Analysis of emergency resuscitative thoracotomy in the combat setting.

INTRODUCTION: Emergency resuscitative thoracotomy (ERT) is a resource-intensive procedure that can deplete a combat surgical team's supply and divert attention from casualties with more survivable injuries. An understanding of survival after ERT in the combat trauma population will inform surgical decision-making. METHODS: We requested all encounters from 2007 to 2023 from the Department of Defense Trauma Registry (DoDTR). We analysed any documented thoracotomy in the emergency department and excluded any case for which it was not possible to distinguish ERT from operating room thoracotomy. The primary outcome was 24-hour mortality. RESULTS: There were 48 301 casualties within the original dataset. Of those, 154 (0.3%) received ERT, with 114 non-survivors and 40 survivors at 24 hours. There were 26 (17%) survivors at 30 days. The majority were performed in role 3. The US military made up the largest proportion among the non-survivors and survivors. Explosives predominated in both groups (61% and 65%). Median Composite Injury Severity Scores were lower among the non-survivors (19 vs 33). Non-survivors had a lower proportion of serious head injuries (13% vs 40%) and thorax injuries (32% vs 58%). Median RBC consumption was lower among non-survivors (10 units vs 19 units), as was plasma (6 vs 16) and platelets (0 vs 3). The most frequent interventions and surgical procedures were exploratory thoracotomy (n=140), chest thoracostomy (n=137), open cardiac massage (n=131) and closed cardiac massage (n=121). CONCLUSION: ERT in this group of combat casualties resulted in 26% survival at 24 hours. Although this proportion is higher than that reported in civilian data, more rigorous prospective studies would need to be conducted or improvement in the DoDTR data capture methods would need to be implemented to determine the utility of ERT in combat populations.

Recommended medical and non-medical factors to assess military preventable deaths: subject matter experts provide valuable insights.

INTRODUCTION: Historically, there has been variability in the methods for determining preventable death within the US Department of Defense. Differences in methodologies partially explain variable preventable death rates ranging from 3% to 51%. The lack of standard review process likely misses opportunities for improvement in combat casualty care. This project identified recommended medical and non-medical factors necessary to (1) establish a comprehensive preventable death review process and (2) identify opportunities for improvement throughout the entire continuum of care. METHODS: This qualitative study used a modified rapid assessment process that includes the following steps: (1) identification and recruitment of US government subject matter experts (SMEs); (2) multiple cycles of data collection via key informant interviews and focus groups; (3) consolidation of information collected in these interviews; and (4) iterative analysis of data collected from interviews into common themes. Common themes identified from SME feedback were grouped into the following subject areas: (1) prehospital, (2) in-hospital and (3) forensic pathology. RESULTS: Medical recommendations for military preventable death reviews included the development, training, documentation, collection, analysis and reporting of the implementation of the Tactical Combat Casualty Care Guidelines, Joint Trauma System Clinical Practice Guidelines and National Association of Medical Examiners autopsy standards. Non-medical recommendations included training, improved documentation, data collection and analysis of non-medical factors needed to understand how these factors impact optimal medical care. CONCLUSIONS: In the operational environment, medical care must be considered in the context of non-medical factors. For a comprehensive preventable death review process to be sustainable in the military health system, the process must be based on an appropriate conceptual framework implemented consistently across all military services.

Nutritional anemia in the English-speaking Caribbean and Suriname.

Anemia is a problem in all countries of the English-speaking Caribbean where data are available. It affects mostly preschool age children and pregnant and lactating women. The most common cause is a deficiency of iron. This is probably due to an adequate intake with a low absorption. A deficiency of folate is also probably a responsible factor in the pathogenesis of some of the anemias. Anemias associated with parasitic infestations such as hookworm and whipworm and hemoglobinopathies such as sickle cell anemia are also noted.

Nutrient-cost nomogram: an appropriate technology.

The nutrient-cost concept is important in food and nutrition planning and applied nutrition programs. There is a need to develop a simple and quick method of calculating nutrient-cost values. A nomogram, which provides a new technology, has been devised to do this. The use of the nomogram and its theoretical basis are described.

A survey of the anemia status of preschool age children and pregnant and lactating women in Jamaica.

An island-wide anemia survey was conducted in Jamaica on pregnant and lactating women and preschool age children. The results indicate that anemia is a serious public health problem in Jamaica. Of pregnant women, 61.6% had Hb levels below 11.0 g/dl. Of lactating women 58.7% had Hb levels below 12.0 g/dl. Of preschool age children 69.1% had Hb levels below 11.0 g/dl. Public health and fortification programs for the control of anemia have been implemented by the government and are currently being reviewed.

The Gomez classification. Time for a change?

The Gomez classification of nutritional status is well known and widely used. However, it has a considerable number of drawbacks and it is questionable whether it should continue to be used. The history of the classification, its value, and its disadvantages are examined and an alternative classification based on more recent reference values of weight-for-age is proposed.

An evaluation of methods of screening for anaemia.

Screening methods for anaemia were selected for testing on the grounds of cheapness, simplicity, sturdiness, accuracy and independence of mains electricity or batteries. The methods evaluated were the copper sulfate method, the Dare haemoglobinometer, the Lovibond comparator, the A. O. Spencer haemoglobinometer, and the Tallqvist method. A new device, the Carib haemoglobin comparator, was developed. The Dare and Lovibond instruments were found to be inaccurate in the laboratory. The other instruments were tested by primary health care workers in clinics in Jamaica. The Carib haemoglobin comparator and the copper sulfate method were found to be accurate, easy to use, and cheap. Both methods are considered to be useful for screening for anaemia at primary health care level.

CT versus sonography for monitoring radiofrequency ablation in a porcine liver.

OBJECTIVE: The objective of this study was to compare CT and sonography for monitoring radiofrequency (RF) lesions in porcine livers. SUBJECTS AND METHODS: RF lesions (n = 12) were created in three pig livers by applying 13 min of current to a multielectrode RF probe with a target temperature of 95 degrees C. Helical unenhanced CT and corresponding axial sonography were performed before ablation, at 2 min, 8 min, and immediately after ablation. Contrast-enhanced CT was performed after ablation. CT scans and sonograms were evaluated by blinded observers for conspicuity of the RF lesion, edge detection (visibility of liver-lesion interface), and artifacts. Hounsfield units were recorded at every time interval, and radiologic-pathologic correlation for lesion size and configuration was performed. RESULTS: Mean size of RF lesions was 3. 03 +/- 0.9 cm. On CT, RF lesions had consistently lower attenuation values than surrounding liver (22.2 H lower than liver at 8 min, p < 0.0001). Echogenicity was variable with sonography (hypoechoic = 59%, hyperechoic = 25%, isoechoic = 16%). Unenhanced CT significantly improved conspicuity, edge detection of RF lesions, and decreased artifacts compared with sonography (p < 0.05). Contrast-enhanced CT improved RF lesion detection, border discrimination, and artifacts compared with sonography (p < 0.05). Unenhanced CT had the best correlation to pathologic size (r = 0.74), followed by contrast-enhanced CT (r = 0.72) and sonography (r = 0.56). Contrast-enhanced CT best correlated with lesion shape, but slightly overestimated size because of areas of ischemia peripheral to the RF lesion. CONCLUSION: In this animal model, unenhanced CT was an effective way to monitor RF ablation compared with sonography because of increased lesion discrimination, reproducible decreased attenuation during ablation, and improved correlation to pathologic size.

Desarrollo de proyectos por equipos multidisciplinarios: ejemplo de un instituto de alimentación y nutrición / Project development by multidisciplinary teams: an example from a food and nutrition institute

Las organizaciones que tratan de mejorar la salud y la nutrición mundiales enfrentan no solo problemas específicos de salud o nutrición sino también dificultades de desarrollo, tal como falta de educación pública, que posibilitan la persistencia de problemas más específicos. Este artículo describe un enfoque de matriz que el Instituto de Alimentación y Nutrición del Caribe ha considerado útil para tratar esta compleja situación (AU)