Independent association of bone mineral density and trabecular bone score to vertebral fracture in male subjects with chronic obstructive pulmonary disease.

Osteoporosis is a major comorbidity of chronic obstructive pulmonary disease (COPD), but the mechanism of bone fragility is unknown. We demonstrated that trabecular bone score, a parameter of bone quality, was associated with systemic inflammation and was a significant determinant of vertebral fracture independent of bone mineral density. INTRODUCTION: COPD is a major cause of secondary osteoporosis. However, the mechanism of bone fragility is unclear. We previously reported that vertebral fracture was highly prevalent in male COPD patients. To obtain clues to the mechanism of COPD-associated osteoporosis, we attempted to identify determinants of prevalent vertebral fracture in this study. METHODS: In this cross-sectional study, we recruited 61 COPD males and examined pulmonary function, vertebral fractures, bone mineral density (BMD), trabecular bone score (TBS), bone turnover markers, and inflammatory parameters. Determinants of the bone parameters were examined by multivariable analyses. RESULTS: The prevalence of any and grade 2 or 3 fractures was 75.4 and 19.7%, respectively. Osteoporosis and osteopenia defined by BMD were present in 37.7 and 39.3%, respectively. TBS was significantly lower in higher Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages compared to GOLD 1. Multivariable logistic regression analysis revealed that both TBS and BMD were independent determinants of grade 2 or 3 vertebral fractures (OR = 0.271, 95%CI 0.083-0.888, p = 0.031; OR = 0.242, 95%CI 0.075-0.775, p = 0.017) after adjustment for age. Correlates of TBS included age, BMD, high-sensitivity C-reactive protein (hsCRP), pulmonary function parameters, parathyroid hormone, and Tracp-5b. In multivariable regression analysis, hsCRP was the only independent determinant of TBS besides age and BMD. In contrast, independent determinants of BMD included body mass index and, to a lesser extent, 25-hydroxyvitamin D. CONCLUSION: Both BMD and TBS were independently associated with grade 2 or 3 vertebral fracture in COPD male subjects, involving distinct mechanisms. Systemic inflammation, as reflected by increased hsCRP levels, may be involved in deterioration of the trabecular microarchitecture in COPD-associated osteoporosis, whereas BMD decline is most strongly associated with weight loss.

Levodopa-induced dyskinesia: clinical features, incidence, and risk factors.

Symptoms of Parkinson's disease have been controlled with levodopa for many years; however, motor complications consisting of wearing off of medication effect and dyskinesias tend to occur within a few years of starting levodopa. Motor complications can begin a few months after taking levodopa, with the average time to onset estimated to be 6.5 years. Dyskinesias can be troublesome and require intervention. Levodopa-induced dyskinesia can be composed of a variety of movement disorders including chorea, dystonia, ballism, myoclonus, and akathisia. Based on the clinical pattern, the most common dyskinesia is chorea and choreoathetosis. The clinical manifestations can be divided into three main categories based on their clinical movement patterns and the temporal correlation between the occurrence of dyskinesia and the levodopa dosing: on or peak-dose dyskinesias, biphasic dyskinesias, and Off dyskinesias. Severe cases of dyskinesia have been reported, with the extreme being dyskinesia-hyperpyrexia syndrome. The prevalence of LID has been reported in many studies, but the reported incidence varies. The rate of LID development is from 3 to 94%. The prevalence of LID mainly depends on age at onset, disease duration, and severity, and duration of levodopa therapy. Some of the risk factors for the development of dyskinesia are modifiable. Modifiable risk factors include levodopa dose and body weight. Non-modifiable risk factors include age, gender, duration of disease, clinical subtype, disease progression, disease severity, and genetic factors.

The modified 'Jo'burg' technique for securing intercostal chest drains.

Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel as an emergency procedure during the initial resuscitation period and often within a stressful environment. Approximately one-fifth of all ICD insertions are associated with complications. In a retrospective review of over 1000 ICD insertions, 7% of the complications observed were due to inadequate fixation, resulting in dislodgement. The risk of dislodgement is greatest during transit or transfer of a casualty. In a military setting, this may involve movement of a casualty in a non-permissive environment and includes transfer on and off rotary wing, fixed wing, road vehicle and maritime transport platforms as well as between stretchers and hospital beds. While ICD insertion follows a standard technique in accordance with the Advanced Trauma Life Support guidelines, the method of securing ICDs has not been standardised across the Defence Medical Services (DMS). The aim of this paper is to first propose a modified version of a tried and tested technique of securing ICDs with alternative steps described for medical staff unfamiliar with surgical knot tying by hand. Second, we present the results from a pilot validation study of this technique when introduced to candidates on a trauma surgical skills course. We describe and demonstrate a robust, easily teachable and reproducible technique for securing ICDs. We would advocate the use of this technique among both surgically and non-surgically trained medical personnel and suggest that this should become the standardised technique for securing ICDs across the DMS. This could be easily implemented by introducing this technique into the various military trauma courses, for example the Military Operational Surgical Training, Medical Emergency Response Team and Critical Care Air Support Team courses.

The induction of autoimmune hepatitis in the human leucocyte antigen-DR4 non-obese diabetic mice autoimmune hepatitis mouse model.

Autoimmune hepatitis (AIH) is a chronic liver disease characterized by progressive inflammation, female preponderance and seropositivity for autoantibodies such as anti-smooth muscle actin and/or anti-nuclear, anti-liver kidney microsomal type 1 (anti-LKM1) and anti-liver cytosol type 1 (anti-LC1) in more than 80% of cases. AIH is linked strongly to several major histocompatibility complex (MHC) alleles, including human leucocyte antigen (HLA)-DR3, -DR7 and -DR13. HLA-DR4 has the second strongest association with adult AIH, after HLA-DR3. We investigated the role of HLA-DR4 in the development of AIH by immunization of HLA-DR4 (DR4) transgenic non-obese diabetic (NOD) mice with DNA coding for human CYP2D6/FTCD fusion autoantigen. Immunization of DR4 mice leads to sustained mild liver injury, as assessed biochemically by elevated alanine aminotransferase, histologically by interface hepatitis, plasma cell infiltration and mild fibrosis and immunologically by the development of anti-LKM1/anti-LC1 antibodies. In addition, livers from DR4 mice had fewer regulatory T cells (Tregs ), which had decreased programmed death (PD)-1 expression. Splenic Tregs from these mice also showed impaired inhibitory capacity. Furthermore, DR4 expression enhanced the activation status of CD8+ T cells, macrophages and dendritic cells in naive DR4 mice compared to naive wild-type (WT) NOD mice. Our results demonstrate that HLA-DR4 is a susceptibility factor for the development of AIH. Impaired suppressive function of Tregs and reduced PD-1 expression may result in spontaneous activation of key immune cell subsets, such as antigen-presenting cells and CD8+ T effectors, facilitating the induction of AIH and persistent liver damage.

Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma.

BACKGROUND: Lower extremity vascular trauma (LEVT) is a major cause of amputation. A clear understanding of prognostic factors for amputation is important to inform surgical decision-making, patient counselling and risk stratification. The aim was to develop an understanding of prognostic factors for amputation following surgical repair of LEVT. METHODS: A systematic review was conducted to identify potential prognostic factors. Bayesian meta-analysis was used to calculate an absolute (pooled proportion) and relative (pooled odds ratio, OR) measure of the amputation risk for each factor. RESULTS: Forty-five studies, totalling 3187 discrete LEVT repairs, were included. The overall amputation rate was 10·0 (95 per cent credible interval 7·4 to 13·1) per cent. Significant prognostic factors for secondary amputation included: associated major soft tissue injury (26 versus 8 per cent for no soft tissue injury; OR 5·80), compartment syndrome (28 versus 6 per cent; OR 5·11), multiple arterial injuries (18 versus 9 per cent; OR 4·85), duration of ischaemia exceeding 6 h (24 versus 5 per cent; OR 4·40), associated fracture (14 versus 2 per cent; OR 4·30), mechanism of injury (blast 19 per cent, blunt 16 per cent, penetrating 5 per cent), anatomical site of injury (iliac 18 per cent, popliteal 14 per cent, tibial 10 per cent, femoral 4 per cent), age over 55 years (16 versus 9 per cent; OR 3·03) and sex (men 7 per cent versus women 8 per cent; OR 0·64). Shock and nerve or venous injuries were not significant prognostic factors for secondary amputation. CONCLUSION: A significant proportion of patients who undergo lower extremity vascular trauma repair will require secondary amputation. This meta-analysis describes significant prognostic factors needed to inform surgical judgement, risk assessment and patient counselling.

A survey of major trauma centre staffing in England.

INTRODUCTION: Trauma care delivery in England has been transformed by the development of trauma networks, and the designation of trauma centres. A specialist trauma service is a key component of such centres. The aim of this survey was to determine to which extent, and how, the new major trauma centres (MTCs) have been able to implement such services. METHODS: Electronic questionnaire survey of MTCs in England. RESULTS: All 22 MTCs submitted responses. Thirteen centres have a dedicated major trauma service or trauma surgery service, and a further four are currently developing such a service. In 7 of these 17 centres, the service is or will be provided by orthopaedic surgeons, in 2 by emergency medicine departments, in another 2 by general or vascular surgeons, and in 6 by a multidisciplinary group of consultants. DISCUSSION: A large proportion of MTCs still do not have a dedicated major trauma service. Furthermore, the models which are emerging differ from other countries. The relative lack of involvement of surgeons in MTC trauma service provision is particularly noteworthy, and a potential concern. The impact of these different models of service delivery is not known, and warrants further study.

Venous thromboembolism: reducing the risk in a Role 3 setting.

BACKGROUND: Venous thromboembolism (VTE) represents a significant preventable cause of hospital mortality. VTE assessment and prophylaxis rates are key patient safety and quality of care indicators. The aim of this study was to audit low molecular weight heparin (LMWH) and graduated elasticated compression stockings (GECS) prescriptions compared with the current Clinical Guidelines for Operations. METHODS: Complete audit loop in the Role 3 Hospital, Camp Bastion, Afghanistan. A multifaceted intervention programme incorporating physician and nurse education and pre-printed medication charts was introduced to improve VTE assessment and prophylaxis rates. RESULTS: Only 111/301 (36.9%) of patients in the pre-intervention cohort had a VTE risk assessment performed; this improved to 142/155 (91.6%, p<0.0001) post-intervention. A total of 57/88 (64.8%) patients prescribed LMWH pre-intervention had a documented assessment of bleeding risk performed; this rose to 65/66 (98.5%, p=0.0003) post-intervention. In pre-intervention, only 63/213 (29.6%) patients had a documented reassessment of VTE and bleeding risk at 24 h; reassessment rates rose to 68.8% (66/96 patients, p<0.0001) post-intervention. Of those patients at risk of VTE without ongoing bleeding risk, 62/96 (64.6%) had LMWH prescribed pre-intervention; this rose to 57/62 (91.9%) post-intervention (p<0.0001). Inappropriate LMWH prescription rates fell from 26/190 (13.7%) to 4/85 (4.7%, p=0.035) post-intervention. In those patients in whom GECS were not contraindicated, prescription rates rose from 23/95 (24.2%) to 42/62 (67.7%, p<0.0001) post-intervention. CONCLUSIONS: Inclusion of pre-printed LMWH/GECS prescriptions and risk assessment stickers in the mediction chart significantly improved rates of VTE risk assessment and prophylaxis. These easily reproducible and low-cost interventions could improve patient safety on deployment.

Opportunities for improvement in the management of patients who die from haemorrhage after trauma.

BACKGROUND: Bleeding is the leading cause of preventable death after injury. This retrospective study aimed to characterize opportunities for performance improvement (OPIs) identified in patients who died from bleeding and were considered by the quality improvement system of a major trauma centre. METHODS: All trauma deaths in 2006-2010 were discussed at the trauma morbidity and mortality meeting. Deaths from haemorrhage were identified and subjected to qualitative and quantitative evaluation. OPIs were identified and remedial action was taken. RESULTS: During the study interval there were 7511 trauma team activations; 423 patients died. Haemorrhage was the second most common cause of death, in 112 patients, and made a substantial contribution to death in a further 15. For 84 of these 127 patients, a total of 150 OPIs were identified. Most arose in the emergency department, but involved personnel from many departments. Problems with decision-making were more common than errors in technical skill. OPIs frequently involved the decision between surgery, radiology and further investigation. Delayed and inappropriate surgery occurred even when investigation and diagnosis were appropriate. The mortality rate among patients presenting in shock fell significantly over the study interval (P < 0·026). CONCLUSION: Problems with judgement are more common than those of skill. Death from traumatic haemorrhage is associated with identifiable, remediable failures in care. The implementation of a systematic trauma quality improvement system was associated with a fall in the mortality rate among patients presenting in shock.

Kv1.3 blockers ameliorate allergic contact dermatitis by preferentially suppressing effector memory T cells in a rat model.

BACKGROUND: The Kv1.3 voltage-gated potassium channel is selectively upregulated upon activation in effector memory T (TEM ) cells in inflamed tissue, and plays an important role in maintenance of T-cell activation. Although Kv1.3 blockers have been shown to ameliorate allergic contact dermatitis (ACD) in a rat model, it remains unknown whether the effect of Kv1.3 blockers on ACD is mediated by suppressing TEM cell function and/or whether naive T-cells or central memory T (TCM ) cells are influenced. AIM: To analyse the detailed mechanism of Kv1.3 blockers in a rat model of ACD. METHODS: We examined the effects of a Kv1.3 blocker on inflammation and production of the effector cytokine interferon (IFN)-γ in inflamed tissue in rat ACD. Single-cell suspensions were isolated from inflamed rat ears (TEM cells), and regional lymph nodes (naive T/TCM cells), and the effect of Kv1.3 blockers on anti-CD3-stimulated IFN-γ production in vitro was measured. RESULTS: The Kv1.3 blocker significantly suppressed ear inflammation and IFN-γ production at the protein level in vivo. It also suppressed in vitro IFN-γ production from TEM cells from inflamed tissues, but did not suppress the function of naive T/TCM cells from lymph nodes. CONCLUSIONS: We found that the Kv1.3 blocker ameliorated ACD by inhibiting TEM cell functions only, thus Kv1.3 blockers could be a potentially selective therapeutic agent for TEM cell-mediated inflammatory skin diseases without producing harmful side-effects.

Military treatment of splenic injury in the era of non-operative management.

OBJECTIVES: Management of blunt splenic injury (BSI) in battlefield casualties is controversial. Splenectomy is the traditional treatment, as setting the conditions for selective non-operative management (SNOM) is difficult in the operational environment. On mature operations, it may be feasible to adopt a more conservative approach and manage the patient according to civilian protocols. The aim of this study was to document the contemporary practice of deployed military surgeons when dealing with BSI and to compare this against a matched cohort of civilian BSI patients. METHOD: The Joint Theatre Trauma Registry held at the Royal Centre for Defence Medicine, Birmingham, was thoroughly examined to yield patients with BSI. The study encompassed a 55-month period ending September 2009. Data abstracted included patient demographics, injury epidemiology, grade of splenic injury, treatment and outcome. These data were compared with a registry database from a UK civilian major trauma centre. RESULT: Of 1516 military trauma patients, 16 (1%) had a splenic injury, of which five were excluded either because of fatalities due to overwhelming injury or penetrating trauma. The remaining 11 had a blunt component. Median (IQR) injury severity score (ISS) was 17 (15-21). Nine underwent a splenectomy with median (IQR) ISS of 17 (12-18). Of this group, organ injury grades were documented in 10 patients (four Grade V injuries, three Grade IV and three Grade II). All patients survived surgery. There were no complications in survivors as a result of splenic conservation in the military group. Data from the civilian major trauma centre database showed 160 (2%) patients sustained a splenic injury, of which 131 (82%) had a blunt mechanism, 43/160 (27%) and 9/160 (6%) patients underwent splenectomy and angio-embolisation, respectively. CONCLUSIONS: Patients with BSI, an uncommon finding in combat casualties, are occasionally selected for conservative management, contrary to previous military surgical paradigms but in keeping with the civilian shift to SNOM. Guidelines to clarify the place of SNOM are required to assist surgical decision making on deployed operations.

Effectiveness of 1 dose of 2009 influenza A (H1N1) vaccine at preventing hospitalization with pandemic H1N1 influenza in children aged 7 months-9 years.

The availability of a well-established immunization registry to provide vaccination information, a school-located vaccination campaign followed by continued 2009 influenza A (H1N1) (pH1N1) activity, and a requirement to report hospitalized influenza cases provided an opportunity to estimate vaccine effectiveness (VE) of an initial dose of pH1N1 monovalent vaccine in children aged 7 months-9 years. Seventy-eight case children and 729 date-of-birth- and zipcode-matched controls were studied. The VE of a single vaccine dose in preventing pH1N1 hospitalization ≥ 14 days after vaccination was 82% (95% confidence interval [CI], 0%-100%; P = .04) in children aged 3-9 years but was zero (-3%; 95% CI, <0%-75%) in children aged 7-35 months. These findings are consistent with those from prelicensure immunogenicity studies and have implications for interpretation of immunogenicity studies and setting priorities for vaccination of young children in future pandemics. Immunization registries can provide a simple, rapid assessment of VE to evaluate and inform vaccination policy.

Defence Medical Services' REBOA training course.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) enables temporary haemorrhage control and physiological stabilisation. This article describes the bespoke Defence Medical Services (DMS) training package for effectively using REBOA. The article covers how the course was designed, how the key learning objectives are taught, participant feedback and the authors' perceptions of future training challenges and opportunities. Since the inaugural training course in April 2019, the authors have delivered six courses, training over 100 clinicians. For the first time in the UK DMS, we designed and delivered a robust specialist endovascular training programme, with demonstrable, significant increases in confidence and competence. As a result of this course, the first DMS REBOA-equipped forward surgical teams deployed in June 2019. Looking to the future, there is a requirement to develop an assessment of skill retention and the potential need for revalidation.

Balloons on the battlefield: REBOA implementation in the UK Defence Medical Services.

Established in 2018, the Defence Endovascular Resuscitation (DefER) group recognised that resuscitative endovascular balloon occlusion of the aorta (REBOA) offered an option to improve survival in battle casualties dying from haemorrhage, particularly in remote and austere surgical settings. Following a successful jHub opportunity assessment, DefER purchased training and operational kit at pace. By 1 April 2019, the first forward surgical group undertook a bespoke endovascular training and assessment package. Results of the pilot were presented back to a jHub 4* Innovation Board, which initially awarded £500 000 to fund the project to full implementation. Med Op Cap provided a solution to establish REBOA as a core capability on to the 370 modules. REBOA catheters and arterial access kit are now available to deployed Role 2 facilities across defence as an adjunct to damage control resuscitation in specific circumstances. REBOA has, from a standing start, gained pan-Defence Medical Services (DMS) endorsement and has been integrated into deployed damage control resuscitation. To establish a new resuscitation capability across all Role 2 platforms within 15 months of inception represents implementation at pace. This agility was unlocked by empowering clinicians to develop the platform in conjunction with commercial procurement. This article describes how this innovative pathway facilitated the rapid introduction of a lifesaving haemorrhage control technique to equip DMS clinicians.

Remote ultrasound diagnostics disrupting traditional military frontline healthcare delivery.

Accurate and reliable diagnostic capability is essential in deployed healthcare to aid decision-making and mitigate risk. This is important for both the patient and the deployed healthcare system, especially when considering the prioritisation of scarce aeromedical evacuation assets and frontline resources. Novel ultrasound tele-guidance technology presents a valuable diagnostic solution for remotely deployed military clinicians. This report discusses the first use of a consultant radiologist guiding a clinician, untrained in ultrasound, to perform an ultrasound scan via a live tele-guidance feed in the deployed environment using the Butterfly iQ+ tele-guidance system. Distance scanning provided a diagnostic quality report when compared with locally performed imaging to improve patient care and maintain operational output. This example demonstrates feasibility of remote point-of-care imaging systems in provision of location-agnostic high-quality diagnostic capability. Future opportunities to develop care pathways using bedside tele-diagnostics will democratise access, drive efficiency and improve patient care experience and outcomes.

Factors affecting outcome after traumatic limb amputation.

BACKGROUND: Traumatic leg amputation commonly affects young, active people and leads to poor long-term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation. METHODS: A comprehensive search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases was performed, using the terms 'leg injury', 'amputation' and 'outcome'. Articles reporting outcomes following traumatic leg amputation were included. RESULTS: Studies demonstrated that pain, psychological illness, decreased physical and vocational function, and increased cardiovascular morbidity and mortality were common causes of disability after traumatic leg amputation. The evidence highlights that appropriate preoperative management and operative techniques, in conjunction with suitable rehabilitation and postoperative follow-up, can lead to improved treatment outcome and patient satisfaction. CONCLUSION: Patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health. Clinicians involved in their care have many opportunities to improve their outcome using a variety of therapeutic variables. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Imaging vascular trauma.

BACKGROUND: Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions. METHODS: A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000-2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included. RESULTS: Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury. CONCLUSION: Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.

Epidemiology and outcome of vascular trauma at a British Major Trauma Centre.

OBJECTIVES: In the United Kingdom, the epidemiology, management strategies and outcomes from vascular trauma are unknown. The aim of this study was to describe the vascular trauma experience of a British Trauma Centre. METHODS: A retrospective observational study of all patients admitted to hospital with traumatic vascular injury between 2005 and 2010. RESULTS: Vascular injuries were present in 256 patients (4.4%) of the 5823 total trauma admissions. Penetrating trauma caused 135 (53%) vascular injuries whilst the remainder resulted from blunt trauma. Compared to penetrating vascular trauma, patients with blunt trauma were more severely injured (median ISS 29 [18-38] vs. ISS 11 [9-17], p < 0.0001), had greater mortality (26% vs. 10%; OR 3.0, 95% CI 1.5-5.9; p < 0.01) and higher limb amputation rates (12% vs. 0%; p < 0.0001). Blunt vascular trauma patients were also twice as likely to require a massive blood transfusion (48% vs. 25%; p = 0.0002) and had a five-fold longer hospital length of stay (median 35 days (15-58) vs. 7 (4-13), p<0.0001) and critical care stay (median 5 days (0-11) vs. 0 (0-2), p < 0.0001) compared to patients with penetrating trauma. Multivariate regression analysis showed that age, ISS, shock and zone of injury were independent predictors of death following vascular trauma. CONCLUSION: Traumatic vascular injury accounts for 4% of admissions to a British Trauma Centre. These patients are severely injured with high mortality and morbidity, and place a significant demand on hospital resources. Integration of vascular services with regional trauma systems will be an essential part of current efforts to improve trauma care in the UK.

Skill decay in surgeons deployed on military operations: a systematic review.

INTRODUCTION: Decay of surgical skills due to paucity of opportunity to operate is a potential threat to patients being cared for by the Defence Medical Services while on operational deployment. Our aim was to review the literature regarding skill decay in the trained surgeon in order to understand how it may affect clinical performance and patient outcomes. We also wished to survey the likely causes of such decay and possible means of mitigation. METHODS: A systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Study bias assessment was also undertaken. Content summaries for the papers included study design and methodology, participant level of experience, measures and magnitude of effect, duration of no practice, and study limitations. RESULTS: Five papers met the selection criteria. There were insufficient quantitative data on the impact of surgical skill decay on patient outcome, surgeon performance or mitigation strategies, and a meaningful quantitative synthesis could not be undertaken. CONCLUSIONS: This systematic review of the literature found very little specific evidence confirming or refuting surgical skill decay in trained surgeons, with measurement of decay hampered by the lack of an accepted methodology. Studying this in the deployed setting may offer a firmer evidence base from which to generate policy. Potential mitigation strategies are discussed.PROSPERO registration number ID260846.

Outcome after vascular trauma in a deployed military trauma system.

BACKGROUND: Military injuries to named blood vessels are complex limb- and life-threatening wounds that pose significant difficulties in prehospital and surgical management. The aim of this study was to provide a comprehensive description of the epidemiology, treatment and outcome of vascular injury among service personnel deployed on operations in Afghanistan and Iraq. METHODS: Data from the British Joint Theatre Trauma Registry were combined with hospital records to review all cases of vascular trauma in deployed service personnel over a 5-year interval ending in January 2008. RESULTS: Of 1203 injured service personnel, 110 sustained injuries to named vessels; 66 of them died before any surgical intervention. All 25 patients who sustained an injury to a named vessel in the abdomen or thorax died; 24 did not survive to undergo surgery and one casualty in extremis underwent a thoracotomy, but died. Six of 17 patients with cervical vascular injuries survived to surgical intervention; two died after surgery. Of 76 patients with extremity vascular injuries, 37 survived to surgery with one postoperative death. Interventions on 38 limbs included 19 damage control procedures (15 primary amputations, 4 vessel ligations) and 19 definitive limb revascularization procedures (11 interposition vein grafts, 8 direct repairs), four of which failed necessitating three amputations. CONCLUSION: In operable patients with extremity injury, amputation or ligation is often required for damage control and preservation of life. Favourable limb salvage rates are achievable in casualties able to withstand revascularization. Despite marked progress in contemporary battlefield trauma care, torso vascular injury is usually not amenable to surgical intervention.

Synthesis of ethanol-soluble few-layer graphene nanosheets for flexible and transparent conducting composite films.

We report a facile method of preparing few-layer graphene nanosheets (FLGs), which can be soluble in ethanol. Atomic force microscopy and high-resolution transmission electron microscopy studies reveal that FLGs have average thicknesses in the range of 2.6-2.8 nm, corresponding to 8-9 layers. A graphene/nafion composite film has a sheet resistance of 9.70 kΩ/sq at the transmittance of 74.5% (at 550 nm) while the nafion film on polyethylene terephthalate has a sheet resistance of 128 kΩ/sq at transmittance of 90.0%. For the cycling/bending test, almost no change in resistance was exhibited when the film was bent at an angle up to 140°, and no obvious deviation in resistance could be found after 100 bending cycles was applied. In addition, an FLGs-poly(3,4-ethylenedioxythiophene):poly(styrenesulfonate) composite layer was demonstrated as the effective hole transporting layer to improve the hole transporting ability in an organic photovoltaic device, with which the power conversion efficiency was enhanced from 3.10% to 3.70%. The results demonstrated the promising applications of FLGs on graphene-based electronics, such as transparent electrode and flexible conducting film.