Non-battle injury among repatriated UK armed forces since cessation of combat operations: a prospective observational study.

AIM: To describe the mechanisms, burden of injury, inpatient management and rehabilitation requirements of wounded military personnel at the UK Role 4 (R4) facility within the first 12 months following cessation of combat operations in Afghanistan. METHODS: All aeromedical evacuations were recorded prospectively between October 2014 and October 2015. Demographic, logistical and clinical data were derived manually from referring medical unit and patient movement requests in addition to host nation and R4 medical records. RESULTS: Ninety-five patients were repatriated to R4 following traumatic injury: 98.9% (n=94) were male, and median age was 27 years (IQR 25-36 years). The most common mechanisms of injury (MOIs) were sports 26.3% (n=25), falls <2 m 11.6% (n=11) and road traffic collisions 9.8% (n=9). The most common anatomical regions of injury were isolated lower limb 24.1% (n=22), isolated hand 20.0% (n=19) and polytrauma 14.7% (n=14). Median Injury Severity Score was 4 (IQR 4-9), mean 8 (range 1-41). Eleven patients (11.6%) were discharged to rehabilitation units, of whom 7 (63.6%) required neurorehabilitation. CONCLUSION: Although service personnel sustain civilian-type injuries, the specific rehabilitation goals and shift in the acute rehabilitation requirements for military personnel must be considered in the absence of enduring combat operations. It is notable that permanent medical downgrading secondary to trauma still occurs outside of warfare. The colocation of civilian major trauma services and R4 has ensured a mutually beneficial partnership that contributes to institutional memory and improves the coordination of patient pathways. The importance of relevant resource allocation, training, support and logistical considerations remain, even during the current scale of military activity overseas.

The management and outcome of open fractures of the femur sustained on the battlefield over a ten-year period.

This is a retrospective study of survivors of recent conflicts with an open fracture of the femur. We analysed the records of 48 patients (48 fractures) and assessed the outcome. The median follow up for 47 patients (98%) was 37 months (interquartile range 19 to 53); 31 (66%) achieved union; 16 (34%) had a revision procedure, two of which were transfemoral amputation (4%). The New Injury Severity Score, the method of fixation, infection and the requirement for soft-tissue cover were not associated with a poor outcome. The degree of bone loss was strongly associated with a poor outcome (p = 0.00204). A total of four patients developed an infection; two with S. aureus, one with E. coli and one with A. baumannii. This study shows that, compared with historical experience, outcomes after open fractures of the femur sustained on the battlefield are good, with no mortality and low rates of infection and late amputation. The degree of bone loss is closely associated with a poor outcome.

Medium-term outcomes following limb salvage for severe open tibia fracture are similar to trans-tibial amputation.

Extremity injuries define the surgical burden of recent conflicts. Current literature is inconclusive when assessing the merits of limb salvage over amputation. The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to equivalent outcomes for unilateral trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 and 2010, as described in a previously published series, were contacted. Consenting individuals conducted a brief telephone interview and were asked to complete a SF-36 questionnaire. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation between 2004 and 2010. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria. Telephone follow-up and SF-36 questionnaire data was available for 30 patients (61%). The median follow-up was 4 years (49 months, IQR 39-63). Ten of the 30 patients required revision surgery, three of which involved conversion from initial fixation to a circular frame for non- or mal-union. Twenty-two of the 30 patients (73%) recovered sufficiently to complete an age-standardised basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35-54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores between the limb salvage and amputation groups (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma.

Do stimulants improve self-esteem in children with ADHD and peer problems?

The self-esteem of children with Attention Deficit Hyperactivity Disorder (ADHD) has been shown to be low. The effects of stimulant medication upon their self-esteem have not been systematically studied. The present study employed a reliable self-report instrument to measure the self-esteem of children with ADHD medicated with stimulants vs. those who were unmedicated. Results showed that stimulants were associated with significantly higher self-esteem. Children with ADHD prescribed stimulants reported feeling more intelligent and more popular than unmedicated children with ADHD. Children with ADHD and Oppositional Defiant Disorder (ODD) prescribed stimulants reported feeling better behaved. Significant correlations indicated that higher doses were associated with higher self-esteem. The present results suggest a need for a well-controlled study to determine if stimulants were responsible for the observed differences in self-esteem.

The development of a paediatric quality of life questionnaire to measure post-operative pain following tonsillectomy.

In this paper we describe the process through which a Paediatric Quality of Life Questionnaire was developed to assess the pain experienced by children following tonsillectomy. The impetus behind the questionnaire development was the clinical observation that the pain experienced by children undergoing tonsillectomy was not being detected and analgesia was not being prescribed in adequate amounts. The eight-item questionnaire provides the independent observer with an objective measure of the physical and emotional distress a child experiences post-tonsillectomy to which analgesic requirements can be titrated. The questionnaire was tested on a sample of 48 children aged between 2 and 13 years (average age 7.1 years) who underwent elective dissection tonsillectomy by the same surgeon using a standardised operative technique. The conclusions substantiate the hypothesis that there is the need for an assessment tool based on non-verbal behaviour to measure post-operative pain in children. In the discussion we summarise the increasing role of quality of life assessments in surgical practice.

Adolescent Multiphasic Personality Inventory and its utility in assessing suicidal and violent adolescents.

Adolescent Multiphasic Personality Inventory profiles of inpatient adolescents were examined to identify differences between suicidal (danger to self, n = 145) and violent (danger to others, n = 36) adolescents. Participants were 181 inpatients (12-17 years old, mean age, 14.7 years) admitted to an adolescent psychiatric unit of a southern California county hospital. Results indicate that the suicide group had significantly higher scores than the violent group on five scales (Hypochondriasis, Psychasthenia, Paranoia, Schizophrenia, and Social Introversion). This scales, singly or in combination, have been found to be indicative of psychotic process. This suggests the presence of psychotic process in suicidal, but not violent, adolescents.

Parent-assisted transfer of children's social skills training: effects on children with and without attention-deficit hyperactivity disorder.

OBJECTIVE: Previous research has demonstrated that peer rejection is a significant part of the clinical presentation of many children with attention-deficit hyperactivity disorder (ADHD). Outcome studies of treatment interventions have typically failed to show generalization of treatment gains to the home and classroom. This has been especially true for children who have comorbid oppositional defiant disorder (ODD). The present study was intended to demonstrate generalization of an outpatient social skills training program when parents were trained in skills relevant to their child's social adjustment. METHOD: Thirty-five children with ADHD and 14 children without ADHD were given 12 sessions of treatment (treatment group). Outcome was compared with 12 children with ADHD and 12 children without ADHD who were on a waitlist for treatment (waitlist group). Nineteen children with ODD were in the treatment group and five in the waitlist. Stimulant medication was prescribed for all children with ADHD. RESULTS: Subjects with ADHD showed improvement comparable with that of subjects without ADHD on all teacher- and parent-reported measures of peer adjustment and social skills, except teacher-reported withdrawal. Children with ODD had outcome comparable with that of children without ODD. Effect sized ranged from 0.93 to 1.34 indicating that the average treatment group subject was better off than 83.4% of waitlist subjects on outcome measures. CONCLUSIONS: The present results suggest that children with ADHD are best heiped by a combination of social skills training for themselves, collateral training for their parents and stimulant medication.

Use of the Child Behavior Checklist and DSM-III-R diagnosis in predicting outcome of children's social skills training.

A standardized 12-week cognitive-behavioral social skills package in which parents assisted children with socialization homework assignments, was presented to 52 nonpsychotic outpatient boys, many of whom were diagnosed with DSM-III-R Attention Deficit-Hyperactivity Disorder and Oppositional Defiant Disorder. Results demonstrated that the Thought Problems factor of the mother-completed Child Behavior Checklist aided in predicting changes in teacher-rated aggression. DSM-III-R diagnosis of Oppositional Defiant Disorder predicted changes in teacher-rated withdrawal subsequent to treatment. The need for research to determine which children benefit from which treatment was discussed.

External cephalic version of the breech presentation under tocolysis.

External cephalic version with tocolysis at or near term has been advocated to avoid cesarean birth for breech presentation. In our institution this maneuver was successfully performed in 207 of 304 parturients without major complications, and all but six had vertex presentation at delivery. The success of version was inversely correlated with gestational age but was not correlated with ease of version, number of attempts, or placental location. When this 3-year period was compared with the previous three years (1979 to 1981), there was a significant reduction in the number of breech presentations during labor, whereas the total delivery rate remained relatively constant over the 6-year period. It appears that in a carefully selected population, external version near term can be used safely to reduce the need for abdominal birth because of breech presentation.