BACKGROUND: The global burden of trauma disproportionately affects low-income countries and middle-income countries (LMIC), with variability in trauma systems between countries. Military and civilian healthcare systems have a shared interest in building trauma capacity for use during peace and war. However, in LMICs it is largely unknown if and how these entities work together. Understanding the successful integration of these systems can inform partnerships that can strengthen trauma care. This scoping review aims to identify examples of military-civilian trauma systems integration and describe the methods, domains, and indicators associated with integration including barriers and facilitators.
METHODS: A scoping review of all appropriate databases was performed to identify papers with evidence of military and civilian trauma systems integration. After manuscripts were selected for inclusion, relevant data was extracted and coded into methods of integration, domains of integration, and collected information regarding indicators of integration, which were further categorized into facilitators or barriers.
RESULTS: Seventy-four studies were included with authors from 18 countries describing experiences in 23 countries. There was a predominance of authorship and experiences from High-Income Countries (91.9 and 75.7%, respectively). Five key domains of integration were identified; Academic Integration was the most common (45.9%). Among indicators, the most common facilitator was administrative support and the lack of this was the most common barrier. The most common method of integration was Collaboration (50%).
CONCLUSIONS: Current evidence demonstrates the existence of military and civilian trauma systems integration in several countries. High-income country data dominates the literature, and thus a more robust understanding of trauma systems integration, inclusive of all geographic locations and income statuses, is necessary prior to development of a framework to guide integration. Nonetheless, the facilitators identified in this study describe the factors and environment in which integration is feasible and highlight optimal indicators of entry.

Treatment of volumetric muscle loss (VML) faces challenges due to its unique pathobiology and lower priority in severe musculoskeletal injury management. Consequently, a need exists for multi-stage VML treatment strategies to accommodate delayed interventions owing to comorbidity management or prolonged casualty care in combat settings. To this end, polyvinyl alcohol (PVA) was used at concentrations of 5%, 7.5%, and 10% to generate provisional muscle void fillers (MVFs) of varying stiffness values (1.125 kPa, 3.700 kPa, and 7.699 kPa) to stabilize VML injuries as part of a two-stage approach. These were implanted into a rat model for a duration of 4 weeks, then explanted and either left untreated (control) or treated through minced muscle grafting (MMG). Additional benchmarks included acute MMG and unrepaired groups. At the MVF explant, the 7.5% PVA group exhibited superior neuromuscular function compared to the 5% and 10% PVA groups, the least fibrosis, and the largest median myofiber size among all groups at the 12-week endpoint. Despite the 7.5% PVA\'s superiority amongst the two-stage treatment groups, neuromuscular function was neither improved nor impaired relative to acute treatment benchmarks. This suggests that the future success of a two-stage VML treatment strategy will necessitate a more effective definitive intervention.

UNASSIGNED: Military working dogs (MWDs) are essential for military operations in a wide range of missions. With this pivotal role, MWDs can become casualties requiring specialized veterinary care that may not always be available far forward on the battlefield. Some injuries such as pneumothorax, hemothorax, or abdominal hemorrhage can be diagnosed using point of care ultrasound (POCUS) such as the Global FAST® exam. This presents a unique opportunity for artificial intelligence (AI) to aid in the interpretation of ultrasound images. In this article, deep learning classification neural networks were developed for POCUS assessment in MWDs.
UNASSIGNED: Images were collected in five MWDs under general anesthesia or deep sedation for all scan points in the Global FAST® exam. For representative injuries, a cadaver model was used from which positive and negative injury images were captured. A total of 327 ultrasound clips were captured and split across scan points for training three different AI network architectures: MobileNetV2, DarkNet-19, and ShrapML. Gradient class activation mapping (GradCAM) overlays were generated for representative images to better explain AI predictions.
UNASSIGNED: Performance of AI models reached over 82% accuracy for all scan points. The model with the highest performance was trained with the MobileNetV2 network for the cystocolic scan point achieving 99.8% accuracy. Across all trained networks the diaphragmatic hepatorenal scan point had the best overall performance. However, GradCAM overlays showed that the models with highest accuracy, like MobileNetV2, were not always identifying relevant features. Conversely, the GradCAM heatmaps for ShrapML show general agreement with regions most indicative of fluid accumulation.
UNASSIGNED: Overall, the AI models developed can automate POCUS predictions in MWDs. Preliminarily, ShrapML had the strongest performance and prediction rate paired with accurately tracking fluid accumulation sites, making it the most suitable option for eventual real-time deployment with ultrasound systems. Further integration of this technology with imaging technologies will expand use of POCUS-based triage of MWDs.

The treatment of war injuries represents a continuing and recurrent challenge in modern reconstructive surgery. Previously, tumor resections and sepsis-related resections were mainly responsible for lengthy bone defects in Germany. In recent years another picture has increasingly emerged, particularly caused by the medical support of Ukraine. Aspects of military surgery are also becoming more important in civil hospitals, especially in the treatment of gunshot and explosion injuries. In Germany, war injuries are currently secondarily treated, as the distribution of patients is carried out according to the cloverleaf principle, weeks or months after the occurrence of the primary injury. In addition to complex bone and soft tissue defects of the extremities following such injuries, which often affect neural and vascular structures, reconstruction is often complicated by an increasing spectrum of multidrug-resistant pathogens. The definition of microbiological terms, such as contamination, colonization, critical colonization, local and systemic infections are important in the clinical routine in order to initiate a targeted treatment, especially in treatment with antibiotics. Wound swabs for determination of the spectrum of pathogens and the optimal testing of resistance are important for selecting the appropriate antibiotic agents. The concept of antibiotic stewardship (ABS) is established in many hospitals to improve the quality of antibiotic treatment and to minimize the formation of resistance. The selection of the method of reconstruction depends on the condition of the patient, the overall clinical constellation and the function to be expected after completion of treatment. The treatment of injuries due to violence and terrorism necessitates clear concepts and an interdisciplinary approach, especially with respect to microbiological challenges and increasing resistance situations.
UNASSIGNED: Die Behandlung von Kriegsverletzungen stellt in der modernen Wiederherstellungschirurgie eine ständige und wiederkehrende Herausforderung dar. Früher waren Tumorresektionen und septisch bedingte Resektionen hauptverantwortlich für langstreckige knöcherne Defekte in Deutschland. In den letzten Jahren zeigt sich ein zunehmend anderes Bild, v. a. bedingt durch die medizinische Unterstützung der Ukraine. Aspekte der Militärchirurgie gewinnen auch in zivilen Krankenhäusern an Bedeutung, insbesondere bei der Behandlung von Schuss- und Explosionsverletzungen. Aktuell werden in Deutschland Kriegsverletzungen postprimär versorgt, da die Verteilung der Patienten über das Kleeblattprinzip Wochen bis Monate nach Eintritt der Primärverletzung erfolgt. Neben den komplexen Knochen- und Weichteildefekten der Extremitäten nach solchen Verletzungen, die oft Nerven- und Gefäßstrukturen betreffen, wird die Rekonstruktion durch ein zunehmend multiresistentes Keimspektrum erschwert. Mikrobiologische Begriffsdefinitionen wie Kontamination, Kolonisation, kritische Kolonisation sowie lokale und systemische Infektion sind im klinischen Alltag von Bedeutung, um eine zielführende Behandlung einzuleiten, insbesondere bei der Antibiotikatherapie. Wundabstriche zur Bestimmung des Keimspektrums und die optimale Resistenztestung sind wichtig für die Auswahl der geeigneten Antibiotika. Das Konzept der Antibiotic Stewardship (ABS) ist in vielen Kliniken etabliert, um die Qualität der antibiotischen Therapie zu verbessern und Resistenzbildungen zu minimieren. Die Auswahl der Rekonstruktionsmethode richtet sich nach dem Patientenzustand, der klinischen Gesamtkonstellation und der zu erwartenden Funktion nach Abschluss der Behandlung. Die Therapie von Verletzungen durch Gewalt und Terror erfordert klare Konzepte und einen interdisziplinären Ansatz, insbesondere im Hinblick auf mikrobiologische Herausforderungen und zunehmende Resistenzlagen.

We report a patient with nonimmune fetal hydrops and multiple pathologic fractures. RNA analysis revealed a novel PIEZO1 variant. This report is the first to elucidate PIEZO1\'s role as a critical regulator of bone mass and strength.

暂无摘要。

Aggregate statistics can provide intra-conflict and inter-conflict mortality comparisons and trends within and between U.S. combat operations. However, capturing individual-level data to evaluate medical and non-medical factors that influence combat casualty mortality has historically proven difficult. The Department of Defense (DoD) Trauma Registry, developed as an integral component of the Joint Trauma System during recent conflicts in Afghanistan and Iraq, has amassed individual-level data that have afforded greater opportunity for a variety of analyses and comparisons. Although aggregate statistics are easily calculated and commonly used across the DoD, other issues that require consideration include the impact of individual medical interventions, non-medical factors, non-battle-injured casualties, and incomplete or missing medical data, especially for prehospital care and forward surgical team care. Needed are novel methods to address these issues in order to provide a clearer interpretation of aggregate statistics and to highlight solutions that will ultimately increase survival and eliminate preventable death on the battlefield. Although many U.S. military combat fatalities sustain injuries deemed non-survivable, survival among these casualties might be improved using primary and secondary prevention strategies that prevent injury or reduce injury severity. The current commentary proposes adjustments to traditional aggregate combat casualty care statistics by integrating statistics from the DoD Military Trauma Mortality Review process as conducted by the Joint Trauma System and Armed Forces Medical Examiner System.

BACKGROUND: Thoracic trauma occurs frequently in combat and is associated with high mortality. Tube thoracostomy (chest tube) is the treatment for pneumothorax resulting from thoracic trauma, but little data exist to characterize combat casualties undergoing this intervention. We sought to describe the incidence of these injuries and procedures to inform training and materiel development priorities.
METHODS: This is a secondary analysis of a Department of Defense Trauma Registry (DoDTR) data set from 2007 to 2020 describing prehospital care within all theaters in the registry. We described all casualties who received a tube thoracostomy within 24 hours of admission to a military treatment facility. Variables described included casualty demographics; abbreviated injury scale (AIS) score by body region, presented as binary serious (=3) or not serious (<3); and prehospital interventions.
RESULTS: The database identified 25,897 casualties, 2,178 (8.4%) of whom received a tube thoracostomy within 24 hours of admission. Of those casualties, the body regions with the highest proportions of common serious injury (AIS >3) were thorax 62% (1,351), extremities 29% (629), abdomen 22% (473), and head/neck 22% (473). Of those casualties, 13% (276) had prehospital needle thoracostomies performed, and 19% (416) had limb tourniquets placed. Most of the patients were male (97%), partner forces members or humanitarian casualties (70%), and survived to discharge (87%).
CONCLUSIONS: Combat casualties with chest trauma often have multiple injuries complicating prehospital and hospital care. Explosions and gunshot wounds are common mechanisms of injury associated with the need for tube thoracostomy, and these interventions are often performed by enlisted medical personnel. Future efforts should be made to provide a correlation between chest interventions and pneumothorax management in prehospital thoracic trauma.

During distributed maritime operations, individual components of the naval force are more geographically dispersed. As the U.S. Navy further develops this concept, smaller vessels may be operating at a significant time and distance away from more advanced medical capabilities. Therefore, during both current and future contested Distributed Maritime Operations, Role 1 maritime caregivers such as Independent Duty Corpsman will have to manage patients for prolonged periods of time. This manuscript presents an innovative approach to teaching complex operational medicine concepts (including Prolonged Casualty Care [PCC]) to austere Role 1 maritime caregivers using a hypothetical scenario involving a patient with sepsis and septic shock. The scenario incorporates the Joint Trauma System PCC Clinical Practice Guidelines (CPG) and other standard references. The scenario includes a stem clinical vignette, expected clinical changes for the affected patient at specific time points (e.g., time 0, 1, 2, and 48h), and expected interventions based on the PCC CPG and available shipboard equipment. Epidemiology of sepsis in the deployed environment is also reviewed. This process also identifies opportunities to improve training, clinical skills sustainment, and standard shipboard medical supplies.

BACKGROUND: Medical training and evaluation are important for mission readiness in the pararescue career field. Because evaluation methods are not standardized, evaluation methods must align with training objectives. We propose an alternative evaluation method and discuss relevant factors when designing military medical evaluation metrics.
METHODS: We compared two evaluation methods, the traditional checklist (TC) method used in the pararescue apprentice course and an alternative weighted checklist (AWC) method like that used at the U.S. Army static line jumpmaster course. The AWC allows up to two minor errors, while critical task errors result in autofailure. We recorded 168 medical scenarios during two Apprentice course classes and retroactively compared the two evaluation methods.
RESULTS: Despite the possibility of auto-failure with the AWC, there was no significant difference between the two evaluation methods, and both showed similar overall pass rates (TC=50% pass, AWC=48.8% pass, p=.41). The two evaluation methods yielded the same result for 147 out of 168 scenarios (87.5%).
CONCLUSIONS: The AWC method strongly emphasizes critical tasks without significantly increasing failures. It may provide additional benefits by being more closely aligned with our training objectives while providing quantifiable data for a longitudinal review of student performance.