Negative pressure wound therapy (NPWT) on closed incisions to prevent surgical site infection in high-risk patients in hepatopancreatobiliary surgery: study protocol for a randomized controlled trial-the NP-SSI trial.

BACKGROUND: Incisional surgical site infections (iSSI) in hepatopancreatobiliary (HPB) surgery usually lead to prolonged hospital stays, consume valuable resources, and impact on patients' outcome. Prophylactic closed incision negative pressure wound therapy (ciNPWT) to decrease wound complications has become available. Owing to an increasing number of studies, evidence for superiority in many indication areas has accumulated; however, in general surgery, there are a few data and those have shown contradictory results. METHODS: In this monocentric, prospective, randomized, controlled, two-armed study, the influence of ciNPWT on incisional surgical site infection rates after HPB operations will be investigated. A total of 222 patients will be randomized 1:1 to an interventional group (7-day treatment with ciNPWT) or a control group (treated with gauze dressing). The primary parameter to evaluate efficacy is the rate of incisional SSIs within 30 days after surgery. Additionally, several clinically relevant secondary outcomes will be assessed. DISCUSSION: A reduction in the rate of incisional SSIs would not only lead to a significant cost reduction and shorter postoperative length of stay, but may also improve postoperative quality of life for patients. While earlier publications have shown advantages for ciNPWT, recent studies did not confirm a positive effect regarding iSSI rate. Even if iSSI rate is not reduced, findings obtained from the secondary endpoints may be of clinical relevance, such as reduction of wound complication rates. TRIAL REGISTRATION: This trial has been registered in the German Clinical Trials Register, DRKS 00015136 . Registered on 19 February 2019 and has been approved by the local ethics committee of the University of Regensburg: 18-1225-101.

Critical concerns in Iraq/Afghanistan war veteran-forensic interface: veterans treatment court as diversion in rural communities.

The veteran-forensic interface is an emerging area of relevance to forensic clinicians assessing or treating returning Iraq and Afghanistan war veterans facing criminal sanctions. Veterans' Treatment Court (VTC) represents a recent diversion mechanism for low-level offenses that is based on a collaborative justice model. Thirty-nine percent of veterans who served in Iraq or Afghanistan and receiving VA services reside in rural areas. Rural veterans facing criminal justice charges may be at a disadvantage due to limited access to forensic psychiatrists with relevant expertise in providing veterans services for diversion. Therefore, widening the pool of forensic clinicians who have such expertise, as well as knowledge of the signature wounds of the wars as related to aggression and reckless behavior is necessary. This article presents an overview of VTCs and discusses the role of forensic clinicians as stakeholders in this process.

Critical concerns in Iraq/Afghanistan war veteran-forensic interface: combat-related postdeployment criminal violence.

Identifying whether there is a nexus between Iraq and Afghanistan combat injuries and civilian violence on return from deployment is complicated by differences in reactions of individuals to combat exposure, the overlapping effects of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), and the low base rate of civilian violence after combat exposure. Moreover, the overall prevalence of violence among returning Iraq and Afghanistan combat war veterans has not been well documented. Malingered symptoms and either exaggeration or outright fabrication of war zone exposure are challenges to rendering forensic opinions, with the risk reduced by accessing military documents that corroborate war zone duties and exposure. This article serves as a first step toward understanding what may potentiate violence among returning Iraq and Afghanistan veterans. We offer a systematic approach toward the purpose of forensic case formulation that addresses whether combat duty/war zone exposure and associated clinical conditions are linked to criminal violence on return to civilian life.