Delivery of UK military upper limb prosthetics: current concepts and future directions.

Upper limb prosthetics have a challenging task. A natural upper limb combines strength, coordination and dexterity to accomplish daily activities such as eating, writing, working and social interaction. Artificially replicating these functions requires a prosthetic with composite, synchronous motor function while maintaining sensory feedback and skeletal stability. Achieving these functions requires interfaces between biology and machine across nerve, muscle, bone and skin. This leads to issues related to infection, foreign material encapsulation and implant stability, and electrical signal transduction and interpretation. Over the last 20 years the advent of technologies such as osseointegration, targeted muscle reinnervation, implantable myoelectric sensors, peripheral nerve interfaces and pattern recognition technology has sought to address these problems.Due to many advances in prehospital care, truncated timelines to damage control surgery and improved combat personal protective equipment, the numbers of amputees have increased with more patients surviving injury. From October 2001 to March 2019 there were 333 amputees from Afghanistan and Iraq compared with 457 fatalities over a similar period. Over a third of these were significant multiple amputees. With a functional, robust upper limb prosthetic which mirrors or exceeds normal function, injured service personnel could be returned to an active combat role. This has benefits for their physical and mental health, improves employability prospects and allows Defence to retain some of its most highly motivated and skilled people who represent significant financial investment.

Clinical variation in the treatment of trigger finger: An international survey of orthopaedic and plastic surgeons.

Trigger finger is a common condition affecting the hand. Therapeutic variability surrounds the management of trigger finger, especially in the mild cases. The aim of this study was to survey secondary care surgeons to describe the current management of trigger fingers. The steering group developed a survey for hand surgeons. Following piloting, the survey was distributed to hand surgeons in the United Kingdom and The Netherlands. A total of 713 plastic surgeons and orthopaedic surgeons were invited to participate in the online survey and 440 (62%) surgeons completed the survey. In both mild and moderate cases of trigger finger, steroid injection was the preferred treatment option. Open surgery was the treatment of choice for severe cases. However, there was variation in delivery of care, including type and dosage of steroid, site of injection, interval between injections, maximum number of injections, type of incision and treatment of patients with diabetes or rheumatoid arthritis. This highlights the need for a better evidence base for the treatment of trigger fingers.

Laboratory studies assessing the microbial biocontrol potential of diverse strains of Beauveria bassiana isolated from coffee berry borer, with emphasis on strains from Hawai'i Island and comparisons to commercial strain GHA.

A series of experiments investigated genetically diverse strains of Beauveria bassiana (Bb) isolated from coffee berry borer (CBB). Objectives included assessment of their biocontrol potential, particularly in comparison to Bb commercial strain GHA currently applied for CBB control, and identification of various attributes potentially contributing to their comparatively greater epizootic potential in CBB populations. Bioassays identified one strain from Hawai'i Island and one from Puerto Rico with virulence greater than GHA based on equal weights of unformulated conidial powder (CP); however, the greater potency of the CPs was ultimately explained by their 2.4-fold greater conidial densities (ca. 3.1 vs 1.3 × 1011 viable conidia/g CP). Density was explained, in large part, by conidial size, but not by size alone. Bb-inoculated CBB held on moist filter paper were more susceptible to infection than those held on cooked green coffee bean (CGCB). A Bb strain representative of the most common Hawaiian haplotype produced 2.6x more conidia after death of CGCB-held beetles than GHA (19.1 vs 7.3 x106 conidia/cadaver). Following host death, no difference was observed in time to emergence and initial conidial production by GHA and a selected group of Hawaiian strains; however, mass sporulation was initiated within 2 days by strain GHA compared to 4-5 days by the Hawaiian strains. In a preliminary evaluation of conidial mass-production potential, CP yields of several strains were comparable to GHA on a weight basis and significantly greater than GHA on a conidial basis (1.3-1.6 vs 0.7 × 1013 viable conidia/kg barley substrate).

Upskilling the surgical workforce for vascular access provision during the COVID-19 pandemic - The Salisbury experience.

A vascular access device is defined as a catheter inserted into veins allowing fluids and medicines to be delivered intravenously1. The need for such devices in acutely unwell patients has remained steady throughout the COVID-19 pandemic. We describe here our experience of up-skilling the resident plastic surgery and maxillofacial surgical registrars to provide a vascular access service to reduce the workload on our intensive care colleagues. We hope that our practice and an 'all hands on deck' approach to the utilisation of baseline skills within the existing workforce will inform other departments to help ease the burden on critical care departments as we progress through the next stages of the COVID-19 pandemic.

Regulating the femtosecond excited-state lifetime of a single molecule.

The key to controlling reactions of molecules induced with the current of a scanning tunneling microscope (STM) tip is the ultrashort intermediate excited ionic state. The initial condition of the excited state is set by the energy and position of the injected current; thereafter, its dynamics determines the reaction outcome. We show that a STM can directly and controllably influence the excited-state dynamics. For the STM-induced desorption of toluene molecules from the Si(111)-7x7 surface, as the tip approaches the molecule, the probability of manipulation drops by two orders of magnitude. A two-channel quenching of the excited state is proposed, consisting of an invariant surface channel and a tip height-dependent channel. We conclude that picometer tip proximity regulates the lifetime of the excited state from 10 femtoseconds to less than 0.1 femtoseconds.

Prevalence of naturally-occurring strains of Beauveria bassiana in populations of coffee berry borer Hypothenemus hampei on Hawai'i Island, with observations on coffee plant-H. hampei-B. bassiana interactions.

Beauveria bassiana (Bb) strain GHA is a major component of an areawide pest management program for coffee berry borer (CBB) in Hawai'i. Recent studies have aimed to provide comprehensive assessments of the efficacy of the Bb-spray component of these programs for economic analyses; however, evaluations have been complicated by activity of naturally-occurring strains of this pathogen infecting CBB. Investigations were therefore undertaken to characterize these strains, assess their natural epizootic potential, and account for their contribution to CBB population suppression. A number of field sites were encountered with no history of significant use of commercial Bb-based biopesticides and where strain GHA was not detectable. Sampling of these sites was conducted early in the coffee season. Greatest activity of wild-type Bb strains was observed on high-elevation farms (>500 m), where 24-42% of foundress beetles in green coffee berries were infected. In contrast, infection rates did not exceed 4% on farms at low elevations (<300 m). Rates of 23-29% infection, comparable to those on high-elevation farms, were recorded in a stand of feral coffee at 293 m elevation, but the coffee was completely shaded and ventilation restricted by a dense overstory of vegetation. Despite high activity of naturally-occurring Bb at some sites (primarily sites at high elevations with humid, moderate-temperature environments and dense pest populations), these fungi did not prevent CBB from exceeding the economic threshold for commercial spray applications. Nevertheless, the high natural epizootic potential of these fungal strains suggests strong potential for development as microbial biocontrol agents.

A global map of travel time to cities to assess inequalities in accessibility in 2015.

The economic and man-made resources that sustain human wellbeing are not distributed evenly across the world, but are instead heavily concentrated in cities. Poor access to opportunities and services offered by urban centres (a function of distance, transport infrastructure, and the spatial distribution of cities) is a major barrier to improved livelihoods and overall development. Advancing accessibility worldwide underpins the equity agenda of 'leaving no one behind' established by the Sustainable Development Goals of the United Nations. This has renewed international efforts to accurately measure accessibility and generate a metric that can inform the design and implementation of development policies. The only previous attempt to reliably map accessibility worldwide, which was published nearly a decade ago, predated the baseline for the Sustainable Development Goals and excluded the recent expansion in infrastructure networks, particularly in lower-resource settings. In parallel, new data sources provided by Open Street Map and Google now capture transportation networks with unprecedented detail and precision. Here we develop and validate a map that quantifies travel time to cities for 2015 at a spatial resolution of approximately one by one kilometre by integrating ten global-scale surfaces that characterize factors affecting human movement rates and 13,840 high-density urban centres within an established geospatial-modelling framework. Our results highlight disparities in accessibility relative to wealth as 50.9% of individuals living in low-income settings (concentrated in sub-Saharan Africa) reside within an hour of a city compared to 90.7% of individuals in high-income settings. By further triangulating this map against socioeconomic datasets, we demonstrate how access to urban centres stratifies the economic, educational, and health status of humanity.

Using routine blood test results to predict the risk of death for emergency medical admissions to hospital: an external model validation study.

BACKGROUND: The Biochemistry and Haematology Outcome Model (BHOM) relies on the results from routine index blood tests to predict the patient risk of death. We aimed to externally validate the BHOM model. METHOD: We considered all emergency adult medical patients who were discharged from Northern Lincolnshire and Goole (NLAG) hospital in 2014. We compared patient characteristics between NLAG (the validation sample) and the hospital where BHOM was developed. We evaluated the predictive performance, according to discriminative ability (with a concordance statistic, c), and calibration (agreement between observed and predicted risk). RESULT: There were 29 834 emergency discharges of which 24 696 (83%) had complete data. In comparison with the development sample, the NLAG sample was similar in age, blood test results, but experienced a lower mortality (4.7 vs. 8.7%). When applied to NLAG, the BHOM model had good discrimination (c-statistic 0.83 [95% CI 0.823-0.842]). Calibration was good overall, although the BHOM model overpredicted for lowest (<5%, observed = 229, predicted = 286) and highest (≥50%, observed = 31, predicted = 49) risk groups, even after recalibrating for the differences in baseline risk of death. CONCLUSION: Differences in patient case-mix profile and baseline risk of death need to be considered before the BHOM model can be used in another hospital. After re-calibrating for the baseline difference in risk the BHOM model had good discrimination but less adequate calibration.

The end for the 'Roman Sandal': an observational study of methods of securing chest drains in a deployed military setting.

INTRODUCTION: There is ongoing debate regarding the optimal method of securing chest drains in trauma patients. Various courses describe methods for chest drain insertion, but little has been published to identify the best method to secure the drain. AIM: This article aims to examine differences in approach to securing chest drains and the security of the methods used. METHOD: Whilst in a deployed medical treatment facility, 26 clinicians from various specialties and nationalities were asked to secure a pre-placed drain. A 32F drain was placed in a manikin and the clinicians were given a chance to prepare their equipment. They were given a choice of suture and their attempts were observed by one of the researchers. The attempts were timed and photographed. A second researcher, who had not observed the technique, then assessed the security of the drain. RESULTS: 15/26 clinicians used a 'Roman Sandal' technique with 5/26 proving to be insecure. Other techniques used showed no failure. The rate of consultant-secured failure was 12.5% compared to 40% for registrars and 33% for General Duties Medical Officers. CONCLUSIONS: The type of suture used made no difference, but the traditional 'Roman Sandal' method was insecure. Knots tied close to the skin and those that bit into the drain were shown to be most effective.

The management of the acutely swollen ankle.

Patients presenting with an acutely swollen ankle are common in both the military and civilian settings. Accurate diagnosis is vital, as there are various potentially serious causes. This article aims to review the common causes of an acutely swollen ankle, as well as the rarer causes, with their significant consequences.

Significant neurological presentations in commando trained personnel: case studies and consideration of differential diagnosis.

A 27-year-old Royal Marine presented to his sickbay following two episodes of sudden onset visual disturbance. A subsequent MRI Scan demonstrated ischaemic changes in the territory of his right posterior cerebral artery. Transthoracic echocardiography was normal but a bubble contrast study was strongly positive indicating the presence of a relatively large patent foramen ovale (PFO). He underwent endovascular closure of his patent foramen ovale and was subsequently upgraded back to full duties. A 35-year-old Army Sergeant presented with sudden onset collapse, right sided weakness, dysarthria and confusion. He was airlifted to a Host Nation hospital and following a normal CT head underwent thrombolysis in the Emergency Department. This was unsuccessful but a CT guided embolectomy led to complete resolution of symptoms. Subsequent transthoracic echo revealed a PFO. He underwent endovascular closure and has since been returned to full duties. The incidence of PFO is common affecting 27% of the population but the incidence of ischaemic stroke in young adults (aged 15-45 years old) is rare. This maybe linked to the size of the PFOs in symptomatic individuals. These case reports emphasise the requirement for further investigation of individuals presenting with collapse and persisting neurology. Differential diagnosis and initial management for primary care and pre-hospital clinicians is also reviewed.

Surgery in an Afghan population: is pictorial consent and injury pattern recognition identification of patients appropriate?

OBJECTIVE: The aim of this study was to develop a safe way to obtain informed consent and ensure the correct patient was operated on in a generally poorly educated, non-English speaking Afghan patient population admitted to a military role 2 (enhanced) hospital facility. SUMMARY BACKGROUND DATA: Prior to Herrick 9, surgical consent for Afghan patients was obtained via an interpreter in the traditional manner and documented on a U.K. formatted consent form (MOD form 660) (group 1) with patient identification largely being the responsibility of the interpreter. Patient agreement was documented by placing a thumbprint on the form. During Herrick 9, pictorial consent and injury pattern recognition (IPR) identification of patients was introduced. The consent was written as part of the case note narrative with diagrammatic representation of the injuries and the proposed surgery, which was explained by the interpreter (Group 2). METHODS: We compared the consent and identification process for ten consecutive patients from each group. Each method of consent was examined for documentary evidence of the procedure, patient identification and method of patient agreement. The senior Afghan interpreter was asked for his personal views on the benefit or otherwise of the pictorial consent. RESULTS: For group 1, each of the nine MOD form 660s were completed in English by the operating surgeon and included details of the procedure. Seven had been signed by the interpreter. Each had a thumbprint on the form but there was no name or date alongside it. There was no way of confirming that the thumbprint was that of a particular patient. For group 2, pictorial consent was documented in the narrative with specific documentation of the injury pattern of that patient. Confirmation of consent and patient identification by IPR was by the operating surgeon. CONCLUSIONS: When possible, informed consent is required for all patients undergoing surgery in line with Department of Health guidelines. The use of pictorial consent and IPR identification, as part of patient documentation, would appear to be superior in this particular environment.

Determination of the N=16 shell closure at the oxygen drip line.

The neutron unbound ground state of (25)O (Z=8, N=17) was observed for the first time in a proton knockout reaction from a (26)F beam. A single resonance was found in the invariant mass spectrum corresponding to a neutron decay energy of 770_+20(-10) keV with a total width of 172(30) keV. The N=16 shell gap was established to be 4.86(13) MeV by the energy difference between the nu1s(1/2) and nu0d(3/2) orbitals. The neutron separation energies for (25)O agree with the calculations of the universal sd shell model interaction. This interaction incorrectly predicts an (26)O ground state that is bound to two-neutron decay by 1 MeV, leading to a discrepancy between the theoretical calculations and experiment as to the particle stability of (26)O. The observed decay width was found to be on the order of a factor of 2 larger than the calculated single-particle width using a Woods-Saxon potential.

Selective population and neutron decay of an excited state of 23O.

We have observed a resonance in neutron-fragment coincidence measurements that is presumably the first excited state of 23O at 2.8(1) MeV excitation energy which decays into the ground state of 22O. This interpretation is consistent with theory. The reaction mechanism supports the assignment of the observed state as the 5/2+ hole state. This assignment and the recently observed 3/2+ particle state advance the understanding of 23O.

A fluorescence polarization assay for inhibitors of Hsp90.

Hsp90 encodes a ubiquitous molecular chaperone protein conserved among species which acts on multiple substrates, many of which are important cell-signaling proteins. Inhibition of Hsp90 function has been promoted as a mechanism to degrade client proteins involved in tumorigenesis and disease progression. Several assays to monitor inhibition of Hsp90 function currently exist but are limited in their use for a drug discovery campaign. Using data from the crystal structure of an initial hit compound, we have developed a fluorescence polarization assay to monitor binding of compounds to the ATP-binding site of Hsp90. This assay is very robust (Z' > 0.9) and can detect affinity of compounds with IC50s to 40 nM. We have used this assay in conjunction with cocrystal structures of small molecules to drive a structure-based design program aimed at the discovery and optimization of a novel class of potent Hsp90 inhibitors.

Psychological factors and hyperemesis gravidarum.

Hyperemesis gravidarum (HG) is a condition of severe, intractable nausea and vomiting during pregnancy. It has long been held that HG is a psychosomatic illness reflective of a long-term psychological trait, that is, conversion disorder. We investigated this possibility by conducting a two-phase study: (1) a comparison of women with (n = 9) and without (n = 10) HG during pregnancy and (2) a comparison of nonpregnant women who did (n = 10) and did not (n = 12) have HG during their most recent pregnancies. The pattern of findings differed between experiments 1 and 2. During pregnancy, women with HG scored significantly higher on three scales associated with conversion disorder (all p values <0.01) than did women without HG. There were no significant differences between HG subjects and controls after pregnancy. We find no support for the theory that HG is a psychosomatic condition. Rather, it appears to be a complex interaction of biological, psychological, and sociocultural factors.

Demonstration of biofilm in infectious crystalline keratopathy using ruthenium red and electron microscopy.

OBJECTIVE: Bacterial biofilm formation has been implicated in the pathogenesis of infectious crystalline keratopathy. Biofilm cannot be visualized by electron microscopy without the addition of a fixative that stabilizes the polysaccharide-rich bacterial extracellular matrix that surrounds the bacterial colonies in a biofilm. We used ruthenium red as a fixative to evaluate corneal biopsy specimens for the presence of bacterial biofilm in three cases of infectious crystalline keratopathy (ICK) and five cases of chronic microbial keratitis without crystalline changes. DESIGN: Case series with clinicopathologic correlation. PARTICIPANTS: Eight patients underwent corneal biopsy or therapeutic keratoplasty as part of their management for chronic unresponsive microbial keratitis. METHODS: The corneal specimens removed were trisected for microbiology, pathology, and transmission electron microscopy (TEM). The TEM specimens were fixed in 2.5% glutaraldehyde in 0.1 M sodium cacodylate buffer with 0.05% ruthenium red. MAIN OUTCOME MEASURES: Demonstration of bacterial biofilm with TEM. RESULTS: TEM demonstrated organisms with a surrounding extracellular matrix consistent with a bacterial biofilm in the three cases of ICK but not in the five other cases of chronic microbial keratitis. CONCLUSIONS: The presence of biofilm in ICK can be demonstrated with TEM with appropriate fixation techniques that stabilize the bacterial extracellular matrix. Biofilm stains intensely with periodic acid-Schiff because of the polysaccharide-rich extracellular matrix and weakly with Gram stain because of the high proportion of nonviable organisms. Biofilm formation occurs in ICK but probably not in chronic bacterial keratitis without crystalline changes. Secretion of an extracellular matrix by bacteria to form a biofilm is a response to a nutrient-deprived environment in which growth and replication is depressed. The extracellular matrix of the biofilm may mask bacterial antigens, explaining the relative lack of inflammatory response in these infections. It may also be one of the mechanisms explaining the resistance to in vivo antimicrobial therapy when in vitro sensitivities have been proven.

Pattern formation: Wingless on the move.

Wingless is a key morphogen in Drosophila. Although it is evident that Wingless acts at a distance from its site of synthesis, there is considerable debate about how the protein travels across a field of cells. Recent studies have provided important new insights into this process, though the issue is still far from being resolved.