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Background: All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient mass-casualty situation (MASCAL)., Methods: The sample included orthopedic (four) and general surgeons (eight) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan, on August 26, 2021. One orthopedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1, expeditionary knowledge (examination score); 2, procedural skills competencies (performance assessment score); and 3, clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases was reviewed and rated (performance score) by the Joint Trauma System's Performance Improvement Branch, a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each predeployment measure and MASCAL surgical care., Results: Predeployment knowledge and clinical activity measures met program benchmarks. Baseline predeployment procedural skills competency scores did not meet program benchmarks; however, those gaps were closed through retraining, ensuring all surgeons met or exceeded the program benchmarks predeployment. There were very large effect sizes (Cohen's d ) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons., Conclusion: The prescribed program measures ensured that all surgeons achieved predeployment performance benchmarks and provided high-quality trauma care to our nation's service members., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "œwork of the United States Government"œ for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background: The clinical demands of mass casualty events strain even the most well-equipped trauma centers and are especially challenging in resource-limited rural, remote, or austere environments. Gynecologists and urologists care for patients with pelvic and abdominal injuries, but the extent to which they are able to serve as "force multipliers" for trauma care is unclear. This study examined the abilities of urologists and gynecologists to perform 32 trauma procedures after mentored training by expert trauma educators to inform the potential for these specialists to independently care for trauma patients., Methods: Urological (6), gynecological surgeons (6), senior (postgraduate year 5) general surgery residents (6), and non-trauma-trained general surgeons (8) completed a rigorous trauma training program (Advanced Surgical Skills Exposure in Trauma Plus). All participants were assessed in their trauma knowledge and surgical abilities performing 32 trauma procedures before/after mentored training by expert trauma surgeons. Performance benchmarks were set for knowledge (80%) and independent accurate completion of all procedural components within a realistic time window (90%)., Results: General surgery participants demonstrated greater trauma knowledge than gynecologists and urologists; however, none of the specialties reached the 80% benchmark. Before training, general surgery, and urology participants outperformed gynecologists for overall procedural abilities. After training, only general surgeons met the 90% benchmark. Post hoc analysis revealed no differences between the groups performing most pelvic and abdominal procedures; however, knowledge associated with decision making and judgment in the provision of trauma care was significantly below the benchmark for gynecologists and urologists, even after training., Conclusion: For physiologically stable patients with traumatic injuries to the abdomen, pelvis, or retroperitoneum, these specialists might be able to provide appropriate care; however, they would best benefit trauma patients in the capacity of highly skilled assisting surgeons to trauma specialists. These specialists should not be considered for solo resuscitative surgical care., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background: Experiences over the last three decades of war have demonstrated a high incidence of traumatic brain injury (TBI) resulting in a persistent need for a neurosurgical capability within the deployed theater of operations. Despite this, no doctrinal requirement for a deployed neurosurgical capability exists. Through an iterative process, the Joint Trauma System Committee on Surgical Combat Casualty Care (CoSCCC) developed a position statement to inform medical and nonmedical military leaders about the risks of the lack of a specialized neurosurgical capability., Methods: The need for deployed neurosurgical capability position statement was identified during the spring 2021 CoSCCC meeting. A triservice working group of experienced forward-deployed caregivers developed a preliminary statement. An extensive iterative review process was then conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. To provide additional context and a civilian perspective, statement commentaries were solicited from civilian clinical experts including a recently retired military trauma surgeon boarded in neurocritical care, a trauma surgeon instrumental in developing the Brain Injury Guidelines, a practicing neurosurgeon with world-renowned expertise in TBI, and the chair of the Committee on Trauma., Results: After multiple revisions, the position statement was finalized, and approved by the CoSCCC membership in February 2023. Challenges identified include (1) military neurosurgeon attrition, (2) the lack of a doctrinal neurosurgical capabilities requirement during deployed combat operations, and (3) the need for neurosurgical telemedicine capability and in-theater computed tomography scans to triage TBI casualties requiring neurosurgical care., Conclusion: Challenges identified regarding neurosurgical capabilities within the deployed trauma system include military neurosurgeon attrition and the lack of a doctrinal requirement for neurosurgical capability during deployed combat operations. To mitigate risk to the force in a future peer-peer conflict, several evidence-based recommendations are made. The solicited civilian commentaries strengthen these recommendations by putting them into the context of civilian TBI management. This neurosurgical capabilities position statement is intended to be a forcing function and a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields., Level of Evidence: Prognostic and Epidemiological; Level V., (Copyright © 2023 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Introduction: In deployed contexts, military medical care is provided through the coordinated efforts of multiple interdisciplinary teams that work across and between a continuum of widely distributed role theaters. The forms these teams take, and functional demands, vary by roles of care, location, and mission requirements. Understanding the requirements for optimal performance of these teams to provide emergency, urgent, and trauma care for multiple patients simultaneously is critical. A team's collective ability to function is dependent on the clinical expertise (knowledge and skills), authority, experience, and affective management capabilities of the team members. Identifying the relative impacts of multiple performance factors on the accuracy of care provided by interdisciplinary clinical teams will inform targeted development requirements., Materials and Methods: A regression study design determined the extent to which factors known to influence team performance impacted the effectiveness of small, six to eight people, interdisciplinary teams tasked with concurrently caring for multiple patients with urgent, emergency care needs. Linear regression analysis was used to distinguish which of the 11 identified predictors individually and collectively contributed to the clinical accuracy of team performance in simulated emergency care contexts., Results: All data met the assumptions for regression analyses. Stepwise linear regression analysis of the 11 predictors on team performance yielded a model of five predictors accounting for 82.30% of the variance. The five predictors of team performance include (1) clinical skills, (2) team size, (3) authority profile, (4) clinical knowledge, and (5) familiarity with team members. The analysis of variance confirmed a significant linear relationship between team performance and the five predictors, F(5, 240) = 218.34, P < .001., Conclusions: The outcomes of this study demonstrate that the collective knowledge, skills, and abilities within an urgent, emergency care team must be developed to the extent that each team member is able to competently perform their role functions and that smaller teams benefit by being composed of clinical authorities who are familiar with each other. Ideally, smaller, forward-deployed military teams will be an expert team of individual experts, with the collective expertise and abilities required for their patients. This expertise and familiarity are advantageous for collective consideration of significant clinical details, potential alternatives for treatment, decision-making, and effective implementation of clinical skills during patient care. Identifying the most influential team performance factors narrows the focus of team development strategies to precisely what is needed for a team to optimally perform., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Between conflicts, many of the combat casualty care lessons learned are lost as the nation shifts priorities and providers leave the military. Solutions are needed to bridge the knowledge gap created by interwar periods. One of the foremost solutions is partnerships between civilian trauma centers and the military health system. Over the past two decades, a myriad of military-civilian partnerships (MCPs), which vary in their composition, duration, and focus, was created. The objective of this report is to describe the initial attempt of the Department of Defense to catalog existing MCPs to inform both civilian and military stakeholders. This initial catalog is intended as a reference to aid in future MCP development and facilitate the synchronization of efforts to improve trauma care delivery and readiness., Methods: Using methodology from the Institute of Defense Analysis, the total number of eligible trauma centers in the United States was determined. The Institute of Defense Analysis determined eligibility-based American College of Surgeons Trauma Center verification or state trauma center designation. Each military service provided their list of MCPs, which were categorized. Military-civilian partnerships were cataloged by various characteristics and program components. Key variables include number and type of personnel trained, duration of training, and focus, for example, team versus individual focused and training versus maintaining proficiency focused., Results: A total of 1,139 hospitals in the United States are potentially eligible for MCPs. There are at least 87 unique partnerships; the majority are part-time sustainment MCPs. The Air Force has the largest number of providers in MCPs. There are many challenges to maintain accurate and up to date data on MCPs., Conclusion: With the collated information, the Defense Health Agency, military services, special operations community, and civilian partners will be better empowered to optimize the readiness value of their programs and better prepare our military medical providers for the nation's and military's future needs., (Copyright © 2022 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Objectives: The research question asked to what extent do self-rated performance scores of individual surgeons correspond to assessed procedural performance abilities and to peer ratings of procedural performance during a mass casualty (MASCAL) event?, Background: Self-assessment using performance rating scales is ubiquitous in surgical education as a proxy for direct measurement of competence. The validity and reliability of self-ratings as competency measures are susceptible to cognitive biases such as Dunning-Kruger effects, which describe how individuals over/underestimate their own performance compared to assessments from independent sources. The ability of surgeons to accurately self-assess their procedural performance remains undetermined., Methods: A purposive sample of military surgeons (N = 13) who collectively cared for trauma patients during a MASCAL event participated in the study. Pre-event performance assessment scores for 32 trauma procedures were compared with post-event self and peer performance ratings using F tests ( P < 0.05) and effect sizes (Cohen's d )., Results: There were no significant differences between peer ratings and performance assessment scores. There were significant differences between self-ratings and both peer ratings ( P < 0.001) and performance assessment scores ( P < 0.001). Effect sizes were very large for self to peer rating comparison (Cohen's d = 2.34) and self to performance assessment comparison (Cohen's d = 2.77)., Conclusions: The outcomes demonstrate that self-ratings were significantly lower than the independently determined assessment scores for each surgeon, revealing a Dunning-Kruger effect for highly skilled individuals underestimating their abilities. These outcomes underscore the limitations of self-assessment for measuring competence., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: As combat-related trauma decreases, there remains an increasing need to maintain the ability to care for trauma victims from other casualty events around the world (e.g., terrorism, natural disasters, and infrastructure failures). During these events, military surgeons often work closely with their civilian counterparts, often in austere and expeditionary contexts. In these environments, the primary aim of the surgical team is to implement damage control principles to avert blood loss, optimize oxygenation, and improve survival. Upper-extremity vascular injuries are associated with high rates of morbidity and mortality resulting from exsanguination and ischemic complications; however, fatalities may be avoided if hemorrhage is rapidly controlled. In austere contexts, deployed surgical teams typically include one general surgeon and one orthopedic surgeon, neither of which have acquired the expertise to manage these vascular injuries. The purpose of this study was to examine the baseline capabilities of general surgeons and orthopedic surgeons to surgically expose and control axillary and brachial arteries and to determine if the abilities of both groups could be increased through a focused cadaver-based training intervention., Methods: This study received IRB approval at our institution. Study methods included the use of cadavers for baseline assessment of procedural capabilities to expose and control axillary and brachial vessels, followed by 1:1 procedural training and posttraining re-assessment of procedural capabilities. Inferential analyses included ANOVA/MANOVA for within- and between-group effects (P < .05). Effect sizes were calculated using Cohen's d., Results: Study outcomes demonstrated significant differences between the baseline performance abilities of the two groups, with general surgeons outperforming orthopedic surgeons. Before training, neither group reached performance benchmarks for overall or critical procedural abilities in exposing axillary and brachial vessels. Training led to increased abilities for both groups. There were statistically significant gains for overall procedural abilities, as well as for critical procedural elements that are directly associated with morbidity and mortality. These outcomes were consistent for both general and orthopedic surgeons. Effect sizes ranged between medium (general surgeons) and very large (orthopedic surgeons)., Conclusion: There was a baseline capability gap for both general surgeons and orthopedic surgeons to surgically expose and control the axillary and brachial vessels. Outcomes from the course suggest that the methodology facilitates the acquisition of accurate and independent vascular procedural capabilities in the management of upper-extremity trauma injuries. The impact of this training for surgeons situated in expeditionary or remote contexts has direct relevance for caring for victims of extremity trauma. These outcomes underscore the need to train all surgeons serving in rural, remote, expeditionary, combat, or global health contexts to be able to competently manage extremity trauma and concurrent vascular injuries to increase the quality of care in those settings., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Damage control resuscitation (DCR) simultaneously tackles hemorrhage control and balanced resuscitation in complex multisystem trauma patients. This technique can improve patient outcomes. This review outlines the importance of DCR with hemorrhage control and administration of fresh whole blood or component therapy if not available and avoiding crystalloid administration. Additionally, administration of tranexamic acid and calcium prove beneficial in critically ill trauma patients. Avoidance of acidosis, hypothermia, and coagulopathy remains a key but challenging goal of DCR.

Introduction: Maintaining readiness among Army surgeons is increasingly challenging because of declining operative experience during certain deployments. Novel solutions should be considered., Materials and Methods: A pilot program was conducted to rotate surgical teams from a military treatment facility with a low volume of combat casualty care to one with a higher volume. Pre- and postrotation surveys were conducted to measure relative operative experience, trauma experience, and perceived readiness among rotators., Results: Operative volumes and trauma volumes were increased and that perceived readiness among rotators, especially those with the fewest previous deployments, was improved., Conclusions: Maintaining readiness among Army surgeons is a difficult task, but a combination of increased trauma care while in garrison, as well as increased humanitarian care during deployments, may be helpful. Additionally, rotating providers from facilities caring for few combat casualties to facilities caring for more combat casualties may also be feasible, safe, and helpful., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Surviving the first episode of bacteremia predisposes burn casualties to its recurrence. Herein, we investigate the incidence, mortality, bacteriology, and source of infection of recurrent bacteremia in military burn casualties admitted to the U.S. Army Institute of Surgical Research Burn Center over a 10year period., Methods: Bacteremia was defined as the growth of Gram-positive or Gram-negative organisms in a blood culture that excluded probable skin contaminants. Recurrent bacteremia was defined as a subsequent episode of bacteremia ≥7 days after the first episode. Polymicrobial bacteremia was the presence of more than one pathogen in the same blood culture. Bacteremia was attributed to UTI, pneumonia, or wound sepsis. All other bacteremias were considered non-attributable bloodstream infections. Univariate and multivariate analyses determined factors predictive of clinical outcome., Results: Out of 952 combat-related burn casualties screened, 166 cases were identified; 63% (non-recurrent) and 37% (recurrent) with median time to recurrence of 20 days. Univariate and multivariate analysis showed that the mortality rate was two and nine-fold, respectively, higher with recurrent bacteremia. Univariate analysis found that except for urinary tract infection, large burn size (>20%), 3rd degree burns, increased injuiry severity, perineal burns, and mechanical ventilator days were independent factors predictive of recurrence of bacteremia as well as increased mortality in the recurrent bacteremia cohort. Acinetobacter baumannii complex (63%) was prevalent in the non-recurrent group, while Klebsiella pneumoniae (46% vs. 30%) and Pseudomonas aeruginosa (35% vs. 26%) were prevalent in recurrent bacteremia. Half of the recurrent bacteremia cases were polymicrobial, compared to 9% in non-recurrent bacteremia. Pneumonia was prevalent in non-recurrent bacteremia (38%) and a combination of pneumonia and wound sepsis (29%) in recurrent bacteremia casualties., Conclusions: Recurrent bacteremia increases mortality in military burn casualties. Additional research is needed to address and mitigate the underlying causes, thereby improving survival., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)

Management of wartime burn casualties can be very challenging. Burns frequently occur in the setting of other blunt and penetrating injuries. This clinical practice guideline provides a manual for burn injury assessment, resuscitation, wound care, and specific scenarios including chemical and electrical injuries in the deployed or austere setting. The clinical practice guideline also reviews considerations for the definitive care of local national patients, including pediatric patients, who are unable to be evacuated from theater. Medical providers are encouraged to contact the US Army Institute of Surgical Research (USAISR) Burn Center when caring for a burn casualty in the deployed setting.

Background: The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study., Methods: Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed., Results: There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade., Conclusion: The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms., Level of Evidence: Prognostic, level III.

Purpose: Among service members injured in Iraq and Afghanistan, to determine the risk of mortality associated with combat-related burns to the genitalia, perineum, and buttocks., Materials and Methods: The prospectively maintained burn registry from the United States Army Institute of Surgical Research was retrospectively reviewed to identify all service members with combat-related burns sustained in Iraq and Afghanistan from March 2003 to October 2013. The two primary risk factors of interest were (1) any burn to the genitals, perineum, and/or buttocks (PB) and (2) burns involving the entire perineal, genital, and buttock region (complete PB). Cox proportional hazard models were used to estimate the risk of mortality for both primary risk factors, and adjusted for severe non-burn-related trauma, percent of burn over total body surface area (TBSA), inhalational injury, time to urinary tract infection, and time to bacteremia. A post-hoc analysis was performed to explore the potential effect modification of TBSA burned on the relationship between PB and mortality., Results: Among the 902 U.S. service members with combat-related burns sustained during the study period, 226 (25.0%) had involvement of the genitalia, perineum, and/or buttocks. Complete PB was associated with a crude risk of mortality (HR: 5.3; 2.9-9.7), but not an adjusted risk (HR=1.8; 0.8-4.0). However, TBSA burned was identified as a potential negative effect modifier. Among patients with burns <60% TBSA, sustaining a complete PB conferred an adjusted risk of death (HR=2.7; 1.1-6.8). Further, patients with a perineal burn had a five-fold increased incidence of bacteremia. In adjusted models, each event of bacteremia increased the risk of mortality by 92% (HR 1.92; 1.39-2.65). Perineal burns were associated with a two-fold increased incidence of severe non-burn related trauma that also doubled mortality risk in adjusted models (HR 2.29; 1.23-4.27)., Conclusions: Among those with relatively survivable combat-related burns (<60% TBSA), genital/perineal/buttock involvement increases the risk of death. Bacteremia may account for part of this increased risk, but does not fully explain the independent risk associated with perineal burns., (Published by Elsevier Ltd.)

Introduction: Existing trials studying the use of Gastrografin for management of adhesive small bowel obstruction (SBO) are limited by methodological flaws and small sample sizes. We compared institutional protocols with and without Gastrografin (GG), hypothesizing that a SBO management protocol utilizing GG is associated with lesser rates of exploration, shorter length of stay, and fewer complications., Methods: A multi-institutional, prospective, observational study was performed on patients appropriate for GG with adhesive SBO. Exclusion criteria were internal/external hernia, signs of strangulation, history of abdominal/pelvic malignancy, or exploration within the past 6 weeks. Patients receiving GG were compared to patients receiving standard care without GG., Results: Overall, 316 patients were included (58 ± 18 years; 53% male). There were 173 (55%) patients in the GG group (of whom 118 [75%] successfully passed) and 143 patients in the non-GG group. There were no differences in duration of obstipation (1.6 vs. 1.9 days, p = 0.77) or small bowel feces sign (32.9% vs. 25.0%, p = 0.14). Fewer patients in the GG protocol cohort had mesenteric edema on CT (16.3% vs. 29.9%; p = 0.009). There was a lower rate of bowel resection (6.9% vs. 21.0%, p < 0.001) and exploration rate in the GG group (20.8% vs. 44.1%, p < 0.0001). GG patients had a shorter duration of hospital stay (4 IQR 2-7 vs. 5 days IQR 2-12; p = 0.036) and a similar rate of complications (12.5% vs. 17.9%; p = 0.20). Multivariable analysis revealed that GG was independently associated with successful nonoperative management., Conclusion: Patients receiving Gastrografin for adhesive SBO had lower rates of exploration and shorter hospital length of stay compared to patients who did not receive GG. Adequately powered and well-designed randomized trials are required to confirm these findings and establish causality., Level of Evidence: Therapeutic, level III.

Fluid resuscitation is the foundation of management in burn patients and is the topic of considerable research. One adjunct in burn resuscitation is continuous, high-dose vitamin C (ascorbic acid) infusion, which may reduce fluid requirements and thus decrease the risk for over resuscitation. Research in preclinical studies and clinical trials has shown continuous infusions of high-dose vitamin C to be beneficial with decrease in resuscitative volumes and limited adverse effects. However, high-dose and low-dose vitamin C supplementation has been shown to cause secondary calcium oxalate nephropathy, worsen acute kidney injury, and delay renal recovery in non-burn patients. To the best of our knowledge, the authors present the first case series in burn patients in whom calcium oxalate nephropathy has been identified after high-dose vitamin C therapy.

Burns are frequently encountered on the modern battlefield, with 5% - 20% of combat casualties expected to sustain some burn injury. Addressing immediate life-threatening conditions in accordance with the MARCH protocol (massive hemorrhage, airway, respirations, circulation, hypothermia/head injury) remains the top priority for burn casualties. Stopping the burning process, total burn surface area (TBSA) calculation, fluid resuscitation, covering the wounds, and hypothermia management are the next steps. If transport to definitive care is delayed and the prolonged field care stage is entered, the provider must be prepared to provide for the complex resuscitation and wound care needs of a critically ill burn casualty., (2015.)

Background: Survivors of combat trauma can have long and challenging recoveries, which may be complicated by infection. Invasive fungal infections are a rare but serious complication with limited treatment options. Currently, aggressive surgical debridement is the standard of care, with antifungal agents used adjunctively with uncertain efficacy. Anecdotal evidence suggests that antifungal agents may be ineffective in the absence of surgical debridement, and studies have yet to correlate antifungal concentrations in plasma and wounds., Case Presentation: Here we report the systemic pharmacokinetics and wound effluent antifungal concentrations of five wounds from two male patients, aged 28 and 30 years old who sustained combat-related blast injuries in southern Afghanistan, with proven or possible invasive fungal infection. Our data demonstrate that while voriconazole sufficiently penetrated the wound resulting in detectable effluent levels, free amphotericin B (unbound to plasma) was not present in wound effluent despite sufficient concentrations in circulating plasma. In addition, considerable between-patient and within-patient variability was observed in antifungal pharmacokinetic parameters., Conclusion: These data highlight the need for further studies evaluating wound penetration of commonly used antifungals and the role for therapeutic drug monitoring in providing optimal care for critically ill and injured war fighters.

Background: The impact of local recurrence and surgical resection margin status on survival in extremity soft-tissue sarcomas remains to be clearly defined. Our aim was to conduct a retrospective analysis of prospectively collected data to determine the prognostic relevance of positive resection margins and local recurrence for extremity soft-tissue sarcomas for survival., Methods: Three hundred and sixty-three patients who underwent resection of localized primary extremity soft-tissue sarcomas with curative intent were selected from the United States Department of Defense Automated Central Tumor Registry. Outcomes for local recurrence, distant recurrence, disease-specific survival, and overall survival were analyzed according to clinical, pathological, and treatment variables with use of the Kaplan-Meier method (log-rank test) and the multivariate Cox regression model., Results: Positive margins (hazard ratio, 1.99 [95% confidence interval, 1.15 to 3.45]), local recurrence (hazard ratio, 2.93 [95% confidence interval, 1.38 to 6.23]), and distant recurrence (hazard ratio, 12.13 [95% confidence interval, 5.97 to 24.65]) were significantly associated with overall survival on multivariate Cox regression analysis. However, for disease-specific survival, local recurrence was not significant and tumor size of >10 cm (hazard ratio, 2.83 [95% confidence interval, 1.15 to 6.95]), positive margins (hazard ratio, 1.95 [95% confidence interval, 1.05 to 3.63]), and distant recurrence (hazard ratio, 9.46 [95% confidence interval, 4.37 to 20.47]) were independent adverse prognostic factors. The disease-specific survival rate for patients with localized soft-tissue sarcomas was 89% (95% confidence interval, 85% to 92%) for five years and 75% (95% confidence interval, 70% to 81%) for ten years., Conclusions: Positive surgical margins are consistently associated with adverse survival-related outcomes in localized soft-tissue sarcomas of the extremity. Local recurrence had a significant impact on overall survival, but not on disease-specific survival.

Introduction: Machine learning can enable the development of predictive models that incorporate multiple variables for a systems approach to organ allocation. We explored the principle of Bayesian Belief Network (BBN) to determine whether a predictive model of graft survival can be derived using pretransplant variables. Our hypothesis was that pretransplant donor and recipient variables, when considered together as a network, add incremental value to the classification of graft survival., Methods: We performed a retrospective analysis of 5,144 randomly selected patients (age ≥18, deceased donor kidney only, first-time recipients) from the United States Renal Data System database between 2000 and 2001. Using this dataset, we developed a machine-learned BBN that functions as a pretransplant organ-matching tool., Results: A network of 48 clinical variables was constructed and externally validated using an additional 2,204 patients of matching demographic characteristics. This model was able to predict graft failure within the first year or within 3 years (sensitivity 40%; specificity 80%; area under the curve, AUC, 0.63). Recipient BMI, gender, race, and donor age were amongst the pretransplant variables with strongest association to outcome. A 10-fold internal cross-validation showed similar results for 1-year (sensitivity 24%; specificity 80%; AUC 0.59) and 3-year (sensitivity 31%; specificity 80%; AUC 0.60) graft failure., Conclusion: We found recipient BMI, gender, race, and donor age to be influential predictors of outcome, while wait time and human leukocyte antigen matching were much less associated with outcome. BBN enabled us to examine variables from a large database to develop a robust predictive model.

The inflammatory response to severe traumatic injury results in significant morbidity and mortality. Lymphocytes have recently been identified as critical mediators of the early innate immune response to ischemia-reperfusion injury. Experimental manipulation of lymphocytes following hemorrhagic shock may prevent secondary immunologic injury in surgical and trauma patients. The objective of this study is to evaluate the lymphocyte sequestration agent FTY720 as an immunomodulator following experimental hemorrhagic shock in a swine liver injury model. Yorkshire swine were anesthetized and underwent a grade III liver injury with uncontrolled hemorrhage to induce hemorrhagic shock. Experimental groups were treated with a lymphocyte sequestration agent, FTY720, (n = 9) and compared to a vehicle control group (n = 9). Animals were observed over a 3 day survival period after hemorrhage. Circulating total leukocyte and neutrophil counts were measured. Central lymphocytes were evaluated with mesenteric lymph node and spleen immunohistochemistry (IHC) staining for CD3. Lung tissue infiltrating neutrophils were analyzed with myeloperoxidase (MPO) IHC staining. Relevant immune-related gene expression from liver tissue was quantified using RT-PCR. The overall survival was 22.2% in the vehicle control and 66.7% in the FTY720 groups (p = 0.081), and reperfusion survival (period after hemorrhage) was 25% in the vehicle control and 75% in the FTY720 groups (p = 0.047). CD3(+) lymphocytes were significantly increased in mesenteric lymph nodes and spleen in the FTY720 group compared to vehicle control, indicating central lymphocyte sequestration. Lymphocyte disruption significantly decreased circulating and lung tissue infiltrating neutrophils, and decreased expression of liver immune-related gene expression in the FTY720 treated group. There were no observed infectious or wound healing complications. Lymphocyte sequestration with FTY720 improves survival in experimental hemorrhagic shock using a porcine liver injury model. These results support a novel and clinically relevant lymphocyte immunomodulation strategy to ameliorate secondary immune injury in hemorrhagic shock.

This pilot study compared the use of the Lifor Organ Preservation Medium (RTLF) at room temperature with hypothermic Belzer machine preservation solution (CMPS) and room in vitro temperature Belzer machine preservation solution (RTMPS) in a porcine model of uncontrolled donation after cardiac death (DCD). In this study, 5 porcine kidneys for each perfusate group were recovered under a DCD protocol. The kidneys were recovered, flushed, and placed onto a renal preservation system following standard perfusion procedures. The average flow rate for CMPS was 36.2 +/- 7.2549 mL/min, RTMPS was 90.2 +/- 9.7159 mL/min, and RTLF was 103.1 +/- 5.1108 mL/min. The average intrarenal resistance for CMPS was 1.33 +/- 0.1709 mm Hg/mL per minute, RTMPS was 0.84 +/- 0.3586 and RTLF was 0.39 +/- 0.04. All perfusion parameters were statistically significant (P < .05) at all time points for the CMPS when compared with both RTMPS and RTLF. All perfusion parameters for RTMPS and RTLF were equivalent for the first 12 hours; thereafter, RTLF became significantly better than RTMPS at 18 and 24 hours. It appears that both RTMPS and RTLF have equivalent perfusion characteristic for the initial 12 hours of perfusion, but LF continues to maintain a low resistance and high flow up to 24 hours. The results of this pilot study indicate that RTLF may represent a better alternative to pulsatile perfusion with CMPS and requires validation in an in vivo large animal transplant model.

Purpose: The purpose of this paper is to compare intraoperative biopsy results of previously ablated liver tumors with their preoperative computed tomography (CT) and intraoperative laparoscopic ultrasound (LUS) appearances in patients undergoing repeat radiofrequency ablation (RFA)., Methods: Seventy repeat RFA procedures were performed in 59 (13%) patients. Laparoscopically, suspected recurrent and stable appearing foci were biopsied using an 18 G biopsy gun. Preoperative CT and LUS appearances of the previously ablated lesions were compared with core biopsy results., Results: There were 33 patients with colorectal cancer, 11 with hepatocellular cancer, 8 with neuroendocrine tumors, and 7 with other tumor types. Two hundred lesions were treated by RFA in these 70 repeat ablations. Suspected recurrent tumor foci were enhanced on CT and produced a more finely stippled echo pattern on LUS. Biopsy confirmed recurrent tumor in 72 of 84 such lesions. Previously ablated foci had a CT appearance of a hypodense, nonenhancing lesion without evidence of adjacent enhancing foci. Laparoscopic ultrasound appearance was of a hypoechoic lesion with a coarse internal pattern with the tracks of the ablation catheter probes often still visible. Biopsy found necrotic tissue in 21 of 22 such lesions appearing radiologically to be without recurrence. Biopsy of an ablated focus adjacent to an area of suspected recurrence showed necrotic tissue in 17 of 22 lesions and viable cancer in 5., Conclusion: CT and LUS appearance of previously ablated foci showed good correlation with core biopsies. CT scan is reliable in following RFA lesions, without the need for routine biopsy. LUS reliably distinguished recurrent from ablated lesions in patients undergoing repeat ablation.

Purpose: To determine the effect omission of axillary lymph node dissection has on outcome in patients treated with breast-conserving therapy for early-stage invasive breast cancer., Materials and Methods: The authors evaluated 492 patients with breast cancer treated with (n = 32) and without (n = 456) axillary lymph node dissection. The primary tumor characteristics of the two groups were similar, though the median age was different. All patients received whole-breast radiation (mean dose, 50 Gy); additional tumor bed boosts and nodal irradiation were used more often in patients without dissection., Results: Median follow-up in patients without and with dissection was 60 and 52 months, respectively. The 5-year survival was 88% and 93%, respectively. There were no regional failures in the group treated without dissection. Crude rates of local and distant failure were similar for both groups., Conclusion: Omission of axillary lymph node dissection should be considered in patients whose pathologic nodal status will not influence decisions regarding adjuvant therapy.