Understanding progressive tissue loss and wound burden in combat casualties: lessons learnt for future operational capability.

Understanding tissue loss following injury is important due to its prevalence among the war-wounded and the impact it has on subsequent treatment and rehabilitation. Progressive tissue loss is a type of tissue loss that has complicated extremity injury in recent conflicts. It has resulted in more proximal residual limb lengths and has influenced rehabilitation. Quantifying wound burden in combat casualties remains a challenge due to poor quality of data sets that lack the capacity for detailed analysis. The aims of this article are to outline the current hurdles in attempting to quantify wound burden in combat casualties and to propose simple interventions to improve data capture for future analysis.

Unplanned readmissions after hernia repair.

INTRODUCTION: Several quality indices have been set up for evaluating the impact of the reduction of the length of stay (LOS), such as the 30-day unplanned readmission (UR30) rate. The main goal of our study was to analyze the UR30 following groin hernia repair (GHR), primary- (PVHR), and incisional ventral hernia repairs (IVHR). METHODS: A French registry-based multicenter study was conducted using prospective data from all consecutive patients registered from 2015 to 2021. RESULTS: The overall incidence of UR30 was 1.32%. This included 160/18,042 (0.87%) for GHR, 41/4012 (1.02%) for PVHR, and 145/3754 (3.86%) for IVHR. The leading cause of UR30 was postoperative complications (POC). The nature of the predominant complications varied among the three categories. The correlation between UR30 and POC (and risk factors for POC) was strong in GHR but was not in IVHR due to a 'protective' longer LOS in this subgroup. As the LOS has decreased over the last years, this has 'mechanically' resulted in an increase in the occurrence of UR30, but not in a rise of POC, neither in volume nor in severity. The reduction of LOS just shifted the problem from inpatient to outpatient settings. CONCLUSION: Since the steady development of day-care surgery, the prevention of the UR not only hinges on the prevention of the POC but newly on a better organization of outpatient care which is currently a huge challenge due to a GPs' and nurses' shortage in France.

4A after access: a new mnemonic to aid timely administration of IV/IO treatment in trauma patients.

Administration of medication is a well-established part of prehospital trauma care. Guidance varies on the types of recommended medications and when they should be administered. Mnemonics have become commonplace in prehospital medicine to facilitate recall and retention. However, there is no comprehensive aid for the administration of medication in trauma patients. We propose a new mnemonic for the delivery of relevant intravenous or intraosseous medications in trauma patients. A '4A after Access' approach should enhance memory recall for the efficient provision of patient care. These 4As are: antifibrinolysis, analgesia, antiemesis and antibiotics. This mnemonic is designed to be used as an optional aide memoire in conjunction with existing treatment algorithms in the military prehospital setting.

CuNi Nanoalloys with Tunable Composition and Oxygen Defects for the Enhancement of the Oxygen Evolution Reaction.

Colloidal synthesis is an excellent tool for the study of cooperative effects in nanoalloys. In this work, bimetallic CuNi nanoparticles of defined size and composition are fully characterized and tested for the oxygen evolution reaction. Copper addition to nickel leads to modifications in the structural and electronic properties, showing a higher concentration of surface oxygen defects and formation of active Ni3+ sites under reaction conditions. The ratio OV /OL between oxygen vacancies and lattice oxygen shows a clear correlation with the overpotential, being an excellent descriptor of the electrocatalytic activity. This is attributed to modifications in the crystalline structure, leading to lattice strain and grain size effects. Bimetallic Cu50 Ni50 NP showed the lowest overpotential (318 mV vs RHE), low Tafel slope (63.9 mV dec-1 ), and excellent stability. This work unravels the relative concentration between oxygen defects and lattice oxygen (OV /OL ) as an excellent descriptor of the catalytic activity of bimetallic precatalysts.

Acquisition and retention of military surgical competencies: a survey of surgeons' experiences in the UK Defence Medical Services.

INTRODUCTION: The acquisition and retention of militarily relevant surgical knowledge and skills are vital to enable expert management of combat casualties on operations. Opportunities for skill sustainment have reduced due to the cessation of combat operations in Iraq and Afghanistan and lack of military-relevant trauma in UK civilian practice. METHODS: A voluntary, anonymous online survey study was sent to all UK Defence Medical Services (DMS) surgical consultants and higher surgical trainees in Trauma and Orthopaedics, Plastic and Reconstructive, and General and Vascular surgical specialties (three largest surgical specialties in the DMS in terms of numbers). The online questionnaire tool included 20 questions using multiple choice and free text to assess respondents' subjective feelings of preparedness for deployment as surgeons for trauma patients. RESULTS: There were 71 of 108 (66%) responses. Sixty-four (90%) respondents were regular armed forces, and 46 (65%) worked in a Major Trauma Centre (MTC). Thirty-three (47%) had never deployed on operations in a surgical role. Nineteen (27%) felt they had sufficient exposure to penetrating trauma. When asked 'How well do you feel your training and clinical practice prepares you for a surgical deployment?' on a scale of 1-10, trainees scored significantly lower than consultants (6 (IQR 4-7) vs 8 (IQR 7-9), respectively; p<0.001). There was no significant difference in scores between regular and reservists, or between those working at an MTC versus non-MTC. Respondents suggested high-volume trauma training and overseas trauma centre fellowships, simulation, cadaveric and live-tissue training would help their preparedness. CONCLUSIONS: There was a feeling among a sample of UK DMS consultants and trainees that better preparedness is required for them to deploy confidently as a surgeon for combat casualties. The responses suggest that UK DMS surgical training requires urgent attention if current surgeons are to be ready for their role on deployed operations.

Synthesis of High Surface Area-Group 13-Metal Oxides via Atomic Layer Deposition on Mesoporous Silica.

The atomic layer deposition of gallium and indium oxide was investigated on mesoporous silica powder and compared to the related aluminum oxide process. The respective oxide (GaOx, InOx) was deposited using sequential dosing of trimethylgallium or trimethylindium and water at 150 °C. In-situ thermogravimetry provided direct insight into the growth rates and deposition behavior. The highly amorphous and well-dispersed nature of the oxides was shown by XRD and STEM EDX-mappings. N2 sorption analysis revealed that both ALD processes resulted in high specific surface areas while maintaining the pore structure. The stoichiometry of GaOx and InOx was suggested by thermogravimetry and confirmed by XPS. FTIR and solid-state NMR were conducted to investigate the ligand deposition behavior and thermogravimetric data helped estimate the layer thicknesses. Finally, this study provides a deeper understanding of ALD on powder substrates and enables the precise synthesis of high surface area metal oxides for catalytic applications.

Comparing the surgical management of acute paediatric scrotal pain between adult urologists and general surgeons in the UK: an observational study.

INTRODUCTION: Acute scrotal pain is a common paediatric surgical emergency. Assessment and timely exploration are required to rule out testicular torsion (TT) and prevent unnecessary morbidity. METHODS: A retrospective observational cohort study was carried out at two district general hospitals in the UK for boys aged ≤16 years presenting with acute scrotal pain between January 2014 and October 2017 managed by adult general surgery (AGS) at one hospital and adult urology (AU) at the other. RESULTS: Some 565 patients were eligible for inclusion (n=364 AGS, n=201 AU). A higher proportion of patients underwent surgical exploration at AGS compared with AU (277/346 (80.1%) vs 96/201 (47.8%); p<0.001). Of those who underwent exploration, 101/373 (27.1%) had TT, of whom 25/101 (24.8%) underwent orchidectomy and 125/373 (33.5%) had torted testicular appendage. There was no statistically significant difference in rates of orchidectomy between AGS (19/68, 27.9%) and AU (6/33, 18.2%) with testicular salvage rates of 72.1% and 81.8%, respectively (p=0.334). Patients were twice as likely to be readmitted at AGS as at AU (28/346 (8.1%) vs 8/201 (4.0%); p=0.073). CONCLUSION: Although intraoperative findings were similar between adult general surgeons and urologists, there were significant differences in surgical management, with a higher rate of surgical exploration by general surgeons. Testicular salvage and 30-day postoperative morbidity rates at both institutions were acceptable but the readmission rate was high at 6.6%. It is not known why there is a heterogeneity in management of acute scrotal pain between specialist centres, and further prospective investigations are warranted.

Surgical training during the COVID-19 pandemic at a designated 'cold' site: are we meeting the challenge?

INTRODUCTION: There has been a marked reduction in surgical operative training opportunities during the COVID-19 pandemic. This may be improved by the establishment of 'cold' sites for NHS elective surgery. We investigated the training opportunities at a newly designated elective surgery cold site in the West Midlands, UK. METHODS: An observational retrospective study was undertaken to include all gastrointestinal and urological elective surgery at a single 'cold' site during the first peak of the COVID-19 pandemic. Patient demographics, details of surgery and data relating to surgical training such as primary surgeon and portfolio index procedure were collected. Factors affecting the likelihood of trainees being the primary surgeon were analysed using logistic regression models. RESULTS: There were 880 patients, with a median (interquartile range) age of 62 (48-74). Some 658 (74.8%) procedures were defined as 'index procedures' for specialty training year 4 (ST4) level: 409/509 (80.4%) for urology, 155/235 (66%) for colorectal and 94/136 (69.1%) for upper gastrointestinal (GI). Only 253/880 (28.8%) procedures were performed by a trainee as the primary surgeon: 201/509 (39.4%) for urology, 21/235 (8.9%) for colorectal and 31/136 (22.8%) for upper GI. The likelihood of a trainee being the primary surgeon was reduced for major surgery (p<0.001) and for GI surgery when compared with urology (p<0.001). CONCLUSIONS: Surgical training was facilitated at an elective surgery 'cold' site during the COVID-19 pandemic, but at lower levels than anticipated. Type of surgery influenced trainee participation. Surgical training should be incorporated into 'cold' site elective surgical services if trainees are to be prepared for the future.

Emergency first responder management of combat injuries to the torso in the military, remote and austere settings.

Traumatic injuries to the torso account for almost a quarter of all injuries seen in combat and are typically secondary to blast or gunshot wounds. Injuries due to road traffic collisions or violence are also relatively common during humanitarian and disaster relief efforts. There may also be multiple injured patients in these settings, and surgical care may be limited by a lack of facilities and resources in such a non-permissive environment. The first responder in these scenarios should be prepared to manage patients with severe injuries to the torso. We aim to describe the management of these injuries in the military and austere environment, within the scope of practice of a level 5 registered prehospital practitioner.

Torso body armour coverage defined according to feasibility of haemorrhage control within the prehospital environment: a new paradigm for combat trauma protection.

Developments in military personal armour have aimed to achieve a balance between anatomical coverage, protection and mobility. When death is likely to occur within 60 min of injury to anatomical structures without damage control surgery, then these anatomical structures are defined as 'essential'. However, the medical terminology used to describe coverage is challenging to convey in a Systems Requirements Document (SRD) for acquisition of new armour and to ultimately translate to the correct sizing and fitting of personal armour. Many of those with Ministry of Defence responsible for the procurement of personal armour and thereby using SRDs will likely have limited medical knowledge; therefore, the potentially complex medical terminology used to describe the anatomical boundaries must be translated into easily recognisable and measurable external landmarks. We now propose a complementary classification for ballistic protection coverage, termed threshold and objective, based on the feasibility of haemorrhage control within the prehospital environment.

Risk factors for surgical site infection after groin hernia repair: does the mesh or technique matter?

INTRODUCTION: Surgical site infections (SSIs) following groin hernia repair (GHR) are getting rarer in high income countries despite a wider use of meshes. Among the risk factors for SSIs, those related to the mesh and the surgical technique have rarely been described. METHODS: A registry-based multicenter study using prospectively collected data, including SSIs and their potential risk factors, was conducted in the French Hernia-Club. RESULTS: Between 2012 and 2019, 21,976 consecutive unselected adult patients aged 64.8 ± 15.4 years old (88.9% male) underwent GHR (83.5% unilateral). Fifty four percent were laparoscopic; 97.6% used mesh. The overall incidence of SSI was 0.26%. The incidence of SSI was respectively, 0.24% and 0.19% (p = 0.420) in open vs laparoscopic repairs; 0.19% and 0.25% (p = 0.638) for polyester vs polypropylene mesh; In adjusted multivariate analysis focusing on macroporous meshes (which were the most implanted meshes: 23,148 out of 24,099), there were no differences in terms of SSIs' rates regarding the technique: open versus laparoscopy (p = 0.762) nor the type of mesh used: polypropylene versus polyester (p = 0.557). CONCLUSION: The rate of SSI following GHR was low in this large registry study. Mesh type and surgical technique did not affect SSIs rates. Caution is advised when interpreting these data due to this very low rate of SSI and the potential for a type II error.

Toolbox for atomic layer deposition process development on high surface area powders.

Atomic layer deposition (ALD) is an industrially applied technique for thin film deposition. The vast majority of processes target flat substrates rather than powders. For ALD on powders, new processes are needed, as different reaction conditions are required. Here, two setups are described in detail, which enhance the ALD process development for powders. The first setup described is capable of directly measuring the vapor pressure of a given precursor by a capacitance diaphragm gauge. Promising precursors can be pre-selected, and suitable precursor saturation temperatures can be determined. The second setup consists of four parallel reactors with individual temperature zones to screen the optimal ALD temperature window in a time efficient way. Identifying the precursor saturation temperature beforehand and subsequently performing the first ALD half cycle in the parallel setup at four different reactor temperatures simultaneously will drastically reduce process development times. Validation of both setups is shown for the well-known ALD precursors, trimethylaluminum to deposit aluminum oxide and diethyl zinc to deposit zinc oxide, both on amorphous silica powder.

Damage control resuscitation and surgery for indigenous combat casualties: a prospective observational study.

INTRODUCTION: Specialist units that assist indigenous forces (IF) in their strategic aims are supported by medical teams providing point of injury emergency care for casualties, including IF and civilians (Civ). We investigated the activities of a Coalition Forces far-forward medical facility, in order to inform medical providers about the facilities and resources required for medical support to IF and Civ during such operations. METHODS: A prospective observational study (June to August 2017) undertaken at a far-forward Coalition Forces medical support unit (12 rotating personnel) recorded patient details (IF or Civ), mechanism of injury (MOI), number of blood products used, damage control resuscitation (DCR) and damage control surgery (DCS), number of mass casualty (MASCAL) scenarios, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA) and whole blood emergency donor panels (EDP). RESULTS: 680 casualties included 478 IF and 202 Civ (45.5% of the Civ were paediatric). Most common MOIs were blast (n=425; 62.5%) and gunshot wound (n=200; 29.4%). Fifteen (2.2%) casualties died; 627 (92.2%) were transferred to local hospitals. DCR was used for 203 (29.9%), and DCS for 182 (26.8%) casualties. There were 23 MASCAL scenarios, 1220 transfusions and 32 EDPs. REBOA was performed eight times, and thoracotomy was performed 27 times. CONCLUSIONS: A small medical team provided high-tempo emergency resuscitative care for hundreds of IF and Civ casualties within a short space of time using state-of-the-art resuscitative modalities. DCR and DCS were undertaken with a large number of EDPs, and a high survival-to-transfer rate.

How do deployed general surgeons acquire relevant skill sets and competencies and mitigate skill fade?

There are recognised difficulties internationally with acquisition and retention of skills among deployed military general surgeons. These are compounded by reduced trauma workload in non-deployed roles or during low tempo or limited activity deployments, and the winding-down of combat operations in Iraq and Afghanistan. We summarise the relevant military-run courses, military-civilian collaborations and potential future strategies that have been used to address skill sets and competencies of deployed surgeons. We use examples from the American, British, Danish, French, German and Swedish Armed Forces. There is variation between nations in training, with a combination of didactic lectures, simulation training and trauma placements in civilian settings at home and overseas. Data regarding effectiveness of these techniques are sparse. It is likely that combat surgical skill-set acquisition and maintenance requires a combination of employment at a high-volume trauma centre during a surgeon's non-deployed role, together with military-specific courses and high-fidelity simulation to fill skill gaps. There are multiple newer modalities of training that require further evaluation if they are to prove effective in the future. We aimed to summarise the current methods used internationally to ensure acquisition and retention of vital skill sets for these surgeons.

Remote training for combat medics during the COVID-19 era: lessons learnt for future crises?

BACKGROUND: In response to COVID-19, the UK government ordered strict social distancing measures. The UK Armed Forces followed these to protect the force and ensure readiness to respond to various tasking requests. Clinical training has adapted to ensure geographically dispersed medical personnel are trained while social distancing is maintained. This study aimed to evaluate remote training for Combat Medical Technicians, Medical Assistants and Royal Air Force Medics (CMTs/MAs/RAFMs) during the COVID-19 pandemic and the views of trainers on how this should be delivered now and in the future. METHODS: A mixed quantitative and qualitative survey study was conducted to determine the experiences of a sample of Defence Medical Services personnel with remote training during the COVID-19 pandemic. Medical and nursing officers involved in teaching CMTs/MAs/RAFMs were eligible to participate. RESULTS: There were 52 survey respondents. 78% delivered remote training to CMTs/MAs/RAFMs, predominantly using teleconferencing and small-group webinars. 70% of respondents report CMTs/MAs/RAFMs received more training during the COVID-19 pandemic than before. 94% of respondents felt webinar-based remote training should continue after COVID-19. The perceived benefits of webinar-based training included reduced travel time, more training continuity and greater clinical development of learners. CONCLUSIONS: The challenge of continuing education of medical personnel while maintaining readiness for deployment and adhering to the Government's social distancing measures was perceived to have been met within our study sample. This suggests that such an approach, along with clear training objectives and teleconferencing, may enable personnel to deliver high-quality training in an innovative and secure way.

Platelet function testing in patients with post-operative tonsillectomy bleeding may be a useful early identifier of inherited platelet function disorders.

BACKGROUND: Post-tonsillectomy bleeding is the most frequent complication of tonsillectomy. Inherited platelet function disorders have an estimated prevalence of 1 per cent. Any association between post-tonsillectomy bleeds and undiagnosed inherited platelet function disorders has not been investigated before. OBJECTIVES: To assess the prevalence of inherited platelet function disorders in a cohort of post-tonsillectomy bleed patients. METHODS: An observational cohort study was conducted using hospital digital records. Platelet function analyser 100 ('PFA-100') closure time was tested on post-tonsillectomy bleed patients who presented to hospital. RESULTS: Between 2013 and 2017, 9 of 91 post-tonsillectomy bleed patients who underwent platelet function analyser 100 testing (9.89 per cent) had positive results. Five patients (5.49 per cent) had undiagnosed inherited platelet function disorders. Four patients had false positive results secondary to a non-steroidal anti-inflammatory drug effect (specificity of 95.3 per cent) proven by repeat testing six weeks later, off medication. The false negative rate was 0 per cent. CONCLUSION: The prevalence of inherited platelet function disorders in our post-tonsillectomy bleed cohort is five-fold higher than in the general population. Platelet function analyser 100 testing when patients present with a post-tonsillectomy bleed allows management of their inherited platelet function disorder.