Optimizing combat readiness for military surgeons without trauma fellowship training: Engaging the "voluntary faculty" model.

BACKGROUND: Appropriate operative volume remains a critical component in mitigating surgical atrophy and maintaining clinical competency. The initiation of military-civilian surgical partnerships (MCPs) has been proposed for addressing knowledge, skills, and abilities (KSA) metrics to address concerns over operational readiness and the low acuity experienced by military surgeons. This study investigates the first partnership for Navy surgical staff at a nonacademic Military Treatment Facility (MTF) with a regional academic Army Military Treatment Facility (AMTF) and a civilian, nonacademic level II trauma center devised to improve operational readiness for attending surgeons. We hypothesize that a skill sustainment MCP will allow military surgeons to meet combat readiness standards as measured by the KSA metric. METHODS: A memorandum of understanding was initiated between the Navy Military Treatment Facility (NMTF), the AMTF, and the level II civilian trauma center (CTC). The single military surgeon in this study was classified as "voluntary faculty" at the CTC. Total case volume and acuity were recorded over an 11-month period. Knowledge, skills, and abilities metrics were calculated using the standard national provider identifier number and the novel case-log based method. RESULTS: A total of 156 cases were completed by a single surgeon over the study period, averaging 52 cases per institution. Significantly more KSAs were obtained at the CTC compared with NMTF (5,954 vs. 2,707; p < 0.001). Significantly more emergent cases were observed at the CTC compared with the MTFs (χ 2 = 7.1, n = 96, p < 0.05). At a single site, AMTF, a significant difference in the calculated KSA score, was observed between the national provider identifier and case-log methods (5,278 vs. 3,297; p = 0.04). CONCLUSION: The skill sustainment MCP between NMTF and CTC increased surgical readiness and exposed surgeons to increased operative acuity. The voluntary faculty model reduces direct litigation exposure and encourages clinical competency for military surgeons while remaining a deployable asset to the global military effort. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Similar frequency of atrial perforation between atrial and bicaval dual lumen veno-venous ECMO cannulas in a pediatric population.

PURPOSE: Complications associated with use of dual-lumen venovenous extracorporeal membrane oxygenation (VV-ECMO) cannulas are of concern in pediatric patients. While the risk of atrial perforation is believed to be higher with bicaval cannulas, direct comparison of complication rate between atrial and bicaval cannulas has not been conducted in this population. METHODS: A retrospective review was conducted at a free-standing children's hospital of all patients 0-18 years old, placed on VV-ECMO with a dual-lumen cannula from January 2009 to December 2018. Patients were grouped based on cannula type. Complications were assessed over the entire duration of the ECMO run. Logistic regression analyses were used to evaluate for an association between cannula type and risk of pericardial effusion or cannula-related complication requiring median sternotomy or pericardial drain placement. RESULTS: During the study period 119 patients were placed on VVECMO using a dual-lumen cannula. Eighty-two patients (69%) were <2 years old, 19 (16%) were 2-10 years old, and 18 (15%) were 11-18 years old. Seventy-three were cannulated with an atrial cannula and 46 patients received a bicaval cannula. Pericardial effusions were seen in 30% and 24% of these patients respectively while severe complications were seen in 9.6% and 8.7% of patients respectively. Compared to patients treated with a bicaval cannula, those who received an atrial cannula had similar odds of effusions (OR: 1.41, 95% CI: 0.62-3.36) and severe complications (OR 0.89, 95% CI: 0.27-3.18). After adjusting for age, weight, cannula and circuit manipulations, and use of echocardiography, the OR of effusion was 1.91 (95% CI: 0.65-6.42), and the adjusted OR of severe complication was 0.69 (95% CI: 0.16-3.33). CONCLUSIONS: There were no significant differences in frequency of pericardial effusions or severe cannula-related complications between the treatment groups across all pediatric patients and within the subgroup of patients under 2 years of age.

Conflict-related intentional injuries in Baghdad, Iraq, 2003-2014: A modeling study and proposed method for calculating burden of injury in conflict.

BACKGROUND: Previous research has focused on the mortality associated with armed conflict as the primary measure of the population health effects of war. However, mortality only demonstrates part of the burden placed on a population by conflict. Injuries and resultant disabilities also have long-term effects on a population and are not accounted for in estimates that focus solely on mortality. Our aim was to demonstrate a new method to describe the effects of both lives lost, and years of disability generated by a given conflict, with data from the US-led 2003 invasion and subsequent occupation of Iraq. METHODS AND FINDINGS: Our data come from interviews conducted in 2014 in 900 Baghdad households containing 5,148 persons. The average household size was 5.72 persons. The majority of the population (55.8%) were between the ages of 19 and 60. Household composition was evenly divided between males and females. Household sample collection was based on methodology previously designed for surveying households in war zones. Survey questions were answered by the head of household or senior adult present. The questions included year the injury occurred, the mechanism of injury, the body parts injured, whether injury resulted in disability and, if so, the length of disability. We present this modeling study to offer an innovative methodology for measuring "years lived with disability" (YLDs) and "years of life lost" (YLLs) attributable to conflict-related intentional injuries, using the Global Burden of Disease (GBD) approach. YLDs were calculated with disability weights, and YLLs were calculated by comparing the age at death to the GBD standard life table to calculate remaining life expectancy. Calculations were also performed using Iraq-specific life expectancy for comparison. We calculated a burden of injury of 5.6 million disability-adjusted life years (DALYs) lost due to conflict-related injuries in Baghdad from 2003 to 2014. The majority of DALYs lost were attributable to YLLs, rather than YLDs, 4.99 million YLLs lost (95% uncertainty interval (UI) 3.87 million to 6.13 million) versus 616,000 YLDs lost (95% UI 399,000 to 894,000). Cause-based analysis demonstrated that more DALYs were lost to due to gunshot wounds (57%) than any other cause. Our study has several limitations. Recall bias regarding the reporting and attribution of injuries is possible. Second, we have no data past the time of the interview, so we assumed individuals with ongoing disability at the end of data collection would not recover, possibly counting more disability for injuries occurring later. Additionally, incomplete data could have led to misclassification of deaths, resulting in an underestimation of the total burden of injury. CONCLUSIONS: In this study, we propose a methodology to perform burden of disease calculations for conflict-related injuries (expressed in DALYs) in Baghdad from 2003 to 2014. We go beyond previous reports of simple mortality to assess long-term population health effects of conflict-related intentional injuries. Ongoing disability is, in cross section, a relatively small 10% of the total burden. Yet, this small proportion creates years of demands on the health system, persistent limitations in earning capacity, and continuing burdens of care provision on family members.

Military civilian partnerships: International proposals for bridging the Walker Dip.

The Walker Dip refers to the cycle of the improvement of care for the battle injured soldier over the course of a conflict, followed by the decline in the skills needed to provide this care during peacetime, and the requisite need to relearn those skills during the next conflict. As the operational tempo of the conflicts in Afghanistan and Iraq has declined, concerns have arisen regarding whether US military surgeons are prepared to meet the demands of future conflicts. This problem is not unique to the US military, and allied nations have taken creative steps to address the Walker Dip in their own surgical communities. A panel entitled "Military and Civilian Trauma System Integration: Where Have We Come; Where Are We Going and What Can We Learn from Our International Partners" at the 2018 American Association for the Surgery of Trauma meeting brought together a cadre of civilian and military surgeons with experience in this area. The efforts described involved the creation of a new trauma training program in Doha, Qatar, the military civilian partnership in the Netherlands, and the steps taken to address the deficit of penetrating trauma in Sweden. This article focuses on the lessons that can be learned from our allied partners to assure readiness for deployment among military surgeons. LEVEL OF EVIDENCE: Economic and Value Based Evaluations, level V.

Improving Management of Limb Injuries in Disasters and Conflicts.

It has become clear that disaster relief needs to transition from good intentions or a charity-based approach to a professional, outcome-oriented response. The practice of medicine in disaster and conflict is a profession practiced in environments where lack of resources, chaos, and unpredictability are the norm rather than the exception. With this consideration in mind, the World Health Organization (WHO; Geneva, Switzerland) and its partners set out to improve the disaster response systems. The resulting Emergency Medical Team (EMT) classification system requires that teams planning on engaging in disaster response follow common standards for the delivery of care in resource-constraint environments. In order to clarify these standards, the WHO EMT Secretariat collaborated with the International Committee of the Red Cross (ICRC; Geneva, Switzerland) and leading experts from other stakeholder non-governmental organizations (NGOs) to produce a guide to the management of limb injuries in disaster and conflict.The resulting text is a free and open-access resource to provide guidance for national and international EMTs caring for patients in disasters and conflicts. The content is a result of expert consensus, literature review, and an iterative process designed to encourage debate and resolution of existing open questions within the field of disaster and conflict medical response.The end result of this process is a text providing guidance to providers seeking to deliver safe, effective care within the EMT framework that is now part of the EMT training and verification system and is being distributed to ICRC teams deploying to the field.This work seeks to encourage professionalization of the field of disaster and conflict response, and to contribute to the existing EMT framework, in order to provide for better care for future victims of disaster and conflict.Jensen G, Bar-On E, Wiedler JT, Hautz SC, Veen H, Kay AR, Norton I, Gosselin RA, von Schreeb J. Improving management of limb injuries in disasters and conflicts. Prehosp Disaster Med. 2019;34(3):330-334.

High density placental mesenchymal stromal cells provide neuronal preservation and improve motor function following in utero treatment of ovine myelomeningocele.

PURPOSE: The purpose of this study was to determine whether seeding density of placental mesenchymal stromal cells (PMSCs) on extracellular matrix (ECM) during in utero repair of myelomeningocele (MMC) affects motor function and neuronal preservation in the ovine model. METHODS: MMC defects were surgically created in 33 fetuses and repaired following randomization into four treatment groups: ECM only (n = 10), PMSC-ECM (42 K cells/cm2) (n = 8), PMSC-ECM (167 K cells/cm2) (n = 7), or PMSC-ECM (250-300 K cells/cm2) (n = 8). Motor function was evaluated using the Sheep Locomotor Rating Scale (SLR). Serial sections of the lumbar spinal cord were analyzed by measuring their cross-sectional areas which were then normalized to normal lambs. Large neurons (LN, diameter 30-70 µm) were counted manually and density calculated per mm2 gray matter. RESULTS: Lambs treated with PMSCs at any density had a higher median SLR score (15 [IQR 13.5-15]) than ECM alone (6.5 [IQR 4-12.75], p = 0.036). Cross-sectional areas of spinal cord and gray matter were highest in the PMSC-ECM (167 K/cm2) group (p = 0.002 and 0.006, respectively). LN density was highest in the greatest density PMSC-ECM (250-300 K/cm2) group (p = 0.045) which positively correlated with SLR score (r = 0.807, p < 0.0001). CONCLUSIONS: Fetal repair of myelomeningocele with high density PMSC-ECM resulted in increased large neuron density, which strongly correlated with improved motor function. TYPE OF STUDY: Basic science. LEVEL OF EVIDENCE: N/A.

A cross-sectional investigation of the health needs of asylum seekers in a refugee clinic in Germany.

BACKGROUND: Over one million asylum seekers were registered in Germany in 2016, most from Syria and Afghanistan. The Refugee Convention guarantees access to healthcare, however delivery mechanisms remain heterogeneous. There is an urgent need for more data describing the health conditions of asylum seekers to guide best practices for healthcare delivery. In this study, we describe the state of health of asylum seekers presenting to a multi-specialty primary care refugee clinic. METHODS: Demographic and medical diagnosis data were extracted from the electronic medical records of patients seen at the ambulatory refugee clinic in Dresden, Germany between 15 September 2015 and 31 December 2016. Data were de-identified and analyzed using Stata version 14.0. RESULTS: Two-thousand-seven-hundred and fifty-three individual patients were seen in the clinic. Of these, 2232 (81.1%) were insured by the state indicating arrival within the last 3 months. The median age was 25, interquartile range 16-34. Only 786 (28.6%) were female, while 1967 (71.5%) were male. The most frequent diagnoses were respiratory (17.4%), followed by miscellaneous symptoms and otherwise not classified ailments (R series, 14.1%), infection (10.8%), musculoskeletal or connective tissue (9.3%), gastrointestinal (6.8%), injury (5.9%), and mental or behavioral (5.1%) categories. CONCLUSIONS: This study illustrates the diverse medical conditions that affect the asylum seeker population. Asylum seekers in our study group did not have a high burden of communicable diseases, however several warranted additional screening and treatment, including for tuberculosis and scabies. Respiratory illnesses were more common amongst newly arrived refugees. Trauma-related mental health disorders comprised half of mental health diagnoses.

Fetal Surgery for Myelomeningocele: A Systematic Review and Meta-Analysis of Outcomes in Fetoscopic versus Open Repair.

BACKGROUND/OBJECTIVES: The Management of Myelomeningocele (MMC) Study (MOMS) showed that prenatal repair of MMC resulted in improved neurological outcomes but was associated with high rates of obstetrical complications. This study compares outcomes of open and fetoscopic MMC repair. DATA SOURCES: PubMed and Embase studies reporting outcomes of fetal MMC repair published since the completion of the MOMS. RESULTS: We analyzed 11 studies and found no difference in mortality or the rate of shunt placement for hydrocephalus. Percutaneous fetoscopic repair was associated with higher rates of premature rupture of membranes (91 vs. 36%, p < 0.01) and preterm birth (96 vs. 81%, p = 0.04) compared to open repair, whereas fetoscopic repair via maternal laparotomy reduced preterm birth. The rate of dehiscence and leakage from the MMC repair site was higher after both types of fetoscopic surgery (30 vs. 7%, p < 0.01), while the rate of uterine dehiscence was higher after open repair (11 vs. 0%, p < 0.01). DISCUSSION: Fetoscopic repair is a promising alternative to open fetal MMC repair with a lower risk of uterine dehiscence; however, fetoscopic techniques should be optimized to overcome the high rate of dehiscence and leakage at the MMC repair site. A fetoscopic approach via maternal laparotomy reduces the risk of preterm birth.

Restrictions on surgical resident shift length does not impact type of medical errors.

BACKGROUND: In 2011, resident duty hours were restricted in an attempt to improve patient safety and resident education. With the goal of reducing fatigue, shorter shift length leads to more patient handoffs, raising concerns about adverse effects on patient safety. This study seeks to determine whether differences in duty-hour restrictions influence types of errors made by residents. MATERIALS AND METHODS: This is a nested retrospective cohort study at a surgery department in an academic medical center. During 2013-14, standard 2011 duty hours were in place for residents. In 2014-15, duty-hour restrictions at the study site were relaxed ("flexible") with no restrictions on shift length. We reviewed all morbidity and mortality submissions from July 1, 2013-June 30, 2015 and compared differences in types of errors between these periods. RESULTS: A total of 383 patients experienced adverse events, including 59 deaths (15.4%). Comparing standard versus flexible periods, there was no difference in mortality (15.7% versus 12.6%, P = 0.479) or complication rates (2.6% versus 2.5%, P = 0.696). There was no difference in types of errors between periods (P = 0.050-0.808). The most number of errors were due to cognitive failures (229, 59.6%), whereas the fewest number of errors were due to team failure (127, 33.2%). By subset, technical errors resulted in the highest number of errors (169, 44.1%). There were no differences between types of errors of cases that were nonelective, at night, or involving residents. CONCLUSIONS: Among adverse events reported in this departmental surgical morbidity and mortality, there were no differences in types of errors when resident duty hours were less restrictive.

Honey oil burns: a growing problem.

There is an emerging mechanism of burn injury as a result of the ignition of butane, during the manufacture of a tetrahydrocannabinol concentrate known as butane honey oil. The authors report of a series of patients who presented with this mechanism of injury and a description of the process that causes these burns. Patient data were gathered from the medical records of eight patients treated at the University of California Davis Medical Center and Shriners Hospital of Northern California. Information on the manufacturing process of butane honey oil was gathered from Internet searches and published literature on the topic. The burns witnessed at the abovementioned institutions ranged from 16 to 95% TBSA, with an average of 49.9%. The average length of stay for the patients was 118.3 hospital days and 114.4 intensive care unit days, with an average of 43.8 days spent on mechanical ventilation. The average age of patients was 22 years, with only one patient above the age of 30 years. Accidents during honey oil production have resulted in a surge of burn injuries in our community during the past year. The manufacture of this product, which involves the use of volatile butane gas, is gaining in popularity. Although considered to be safer than previous methods, multiple casualties with extensive burn injuries have resulted from this process. Associated injuries from blast trauma or chemical burns are not likely to occur in these types of explosions and have not been observed in the series reported in this article. In light of the increasing popularity of honey oil, it is important for burn care providers to gain awareness and understanding of this problem and its growing presence in the community.

Repair of a duplicate mitral valve in a patient with ascending aortic aneurysm and bicuspid aortic valve.

We present the case of a 48-year-old man presenting to the emergency department with acute onset of chest pain radiating to the back in the setting of a known ascending aortic aneurysm. Preoperative echocardiography revealed an incompetent duplicate mitral valve, with a medially directed eccentric 3+ jet of mitral regurgitation, and a bicuspid aortic valve. The patient was scheduled for aortic root and valve replacement with concurrent mitral valve repair. Intraoperative examination revealed an incompetent duplicate mitral valve separated from the physiologic mitral valve by a band of interatrial tissue. Successful repair was undertaken by oversewing the mitral valve. Postoperative echocardiography allowed for evaluation of this unique repair, which revealed no evidence of further mitral regurgitation and confirmed a successful repair of the mitral regurgitation without any need for an implantable device. Our goal is that this case and its positive treatment outcome, along with our three-dimensional echocardiographic images correlated with the intraoperative findings and photographs, will further the understanding of the diagnosis and treatment of this rare condition.