Delayed Presentation of Small Bowel Injury Following Extraperitoneal Ballistic Injury.

Lack of peritoneal violation has been a strong tenet of nonoperative management for extraperitoneal penetrating injuries. There have been reports of intraperitoneal injuries without peritoneal violation in adult trauma literature. Such reports are scarce in pediatric trauma. We report delayed presentation of a small bowel injury in a 4-year-old male following extraperitoneal ballistic injury. No peritoneal violation was noted on wound exploration allowing conservative management. Patient developed abdominal distention on postoperative day 1, and radiologic imaging showed intraperitoneal air warranting an exploratory laparotomy. Intraperitoneal injuries without peritoneal violation have been attributed to the transmission of kinetic energy through the extraperitoneal tissue. Clinical judgment, physical exam, and radiologic adjuncts are of the utmost importance in management. Given our findings, extraperitoneal penetrating injuries certainly warrant extended observation of the patient.

Microinvasive glaucoma surgeries: critical summary of clinical trial data with and without phacoemulsification.

PURPOSE OF REVIEW: To critically summarize and examine published data from randomized controlled clinical trials (RCTs) investigating the safety and efficacy of microinvasive glaucoma surgeries (MIGS) with and without cataract surgery versus cataract surgery alone. RECENT FINDINGS: Three RCTs with standardized outcomes and rigorous methodology demonstrate superiority of the iStent (Glaukos), CyPass (Alcon), and Hydrus (Alcon) MIGS devices in combination with cataract surgery versus cataract surgery alone. The trials all involved medication washouts at baseline and also after 24 months of follow-up. In each of the trials, a greater proportion of participants randomized to the combined MIGS procedures achieved at least 20% unmedicated intraocular pressure (IOP) lowering compared with cataract surgery alone. With the exception of the CyPass device, which has been voluntarily withdrawn from the market, adverse events associated with MIGS were acceptable and consistent with routine intraocular surgeries. Follow-up studies demonstrate sustained efficacy, greater probabilities of visual field preservation, increased cost-effectiveness, and enhanced quality of life associated with MIGS procedures. SUMMARY: Data related to MIGS platforms for treatment of open-angle glaucoma with or without co-existing cataract supports their continued adoption in clinical practice. Future studies comparing various techniques and devices in a standardized fashion are needed.

A Bayesian functional data model for surveys collected under informative sampling with application to mortality estimation using NHANES.

Functional data are often extremely high-dimensional and exhibit strong dependence structures but can often prove valuable for both prediction and inference. The literature on functional data analysis is well developed; however, there has been very little work involving functional data in complex survey settings. Motivated by physical activity monitor data from the National Health and Nutrition Examination Survey (NHANES), we develop a Bayesian model for functional covariates that can properly account for the survey design. Our approach is intended for non-Gaussian data and can be applied in multivariate settings. In addition, we make use of a variety of Bayesian modeling techniques to ensure that the model is fit in a computationally efficient manner. We illustrate the value of our approach through two simulation studies as well as an example of mortality estimation using NHANES data.

Effect of special operational forces surgical resuscitation teams on combat casualty survival: A narrative review.

IMPORTANCE: The most common cause of preventable death on the conventional battlefield or on special operations force (SOF) missions is hemorrhage. SOF missions may take place in remote and austere locations. Many preventable deaths in combat occur within 30 min of wounding. Therefore, SOF damage control resuscitation (DCR) and damage control surgery (DCS) teams may improve combat casualty survival in the SOF environment. OBJECTIVE: To determine the effect of SOF DCR and DCS teams on combat casualty survival. Also, to describe commonalities in team structure, logistics, and blood product usage. DESIGN: A narrative review of the English literature used a Medline and Embase search strategy. The authors were contacted for more details as required. The risk of bias was assessed using the Cochrane Collaboration's ROBINS-I tool. Pooling of data was not done to the heterogeneity of studies. RESULTS: Weak evidence was identified showing a clinical benefit of SOF DCR and DCS teams. Conflicting evidence from less rigorous studies was also found. The overall risk of bias using ROBINS-I was serious to critical. Several commonalities in team structure, training, and logistics were found. CONCLUSIONS AND RELEVANCE: There is conflicting evidence regarding the effect SOF DCR and DCS teams have on combat casualty survival. There is no strong evidence that SOF DCR and DCS teams cause harm. More robust data collection is recommended to evaluate these teams.

Open Retroperitoneal Inferior Vena Cava Cannulation for Distal Ventriculoatrial Shunt Catheter Placement.

Multiple alternative sites for distal ventriculoperitoneal shunts have been described including pleural, atrial, ureteral, fallopian, and gallbladder placement. In medically complex patients the sites for cerebrospinal fluid (CSF) diversion can be exhausted. We present a case where open retroperitoneal inferior vena cava cannulation was used for successful atrial catheter placement in a 17-month-old female. The patient had a complex abdominal, pulmonary, and vascular history precluding placement of the distal catheter in other sites or atrial placement through more peripheral venous cannulation. The patient underwent uncomplicated open retroperitoneal exposure of her inferior vena cava (IVC) with cannulation and placement of atrial catheter under fluoroscopic guidance. At the follow-up one year after surgery, the patient did not require revision with appropriate placement of the distal atrial catheter.

Undiagnosed Metachromatic Leukodystrophy Presenting as Severe Gastrointestinal Bleeding and Cholestasis from Hemobilia.

Metachromatic leukodystrophy (MLD) is a neurodegenerative disorder caused by the accumulation of lipids called sulfatides throughout the nervous system. Sulfatides can also collect in other organs throughout the body including the gallbladder where they form polyps. Gallbladder polyps rarely have been found to bleed in patients with known MLD, presumably due to polyp shearing. Here we present a case of a child with autism presenting with severe gastrointestinal bleeding and direct hyperbilirubinemia, requiring significant resuscitation and biliary drain placement to tamponade ongoing bleeding. Subsequent neurologic and genetic investigation led to the diagnosis of MLD, with laparoscopic cholecystectomy revealing extensive, elongated gallbladder polyps. Clinicians who care for patients with MLD, including gastroenterologists who manage their progressive oropharyngeal dysphagia, should be aware of the risk for this life-threatening complication. Moreover, pediatric gastroenterologists and hepatologists should maintain a high index of suspicion for MLD in new patients presenting with developmental regression and gastrointestinal bleeding.

PREOPERATIVE DOMED MACULAR CONTOUR CORRELATES WITH POSTOPERATIVE VISUAL GAIN AFTER VITRECTOMY FOR SYMPTOMATIC EPIRETINAL MEMBRANE.

PURPOSE: Evaluate macular features on preoperative ocular coherence tomography as indicators of postoperative visual gain following vitrectomy for epiretinal membrane (ERM). METHODS: A retrospective chart review of 66 eyes that underwent vitrectomy with membrane and internal limiting membrane peeling for symptomatic ERM. Inclusion criteria required a pre-op visual acuity of at least 20/200 and minimum follow-up of 1 year. In addition, 31 of these eyes with complete 5-line raster pre-op ocular coherence tomography had segmentation analysis which included noncentral ERM to inner nuclear layer and ERM to outer plexiform layer measurements. RESULTS: Eyes with "domed" pre-op macular contour had a mean preoperative acuity of 20/70 and gained a mean 2.4 lines at one year, compared with those with "flat" or "depressed" macular contour, having a 20/60 mean preoperative acuity and 0.6 lines gained (P = 0.02). Changes for other ocular coherence tomography features examined were not statistically significant. Paracentral ERM to inner nuclear layer measurements had moderate correlation, whereas paracentral ERM to outer plexiform layer measurements had weak correlation with gain in visual acuity. CONCLUSION: An inner macular-domed contour in eyes with ERM predicted better visual gain after vitrectomy with ERM and internal limiting membrane peeling compared with a flat or depressed contour.

Novel Essential Amino Acid Supplements Following Resistance Exercise Induce Aminoacidemia and Enhance Anabolic Signaling Irrespective of Age: A Proof-of-Concept Trial.

We investigated the effects of ingesting a leucine-enriched essential amino acid (EAA) gel alone or combined with resistance exercise (RE) versus RE alone (control) on plasma aminoacidemia and intramyocellular anabolic signaling in healthy younger (28 ± 4 years) and older (71 ± 3 years) adults. Blood samples were obtained throughout the three trials, while muscle biopsies were collected in the postabsorptive state and 2 h following RE, following the consumption of two 50 mL EAA gels (40% leucine, 15 g total EAA), and following RE with EAA (combination (COM)). Protein content and the phosphorylation status of key anabolic signaling proteins were determined via immunoblotting. Irrespective of age, during EAA and COM peak leucinemia (younger: 454 ± 32 µM and 537 ± 111 µM; older: 417 ± 99 µM and 553 ± 136 µM) occurred ~60-120 min post-ingestion (younger: 66 ± 6 min and 120 ± 60 min; older: 90 ± 13 min and 78 ± 12 min). In the pooled sample, the area under the curve for plasma leucine and the sum of branched-chain amino acids was significantly greater in EAA and COM compared with RE. For intramyocellular signaling, significant main effects were found for condition (mTOR (Ser2481), rpS6 (Ser235/236)) and age (S6K1 (Thr421/Ser424), 4E-BP1 (Thr37/46)) in age group analyses. The phosphorylation of rpS6 was of similar magnitude (~8-fold) in pooled and age group data 2 h following COM. Our findings suggest that a gel-based, leucine-enriched EAA supplement is associated with aminoacidemia and a muscle anabolic signaling response, thus representing an effective means of stimulating muscle protein anabolism in younger and older adults following EAA and COM.

Exploring the use of WhatsApp in out-of-hours pharmacy services: A multi-site qualitative study.

BACKGROUND: WhatsApp is an instant messaging application that has grown in popularity over the last decade. The literature has focused on the use of WhatsApp in medical, surgical and nursing disciplines, with little work exploring pharmacists' experiences of using WhatsApp to provide services. OBJECTIVE(S): The aim of this research was to explore pharmacists' experiences of using WhatsApp to support delivery of out-of-hours pharmacy services. METHODS: A qualitative design was underpinned by a phenomenological philosophy. Focus groups and an extract of the WhatsApp transcript were thematically analysed using NVivo. RESULTS: Over three hundred communication events (1580 messages) were analysed in the WhatsApp transcript. Message type was classified as follows; handover (26%, n = 410), procedural queries (26%, n = 410), laptop location (18%, n = 284), whole staff communication (24%, n = 379), clinical queries (5%, n = 79), and administrative communications (1%, n = 16). A total of five focus groups were conducted between October and November 2017 with 27 participants that included pharmacists with different levels of experience. The findings suggest that WhatsApp improved communication between junior and senior pharmacists, particularly during the global cyber crisis, and provided an opportunity to share best practice. Concerns were raised regarding the encroachment of work activities into personal time. Additionally, the tacit approval by senior pharmacists to group information sharing and solution development, despite the potential for non-active participation, highlighted the issue of collective complicity. CONCLUSIONS: WhatsApp can be a useful platform to support the delivery of out-of-hours services through professional development, improving communication and supporting relationships. This paper demonstrates that service managers must consider multiple ethico-legal and social frameworks when developing or allowing the organic development of such communication methods within healthcare provider organisations.

Skeletal muscle, haematological and splenic volume characteristics of elite breath-hold divers.

PURPOSE: The aim of the study was to provide an evaluation of the oxygen transport, exchange and storage capacity of elite breath-hold divers (EBHD) compared with non-divers (ND). METHODS: Twenty-one healthy males' (11 EBHD; 10 ND) resting splenic volumes were assessed by ultrasound and venous blood drawn for full blood count analysis. Percutaneous skeletal muscle biopsies were obtained from the m. vastus lateralis to measure capillarisation, and fibre type-specific localisation and distribution of myoglobin and mitochondrial content using quantitative immunofluorescence microscopy. RESULTS: Splenic volume was not different between groups. Reticulocytes, red blood cells and haemoglobin concentrations were higher (+ 24%, p < 0.05; + 9%, p < 0.05; + 3%, p < 0.05; respectively) and mean cell volume was lower (- 6.5%, p < 0.05) in the EBHD compared with ND. Haematocrit was not different between groups. Capillary density was greater (+ 19%; p < 0.05) in the EBHD. The diffusion distance (R95) was lower in type I versus type II fibres for both groups (EBHD, p < 0.01; ND, p < 0.001), with a lower R95 for type I fibres in the EBHD versus ND (- 13%, p < 0.05). Myoglobin content was higher in type I than type II fibres in EBHD (+ 27%; p < 0.01) and higher in the type I fibres of EBHD than ND (+ 27%; p < 0.05). No fibre type differences in myoglobin content were observed in ND. Mitochondrial content was higher in type I than type II fibres in EBHD (+ 35%; p < 0.05), with no fibre type differences in ND or between groups. CONCLUSIONS: In conclusion, EBDH demonstrate enhanced oxygen storage in both blood and skeletal muscle and a more efficient oxygen exchange capacity between blood and skeletal muscle versus ND.

The NATO Special Operations Surgical Team Development Course A Program Overview.

The Special Operations Surgical Team Development Course (SOSTDC) is a 5-day course held two or three times a year at the North Atlantic Treaty Organization (NATO) training facility within the Special Operations Medical Branch (SOMB) of the Allied Centre for Medical Education (ACME). Its aim is to teach, train, develop, and encourage NATO partner nations to provide robust, hardened, and clinically able surgical resuscitation teams that are capable of providing close support to Special Operations Forces (SOF).

The Potential Use of the Abdominal Aortic Junctional Tourniquet® in a Military Population: A Review of Requirement, Effectiveness, and Usability.

Uncontrolled hemorrhage is the leading cause of preventable prehospital death on the battlefield; 20% is junctional. This is a challenge to manage in the forward and prehospital military environment. With the widespread use of body armor, peripheral tourniquets and continued asymmetric warfare this consistent figure is unlikely to reduce. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an often-quoted potential solution; however, this invasive strategy requires a high skill level alongside a significant failure and complication rate. The Abdominal Aortic Junctional Tourniquet® (AAJT) is a noninvasive potential adjunct for the management of hemorrhage below the level of the aortic bifurcation with published case reports of successful use in prehospital blast and gunshot wounds. When placed at the level of the aortic bifurcation, alongside a pelvic binder, it can be used to control pelvic hemorrhage, buying time until definitive management. Importantly it has a low training burden and is easy to use. The AAJT has potential use as a prehospital device in the exsanguinating patient, those in traumatic cardiac arrest, as a bridging device, and as fluid conserving device in resource-limited environments. The evidence surrounding the AAJT is reviewed, and potential uses in the military setting are suggested.

Predicting Profile Soil Properties with Reflectance Spectra via Bayesian Covariate-Assisted External Parameter Orthogonalization.

In situ, diffuse reflectance spectroscopy (DRS) profile soil sensors have the potential to provide both rapid and high-resolution prediction of multiple soil properties for precision agriculture, soil health assessment, and other applications related to environmental protection and agronomic sustainability. However, the effects of soil moisture, other environmental factors, and artefacts of the in-field spectral data collection process often hamper the utility of in situ DRS data. Various processing and modeling techniques have been developed to overcome these challenges, including external parameter orthogonalization (EPO) transformation of the spectra. In addition, Bayesian modeling approaches may improve prediction over traditional partial least squares (PLS) regression. The objectives of this study were to predict soil organic carbon (SOC), total nitrogen (TN), and texture fractions using a large, regional dataset of in situ profile DRS spectra and compare the performance of (1) traditional PLS analysis, (2) PLS on EPO-transformed spectra (PLS-EPO), (3) PLS-EPO with the Bayesian Lasso (PLS-EPO-BL), and (4) covariate-assisted PLS-EPO-BL models. In this study, soil cores and in situ profile DRS spectrometer scans were obtained to ~1 m depth from 22 fields across Missouri and Indiana, USA. In the laboratory, soil cores were split by horizon, air-dried, and sieved (<2 mm) for a total of 708 samples. Soil properties were measured and DRS spectra were collected on these air-dried soil samples. The data were randomly split into training (n = 308), testing (n = 200), and EPO calibration (n = 200) sets, and soil textural class was used as the categorical covariate in the Bayesian models. Model performance was evaluated using the root mean square error of prediction (RMSEP). For the prediction of soil properties using a model trained on dry spectra and tested on field moist spectra, the PLS-EPO transformation dramatically improved model performance relative to PLS alone, reducing RMSEP by 66% and 53% for SOC and TN, respectively, and by 76%, 91%, and 87% for clay, silt, and sand, respectively. The addition of the Bayesian Lasso further reduced RMSEP by 4⁻11% across soil properties, and the categorical covariate reduced RMSEP by another 2⁻9%. Overall, this study illustrates the strength of the combination of EPO spectral transformation paired with Bayesian modeling techniques to overcome environmental factors and in-field data collection artefacts when using in situ DRS data, and highlights the potential for in-field DRS spectroscopy as a tool for rapid, high-resolution prediction of soil properties.

The Combat Application Tourniquet Versus the Tactical Mechanical Tourniquet.

BACKGROUND: Exsanguination from limb injury is an important battlefield consideration that is mitigated with the use of emergency tourniquets. The Combat Application Tourniquet (C-A-T®) is the current British military standard tourniquet. METHODS: We tested the self-application of a newer tourniquet system, the Tactical Mechanical Tourniquet (TMT), against self-application of the C-A-T. A total of 24 healthy British military volunteers self-applied the C-A-T and the TMT to their mid thigh in a randomized, sequential manner. Popliteal artery flow was monitored with a portable ultrasound machine, and time until arterial occlusion was measured. Pain scores were also recorded. Results The volunteers allowed testing on their lower limbs (n = 48 legs). The C-A-T was applied successfully to 22 volunteers (92%), and the TMT was successfully applied to 17 (71%). Median time to reach complete arterial occlusion was 37.5 (interquartile range [IQR], 27-52) seconds with the C-A-T, and 35 (IQR, 29-42) seconds with the TMT. The 2.5-second difference in median times was not significant (ρ = .589). The 1-in-10 difference in median pain score was also not significant (ρ = .656). The success or failure of self-application between the two tourniquet models as assessed by contingency table was not significant (p= .137). CONCLUSION: The TMT is effective when self-applied at the mid thigh. It does not offer an efficacy advantage over the C-A-T.

Neuromuscular Fatigue and Recovery after Heavy Resistance, Jump, and Sprint Training.

PURPOSE: Training methods that require maximal intensity efforts against light and heavy resistance are commonly used for athletic development. Typically, these sessions are separated by at least 48 h recovery on the assumption that such efforts elicit marked fatigue of the central nervous system (CNS), but this posit has not been well studied. The aim of the study was to assess the etiology and recovery of fatigue after heavy-resistance (strength), jump, and sprint training methods. METHODS: Ten male athletes completed three training sessions requiring maximal efforts that varied in their loading characteristics: (i) heavy-resistance exercise (10 × 5 back squats at 80% one-repetition maximum [1RM]) (STR), (ii) jumping exercise (10 × 5 jump squats) (JUMP), and (iii) maximal sprinting (15 × 30 m) (SPR). Preparticipants, postparticipants, and 24-, 48-, and 72-h postparticipants completed a battery of tests to measure neuromuscular function using electrical stimulation of the femoral nerve, and single- and paired-pulse magnetic stimulation of the motor cortex, with evoked responses recorded from the knee extensors. Fatigue was self-reported at each time point using a visual analog scale. RESULTS: Each intervention elicited fatigue that resolved by 48 (JUMP) and 72 h (STR and SPR). Decrements in muscle function (reductions in the potentiated quadriceps twitch force) persisted for 48 h after all exercise. Reductions in voluntary activation were present for 24 h after JUMP and SPRINT, and 48 h after STR. No other differences in CNS function were observed as a consequence of training. CONCLUSION: Strength, jump, and sprint training requiring repeated maximum efforts elicits fatigue that requires up to 72 h to fully resolve, but this fatigue is not primarily underpinned by decrements in CNS function.

Improvised first aid techniques for terrorist attacks.

Terrorist acts occur every day around the world. Healthcare professionals are often present as bystander survivors in these situations, with none of the equipment or infrastructure they rely on in their day-to-day practice. Within several countries there has been a move to disseminate the actions to take in the event of such attacks: in the UK, Run, Hide, Tell, and in the USA, Fight Back This paper outlines how a very basic medical knowledge combined with everyday high-street items can render highly effective first aid and save lives. We discuss and summarise modern improvised techniques. These include the ABCDE approach of treating catastrophic haemorrhage before airway management, bringing together improvised techniques from the military and wilderness medicine. We explain how improvised tourniquets, wound dressings, splinting and traction devices can be fabricated using items from the high street: nappies, tampons, cling film, duct tape and tablecloths. Cervical spine immobilisation is a labour-intensive protocol that is often practised defensively. With little evidence to support the routine use of triple immobilisation, this should be replaced with a common sense dynamic approach such as the Montana neck brace. Acid or alkali attacks are also examined with simple pragmatic advice. Analgesia is discussed in the context of a prehospital setting. Pharmacy-obtained oral morphine and diclofenac suppositories can be used to treat moderate pain without relying on equipment for intravenous/intraosseous infusion in prolonged hold situations. The differentiation between concealment and cover is summarised: scene safety remains paramount.