Utilization profile of the Canadian-led coalition Role 2 Medical Treatment Facility in Iraq: the growing requirement for multinational interoperability

Background: The Canadian Armed Forces deployed a Role 2 Medical Treatment Facility (R2MTF) to Iraq in November 2016 as part of Operation IMPACT. We compared the multinational interoperability required of this R2MTF with that of similar facilities previously deployed by Canada or other nations. Methods: We reviewed data (Nov. 4, 2016, to Oct. 3, 2017) from the electronic Disease and Injury Surveillance Report and the Daily Medical Situation Report. Clinical activity was stratified by Global Burden of Diseases category, ICD-10 code, mechanism of injury, services used, encounter type, nationality and blood product usage. We reviewed the literature to identify utilization profiles for other MTFs over the last 20 years. Results: In total, 1487 patients were assessed. Of these, 5.0% had battle injuries requiring damage-control resuscitation and/or damage-control surgery, with 55 casualties requiring medical evacuation after stabilization. Trauma and disease non-battle injuries accounted for 44% and 51% of patient encounters, respectively. Other than dental conditions, musculoskeletal disorders accounted for most presentations. Fifty-seven units of fresh frozen plasma and 64 units of packed red blood cells were used, and the walking blood bank was activated 7 times. Mass casualty activations involved coordination of health care and logistical resources from more than 12 countries. In addition to host nation military and civilian casualties, patients from 15 different countries were treated with similar frequency. Conclusion: The experience of the Canadian R2MTF in Iraq demonstrates the importance of multinational interoperability in providing cohesive medical care in coalition surgical facilities. Multinational interoperability derives from a unique relationship between higher medical command collaboration, international training and adherence to common standards for equipment and clinical practice.

Contexte: Les Forces armées canadiennes ont déployé une installation de traitement médical de rôle 2 (ITMR2) en Iraq en novembre 2016 dans le cadre de l'opération IMPACT. Nous avons comparé l'interopérabilité multinationale requise par cette ITMR2 à celle d'installations semblables déjà déployées par le Canada ou d'autres pays. Méthodes: Nous avons examiné les données (du 4 novembre 2016 au 3 octobre 2017) du rapport électronique de surveillance des maladies et des blessures et du rapport quotidien sur la situation médicale. L'activité clinique a été stratifiée selon la catégorie du fardeau mondial des maladies, le code de la CIM­10, le mécanisme de traumatisme, les services utilisés, le type de contact, la nationalité et l'utilisation de produits sanguins. Enfin, nous avons aussi examiné la littérature pour déterminer les profils d'utilisation d'autres ITM au cours des 20 dernières années. Résultats: Au total, 1487 patients ont été évalués. De ce nombre, 5,0 % avaient subi des blessures au combat qui nécessitaient une réanimation ou une intervention chirurgicale de contrôle des dommages, ou les deux, et 55 blessés avaient eu besoin d'évacuation médicale après stabilisation. Les traumatismes et les maladies non liées au combat représentaient respectivement 44 % et 51 % des contacts avec les patients. Outre les troubles dentaires, les troubles musculosquelettiques étaient à l'origine de la plupart des présentations. Par ailleurs, 57 unités de plasma frais congelé et 64 unités de concentré de globules rouges ont été utilisées, et la banque de sang ambulante a été activée 7 fois. La mobilisation nécessaire pour traiter un nombre massif de victimes a nécessité la coordination des soins de santé et des ressources logistiques de plus de 12 pays. En plus des victimes militaires et civiles du pays hôte, des patients de 15 pays différents ont été traités à une fréquence semblable. Conclusion: L'expérience de l'ITMR2 canadienne en Iraq démontre l'importance de l'interopérabilité multinationale quant à la prestation de soins médicaux cohérents dans les installations chirurgicales de la coalition. L'interopérabilité multinationale découle d'une relation unique s'appuyant sur la collaboration des membres du commandement médical supérieur, de la formation internationale et le respect de normes communes pour l'équipement et la médecine clinique.

Impact of traumatic upper-extremity amputation on the outcome of injury caused by an antipersonnel improvised explosive device

Background: We have previously reported a higher than expected rate of upper-extremity amputation (UEA) in victims of an antipersonnel improvised explosive device (AP-IED) compared with a similar cohort injured by antipersonnel mines (APM). The goal of this study was to describe the rate, severity and impact of UAE caused by an AP-IED. Methods: We analyzed a prospective database of 100 consecutive dismounted AP-IED victims with pattern 1 injuries to compare the outcomes of the cohort with UEA to that without. Results: We found that UEA (8 above elbow, 19 below elbow, 1 through elbow, 3 hand, 15 digit(s)) was much more prevalent with AP-IED than with APM (40% v. 6%, p < 0.001). In addition, UEA was associated with a higher rate of multiple amputations (39 [98%] v. 32 [53%], p < 0.001), bilateral lower-extremity amputation (LEA; 33 [82.5%] v. 30 [53.3%], p = 0.003) and facial injury (8 [20%] v. 4 [6.4%], p = 0.044), but not with pelvic disruption (10 [25%]), genitoperineal mutilation (19 [48%]), eye injury (6 [15%]), or skull fracture (6 [15%]). The fatality rate was higher in patients with UEA than in those without (12 [30%] v. 7 [12%], p = 0.022). Conclusion: Upper-extremity amputation is more prevalent with AP-IED than APM. Presence of UEA is associated with more severe injury and increased risk of death in AP-IED victims. Upper-limb injury has significant consequences for rehabilitation from LEA, which universally accompanies UEA in AP-IED victims. Upper-extremity injury should be amenable to prevention by innovative personal protective equipment designed to protect the flexed elbow.

Contexte: Nous avons déjà fait état d'un taux plus élevé que prévu d'amputations des membres supérieurs (AMS) chez les victimes d'engins explosifs artisanaux (EEA) comparativement à une cohorte similaire blessée par des mines antipersonnel (MAP). L'objectif de cette étude est de décrire le taux, la gravité et l'impact des AMS causées par des EEA. Méthodes: Nous avons analysé une base de données prospective de 100 victimes consécutives d'EEA alors qu'elles se trouvaient hors de leur véhicule et présentant des blessures de type 1 afin de comparer les résultats des cohortes ayant subi ou non des AMS. Résultats: Nous avons constaté que l'AMS (8 au-dessus du coude, 19 sous le coude, 1 au niveau du coude, 3 mains et 15 doigts) était beaucoup plus prévalente avec les EEA qu'avec les MAP (40 % c. 6 %, p < 0,001). De plus, l'AMS a été associée à un taux plus élevé d'amputations multiples (39 [98 %] c. 32 [53 %], p < 0,001), d'amputations bilatérales des membres inférieurs (AMI) (33 [82,5 %] c. 30 [53,3 %], p = 0,003) et de blessures au visage (8 [20 %] c. 4 [6,4 %], p = 0,044), mais non de blessures au bassin (10 [25%]), de mutilations génitopérinéales (19 [48 %]), de blessures oculaires (6 [15 %]), ou de fractures du crâne (6 [15 %]). Le taux de létalité a été plus élevé chez les patients ayant subi une AMS que chez ceux qui n'en ont pas subi (12 [30 %] c. 7 [12 %], p = 0,022). Conclusion: L'amputation des membres supérieurs est plus prévalente avec les EEA qu'avec les MAP. L'AMS est associée à des blessures plus graves et à un risque plus grand de décès chez les victimes d'un EEA. Les blessures aux membres supérieurs ont de graves conséquences sur la réadaptation nécessaire après l'AMI, qui accompagne presque toujours l'AMS chez les victimes d'un EEA. Les blessures aux membres supérieurs devraient pouvoir être évitées grâce à de l'équipement de protection individuelle novateur conçu pour protéger le coude fléchi.

Neurologic complications of distal biceps tendon repair with 1-incision endobutton fixation.

Functional outcomes of biceps tendon rupture may be optimized with operative treatment. We conducted a retrospective study to determine the neurologic complications of using 1-incision Endobutton fixation to repair distal biceps tendon ruptures. Patients with distal biceps tendon ruptures treated with a 1-incision technique and Endobutton fixation were included. The primary outcome measure was frequency of neurologic complications. All 50 patients in the study were men. Mean age was 45 years. Twenty-one patients (42%) had at least 1 complication. Injury to the lateral antebrachial cutaneous nerve (LACN) was the most common (36%). Mean time to diagnosis was 17 days (range, 0 to 40 days). Posterior interosseous, anterior interosseous, and superficial radial nerve palsies each occurred at a 4% rate. Mean follow-up was 133 days. This study involved the largest cohort of patients with distal biceps tendon rupture repaired with Endobutton fixation using a 1-incision technique. The LACN injury rate (36%) was higher than in other studies using the same technique (0% to 22%). Injury rates for other neural structures near the elbow were comparable to those in the literature.

Subungual exostosis of the toes: a systematic review.

BACKGROUND: Subungual exostosis is a relatively common benign bone tumor that occurs in the distal phalanges of the toes and can be a source of pain and nail deformity. There is controversy about the treatment of these lesions and there are few studies that have synthesized what is known and provided meaningful information on treatment. QUESTIONS/PURPOSES: We performed a systematic review to address the following questions: (1) What is the best surgical approach for excising these lesions? (2) What is the age range, sex distribution, and presenting symptoms of subungual exostoses and which toe is most frequently affected? (3) What complications arise from treatment? METHODS: Two authors independently searched multiple databases (Medline, 1950-May 2013; Cochrane EBM database, and EMBASE, 1980-May 2013 provided by OVID; ACP Journal Club, 2003-May 2013; CINAHL by EBSCO, 1937-May 2013; and PubMed by NLM, 1940-May 2013), and key words were chosen to achieve a broad search strategy. We included studies on the management of toe exostoses with > 10 cases and we excluded studies that reported on upper extremity exostoses or osteochondromas. Demographic and treatment data were collected from each article by two independent authors and collated. A total of 124 abstracts were screened, and 116 articles were reviewed in full, of which 13 met the inclusion criteria. RESULTS: Complete marginal excision through a fish mouth incision protecting the nail led to a recurrence rate of 4% and satisfactory clinical results, defined as no requirement for postoperative intervention and a satisfactory clinical appearance in 73%. Most studies provided incomplete descriptions of specific surgical techniques used. Fifty-five percent of the patients were younger than 18 years of age. A history of toe trauma before diagnosis was present in approximately 30% of the cases. Delayed diagnosis occurred in approximately 10% of the cases and onychodystrophy occurred in more than 10%. CONCLUSIONS: There is weak evidence to guide management of subungual exostosis. Adequate wound management postexcision aiming to minimize disruption to the nail bed and matrix may prevent onychodystrophy, which is a common complication of treatment.

A novel management strategy for subungual exostosis.

Subungual exostosis is a relatively uncommon benign bone tumour that mostly affects the toes of young people and can be a source of significant impact on health-related quality of life. Treatment consists of marginal excision and meticulous wound closure. We presented a case of subungual exostosis in the hallux of a young Caucasian girl. Once diagnosed, the lesion was completely excised leaving a sizable defect in the nail bed and skin folds. A pedicled vacuum assisted closure (VAC) device was used postoperatively in an attempt to minimise the tissue deficit. At 1-year follow-up, the nail had regrown and tissue reformed producing an optimal functional and cosmetic result with no recurrence. Postoperative wound complications in the setting of subungual exostosis are significant and a great variability exists in their appropriate management. We presented the novel use of the VAC device in the successful management of subungual exostosis.

Simultaneous bilateral distal biceps tendon ruptures repaired using an endobutton technique: a case report.

INTRODUCTION: The simultaneous rupture of both distal biceps tendons is a rare clinical entity that is difficult to treat and can have poor outcomes. A variety of treatment and rehabilitation options exist and have been reported for single sided and staged bilateral repairs, but none have described an approach for acute bilateral ruptures. Repairing distal biceps tendon ruptures using a single anterior incision and a cortical suspensory button technique has become increasingly popular in recent years. We present a report of our surgical approach using an endobutton technique and rehabilitation algorithm for this unusual injury pattern. CASE PRESENTATION: A 43-year-old Caucasian man presented with acute onset bilateral elbow pain while lifting a large sheet of drywall off the ground. He initially felt a 'pop' on the right and almost immediately felt another on the left after having to quickly shift the weight. He was unable to continue working and sought medical attention. His pain was predominantly in his bilateral antecubital fossae and he had significant swelling and ecchymoses. His clinical examination demonstrated no palpable tendon, a retracted biceps muscle belly, and clear supination weakness. Magnetic resonance imaging was performed and showed bilateral distal biceps tendon ruptures with retraction on both sides. After discussion with our patient, we decided that both sides would be repaired using a single anterior incision with endobutton fixation, first his right followed by his left six weeks later. CONCLUSION: Overall, our patient did very well and had returned to full manual work by our last follow-up at 30 months. Although he was never able to return to competitive recreational hockey and was left with mild lateral antebrachial cutaneous nerve dysesthesias on his right, he felt he was at 85% of his premorbid level of function. We describe what we believe to be, to the best of our knowledge, the first case of simultaneous bilateral distal biceps tendon ruptures successfully treated with a single-incision endobutton technique, which represents a valid option in managing this difficult problem.

Glucagon-like peptide-2 receptor activation in the rat intestinal mucosa.

Glucagon-like peptide-2 (GLP-2) increases small intestinal growth and function in rodents and human subjects. GLP-2 exerts its effects through a seven-transmembrane domain, G protein-coupled receptor (GLP-2R), stimulating cAMP generation and activating protein kinase A signaling in heterologous cell lines transfected with the GLP-2R. As intestinal cell lines expressing the GLP-2R have not been identified, we developed methods for studying GLP-2R signaling in the rat small intestinal mucosa in vitro. Isolated rat intestinal mucosal cells expressed mRNA transcripts for the GLP-2R, as well as for chromogranin A and beta-tubulin III, markers for enteroendocrine and neural cells, respectively. cAMP production in response to [Gly2]GLP-2, a degradation-resistant analog of GLP-2, was maximal at 10-11 m (268 +/- 93% of control, P < 0.001), with reduced cAMP accumulation observed at higher doses. The cAMP response was diminished by pretreatment with 10-9 m GLP-2, and was abolished by pretreatment with 10-6 m GLP-2 (P < 0.05), indicating receptor desensitization. GLP-2 treatment of isolated mucosal cells increased 3H-thymidine incorporation (to 128 +/- 8% of controls, P < 0.05), and this was prevented by inhibition of the protein kinase A pathway with H89. In contrast, GLP-2 did not affect p44/p42 MAPK phosphorylation or the levels of cytosolic calcium in the mucosal cell preparation. These results provide the first evidence that activation of the endogenous rat mucosal GLP-2 receptor is linked to activation of a cAMP/protein kinase A-dependent, growth-promoting pathway in vitro.