Repatriation for diseases or non-battle injuries (DNBI): long-term impact on quality of life.

INTRODUCTION: Throughout history, diseases and non-battle injuries (DNBI) have threatened deployed forces more than battlefield injuries. During the Dutch involvement in Afghanistan, the amount of DNBI that needed medical evacuation out of theatre (60%) exceeded the number of battle injuries (40%). The aim of this study is to explore the long-term quality of life (QoL) of Dutch service members that acquired a DNBI, warranting repatriation during their deployment to Afghanistan between 2003 and 2014. METHODS: Observational cross-sectional cohort study in a selected group of Dutch service members who deployed to Afghanistan 2003-2014 and were repatriated due to DNBI. Using the 36-item Short Form, EuroQol-6D, Symptom Checklist 90 and Post Deployment Reintegration Scale questionnaires, their outcomes were compared with a control group of deployed service members who did not sustain injuries or illnesses. RESULTS: Groups were comparable in age, rank, number of deployments and social status. There were significant differences found in terms of physical functioning, pain and health perspective. No differences were seen in emotional or psychological outcomes. CONCLUSION: The amount of military service members who contract a DNBI is significant and imposes a burden on the capacity of the medical support, readiness of deployed units and sustainability of ongoing operations. However, regarding QoL, being forced to leave their units and to be repatriated to their home country due to a DNBI seems to have no significant impact on reported psychological symptoms of distress and reintegration experiences. Future research should focus on more in-depth registration of illnesses and not combat related diseases and injuries and even longer-term outcomes.

Early CT scanning in the emergency department in patients with penetrating injuries: does it affect outcome?

BACKGROUND: To be a level I trauma center in the Netherlands a computed tomography (CT) scanner in the emergency department (ED) is considered desirable, as it is presumed that this optimizes the diagnostic process and that therapy can be directed based on these findings. Aim of this study was to assess the effects of implementing a CT scanner in the ED on outcomes in patients with penetrating injuries. METHODS: In this retrospective descriptive study, patients with penetrating injuries (shot and/or stab wounds), presented between 2000 and 2014 were analysed using the hospital's electronic database, and data from the West Netherlands trauma registry and the financial department. RESULTS: 405 patients were included: performing a CT scan upon arrival increased significantly from 26.7 to 67.0% (p = 0.00) after implementation of a CT scanner in the ED, with the mean cost of a CT being 96.85 euros. Overall mortality decreased from 6.9 to 3.7%, although not statistically significant. Intensive care unit admission (ICU-admission) and median hospital length of stay (H-LOS) decreased from 30.9 to 24.5% resp. 3.2 to 1.8 days (p ≤ 0.05). Overall mortality, adjusted for injury severity score (ISS), revised trauma score (RTS), and types of injuries, did not change significantly. CONCLUSION: Patients with penetrating injuries more often received a CT scan on admission after implementation of a CT scanner in the ED. Early CT scanning is useful since it significantly reduces ICU-admissions and decreases H-LOS. It is a cheap and non-invasive diagnostic tool with significant clinical impact, resulting in directed treatment, and improvement of outcomes.

Challenges in the training of military surgeons: experiences from Dutch combat operations in southern Afghanistan.

BACKGROUND: To improve care for battle casualties, we analyzed the surgical workload during the Dutch deployment to Uruzgan, Afghanistan. This surgical workload was compared with the resident surgical training and the pre-deployment medical specialist program. METHODS: Patient data from the trauma registry (2006-2010) at the Dutch Role 2 Medical Treatment Facility (MTF) were analyzed. The case logs of chief residents (n = 15) from the general surgery training program in the Netherlands were used for comparison. RESULTS: The trauma registry query yielded 2,736 casualties, among whom 60 % (1,635/2,736) were classified as disease non-battle casualties and 40 % (1,101/2,736) as battle casualties. During the study period, 1,427 casualties (336 pediatric cases) required 2,319 surgical procedures. Each graduating chief resident handled an average of 1,444 cases, including 165 laparotomies, 19 major vessel repairs, 28 amputations, and 153 fracture stabilizations, during their residency. Residents had limited exposure to injuries requiring a thoracotomy, craniotomy, nephrectomy, IVC repair, or external genital trauma. CONCLUSIONS: The injuries treated at the Dutch Role 2 MTF were often severe, and exposure to pediatric cases was much higher than reported for other combat hospitals in Iraq and in Afghanistan. The current civilian resident training does not equip the trainees with the minimally required competences of a fully trained military surgeon. The recognition in the Netherlands of military surgery as a subspecialty within general (trauma) surgery, with a formal training curriculum, should be considered. The introduction of a North Atlantic Treaty Organization Military (and Disaster) Surgery standard may facilitate the achievement of this aim.

[Pain in the symphyseal region after parturition: possibly osteomyelitis]. / Pijnklachten in de symfyseregio na een bevalling: mogelijk osteomyelitis.

A 29-year-old woman 3 weeks after her first childbirth suffered from atypical and progressive pain in the pelvis, which turned out to be a symptom of osteomyelitis of the pubic bone. She recovered after treatment with antibiotics and 6 weeks' stabilization of the pelvis. Symptoms of osteomyelitis resemble those of pubic osteitis, symphyseal rupture and symphysiolysis. Radiologically, osteomyelitis is characterized by development of infiltrates, cortical involvement and local osteopenia. Isolation of micro-organisms in a bone culture after puncture is regarded as proof of the diagnosis. The treatment is primarily with antibiotics, if abscesses or sequestra develop these should be relieved and/or removed.

[Catheter fracture and embolization: a rare complication of a permanent implanted intravenous catheter system]. / Katheterbreuk en -embolisatie: een zeldzame complicatie van een langdurig geïmplanteerd intraveneus kathetersysteem.

An implantable venous access system was used in a 55-year-old woman with metastatic breast cancer for the delivery of chemotherapy. Four months after implantation the catheter was resistant to the injection of fluids. A chest X-ray showed fracture of the catheter with embolisation to the right pulmonary artery. Analysis of the fractured catheter after removal showed that the fracture was caused by catheter pinch-off. Catheter pinch-off is caused by friction of the catheter between the clavicle and the first rib. The incidence of this rare complication is estimated at 0.1-1%. The incidence of catheter pinch-off can be reduced by a lateral insertion technique and by radiographic monitoring after implantation.

A uniform approach for esophagectomy with or without thoracotomy.

In patients with carcinoma of the esophagus, it is advisable to perform a total esophagectomy. We prefer a cervico-abdominal procedure and use the stomach to reconstruct the alimentary tract. Sometimes the operation needs to be extended with a right-sided thoracotomy. We have used this method of positioning and draping successfully in more than 70 patients in the last two years. This method enables us to perform a three stage operation if necessary without repositioning the patient and renewed preparation of the operative field.

Leiomyoma of the distal oesophagus mimicking achalasia.

An unusual case of a patient with symptoms suggestive of oesophageal achalasia is described. Most oesophageal tumour growths causing secondary achalasia are associated with malignant tumours. This patient had a large oesophageal leiomyoma closely mimicking achalasia. Treatment consisted of oesophagectomy by laparotomy and right-sided thoracotomy. A gastric tube was constructed with a cervical oesophago-gastrostomy. The patient responded well to the treatment and left the hospital after 13 days. Five other cases of benign oesophageal tumours inducing achalasia-like symptoms could be traced. Three of these were leiomyomas.