Abdominal Aortic Junctional Tourniquet - Stabilized (AAJTS) can be applied both successfully and rapidly by Combat Medical Technicians (CMTs).

BACKGROUND: 'Non-compressible' haemorrhage is the leading cause of preventable battlefield death, often requiring surgical or radiological intervention, which is precluded in the pre-hospital environment. One-fifth of such bleeds are junctional and therefore potentially survivable. We examine the use of the Abdominal Aortic Junctional Tourniquet - Stabilized (AAJTS) among UK Combat Medical Technicians (CMTs) as a device to control junctional haemorrhage with external compression of the abdominal aorta-compression of junctional haemorrhage previously considered 'non-compressible.' This follows animal studies showing that the AAJTS achieves control of haemorrhage and improves physiological parameters. METHODS: CMTs were selected and applied the AAJTS to each other following a 1-hour training package. A consultant radiologist-operated hand-held ultrasound monitored flow changes in the subjects' common femoral artery. CMTs were then surveyed for their opinions as to utility and function. RESULTS: 21 CMTs were screened and 17 CMTs participated with 34 total applications (16 day and 18 low-light). 27/34 (79%) achieved a successful application. The median application time was 75 s in daylight and 57 s in low-light conditions. There was no significant difference in Body Mass Index (p=0.23), median systolic blood pressure (p=0.19), nor class of CMT (p=0.10) between successful and unsuccessful applications. Higher systolic blood pressure was associated with longer application times (p=0.03). Users deemed the device easy to use (median score 4.4 on a 5-point Likert scale). CONCLUSION: CMTs can use AAJTS successfully after a 1-hour training session in the majority of applications. Application was successful in both daylight and low-light conditions. Self-reported usability ratings were high.

Defence Medical Rehabilitation Centre (DMRC) COVID-19 Recovery Service.

Coronavirus disease 2019 (COVID-19) causes significant mortality and morbidity, with an unknown impact in the medium to long term. Evidence from previous coronavirus epidemics indicates that there is likely to be a substantial burden of disease, potentially even in those with a mild acute illness. The clinical and occupational effects of COVID-19 are likely to impact on the operational effectiveness of the Armed Forces. Collaboration between Defence Primary Healthcare, Defence Secondary Healthcare, Defence Rehabilitation and Defence Occupational Medicine resulted in the Defence Medical Rehabilitation Centre COVID-19 Recovery Service (DCRS). This integrated clinical and occupational pathway uses cardiopulmonary assessment as a cornerstone to identify, diagnose and manage post-COVID-19 pathology.

Cardiopulmonary exercise testing excludes significant disease in patients recovering from COVID-19.

OBJECTIVE: Post-COVID-19 syndrome presents a health and economic challenge affecting ~10% of patients recovering from COVID-19. Accurate assessment of patients with post-COVID-19 syndrome is complicated by health anxiety and coincident symptomatic autonomic dysfunction. We sought to determine whether either symptoms or objective cardiopulmonary exercise testing could predict clinically significant findings. METHODS: 113 consecutive military patients were assessed in a comprehensive clinical pathway. This included symptom reporting, history, examination, spirometry, echocardiography and cardiopulmonary exercise testing (CPET) in all, with chest CT, dual-energy CT pulmonary angiography and cardiac MRI where indicated. Symptoms, CPET findings and presence/absence of significant pathology were reviewed. Data were analysed to identify diagnostic strategies that may be used to exclude significant disease. RESULTS: 7/113 (6%) patients had clinically significant disease adjudicated by cardiothoracic multidisciplinary team (MDT). These patients had reduced fitness (V̇O2 26.7 (±5.1) vs 34.6 (±7.0) mL/kg/min; p=0.002) and functional capacity (peak power 200 (±36) vs 247 (±55) W; p=0.026) compared with those without significant disease. Simple CPET criteria (oxygen uptake (V̇O2) >100% predicted and minute ventilation (VE)/carbon dioxide elimination (V̇CO2) slope <30.0 or VE/V̇CO2 slope <35.0 in isolation) excluded significant disease with sensitivity and specificity of 86% and 83%, respectively (area under the receiver operating characteristic curve (AUC) 0.89). The addition of capillary blood gases to estimate alveolar-arterial gradient improved diagnostic performance to 100% sensitivity and 78% specificity (AUC 0.92). Symptoms and spirometry did not discriminate significant disease. CONCLUSIONS: In a population recovering from SARS-CoV-2, there is reassuringly little organ pathology. CPET and functional capacity testing, but not reported symptoms, permit the exclusion of clinically significant disease.

Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study.

BACKGROUND: Tension pneumothorax following trauma is a life-threatening emergency and radiological investigation is normally discouraged prior to treatment in traditional trauma doctrines such as ATLS. Some trauma patients may be physiologically stable enough for diagnostic imaging and occult tension pneumothorax is discovered radiologically. We assessed the outcomes of these patients and compared them with those with clinical diagnosis of tension pneumothorax prior to imaging. METHODS: A multicentre civilian-military collaborative network of six major trauma centres in the UK collected observational data from adult patients who had a diagnosis of traumatic tension pneumothorax during a 33-month period. Patients were divided into 'radiological' (diagnosis following CT/CXR) or 'clinical' (no prior CT/CXR) groups. The effect of radiological diagnosis on survival was analysed using multivariable logistic regression that included the covariates of age, gender, comorbidities and Injury Severity Score. RESULTS: There were 133 patients, with a median age of 41 (IQR 24-61); 108 (81%) were male. Survivors included 49 of 59 (83%) in the radiological group and 59 of 74 (80%) in the clinical group (p=0.487). Multivariable logistic regression showed no significant association between radiological diagnosis and survival (OR 2.40, 95% CI 0.80 to 7.95; p=0.130). There was no significant difference in mortality between the groups. CONCLUSION: Radiological imaging may be appropriate for selected trauma patients at risk of tension pneumothorax if they are considered haemodynamically stable. Trauma patients may be physiologically stable enough for radiological imaging but have occult tension pneumothorax because they did not have the typical clinical presentation. The historical dogma of the 'forbidden scan' no longer applies to such patients.

Combat Application Tourniquet fares well in a chemical, biological, radiological or nuclear dress state.

INTRODUCTION: There is a need for a military tourniquet to control catastrophic haemorrhage in a chemical, biological, radiological or nuclear (CBRN) threat environment. No published data exist as to the efficacy of tourniquets while wearing British military CBRN individual protective equipment (IPE). METHODS: 12 volunteers from the counter CBRN instructors' course allowed testing on 24 legs. A Combat Application Tourniquet (C-A-T) was applied to all volunteers at the level of the midthigh. 12 legs were tested while wearing CBRN IPE (both operator and simulated casualty), and the control group of 12 legs was tested while wearing conventional combat dress state (both operator and simulated casualty). The order of leg laterality and dress state were sequenced according to a prerandomised system. Efficacy was measured via use of an ultrasound probe at the popliteal artery. Tourniquets were considered effective if arterial flow was completely occluded on ultrasound imaging. Data were collected on time to successful application, failure of tourniquets and pain scores as rated by the visual analogue scale (1-10). RESULTS: There were no failures of tourniquet application in the CBRN group, and two failures (17%) in the control group. Failures were pain threshold exceeded (n=1) and tourniquet internal strap failure (n=1). The mean application time for the CBRN group was 28.5 s (SD 11.7) and 23.7 s (SD 9.8) for the conventional combat group. There was no statistically significant difference (p=0.27). The median CBRN pain score was 2.0 (IQR 2.0-3.5). The median control pain score was 4.0 (IQR 3-6). This was a statistically significant difference (p=0.002). CONCLUSION: C-A-Ts applied to simulated casualties in CBRN IPE at the midthigh are at least as efficacious as those applied to the midthigh in a conventional combat dress state. The pain experienced was less in CBRN IPE than when in a conventional combat dress state.

Civil-military cooperation on operational deployment: the Bentiu State Hospital medical training programme.

The United Nations Mission in South Sudan has a mandate to protect civilians and support the delivery of humanitarian assistance. Recognising this during Operation TRENTON, UK staff of the UN level 2 hospital were able to support the people of Bentiu through initiatives to develop local health services with on-the-ground civil-military cooperation. The Bentiu State Hospital Medical Training Programme was developed to train and mentor staff associated with healthcare in Bentiu, to help improve service delivery, support local health services with on-the-ground non-governmental organisation/military coordination and to create a platform to facilitate the sharing of information to support local health services with the overall humanitarian response. It was recognised how important it was to deliver a programme that carefully understood the unique challenging limitations, circumstances and environment. Hence careful tailoring of the programme was essential to ensure that the training was valuable, implementable and durable, long beyond the operational deployment of TRENTON. Despite the logistical and practical complexities, the programme was very positively received, and the training team believed that the development and progress made would build a small part of the future infrastructure of healthcare delivery in the region. Future contingency operations are likely to take place in the resource- limited austere environment. As reflected in this deployed initiative, local health training activity providing key knowledge to build resilience for the current and immediate future is a precious and important defence engagement utility.

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.

Highlights of the annual scientific meeting of the 22nd congress of the European Society of Musculoskeletal Radiology (ESSR) 2015.

The meeting included a larger-than-usual number of scientific presentations covering a wide range of MSK topics, with new information related to imaging findings, imaging techniques, and interventional procedures. A large number of electronic posters were also available for review by the meeting participants, significantly adding to the educational content of the meeting. These are still available for review on the EPOS database via the ESSR website. The 23rd annual congress of the ESSR will be held in Zurich on June 9-11, 2016 where the main topic will be the knee and ankle.

Evaluation of biopsy methods in the diagnosis of submandibular space pathology.

The aim of this study was to evaluate the performance of fine needle aspiration cytology (FNAC), ultrasound-guided core needle biopsy (USCNB), punch biopsy, and surgical excision biopsy in neoplasms presenting within the submandibular space. A retrospective analysis of all patients with a pathological diagnosis of a submandibular space neoplasm within a 12-year period (February 1999 to June 2011) was performed. Biopsy results were compared to histopathological diagnosis obtained from surgical excision biopsy. Eighty-one specimens from 44 patients met the search criteria (15 FNAC, 24 USCNB, 7 punch biopsy, and 35 surgical excision biopsy). The final diagnosis was established by USCNB, punch biopsy, or surgical excision biopsy and not by FNAC alone. Surgical excision biopsy was performed as a primary diagnostic (n = 8), secondary diagnostic (n = 15), or as a post-diagnostic therapeutic procedure (n = 12). Non-diagnostic results were: FNAC 11/15, USCNB 2/24, and punch biopsy 1/7. Diagnostic results were: FNAC 2/15, USCNB 20/24, and punch biopsy 5/7. No complications were reported. Although punch biopsy demonstrated good yield and accuracy, its use is restricted to a small cohort of patients. USCNB is a safe and accurate technique in the submandibular space, with a low non-diagnostic rate.