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Because of the blurring of the 'front line' the knowledge and skills once only the province of the military surgeon is now required by the civilian trauma team. The mechanisms of injury and basic resuscitative principles are set out. [ABSTRACT FROM AUTHOR]

Introduction: The conflicts in Iraq and Afghanistan resulted in large numbers of personnel sustaining extremity injuries. In the context of polytrauma, partial hand amputation is often unrecorded. The aim of this work was to quantify the burden of upper limb (UL) amputation at any level occurring concurrently with a major (ankle and proximal) lower limb (LL) amputation. Knowledge of this cohort could aid in prosthetic modification to further improve quality of life outcomes in a population with dexterity loss., Method: A trauma database search was undertaken for all UK military LL amputees from the conflicts in Iraq and Afghanistan. A manual search method was employed to identify from the major LL amputees those who had a concurrent UL amputation at any level (including isolated finger amputation). Demographics, level of amputation, and injury profile data were recorded., Results: Sixty-eight individuals were identified; the most prevalent population was bilateral LL with a unilateral UL amputation (60%). Most UL amputations were partial hand (75%). The was no statistically significant difference between left or right side (p=0.13). On the left side, correlation was found between amputation of the thumb and third digit (rho=0.34; p=0.005) not seen on the right., Conclusion: We have determined the rate of UL amputation at any level, in combination with LL amputation as a result of blast injury. Knowledge of these combinations enables further research to support anecdotal evidence that there is a need for tailored prosthetics in the context of potential dexterity loss making donning and doffing problematic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

This is the second of a two-part review article on the management of conflict injuries, focused on the reconstructive strategies for bone, nerve and soft tissue and to provide guidance on assessing and managing common complications associated with complex upper limb injuries. Following assessment and early surgical management, the conflict casualty will require further wound evaluation and planning prior to definitive reconstruction of limb injuries. Surgical management of the upper limb injury should aim, where possible, to preserve the limb and allow functional reconstruction. The principles of the second look procedure are to assess wound progression, further reduce the risk of infection and plan definitive reconstruction with adequate soft tissue cover. The prerequisites for successful surgical reconstruction are a stable patient, combined orthoplastic surgery expertise supported by physiotherapists and hand therapists.

Upper limb injuries are common in conflict zones. The functions of the upper limb are impossible to replicate with prosthetic replacement and wherever possible attempts should be made to preserve the limb with further secondary reconstruction aimed at restoration of function. Casualty assessment, haemorrhage control and resuscitation are simultaneously undertaken at the receiving medical facility. Primary surgical management involves decontamination and debridement, skeletal stabilization, restoration of vascularity, compartment fasciotomy where indicated and wound temporization with dressings. Operative findings and interventions should be documented and if evacuation of the casualty is possible, copies should be provided in the medical records to facilitate communication in the chain of care. Secondary procedures are required for further assessment and debridement prior to planning reconstruction and definitive fracture stabilization, nerve repair, wound cover or closure.

The incidence of kidney stones is increasing worldwide, and recurrence is common (50% within 5 years). Citrate, the current gold standard therapy, which is usually given as potassium or sodium salts, is used because it raises urine pH and chelates calcium, the primary component of up to 94% of stones. In this study hexametaphosphate (HMP), a potent calcium chelator, was found to be 12 times more effective at dissolving calcium oxalate, the primary component of kidney stones, than citrate. HMP was also observed to be effective against other common kidney stone components, namely calcium phosphate and struvite (magnesium ammonium phosphate). Interestingly, HMP was capable of raising the zeta potential of calcium oxalate particles from -15.4 to -34.6 mV, which may prevent stone growth by aggregation, the most rapid growth mechanism, and thus avert occlusion. Notably, HMP was shown to be up to 16 times as effective as citrate at dissolving human kidney stones under simulated physiological conditions. It may thus be concluded that HMP is a promising potential therapy for calcium and struvite kidney stones.

Heterotopic ossification (HO), the pathological formation of ectopic bone, is a debilitating condition which can cause chronic pain, limit joint movement, and prevent prosthetic limb fitting. The prevalence of this condition has risen in the military population, due to increased survivorship following blast injuries. Current prophylaxes, which aim to target the complex upstream biological pathways, are inconsistently effective ​and have a range of side-effects that make them unsuitable for combat-injured personnel. As such, many patients must undergo further surgery to remove the formed ectopic bone. In this study, a non-toxic, U.S. Food and Drug Administration (FDA) -approved calcium chelator, hexametaphosphate (HMP), is explored as a novel treatment paradigm for this condition, which targets the chemical, rather that biological, ​bone formation pathways. This approach allows not only prevention of pathological bone formation ​but also uniquely facilitates reversal, which current drugs cannot achieve. Targeted, minimally invasive delivery is achieved by loading HMP into an injectable colloidal alginate. These formulations significantly reduce ​the length of the ectopic bone formed in a rodent model of HO, with no effect on the adjacent skeletal bone. This study demonstrates the potential of localized dissolution as a new treatment ​and an alternative to surgery ​for pathological ossification and calcification conditions., Competing Interests: The authors have no competing interests to declare., (© 2020 The Author(s).)

Introduction: Between 2009 and 2015, 3746 children died, and 7904 were injured as a result of armed conflict within Afghanistan. Improvised explosive devices (IEDs) and explosive remnants of war accounted for 29% of child casualties in 2015. The aim of this study was to review the burden of paediatric blast injuries admitted to Camp Bastion, Afghanistan, and to investigate the hypothesis that children suffer proportionally more head injuries than adults., Method: A retrospective analysis was undertaken of prospectively collected data derived from the UK Joint Theatre Trauma Registry of ambulant paediatric (aged 2-15 years) admissions with blast injuries at the Role 3 Field Hospital, Camp Bastion from June 2006 to March 2013. The data set included demographic information, injury profile and severity (New Injury Severity Score) and operative findings. The pattern of injuries were investigated by looking at trends in the number and severity of injuries sustained by each body region., Results: During this period, 295 admissions were identified, 76% of whom were male, with an overall mortality rate of 18.5%. The most common blast mechanism was an IED (68%) causing 80% of fatalities. The lower extremities were the most commonly injured body region, accounting for 31% of total injuries and occurring in 62% of cases. 24.3% of children between 2 and 7 years suffered severe head or neck injuries compared with 19.8% of children aged between 8 and 15 years. 34% of head injuries were rated unsurvivable and accounted for 88% of fatalities. 77% of cases required an operation with a mean operating time of 125 min. The most common first operations were debridement of soft tissues (50%), laparotomy (16%) and lower limb amputation (11%)., Conclusion: Although paediatric blast casualties represented a small percentage of the overall workload at Camp Bastion Role 3 Medical Facility, the pattern of injuries seen suggests that children are more likely to sustain severe head, face and neck injuries than adults., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2020. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Gunshot wounding (GSW) is capable of causing devastating tissue injuries by delivering kinetic energy (KE) through the contact surface area of a projectile. The contact surface area can be increased by yaw, deformation and fragmentation, all of which may be caused by any intermediate layers struck by the projectile prior to entering its target. This study aims to describe whether projectile yaw occurring before penetration of a cadaveric animal limb model causes greater damage with or without clothing layers present using 5.45 × 39 mm projectiles. In total, 12 fallow deer hind limbs were shot, further divided into 4 with no clothing layers (C nil ), 4 with a single clothing layer (C min ) and 4 with maximum clothing layers (C max ) as worn on active duty by UK military personnel. Contrast computed tomography (CT) of limbs was used to measure permanent cavity size and the results were compared using analysis of variance (ANOVA). No significant differences were found among clothing states for each series of measurements taken, with greater cavity sizes noted in all clothing states. This is in contrast to previous work looking at symmetrically flying projectiles in the same model, where a larger permanent cavity was found only with C max present. Projectile yaw is therefore likely to be a key variable with regard to causation of damage within this extremity wound model.

There are difficulties associated with mapping gunshot wound (GSW) patterns within opaque models. Depending on the damage measurement parameters required, there are multiple techniques that can provide methods of "seeing" the GSW pattern within an opaque model. The aim of this paper was to test several of these techniques within a cadaveric animal limb model to determine the most effective. The techniques of interest were flash X-ray, ultrasound, physical dissection, and computed-tomography (CT). Fallow deer hind limbs were chosen for the model with four limbs used for each technique tested. Quarantined 7.62 × 39 mm ammunition was used for each shot, and each limb was only shot once, on an outdoor range with shots impacting at muzzle velocity. Flash X-ray provided evidence of yaw within the limb during the projectile's flight; ultrasound though able to visualise the GSW track, was too subjective and was abandoned; dissection proved too unreliable due to the tissue being cadaveric so also too subjective; and lastly, CT with contrast provided excellent imaging in multiple viewing planes and 3D image reconstruction; this allowed versatile measurement of the GSW pattern to collect dimensions of damage as required. Of the different techniques examined in this study, CT with contrast proved the most effective to allow precise GSW pattern analysis within a cadaveric animal limb model. These findings may be beneficial to others wishing to undertake further ballistic study both within clinical and forensic fields.

Purpose: This study aimed to identify a safe, rapid, and accessible method of estimating muscle volume of key lower limb muscle groups to reduce the time-demand of acquiring this measurement and potentially facilitate its application as a clinical monitoring tool., Methods: Unilateral MRI images were acquired from the 12th thoracic vertebrae to the base of the foot in 18 recreationally active males. Panoramic B-mode ultrasound images were acquired from the same leg at the mid-hip, 25%, 50%, and 75% of thigh length, and 25% of shank length. Body mass, height, limb lengths, and circumferences at the sites corresponding to the ultrasound images were acquired. A single investigator manually analysed all images. Regression analyses were conducted to identify models for estimating volume of the hip extensor, knee extensor and flexor, and ankle plantarflexor muscle groups., Results: Models were developed for estimating hip extensor (SEE = 8.92%, R 2  = 0.690), knee extensor (SEE = 5.24%, R 2  = 0.707) and flexor (SEE = 7.89%, R 2  = 0.357), and ankle plantarflexor (SEE = 10.78%, R 2  = 0.387) muscle group volumes. The hip and knee extensor models showed good potential for generalisation. Systematic error was observed for the knee flexor and ankle plantarflexor models., Conclusions: Hip extensor, knee extensor and flexor, and ankle plantarflexor muscle group volumes can be estimated using B-mode ultrasound images and anthropometric measurements. The error shown for each of the models was sufficient to identify previously reported differences in muscle volume due to training or injury, supporting their clinical application.

The majority of injuries in survivors of gunshot wounds (GSW) are typically to the extremities. Novel wound ballistic research is encouraged to try and capture corporate knowledge on the management of these injuries gained during recent conflicts and understand the wounding patterns seen. With recent work examining the effect of UK military clothing on extremity GSW patterns in a synthetic model, a model with greater biofidelity is needed for ballistic testing. The aim of this study was to assess the effect of UK military clothing on GSW patterns within a cadaveric animal limb model using two types of ammunition commonly used in recent conflicts-7.62 × 39 mm and 5.45 × 39 mm. In total, 24 fallow deer hind limbs were shot, 12 by 7.62 mm projectiles and the remaining 12 shot by 5.45 mm projectiles, further divided into four with no clothing layers (C nil ), four with a single clothing layer (C min ) and four with maximum clothing layers (C max ) as worn on active duty by UK military personnel. Limbs were analysed after ballistic impact using contrast CT scanning to obtain measurements of permanent cavity damage, and results were compared using analysis of variance (ANOVA). Results showed significantly different damage measurements within limbs with C max for both ammunition types compared with the other clothing states. This may result in GSWs that require more extensive surgical management, and invites further study.

With no two gunshot wounds (GSW) being the same, novel research into wound ballistics is challenging. It is evident that the majority of previous wound ballistic research has been conducted without the presence of clothing. Whilst the effect of clothing on wound contamination has been explored, there is a paucity of literature examining the effect of clothing on GSW patterns. The aim of this study was to test the effect of Multi-Terrain Pattern (MTP) UK military clothing on GSW patterns within calibrated blocks of 10% by mass gelatine, using two types of ammunition commonly used in recent conflicts-7.62 × 39 mm and 5.45 × 39 mm. In total, 36 blocks were shot, 18 by each projectile type, further divided into 6 with no clothing layers (C nil ), 6 with a single clothing layer (C min ) and 6 with maximum clothing layers (C max ) worn on active duty. Blocks were analysed with high-speed video and dissection to capture measurements of damage, and results compared using analysis of variance (ANOVA). Results showed significantly different damage measurements within blocks with C max for both ammunition types compared to the other clothing states. This may result in GSWs that require more extensive surgical management, inviting further study.

Introduction: Gunshot wounding (GSW) is the second most common mechanism of injury in warfare after explosive injury. The aim of this study was to define the clinical burden of GSW placed on UK forces throughout the recent Iraq and Afghanistan conflicts., Methods: This study was a retrospective review of data from the UK Military Joint Theatre Trauma Registry (JTTR). A JTTR search identified records within the 12 year period of conflict between 19 Mar 2003 and 27 Oct 2014 of all UK military GSW casualties sustained during the complete timelines of both conflicts. Included cases had their clinical timelines and treatment further examined from time of injury up until discharge from hospital or death., Results: There were 723 casualties identified (177 fatalities, 546 survivors). Median age at the time of injury was 24 years (range 18-46 years), with 99.6% of casualties being male. Most common anatomical locations for injury were the extremities, with 52% of all casualties sustaining extremity GSW, followed by 16% GSW to the head, 15% to the thorax, and 7% to the abdomen. In survivors, the rate of extremity injury was higher at 69%, with head, thorax and abdomen injuries relatively lower at 5%, 11% and 6% respectively. All GSW casualties had a total of 2827 separate injuries catalogued. A total of 545 casualties (523 survivors, 22 fatalities) underwent 2357 recorded surgical procedures, which were carried out over 1455 surgical episodes between admission to a deployed medical facility and subsequent transfer to the Royal Centre for Defence Medicine (RCDM) in the UK. This gave a median of 3 (IQR 2-5) surgical procedures within a median of 2 (IQR 2-3) surgical episodes per casualty. Casualties had a combined length of stay (LoS) of 25 years within a medical facility, with a mean LoS in a deployed facility of 1.9 days and 14 days in RCDM., Conclusion: These findings define the massive burden of injury associated with battlefield GSW and underscore the need for further research to both reduce wound incidence and severity of these complex injuries., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Background: Scapula fractures are relatively uncommon injuries, mostly occurring due to the effects of high-energy trauma. Rates of scapula fractures are unknown in the military setting. The aim of this study is to analyse the incidence, aetiology, associated injuries, treatment and complications of these fractures occurring in deployed military personnel., Methods: All UK military personnel returning with upper limb injuries from Afghanistan and Iraq were retrospectively reviewed using the Royal Centre for Defence Medicine database and case notes (2004-2014)., Results: Forty-four scapula fractures out of 572 upper limb fractures (7.7%) were sustained over 10 years. Blast and gunshot wounds (GSW) were leading causative factors in 85%. Over half were open fractures (54%), with open blast fractures often having significant bone and soft tissue loss requiring extensive reconstruction. Multiple injuries were noted including lung, head, vascular and nerve injuries. Injury Severity Scores (ISS) were significantly higher than the average upper limb injury without a scapula fracture (p<0.0001). Brachial plexus injuries occurred in 17%. While military personnel with GSW have a favourable chance of nerve recovery, 75% of brachial plexus injuries that are associated with blast have poorer outcomes. Fixation occurred with either glenoid fractures or floating shoulders (10%); these were as a result of high velocity GSW or mounted blast ejections. There were no cases of deep soft tissue infection or osteomyelitis and all scapula fractures united., Conclusion: Scapula fractures have a 20 times higher incidence in military personnel compared with the civilian population, occurring predominantly as a result of blast and GSW, and a higher than average ISS. These fractures are often associated with multiple injuries, including brachial plexus injuries, where those sustained from blast have less favourable outcome. High rates of union following fixation and low rates of infection are expected despite significant contamination and soft tissue loss., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Incidences of colorectal cancer (CRC) and inflammatory bowel disease (IBD) are increasing in those aged <50 years., Aim: To identify and quantify clinical features in primary care of CRC/IBD in those aged <50 years. This study considered the two conditions together and aimed to determine which younger patients, presenting in primary care with symptoms, would benefit from investigation for potentially serious colorectal disease., Design and Setting: Matched case-control study using primary care records from the Clinical Practice Research Datalink, UK., Method: Incident cases (aged <50 years) of CRC ( n = 1661) and IBD ( n = 9578) diagnosed between 2000 and 2013 were each matched with up to three controls ( n = 3979 CRC; n = 22 947 IBD). Odds ratios (OR) and positive predictive values (PPV) were estimated for features of CRC/IBD in the year before diagnosis., Results: Ten features were independently associated with CRC/IBD (all P <0.001): rectal bleeding, change in bowel habit, diarrhoea, raised inflammatory markers, thrombocytosis, abdominal pain, low mean cell volume (MCV), low haemoglobin, raised white cell count, and raised hepatic enzymes. PPVs were >3% for rectal bleeding with diarrhoea, thrombocytosis, low MCV, low haemoglobin or raised inflammatory markers; for change in bowel habit with low MCV, thrombocytosis or low haemoglobin; and for diarrhoea with thrombocytosis., Conclusion: This study quantified the risk of serious bowel disease in symptomatic patients aged <50 years in primary care. Rectal bleeding and change in bowel habit are strongly predictive of CRC/IBD when combined with abnormal haematology. The present findings help prioritise patients for colonoscopy where the diagnosis is not immediately apparent., (© British Journal of General Practice 2017.)

Objectives: To estimate data loss and bias in studies of Clinical Practice Research Datalink (CPRD) data that restrict analyses to Read codes, omitting anything recorded as text., Design: Matched case-control study., Setting: Patients contributing data to the CPRD., Participants: 4915 bladder and 3635 pancreatic, cancer cases diagnosed between 1 January 2000 and 31 December 2009, matched on age, sex and general practitioner practice to up to 5 controls (bladder: n=21 718; pancreas: n=16 459). The analysis period was the year before cancer diagnosis., Primary and Secondary Outcome Measures: Frequency of haematuria, jaundice and abdominal pain, grouped by recording style: Read code or text-only (ie, hidden text). The association between recording style and case-control status (χ(2) test). For each feature, the odds ratio (OR; conditional logistic regression) and positive predictive value (PPV; Bayes' theorem) for cancer, before and after addition of hidden text records., Results: Of the 20 958 total records of the features, 7951 (38%) were recorded in hidden text. Hidden text recording was more strongly associated with controls than with cases for haematuria (140/336=42% vs 556/3147=18%) in bladder cancer (χ(2) test, p<0.001), and for jaundice (21/31=67% vs 463/1565=30%, p<0.0001) and abdominal pain (323/1126=29% vs 397/1789=22%, p<0.001) in pancreatic cancer. Adding hidden text records corrected PPVs of haematuria for bladder cancer from 4.0% (95% CI 3.5% to 4.6%) to 2.9% (2.6% to 3.2%), and of jaundice for pancreatic cancer from 12.8% (7.3% to 21.6%) to 6.3% (4.5% to 8.7%). Adding hidden text records did not alter the PPV of abdominal pain for bladder (codes: 0.14%, 0.13% to 0.16% vs codes plus hidden text: 0.14%, 0.13% to 0.15%) or pancreatic (0.23%, 0.21% to 0.25% vs 0.21%, 0.20% to 0.22%) cancer., Conclusions: Omission of text records from CPRD studies introduces bias that inflates outcome measures for recognised alarm symptoms. This potentially reinforces clinicians' views of the known importance of these symptoms, marginalising the significance of 'low-risk but not no-risk' symptoms., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

The need to quantify physicochemical properties of mineralization spans many fields. Clinicians, mineralization researchers, and bone tissue bioengineers need to be able to measure the distribution, quantity, and the mechanical and chemical properties of mineralization within a wide variety of substrates from injured muscle to electrospun polymer scaffolds and everything in between. The techniques available to measure these properties are highly diverse in terms of their complexity and utility. Therefore it is of the utmost importance that those who intend to use them have a clear understanding of the advantages and disadvantages of each technique and its appropriateness to their specific application. This review provides all of this information for each technique and uses heterotopic ossification and engineered bone substitutes as examples to illustrate how these techniques have been applied. In addition, we provide novel data using advanced techniques to analyze human samples of combat related heterotopic ossification., (© 2016 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Introduction: Terrorists have used the explosive device successfully globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of high lethality and target accuracy. The aim of this study was to identify trends and analyse the demographics and casualty figures of terrorist bombings worldwide., Methods: Analysis of the Global Terrorism Database (GTD) and a PubMed/Embase literature search (keywords "terrorist", and/or "suicide", and/or "bombing") from 1970 to 2014 was performed., Results: 58,095 terrorist explosions worldwide were identified in the GTD. 5.08% were suicide bombings. Incidents per year are increasing (P<0.01). Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The kill:wounded ratio was statistically higher in suicide attacks than non-suicide attacks, 1:1.3 and 1:1.24 respectively (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe (13.2%) ranked 4th. The literature search identified 41 publications reporting 167 incidents of which 3.9% detailed building collapse (BC), 60.8% confined space (CS), 23.5% open space (OS) and 11.8% semi-confined space (SC) attacks. 60.4% reported on suicide terrorist attacks. Overall 32 deaths and 180 injuries per incident were seen, however significantly more deaths occurred in explosions associated with a BC. Comparing OS and CS no difference in the deaths per incident was seen, 14.2(SD±17.828) and 15.63 (SD±10.071) respectively. However OS explosions resulted in significantly more injuries, 192.7 (SD±141.147), compared to CS, 79.20 (SD±59.8). Extremity related wounds were the commonest injuries seen (32%)., Discussion/conclusion: Terrorist bombings continue to be a threat and are increasing particularly in the Middle East. Initial reports, generated immediately at the scene by experienced coordination, on the type of detonation (suicide versus non-suicide), the environment of detonation (confined, open, building collapse) and the number of fatalities, and utilising the Kill:Wounded ratios found in this meta-analysis, can be used to predict the number of casualties and their likely injury profile of survivors to guide the immediate response by the medical services and the workload in the coming days., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Non-union of fractured bone is a major cause of morbidity in the orthopaedic population. Despite this, optimal management of non-union is still unclear and remains a significant clinical challenge. Research continues in animal models in an attempt to identify an effective clinical treatment. The proposed systematic review will evaluate current therapies of bone non-union in animal models, in order to identify those that may translate successfully to clinical therapies., Methods/design: The methodology for the systematic review will be in accordance with standard guidelines. All potential sources for pre-clinical studies will be interrogated and the search strategy written in conjunction with a specialist in this field. Data extraction will be conducted by two reviewers to minimise bias. Analysis will be predominantly qualitative because of the heterogeneity that is likely to exist between the studies. However, quantitative synthesis will be performed where homogeneity in a sub-group of studies exists. Quality assessment will be undertaken utilising a risk of bias tool., Discussion: To date, there has not been a systematic review addressing bone non-union therapies in animal models despite the plethora of pre-clinical research currently being undertaken. This protocol details and outlines the methodology and justification for such a review.

Background: Diagnosis of bladder cancer relies on investigation of symptoms presented to primary care, notably visible haematuria. The importance of non-visible haematuria has never been estimated., Aim: To estimate the risk of bladder cancer with non-visible haematuria., Design and Setting: A case-control study using UK electronic primary care medical records, including uncoded data to supplement coded records., Method: A total of 4915 patients (aged ≥40 years) diagnosed with bladder cancer between January 2000 and December 2009 were selected from the Clinical Practice Research Datalink and matched to 21 718 controls for age, sex, and practice. Variables for visible and non-visible haematuria were derived from coded and uncoded data. Analyses used multivariable conditional logistic regression, followed by estimation of positive predictive values (PPVs) for bladder cancer using Bayes' theorem., Results: Non-visible haematuria (coded/uncoded data) was independently associated with bladder cancer: odds ratio (OR) 20 (95% confidence interval [CI] =12 to 33). The PPV of non-visible haematuria was 1.6% (95% CI = 1.2 to 2.1) in those aged ≥60 years and 0.8% (95% CI = 0.1 to 5.6) in 40-59-year-olds. The PPV of visible haematuria was 2.8% (95% CI = 2.5 to 3.1) and 1.2% (95% CI = 0.6 to 2.3) for the same age groups respectively, lower than those calculated using coded data alone. The proportion of records of visible haematuria in coded, rather than uncoded, format was higher in cases than in controls (P<0.002, χ(2) test). There was no evidence for such differential recording of non-visible haematuria by case/control status (P = 0.78), although, overall, the uncoded format was preferred (P<0.001)., Conclusion: Both non-visible and visible haematuria are associated with bladder cancer, although the visible form confers nearly twice the risk of cancer compared with the non-visible form. GPs' style of record keeping varies by symptom and possible diagnosis., (© British Journal of General Practice 2014.)

Any fracture of a bone which communicates with the outside environment via a wound in the skin is classified as an open fracture. This may be from penetration by sharp objects from the exterior, laceration caused by the fracture fragments, or shearing forces that tear or de-glove soft tissue from a limb. These injuries vary in mechanism and severity, ranging from a broken finger caught in a bulkhead door to a catastrophic lower limb fracture suffered from an improvised explosive device (IED). We address the management principles that can be applied to all open fractures regardless of cause.

The use of hypertonic saline Dextran (HSD) for resuscitation following trauma has many potential benefits, especially for the treatment of military casualties, but there is very limited data on the responses following multiple dosing with this fluid. The effects of a second dose of hypertonic saline dextran for resuscitation of uncontrolled intra-abdominal haemorrhage were studied in an experimental model. Under general anaesthesia, 17 large white pigs (weight range, 48-67 kg) were subjected to uncontrolled hemorrhage produced by a tear in the common iliac artery. This resulted in a significant (P < 0.01) reduction of both mean arterial pressure (MAP) and cardiac index. One hour after injury, animals were assigned to one of three groups, receiving either no resuscitation (Group A), or two doses of HSD (at a dose rate of 4 mL/kg), administered either 1 and 4 h after injury (Group B) or 1 and 7 h after injury (Group C). Animals were monitored for 12 h post-injury. A second infusion of HSD caused a significant hypernatremia and diuresis (P< 0.01) in both Groups B and C. There was a non-significant rise in MAP in both treatment groups, and in Group B only, there was a significant increase in cardiac index (P= 0.014). It is concluded that repeat administration of HSD for the resuscitation of uncontrolled hemorrhage results in limited cardiovascular improvements, but that the metabolic sequelae are potentially detrimental to survival.

An animal model was used to study the pathogenesis of pin track infection. The roles of fluid accumulation around the pin/bone interface and mechanical loosening of the pin were specifically studied. In addition, the spread of bacteria in relation to the clinical appearance of the pin track was assessed. This study demonstrated that fluid accumulation around the interface is an important factor in the spread of infection from the superficial wound track to the medulla of the bone. Spread occurs despite the absence of mechanical pin loosening, and can occur before any clinical features of infection are apparent.

Implant sepsis. due to previous external fixator pin track infection, is the most common complication of secondary intramedullary (IM) nailing of the tibia. We have developed an animal model, which allows different treatment methods to be studied. Using an established ovine model of a pin track infection, Staphylococcus aureus was used to infect the external fixator pins, two weeks prior to reamed IM nailing. In the control group, the animals were killed at a mean of 10.5 days following nailing, when widespread infection was evident, with septic arthritis, abscess formation, and infection of the entire length of the tibia in all six animals. In the treatment group, before IM nailing, the pin sites were debrided, and both local and systemic antibiotics were administered. All surgical wounds healed without evidence of infection, 4 of the 6 animals survived for 28 days, and bacteria were only isolated from 1 of the 6 implants. Treatment was successful at reducing, but not eliminating, infection after secondary nailing.

As can be seen from the statistics, the challenges to all medical staff involved in OW97 were considerable. It is to the combined credit of all RN and RFA medical staff that a high standard of medical care was provided throughout the deployment. All operational casualties were treated correctly and without delay and most have made full recovery. Moreover, the varied general naval experience, foreign travel, new colleagues and friends gained from Global deployments such as this is something to be recommended. The authors wish to extend their thanks to all medical staff involved in OW97. Their support and hard work contributed significantly to make the medical aspects of the deployment such a success.

Peroxidation of low density lipoproteins (LDL) may be involved in the development of atherosclerosis which is prevalent in patients with chronic renal failure and renal transplant recipients. We determined the copper ion catalyzed oxidation in vitro, vitamin E content, and chemical and fatty acid composition of LDL isolated from 38 patients with renal disease and 15 healthy subjects. Also the acute effect of hemodialysis treatment on LDL oxidation variables was tested. The lag time in conjugated diene formation during oxidation was significantly (P = 0.011) shorter in LDL from renal transplant recipients (66 min, N = 18) mainly due to significantly (P < 0.05) shorter times in women (47 min, N = 7), compared with healthy subjects (83 min, N = 15), patients on hemodialysis (91 min, N = 13) and patients treated by continuous ambulatory peritoneal dialysis (CAPD) (82 min, N = 7). The maximum rate and the extent of LDL oxidation were significantly (P < 0.01) lower in all patients with renal disease compared with healthy subjects. The triglyceride content of LDL was significantly (P < 0.001) higher in women with kidney grafts (7.3%) compared with levels in the corresponding men (5.3%) and healthy women (5.0%), and was correlated significantly with the lag time in LDL oxidation in renal transplant recipients (Spearmans r = -0.502, P = 0.034). The percentage oleic acid in LDL was significantly higher (P = 0.002) and the percentage linoleic acid was significantly lower (P = 0.046) in patients with renal disease, and may largely account for their lower rates and extent of LDL oxidation. Levels of the LDL oxidation variables and organic lipid peroxide content of LDL were not significantly different before and after hemodialysis and 24 hours later. These results suggest that LDL from women with renal transplants may be abnormally susceptible to oxidation possibly due to increased triglyceride content.

Plasma lathosterol concentration which is an index of cholesterol synthesis rate was measured in 36 patients with chronic renal failure (CRF) including 13 who were dialysis independent, 12 receiving hemodialysis and 11 on continuous ambulatory peritoneal dialysis (CAPD), 17 renal transplant recipients and 27 healthy control subjects. Concentrations of plasma lathosterol were significantly (ANOVA p = 0.03) lower in all categories of renal patients excepting those treated by CAPD, compared with control values. In normolipidemic subjects (cholesterol < or = 6.50 mmol/l and triglycerides < or = 2.0 mmol/l) plasma lathosterol levels in hemodialysis patients and renal transplant recipients were still significantly (ANOVA p = 0.02) lower than control values. In transplant recipients, the plasma lathosterol/cholesterol ratio was significantly (p = 0.02) lower than those treated with azathioprine and prednisone compared with those treated with these drugs and cyclosporin. Significant (p < 0.001) positive correlations were recorded between plasma lathosterol concentration and plasma levels of apolipoprotein B (apoB) and very low density lipoprotein (VLDL) lipids in the renal patients. These data suggest that the rate of cholesterol synthesis may be low in undialysed and hemodialysed patients with CRF and in renal transplant recipients, particularly those treated with double therapy, and may be linked to the metabolism of apoB and VLDL.