patients were male with a mean Injury Severity Score and arrival APACHE II scores of 16.2 ± 10.7 and 7.4 ± 4.2 respectively. Among 128 swab cultures, 100 swab cultures were positive. Swab cultures were obtained from 57 wounds of 49 patients. The results of the test showed that 87.7% of all positive swab cultures contained a single-organism while the rest of the swab-culture results showed polymicrobial growth. Among the isolated microorganisms 65% (76 strains) were Gram-negative rods, 22.2% (26 strains) of Gram-positive cocci, followed by Gram-positive rods (12.8%, 15 strains). We found that epidemiology of wound infection changes with the time after injury. The most common bacterial isolates cultured during the first week were Gram-positive microbes with low pathogenicity. The number of Gram-negative rods increased during the wound healing process. The incidence of Gram-positive microorganisms' growth fell after the first week and increased after third week. During wound healing, bacterial microflora of wounds changes with increasing number of Gram-negative rods with predominance of Acinetobacter species. Predominant microorganisms in positive swab-cultures after first week were nonfermentative Gram-negative bacilli (68% of swab-cultures), which in 53% of the swab-cultures belonged to the genus Acinetobacter, and in 15% to the genus Pseudomonas. The incidence of polymicrobial wound cultures increased from first week to second post-injury week. The most frequent microbial mixture were Acinetobacter baumannii with Enterobacteriaceae or other nonfermentative Gram negative rods with Enterococcus spp. We observed bacteria recovery from wounds during proliferation phase. These wounds had no pure inflammation signs and were free of devitalized tissues. CONCLUSIONS: Any wound is at some risk of becoming infected. In the event of infection, a wound fails to heal, treatment costs rise, and general wound management practices become more resource demanding. Determining the microorganisms which colonize battle wounds and cause wound infection is paramount. This information can help to treat battle wound infections or even changes infection control strategies. The fact of shifting in wound microbiology in the favor of bacteria responsible for healthcare-associated infections support to the proposition that these changes are nosocomially related [4, 14]. For Ukrainian military medicine this study is the first time-specified assessment of battle wound colonization from the World War II.

La atención sanitaria en los tercios españoles / Health care in the spanish tercios

Durante por más de dos siglos, los tercios españoles fueron la base de los ejércitos de España que participaron en numerosas batallas en las innumerables guerras en el que se vio envuelto el Imperio Español. Su organizador militar fue la base de sus triunfosque les hicieron merecedores de el termino de invencibles por su especial estrategia. La organización interna conllevaba un especialmétodo de asistencia sanitaria bien organizado con recursos y de efectividad para la época. Se analiza en el trabajo, la organización sanitaria los recursos disponibles, las enfermedades que se atendían tanto las comunes como las producidas en el campo debatalla por las diferentes armas de fuego como armas blancas y también de los efectos de la artillería como de las explosiones por el uso de la pólvora. (AU)

For more than two centuries, the Spanish Tercios were the base of the Spanish armies that participated in numerous battles in theinnumerable wars in which the Spanish Empire was involved. Their military organizer was the basis of their triumphs that madethem worthy of the term invincible for their special strategy. The internal organization entailed a special well-organized health caremethod with resources and effectiveness for the time. It is analyzed at work, the health organization, the available resources, thediseases that were treated, both the common ones and those produced on the battlefield by the different weapons, both firearms andbladed weapons, and also the effects of artillery and firearms. explosions due to the use of gunpowder. (AU)

Epidemiology and antimicrobial susceptibilities of wound isolates of obligate anaerobes from combat casualties.

Data from recent conflicts related to war wounds and obligate anaerobes are limited. We define the epidemiology and antimicrobial susceptibility of obligate anaerobes from Iraq and Afghanistan casualties (6/2009-12/2013), as well as their association with clinical outcomes. Susceptibility against eleven antibiotics (7 classes) was tested. Overall, 59 patients had 119 obligate anaerobes identified (83 were first isolates). Obligate anaerobes were isolated 7-13 days post-injury, primarily from lower extremity wounds (43%), and were largely Bacteroides spp. (42%) and Clostridium spp. (19%). Patients with pelvic wounds were more likely to have Bacteroides spp. and concomitant resistant gram-negative aerobes. Seventy-three percent of isolates were resistant to ≥1 antimicrobials. Bacteroides spp. demonstrated the most resistance (16% of first isolates). Patients with resistant isolates had similar outcomes to those with susceptible strains. Serial recovery of isolates occurred in 15% of patients and was significantly associated with isolation of Bacteroides spp., along with resistant gram-negative aerobes.

Médicos y sanitarios en el desastre de annual (1921) / Doctors and sanitary in the annual disaster (1921)

El conocido como Desastre de Annual, es una de las más trágicas derrotas sufridas por el ejército español a lo largo de su historia y no solo por el número de muertos y heridos que dio a lugar, sino también por las repercusiones sociales y políticas que tuvo en el país el acontecimiento. Protagonismo destacado en estos hechos el de los integrantes de la Sanidad Militar y en especial médicos, de aquel ejercito derrotado que tuvieron que atender a los heridos y que muchos de ellos fueron muertos en cumplimiento de su deber e incluso en combate. Se expone las circunstancias en las que actuaron, desde las instalaciones sanitarias, medios de trasporte o su actuación en las unidades militares en las que estaban adscritos. (AU)

Known as Annual Disaster, it is one of the most tragic defeats suffered by the Spanish army throughout its history and not only because of the number of deaths and injuries that it resulted, but also because of the social and political repercussions it had. in the country the event. Prominent leading role in these events is that of the members of the Military Health Service and especially doctors, of that defeated army who had to attend to the wounded and many of them were killed in the line of duty and even in combat. The circumstances in which they acted, from the health facilities, means of transportation or their performance in the military units in which they were assigned are exposed. (AU)

Old War Scar Revisited.

In 1828, Jean Nicholas Marjolin, a French surgeon, first described the findings of a neoplastic development arising from a burn scar, now more commonly referred to as a Marjolin's ulcer. A Marjolin's ulcer describes malignant degeneration in any chronic wound. The majority of cases arises in burn scars and are often latent for decades. Marjolin ulcers have been widely identified in post-war time injuries. These ulcers may arise in almost any anatomical location. We report a case of an 82-year-old male that presented with a painful fluctuating mass on the right arm localized to the site of an old grenade blast injury he sustained many years earlier. While the presentation of these cases may be variable, the significance of proper management of the wounds is essential to optimal patient outcomes. An aggressive course and poor prognosis is associated with Marjolin's ulcers that degenerate into squamous cell carcinoma. Early detection and aggressive treatment/management with wide local excision and prompt coverage yield the best results when treating patients with Marjolin's ulcers.

War Wounds - Changing Concepts.

The accepted standard treatment of war wounds through the last century has been debridement and delayed primary closure. However, recently, there has been a renewed Interest In primary closure of these wounds. 1481 war wounds were managed by the authors and out of 789 soft tissue injuries, 389 (47%) were closed primarily (group 1) after meticulous debridement and 220 (28%) underwent delayed primary closure (group 2). The infection rate in group 1 was 4.87% compared to 6.36% in group 2. The average hospital stay in group 1 was 15 days, significantly shorter by 10 days than in group 2. In the war zone both time and resources are at a premium and primary closure of selected wounds offers a better alternative to delayed primary closure.