Non-battle injury among repatriated UK armed forces since cessation of combat operations: a prospective observational study.

AIM: To describe the mechanisms, burden of injury, inpatient management and rehabilitation requirements of wounded military personnel at the UK Role 4 (R4) facility within the first 12 months following cessation of combat operations in Afghanistan. METHODS: All aeromedical evacuations were recorded prospectively between October 2014 and October 2015. Demographic, logistical and clinical data were derived manually from referring medical unit and patient movement requests in addition to host nation and R4 medical records. RESULTS: Ninety-five patients were repatriated to R4 following traumatic injury: 98.9% (n=94) were male, and median age was 27 years (IQR 25-36 years). The most common mechanisms of injury (MOIs) were sports 26.3% (n=25), falls <2 m 11.6% (n=11) and road traffic collisions 9.8% (n=9). The most common anatomical regions of injury were isolated lower limb 24.1% (n=22), isolated hand 20.0% (n=19) and polytrauma 14.7% (n=14). Median Injury Severity Score was 4 (IQR 4-9), mean 8 (range 1-41). Eleven patients (11.6%) were discharged to rehabilitation units, of whom 7 (63.6%) required neurorehabilitation. CONCLUSION: Although service personnel sustain civilian-type injuries, the specific rehabilitation goals and shift in the acute rehabilitation requirements for military personnel must be considered in the absence of enduring combat operations. It is notable that permanent medical downgrading secondary to trauma still occurs outside of warfare. The colocation of civilian major trauma services and R4 has ensured a mutually beneficial partnership that contributes to institutional memory and improves the coordination of patient pathways. The importance of relevant resource allocation, training, support and logistical considerations remain, even during the current scale of military activity overseas.

Symmetric dimethylarginine (SDMA) is raised in women with polycystic ovary syndrome: a pilot study.

Polycystic ovary syndrome (PCOS) is associated with endothelial dysfunction, which may be caused by elevated levels of asymmetric dimethylarginine (ADMA). ADMA reduces nitric oxide production in diabetes mellitus, hypertension and renal failure. Symmetric dimethylarginine (SDMA) is a stereoisomer produced alongside ADMA, and has recently been described as a risk factor for cardiovascular events. In this cross-sectional study based in a teaching hospital, 16 women with PCOS were recruited alongside 15 healthy controls, and fasting venous blood samples were obtained. Renal function was measured, and ADMA and SDMA were analysed using a high-performance liquid chromatography method. After controlling for BMI, mean ADMA and SDMA levels in women with PCOS were higher than in controls (p = 0.036 and p = 0.030, respectively). Renal function was not different between the two groups (p = 0.152). Women with PCOS have raised levels of SDMA, a molecule implicated in endothelial dysfunction and long-term cardiovascular risk.

Initial extremity war wound debridement: a multidisciplinary consensus.

A joint meeting of the Limb Trauma and Wounds Working Groups resulted in the establishment of 29 consensus recommendations for the conduct of initial extremity war wound debridement. Pre-operative, operative and post-operative phases of debridement were considered along with wound irrigation and dressings. Wounds where a different surgical approach is required, such as superficial soft tissue wounds at one end of the spectrum and complex wounds sustained in close proximity to explosions at the other, were also discussed. The recommendations represent the consensus opinion of orthopaedic, vascular and plastic surgeons, as well as nursing officers, from across the Defence Medical Services and are intended to provide useful guidance to the deploying surgeon, regardless of their own personal experience.

Umbilical vein testosterone in female infants born to mothers with polycystic ovary syndrome is elevated to male levels.

The aetiology of polycystic ovary syndrome (PCOS) is poorly understood, but an intrauterine hyperandrogenic environment has been implicated. This study was designed to assess whether the female offspring of mothers with PCOS are exposed to raised levels of testosterone (T) in utero. In this case-control study, three groups of pregnant women were recruited from the labour ward: PCOS women with a female baby (n = 10, PCOS girls); control women with a female baby (n = 20, control girls) and control women with a male baby (n = 10, control boys). Maternal and umbilical vein (UV) blood was assayed for T levels. UV T in PCOS girls was significantly raised, compared with control girls (p < 0.012). The difference in UV T between PCOS girls and control boys was not significant (p < 0.254). This is the first demonstration of a hyperandrogenic in utero environment in PCOS pregnancies; UV T in female infants is raised to male levels.

GABAA-receptor function in hippocampal cells is maintained by phosphorylation factors.

Gamma aminobutyric acid (GABA) mediates fast synaptic inhibition in the central nervous system by activating the chloride-permeable GABAA channel. The GABAA conductance progressively diminishes with time when the intracellular contents of hippocampal neurons are perfused with a minimal intracellular medium. This "run down" of the GABA-activated conductance can be prevented by the inclusion of magnesium adenosine triphosphate and calcium buffer in the intracellular medium. The amount of chloride conductance that can be activated by GABA is determined by competition between a calcium-dependent process that reduces the conductance and a phosphorylation process that maintains the conductance.

A heart-like Na+ current in the medial entorhinal cortex.

Acutely dissociated neurons from the superficial layers of the medial entorhinal cortex of the rat were studied under voltage clamp using the whole-cell patch-clamp configuration. Neurons from the medial entorhinal cortex exhibit a tetrodotoxin (TTX)-resistant Na+ current (ITTX-R; IC50 approximately 146 nM), in addition to the normal TTX-sensitive Na+ current (ITTX-S; IC50 approximately 6 nM). ITTX-R was found in both putative stellate and putative pyramidal neurons from the medial entorhinal cortex. ITTX-R is kinetically indistinguishable from ITTX-S, but can be distinguished from ITTX-S based on its enhanced sensitivity to block by Cd2+, La3+, and Zn2+. ITTX-R is kinetically and pharmacologically similar to the TTX-resistant Na+ current found in cardiac muscle.

Imaging synaptic activity in intact brain and slices with FM1-43 in C. elegans, lamprey, and rat.

The fluorescent probe FM1-43 has been used extensively for imaging vesicle recycling; however, high nonspecific adsorption resulting in elevated background levels has precluded its use in certain tissues, notably brain slices. We have found that a sulfobutylated derivative of beta-cyclodextrin (ADVASEP-7) has a higher affinity for FM1-43 than the plasma membrane. ADVASEP-7 was used as a carrier to remove FM1-43 nonspecifically bound to the outer leaflet of the plasma membrane or extracellular molecules, significantly reducing background staining. This has enabled us to visualize synaptic vesicle recycling in the nematode C. elegans, intact lamprey spinal cord, and rat brain slices.

A correlation analysis of metacarpal & phalangeal injury pattern from improvised explosive devices amongst armed force personnel.

Injuries to the hand during military combat operations, particularly from improvised explosive devices (IEDs) have a significant impact on form, function, mental health and future employment but remain underreported amidst the life and limb-threatening emergencies that garner more attention. An understanding the patterns of hand injuries encountered from IEDs is crucial to optimizing reconstruction and rehabilitation. The aim of this study was to re-evaluate hand injury sustained from IED in order to understand the clinical burden for reconstruction and direct the focus for future hand protection. We identified 484 hand injuries in 380 patients sustained as a result of IEDs among military personnel service in Afghanistan between 2006 and 2013. 53% of all surviving military personnel injured by IEDs sustain injuries to the hand. Analysis of the 103 patients who sustained injury to the metacarpal, phalanges or digital amputation revealed that the middle and ring fingers are most commonly injured. Amputation to the ring finger is strongly associated with injury to the adjacent fingers and amputations to the middle, ring and little fingers concurrently is a commonly observed pattern. The proximal phalanges of the middle and ring fingers had a strong correlation for fracture together. These findings disprove the conventional belief in an ulnar focus of injury and support the quest for a development of combat hand protection that addresses the injury pattern seen.

Channel noise in neurons.

The probabilistic gating of voltage-dependent ion channels is a source of electrical 'channel noise' in neurons. This noise has long been implicated in limiting the reliability (repeatability) of neuronal responses to repeated presentations of identical stimuli. More recently, it has been shown to increase the range of spiking behaviors exhibited in some neural populations. Channel numbers are tied to metabolic efficiency and the stability of resting potential, and channel noise might be exploited by future cochlear implants in order to improve the temporal representation of sound.

The cost of a hot drink scald.

Approximately 6400 children per year are admitted to UK hospitals for treatment of burns [National Burn Care Review Committee Report (NBCRC). Standards and Strategy for Burn Care: a review of burn care in the British Isles. 2001.]. This paper investigates the financial costs involved in the management of uncomplicated, minor paediatric scalds. Three cases (2-4% TBSA scalds) were studied to quantify consumables used, services required during management and costs obtained from appropriate Purchasing Departments and Directorate Accountants. Management in all cases involved a general anaesthetic for cleaning of wounds, application of BioBrane (Bertek Pharmaceuticals) and dressings, observation on Children's Ward and discharge following wound review at 48 h. The calculated mean average cost per case was pound1850. In the period 01/12/2002-30/11/2003, 144 children were admitted to Frenchay hospital, Bristol, for treatment of a minor burn or scald (less than 10%TBSA). This caseload is therefore estimated to currently cost pound266,400 per year. These findings may facilitate improved planning for future resource allocation and could also contribute evidence towards the cost effectiveness of prevention strategies.

Management of burns in the wilderness.

For the practitioner working in the wilderness environment, burns represent a significant challenge. There may be a requirement for non-specialists to provide care with fewer resources than would be available in a specialist unit in the UK. In the wilderness setting, delay prior to reaching specialist care is likely to be an ever present factor. Secondary complications of the burn wound, such as respiratory problems or sepsis may therefore supervene. The paper examines certain aspects of treatment relevant to the wilderness environment, including airway injury, fluid resuscitation and local treatment of the burn wound. Escharotomy and aspects of electrical and chemical injury are also considered.

Imaging free zinc in synaptic terminals in live hippocampal slices.

Some glutamatergic synapses in the mammalian central nervous system exhibit high levels of free ionic zinc in their synaptic vesicles. The precise role of this vesicular zinc remains obscure, despite suggestive evidence for zinc as a neuromodulator. As a step towards elucidating the role of free zinc in the brain we have developed a method for imaging zinc release in live brain slices. A newly synthesized zinc-sensitive fluorescent probe, N-(6-methoxy-8-quinolyl)-p-carboxybenzoylsulphonamide (TFLZn), was used to monitor intracellular zinc in live rat hippocampal slices. The dye loaded into the zinc-rich synaptic vesicles of the mossy fibre terminals in the hippocampal formation. Direct electrical stimulation of the mossy fibre pathway diminished the fluorescence in the mossy fibre terminals, consistent with a stimulus-dependent zinc release. The synaptic release of zinc was followed by the rapid replenishment of the zinc levels in vesicles from an as yet unidentified intracellular zinc source. Furthermore, we present evidence that zinc may play a role in a form of long-term potentiation exhibited by the mossy fibre pathway.

An intracellular medium formulary.

Whole-cell patch-clamp recordings allow diffusible intracellular ions and molecules to be replaced by the contents of the recording pipette. In this review, the formulation of intracellular media is considered with a view to improving the stability of recordings and emulating the intracellular environment.

Isolation of neurons suitable for patch-clamping from adult mammalian central nervous systems.

A method is described for the isolation of neurons from defined regions of the mammalian central nervous system, by a combination of mechanical and enzymatic means. The procedure liberates neurons free of cellular debris and glial investments, allowing the formation of giga-ohm seals with patch clamp electrodes. The characteristic morphology of neurons is maintained, together with the diversity of active channels evident in the intact nervous system.

Paediatric day-case otoplasty: local versus general anaesthetic.

BACKGROUND: Correction of prominent ears (otoplasty) is routinely done as an elective cosmetic procedure. The operation is typically performed under general anaesthesia, which is favoured in the paediatric population, being considered more 'humane' than local anaesthesia. AIM: Our aims were to demonstrate the feasibility of paediatric otoplasty as a day case procedure and to examine the relative efficacy of general versus local anaesthesia, paying particular attention to post-operative morbidity. METHODS: Data were gathered retrospectively from case notes, day case surgery pro-formas and dressing clinic notes to compare post-operative morbidity in the two groups. Specific parameters assessed included vomiting, post-operative bleeding, wound dehiscence, necessity of overnight stay and need for revision surgery. RESULTS: Eighty-five children, underwent a day case otoplasty procedure (age range 4-17 years; mean 7.3). Forty-four received a general anaesthetic, whilst forty-one received percutaneous infiltration of local anaesthetic. Local anaesthetic was well tolerated by the children. No procedure was abandoned due to pain. No disadvantage was demonstrable in either group by performing the operation as a day case procedure. Post-operative vomiting was shown to be a significantly greater problem in the children receiving general anaesthesia (p<0.0001). CONCLUSION: Otoplasty as a day case procedure appears acceptable whether general or local anaesthesia is used. In addition, percutaneous infiltration of local anaesthetic, results in a marked reduction in post-operative vomiting without compromising surgical outcome.

The initial management of acute burns.

The initial management of burns, in common with all trauma, follows the ABCDE approach. The outline management plan detailed above assumes the availability of certain medical supplies but even simple measures are invaluable in burn care if they are all that are available. The most basic supplies required to resuscitate a casualty are oral salt and water in appropriate volumes. Similarly it should be possible in field conditions to monitor vital signs and urine output, dress the burns with clingfilm or plastic bags and wrap the casualty in absorbent materials.

Topical negative pressure and military wounds--a review of the evidence.

BACKGROUND: Topical negative pressure (TNP) has been used as a method of wound management for some years. Use of TNP is accepted best practice at Role 4. There are advocates of using TNP after initial wound surgery at Role 3 or 2E. The evidence to support forward use of TNP is not comprehensive, especially when considering this narrow cohort of patients and injury pattern. It is the aim of this review to evaluate the current evidence for the use of TNP in all wounds, and to find what evidence there is that may be applicable to military wounds. METHODS: A literature search of Cinahl, Embase, Medline, ProQuest and the Cochrane Library was conducted; references were cross-referenced. All Randomised Controlled Trials (RCTs) were included in all languages over a comprehensive time period. An interim review was conducted by the Wound Management Working Group of the Academic Department of Military Surgery and Trauma. A further literature review was conducted to find all papers relating to the use of TNP on military wounds. RESULTS: 17 reports were reviewed relating to 14 studies including 662 patients. Of these 131 were reported to have had traumatic injuries. Significant results were reported with respect to time to wound healing, patient comfort and reduction in wound volumes. Bacterial load was not affected, in the 3 trials which commented on this, but in 1 there was a significant reduction in wound infections in the TNP group. Several of the trials were small, methodology was not consistent therefore no meta-analysis was possible. 2 papers were found describing case series of military patients being treated with TNP. CONCLUSIONS: There is very little published evidence in the form of RCTs to support the use of TNP in the acute traumatic military setting. This review supports the requirement for further investigation to evaluate whether this method of wound management has a place forward of Role 4.