Pediatric Surgical Care in a Dutch Military Hospital in Afghanistan.

BACKGROUND: From August 2006-August 2010, as part of the ISAF mission, the Armed Forces of the Netherlands deployed a role 2 enhanced Medical Treatment Facility (R2E-MTF) to Uruzgan province, Afghanistan. Although from the principle doctrine not considered a primary task, care was delivered to civilians, including many children. Humanitarian aid accounted for a substantial part of the workload, necessitating medical, infrastructural, and logistical adaptations. Particularly pediatric care demanded specific expertise and equipment. In our pre-deployment preparations this aspect had been undervalued. Because these experiences could be influential in future mission planning, we analyzed our data and compared them with international reports. METHODS: This is a retrospective, descriptive study. Using the hospital's electronic database, all pediatric cases, defined as patients <17 years of age, who were admitted between August 2006 and August 2010 to the Dutch R2E-MTF at Multinational Base Tarin Kowt (MBTK), Urzugan, Afghanistan were analyzed. RESULTS: Of the 2736 admissions, 415 (15.2 %) were pediatric. The majority (80.9 %, 336/415) of these admissions were for surgical, often trauma-related, pathology and required 610 surgical procedures, being 26 % of all procedures. Mean length of stay was 3.1 days. The male to female ratio was 70:30. Girls were significantly younger of age than boys. In-hospital mortality was 5.3 %. CONCLUSION: Pediatric patients made up a considerable part of the workload at the Dutch R2E-MTF in Uruzgan, Afghanistan. This is in line with other reports from the recent conflicts in Iraq and Afghanistan, but used definitions in reported series are inconsistent, making comparisons difficult. Our findings stress the need for a comprehensive, prospective, and coalition-wide patient registry with uniformly applied criteria. Civilian disaster and military operational planners should incorporate reported patient statistics in manning documents, future courses, training manuals, logistic planning, and doctrines, because pediatric care is a reality that cannot be ignored.

Incidence and epidemiology of casualties treated at the Dutch role 2 enhanced medical treatment facility at multi national base Tarin Kowt, Afghanistan in the period 2006-2010.

BACKGROUND: To improve care for the injured service member, we have analyzed battle casualty patterns and mechanisms. This study is the first documented report of wounding patterns and mechanisms of battle casualties treated at the Dutch role 2 enhanced medical treatment facility at the multi-national base Tarin Kowt, Uruzgan, Afghanistan. METHODS: Participants were selected from the trauma registry at the Dutch role 2 enhanced medical treatment facility if they fitted the criteria 'battle casualty' and 'disease non-battle injury' between August 2006 and August 2010. RESULTS: The trauma registry query resulted in 2,736 casualties, of which 60 % (N = 1,635) were classified as 'disease non-battle casualties' and 40 % (N = 1,101) as 'battle casualties'. The battle casualties sustained 1,617 combat wounds, resulting in 1.6 wounds per battle casualty. These injuries were predominately caused by explosions (55 %) and gunshots (35 %). The wounding pattern was as follows: head and neck (21 %), thorax (13 %), abdomen (14 %), upper extremity (20 %), and lower extremity (33 %). CONCLUSIONS: The wounding patterns seen at the Dutch role 2 enhanced medical treatment facility at the multi-national base Tarin Kowt resemble the patterns as recorded by other coalition partners. The wounding patterns differ with previous conflicts: a greater proportion of head and neck wounds, and a lower proportion of truncal wounds.

Impact of explosive devices in modern armed conflicts: in-depth analysis of Dutch battle casualties in southern Afghanistan.

BACKGROUND: The patterns and mechanisms of injuries of all Dutch battle casualties (BCs) were analyzed to improve the care for injured service members. We performed an in-depth analysis of all Dutch BCs during the participation of The Netherlands as lead nation in the International Security Assistance Force mission in southern Afghanistan. METHODS: Participants were selected from the trauma registry at the Dutch Role 2 Medical Treatment Facility if they met the criteria for Dutch BC between August 2006 and August 2010. RESULTS: The trauma registry query resulted in 199 Dutch BCs. The battle injuries were predominantly caused by explosions (83.9 %). The case-fatality rate was 9.5 %: 16.5 % were killed in action, and 1.1 % died of wounds. The wounding pattern was as follows: head and neck (32.2 %), thorax (7.8 %), abdomen (12.7 %), upper extremity (17.6 %), lower extremity (29.7 %). The mean Abbreviated Injury Scale and Injury Severity Score were 3 (range 0-5) and 11 (range 1-43), respectively in the wounded-in-action group. CONCLUSIONS: Explosive devices accounted for almost 85 % of the casualties-much higher than in previous wars. Knowledge of the management of these injuries is also valuable in treating casualties from natural disasters or (terrorist) mass casualty situations. An integral multinational joint approach is highly recommended to develop more effective protective equipment and body armor. Prospective registration in a standardized system of data collection that encompasses all echelons of the medical support organization should be implemented.

Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial.

BACKGROUND: Mechanical bowel preparation is a common practice before elective colorectal surgery. We aimed to compare the rate of anastomotic leakage after elective colorectal resections and primary anastomoses between patients who did or did not have mechanical bowel preparation. METHODS: We did a multicentre randomised non-inferiority study at 13 hospitals. We randomly assigned 1431 patients who were going to have elective colorectal surgery to either receive mechanical bowel preparation or not. Patients who did not have mechanical bowel preparation had a normal meal on the day before the operation. Those who did were given a fluid diet, and mechanical bowel preparation with either polyethylene glycol or sodium phosphate. The primary endpoint was anastomotic leakage, and the study was designed to test the hypothesis that patients who are given mechanical bowel preparation before colorectal surgery do not have a lower risk of anastomotic leakage than those who are not. The median follow-up was 24 days (IQR 17-34). We analysed patients who were treated as per protocol. This study is registered with ClinicalTrials.gov, number NCT00288496. FINDINGS: 77 patients were excluded: 46 who did not have a bowel resection; 21 because of missing outcome data; and 10 who withdrew, cancelled, or were excluded for other reasons. The rate of anastomotic leakage did not differ between both groups: 32/670 (4.8%) patients who had mechanical bowel preparation and 37/684 (5.4%) in those who did not (difference 0.6%, 95% CI -1.7% to 2.9%, p=0.69). Patients who had mechanical bowel preparation had fewer abscesses after anastomotic leakage than those who did not (2/670 [0.3%] vs 17/684 [2.5%], p=0.001). Other septic complications, fascia dehiscence, and mortality did not differ between groups. INTERPRETATION: We advise that mechanical bowel preparation before elective colorectal surgery can safely be abandoned.

Combat related vascular injuries: Dutch experiences from a role 2 MTF in Afghanistan.

BACKGROUND: In a combat environment, major vascular trauma endures as the leading cause of death. The Dutch role 2 Medical Treatment Facility (MTF), provided supportive care during the mission in Uruzgan, Afghanistan. Aim of this study was to conduct detailed analysis of the admitted major haemorrhages (vascular injuries) and to compare our findings with NATO coalition partners. METHODS: Retrospective, descriptive study. Participants eligible for this study came from the role 2 MTF admission database, where they fitted the criteria 'Major haemorrhage (class 2 haemorrhage or more according to the ATLS(®) classification) between 2006 and 2010'. Results were contrasted with studies from coalition partners. RESULTS: The query revealed 194 casualties sustaining 208 central (60% abdominal, 40% thoracic/neck), and 99 extremity major haemorrhages leading to 1.6 major haemorrhages per casualty. Survival was significantly better (p<0.05) in the peripheral vascular injuries cohort (96% versus 72%). Primary amputation was needed in 73/84 of lower, and in 8/15 of upper extremity major haemorrhages. Vascular repair or vascular Damage Control Surgery techniques (e.g. shunting) were used in 19/84 cases in the lower, and 7/15 in the upper extremity cohort, with a success rate of 69.2 percent. Amputation rates of coalition partners, using different inclusion and exclusion criteria, ranged from 5 to 60 percent. CONCLUSIONS: Only in a few cases genuine peripheral vascular surgery was needed (<1%). This limited number of reconstructions does not demonstrate the need for extensive skills in all areas of vascular surgery. Achieved success rate until discharge was almost 70%. Vascular damage control surgery seems effective as initial limb saving skill in a role 2 MTF. The difference in usage of definitions concerning vascular injuries in current literature warrants further assessment. For optimal analysis there is need for detailed (NATO wide) registration with uniform definitions for vascular injuries. LEVEL OF EVIDENCE: Level IV--Epidemiologic study.

Increased analgesia administration in emergency medicine after implementation of revised guidelines.

BACKGROUND: The most common complaint of patients attending the emergency department (ED) is pain, caused by different diseases. Yet the treatment of pain at the ED is suboptimal, and oligoanalgesia remains common. The objective of this study is to determine whether the administration of analgesia at the ED increases by implementation of revised guidelines in pain management. METHODS: We conducted a prospective pre-post intervention cohort study with implementation of a revised guideline for pain management at our ED, in which nurses are allowed to administer analgesia (including low-dosage piritramid (opioid) intravenous) without doctor intervention. Numeric Rating Scales (NRS) were measured, and administration of medication (main outcome) was documented. We included every adult patient presenting with pain (NRS 4-10) at the ED. RESULTS: A total of 2107 patients (1089 pre-implementation phase and 1018 post-implementation phase) were included in our study. During pre-implementation, 25.4 % of the patients with NRS between 4 and 10 received analgesia. After implementation, 32.0 % of these patients received analgesia (p < 0.001). CONCLUSIONS: After implementation of the revised guidelines in pain management at the ED, the administration of pain medication increased significantly. Nevertheless, the percentage of patients in pain receiving analgesia remain low (32 % after implementation).

Impact of combat events on first responders: experiences of the armed conflict in Uruzgan, Afghanistan.

INTRODUCTION: Care for battle casualties demands special skills from medics, nurses, and tactical commanders. To date, no inventory has been performed evaluating the first responders (medics, nurses and tactical commanders) around battle casualties. METHOD: This observational cohort study was conducted amongst the first responders (n=195) who were deployed to Southern Afghanistan (2009-2010) in three Marine companies. The survey focused on four main topics: (1) participants general background, (2) exposure to combat (casualty) situations, (3) self-perceived quality of care (1 [low]-10 [high]) in the pre-hospital phase, and (4) the effects of combat stressors on professional skills and social environment using the Post Deployment Reintegration Scale (PDRS) and the Impact of Event Scale-Revised (IES-R). RESULTS: 71% of the eligible Dutch tactical commanders, medics, and nurses participated in this survey. Most (14/16) medics and nurses scored their pre-deployment training as sufficient The overall self-perceived quality of care score was above average (7.8). Most (80%) of the participants were exposed to battle casualties. There were no significant differences regarding rank, gender, age and military task using the impact of event scale and PDRS, except for a worse score on the work negative, family positive and personal positive subscales (p<0.05) in the PDRS for the first responders in comparison to the armed forces norm score. CONCLUSION: The quality of care in the pre-hospital phase was considered adequate, symptoms of post-traumatic stress in this group was low. Active involvement of co-combatants and the social support network are essential in adaption after exposure to combat events. Further research is necessary to identity predisposing preventable high stress factors, and to compose a "waterproof" aftercare programme.

Long-term impact of battle injuries; five-year follow-up of injured Dutch servicemen in Afghanistan 2006-2010.

OBJECTIVES: Units deployed to armed conflicts are at high risk for exposure to combat events. Many battle casualties (BCs) have been reported in the recent deployment to Afghanistan. The long-term impact of these combat injuries, at their five-year end point, is currently unknown. To date, no systematic inventory has been performed of an identified group of BCs in comparison to non-injured service members from the same operational theatre. DESIGN: Observational cross-sectional cohort study. SETTING: Open online survey among Dutch BCs that deployed to Afghanistan (2006-2010). PARTICIPANTS: The Dutch BCs (n = 62) were compared to two control groups of non-injured combat groups (battle exposed [n = 53], and non-battle exposed [n = 73]). MAIN OUTCOME MEASURES: Participants rated their impact of trauma exposure (Impact of Events [IES]), post deployment reintegration (Post Deployment Reintegration Scale [PDRS]), general symptoms of distress (Symptom Checklist 90 [SCL-90]), as well as their current perceived quality of life (EuroQol-6D [EQ-6D]). Also cost effectiveness (Short From health survey [SF-36]) and care consumption were assessed (Trimbos/iMTA questionnaire). RESULTS: Over 90% of BCs were still in active duty. The mean scores of all questionnaires (IES, EQ-6D, SF-36, and SCL-90) of the BC group were significantly higher than in the control groups (p<0.05). The PDRS showed a significantly lower (p<0.05) outcome in the negative subscales. The mean consumption of care was triple that of both control groups. A lower score on quality of life was related to higher levels of distress and impact of trauma exposure. CONCLUSIONS: This study showed a clear long-term impact on a wide range of scales that contributes to a reduced quality of life in a group of BCs. Low perceived cost effectiveness matched with high consumption of care in the BC group in comparison to the control groups. These results warrant continuous monitoring of BCs.

[Von Meyenburg complexes in the liver: not metastases]. / Von meyenburg-complexen in de lever: geen metastasen.

A 74-year-old woman underwent a laparotomy for a rectal carcinoma. Multiple lesions of the liver were discovered as incidental findings. Histopathology revealed that these were Von Meyenburg complexes (VMCs). VMCs, also called biliary hamartomas, are rare and benign malformations of the bile ducts. The lesions present as diffuse greyish-white to greyish-yellow or black nodules of the liver, which on gross inspection and in radiological examinations strongly resemble liver metastases. VMCs are mostly asymptomatic and therefore often an incidental finding at laparotomy or post-mortem examination. The prevalence of VMC is age dependent and is 5.6% in adult patients at post-mortem examination. VMCs are sometimes associated with cholangiocarcinoma. Diagnostic imaging of VMC is difficult and of little specificity. Intraoperative frozen section analysis to differentiate between malignant and benign lesions has a sensitivity of 97% and a specificity of 99%. The benign nature of VMCs means that they do not require treatment. The patient underwent total mesorectal excision and follow-up after 3, 7 and 9 months did not reveal any indications of recurrent colorectal cancer or metastases.