The novel application of the Lightning Process to treat Long COVID in primary care - Case report.

As a result of the COVID-19 pandemic, Long COVID (LC) is now prevalent in many countries. Little evidence exists regarding how this chronic condition should be treated, but guidelines suggest for most people it can be managed symptomatically in primary care. The Lightning Process is a trademarked positive psychology focused self-management programme which has shown to be effective in reducing fatigue and accompanying symptoms in other chronic conditions including Chronic Fatigue Syndrome/Myalgic Encephalomyelitis. Here we outline its novel application to two patients with LC who both reported improvements in fatigue and a range of physical and emotional symptoms post-treatment and at 3 months follow-up.

The Royal College of Surgeons of England Damage Control Orthopaedic Trauma Skills course (DCOTS): resuscitative knowledge and confidence in surgical skills are reliably maintained at six months post course.

INTRODUCTION: Since 2012, the Damage Control Orthopaedic Trauma Skills course (DCOTS) has trained more than 250 surgeons in the principles and practice of damage control orthopaedics and early appropriate care. This Royal College of Surgeons of England (RCS England) course takes place at the RCS England Partner cadaver laboratory at Brighton and Sussex Medical School. Trauma is a leading cause of morbidity and mortality in the UK, and the course has tried to pass on the lessons of war and conflict from its military faculty and hard-won lessons of "developed world" trauma from its experienced civilian faculty. METHODS: Participating surgeons were invited to score their self-reported confidence before attending the DCOTS course, immediately afterwards and again 6 months later. A modified four-point Likert scale was used, with responses from 1 = No Confidence to 4 = Very Confident. Damage control resuscitation principles with damage control surgery showed the greatest retained increase at 6 months - 100% - which is extremely satisfying. RESULTS: Self-reported confidence in pelvic external fixation was initially 93% dropping to 85%, which is also considered good to excellent. For pelvic packing, confidence was 90% at the end of the course, up from 19% precourse. This dropped to 62%, which was still considered good but low for the high standards of the course. This may relate to UK trainees' lack of familiarity with the concept. CONCLUSIONS: Three of the main skills taught on the DCOTS are effectively retained at 6 months post course.

Broström Repair With and Without Augmentation: Comparison of Outcomes at Median Follow-up of 5 Years.

BACKGROUND: An augmented Broström repair with nonabsorbable suture tape has demonstrated strength and stiffness more similar to the native anterior talofibular ligament (ATFL) compared to Broström repair alone at the time of repair in cadaveric models for the treatment of lateral ankle instability. The study purpose was to compare minimum 2-year patient-reported outcomes (PROs) following treatment of ATFL injuries with Broström repair with vs without suture tape augmentation. METHODS: Between 2009 and 2018, patients >18 years old who underwent primary surgical treatment for an ATFL injury with either a Broström repair alone (BR Cohort) or Broström repair with suture tape augmentation (BR-ST Cohort) were identified. Demographic data and PROs, including Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sport subscales, 12-Item Short Form Health Survey (SF-12), Tegner Activity Scale, and patient satisfaction with surgical outcome, were compared between groups, and proportional odds ordinal logistic regression was used. RESULTS: Ninety-one of 102 eligible patients were available for follow-up at median 5 years. The BR cohort had 50 of 53 patients (94%) completed follow-up at a median of 7 years. The BR-ST cohort had 41 of 49 (84%) complete follow-up at a median of 5 years. There was no significant difference in median postoperative FAAM ADL (98% vs 98%, P = .67), FAAM sport (88% vs 91%, P = .43), SF-12 PCS (55 vs 54, P = .93), Tegner score (5 vs 5, P = .64), or patient satisfaction (9 vs 9, P = .82). There was significantly higher SF-12 MCS (55.7 vs 57.6, P = .02) in the BR-ST group. Eight patients underwent subsequent ipsilateral ankle surgery, of which one patient (BR-ST group) was revised for recurrent lateral ankle instability. CONCLUSION: At median 5 years, patients treated for ATFL injury of the lateral ankle with Broström repair with suture tape augmentation demonstrated similar patient-reported outcomes to those treated with Broström repair alone. LEVEL OF EVIDENCE: Level II, retrospective cohort study.

ACLR and military service: time to rethink?

Anterior cruciate ligament (ACL) rupture is a common injury that affects young, active individuals, normally managed with reconstruction in this age group. Current UK Armed Forces policy precludes prospective applicants from joining with an anterior cruciate ligament reconstruction (ACLR). This isdue to the perceived risk of premature osteoarthritis (OA), graft rupture or clinical failure, all of which could make the service person medically non-deployable.The most recent evidence shows that an ACL rupture without associated significant meniscal or osteochondral defect has a similar likelihood of developing OA as to that of the uninjured knee after reconstruction at 20 years postoperatively.Applicants should be considered for service following an ACL rupture without significant concurrent meniscal or osteochondral defect who have undergone ACLR and 18 months of rehabilitation. We recommend these applicants to be graded P2 Medically Fully Deployable (MFD) as per the Joint Service Publication (JSP) guidance for service personnel who undergo ACLR.

Abdominal Aortic Junctional Tourniquet - Stabilized (AAJTS) can be applied both successfully and rapidly by Combat Medical Technicians (CMTs).

BACKGROUND: 'Non-compressible' haemorrhage is the leading cause of preventable battlefield death, often requiring surgical or radiological intervention, which is precluded in the pre-hospital environment. One-fifth of such bleeds are junctional and therefore potentially survivable. We examine the use of the Abdominal Aortic Junctional Tourniquet - Stabilized (AAJTS) among UK Combat Medical Technicians (CMTs) as a device to control junctional haemorrhage with external compression of the abdominal aorta-compression of junctional haemorrhage previously considered 'non-compressible.' This follows animal studies showing that the AAJTS achieves control of haemorrhage and improves physiological parameters. METHODS: CMTs were selected and applied the AAJTS to each other following a 1-hour training package. A consultant radiologist-operated hand-held ultrasound monitored flow changes in the subjects' common femoral artery. CMTs were then surveyed for their opinions as to utility and function. RESULTS: 21 CMTs were screened and 17 CMTs participated with 34 total applications (16 day and 18 low-light). 27/34 (79%) achieved a successful application. The median application time was 75 s in daylight and 57 s in low-light conditions. There was no significant difference in Body Mass Index (p=0.23), median systolic blood pressure (p=0.19), nor class of CMT (p=0.10) between successful and unsuccessful applications. Higher systolic blood pressure was associated with longer application times (p=0.03). Users deemed the device easy to use (median score 4.4 on a 5-point Likert scale). CONCLUSION: CMTs can use AAJTS successfully after a 1-hour training session in the majority of applications. Application was successful in both daylight and low-light conditions. Self-reported usability ratings were high.

Scale-up of the Internet-based Professional Learning to help teachers promote Activity in Youth (iPLAY) intervention: a hybrid type 3 implementation-effectiveness trial.

BACKGROUND: Whole-of-school programs have demonstrated success in improving student physical activity levels, but few have progressed beyond efficacy testing to implementation at-scale. The purpose of our study was to evaluate the scale-up of the 'Internet-based Professional Learning to help teachers promote Activity in Youth' (iPLAY) intervention in primary schools using the RE-AIM framework. METHODS: We conducted a type 3 hybrid implementation-effectiveness study and collected data between April 2016 and June 2021, in New South Wales (NSW), Australia. RE-AIM was operationalised as: (i) Reach: Number and representativeness of students exposed to iPLAY; (ii) Effectiveness: Impact of iPLAY in a sub-sample of students (n = 5,959); (iii) Adoption: Number and representativeness of schools that received iPLAY; (iv) Implementation: Extent to which the three curricular and three non-curricular components of iPLAY were delivered as intended; (v) Maintenance: Extent to which iPLAY was sustained in schools. We conducted 43 semi-structured interviews with teachers (n = 14), leaders (n = 19), and principals (n = 10) from 18 schools (11 from urban and 7 from rural locations) to determine program maintenance. RESULTS: Reach: iPLAY reached ~ 31,000 students from a variety of socio-economic strata (35% of students were in the bottom quartile, almost half in the middle two quartiles, and 20% in the top quartile). EFFECTIVENESS: We observed small positive intervention effects for enjoyment of PE/sport (0.12 units, 95% CI: 0.05 to 0.20, d = 0.17), perceptions of need support from teachers (0.26 units, 95% CI: 0.16 to 0.53, d = 0.40), physical activity participation (0.28 units, 95% CI: 0.10 to 0.47, d = 0.14), and subjective well-being (0.82 units, 95% CI: 0.32 to 1.32, d = 0.12) at 24-months. Adoption: 115 schools received iPLAY. IMPLEMENTATION: Most schools implemented the curricular (59%) and non-curricular (55%) strategies as intended. Maintenance: Based on our qualitative data, changes in teacher practices and school culture resulting from iPLAY were sustained. CONCLUSIONS: iPLAY had extensive reach and adoption in NSW primary schools. Most of the schools implemented iPLAY as intended and effectiveness data suggest the positive effects observed in our cluster RCT were sustained when the intervention was delivered at-scale. TRIAL REGISTRATION: ACTRN12621001132831.

Delay in Knee MRI Scan Completion Since Implementation of the Affordable Care Act:: A Retrospective Cohort Study.

INTRODUCTION: The most impactful resolutions of the Patient Protection and Affordable Care Act (ACA) took effect on January 1, 2014. The clinical and economic effects are widely experienced by orthopaedic surgeons, but are not well quantified. We proposed to evaluate the effect of the ACA on the timing of MRI for knee pathology before and after implementation of the legislation. METHODS: We conducted a retrospective analysis of all knee MRIs done at our institution from 2011 to 2016 (3 years before and after ACA implementation). The MRI completion time was calculated by comparing the dates of initial clinical evaluation and MRI completion. The groups were subdivided based on insurance payer status (Medicare, Medicaid, and commercial payers). The cohorts were compared to determine differences in average completion time and completion rates at time intervals from initial clinic visit before and after ACA implementation. RESULTS: MRI scans of 5,543 knees were included, 3,157 (57%) before ACA implementation and 2,386 (43%) after. There was a 5.6% increase in Medicaid cohort representation after ACA implementation. Patients waited 14 days longer for MRIs after ACA implementation (116 versus 102 days). There were increased completion times for patients in the commercial payer (113 versus 100 days) and Medicaid (131 versus 96 days) groups. Fewer patients had received MRI after ACA implementation within 2, 6, and 12 weeks of their initial clinic visits. DISCUSSION: The time between initial clinical evaluation and MRI scan completion for knee pathology markedly increased after ACA implementation, particularly in the commercial payer and Medicaid cohorts. Additional studies are needed to determine the effect of longer wait times on patient satisfaction, delayed treatment, and increased morbidity. As healthcare policy changes continue, their effects on orthopaedic patients and providers should be closely scrutinized. LEVEL OF EVIDENCE: Level III-Retrospective cohort study.

Image-Guided Transvaginal and Transabdominal Drain Placement for Surgical Navigation in a Patient with Tubo-Ovarian Abscess and Obstructed Hemivagina and Ipsilateral Renal Anomaly Syndrome.

BACKGROUND: We describe a minimally invasive, image-guided technique for obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome complicated by tubo-ovarian abscess (TOA). CASE: A 15-year-old female adolescent with OHVIRA syndrome presented with TOA. Magnetic resonance imaging of the abdomen/pelvis showed a loculated pelvic mass and fluid collection near the obstructed left hemivagina. Tissue quality and ill-defined surgical planes prevented surgical excision. A transabdominal drain was placed via laparoscopic port by Interventional Radiology. She later underwent transvaginal and transabdominal drain placement into the hemivaginal collection using computed tomography and ultrasound guidance, allowing for surgical excision of the vaginal septum, drainage and excision of the TOA, and neosalpingostomy. SUMMARY AND CONCLUSION: Because of the anatomic complexity in OHVIRA syndrome, preoperative minimally invasive techniques with Interventional Radiology collaboration can assist intraoperative anatomic navigation for successful surgical treatment.

Combat Application Tourniquet fares well in a chemical, biological, radiological or nuclear dress state.

INTRODUCTION: There is a need for a military tourniquet to control catastrophic haemorrhage in a chemical, biological, radiological or nuclear (CBRN) threat environment. No published data exist as to the efficacy of tourniquets while wearing British military CBRN individual protective equipment (IPE). METHODS: 12 volunteers from the counter CBRN instructors' course allowed testing on 24 legs. A Combat Application Tourniquet (C-A-T) was applied to all volunteers at the level of the midthigh. 12 legs were tested while wearing CBRN IPE (both operator and simulated casualty), and the control group of 12 legs was tested while wearing conventional combat dress state (both operator and simulated casualty). The order of leg laterality and dress state were sequenced according to a prerandomised system. Efficacy was measured via use of an ultrasound probe at the popliteal artery. Tourniquets were considered effective if arterial flow was completely occluded on ultrasound imaging. Data were collected on time to successful application, failure of tourniquets and pain scores as rated by the visual analogue scale (1-10). RESULTS: There were no failures of tourniquet application in the CBRN group, and two failures (17%) in the control group. Failures were pain threshold exceeded (n=1) and tourniquet internal strap failure (n=1). The mean application time for the CBRN group was 28.5 s (SD 11.7) and 23.7 s (SD 9.8) for the conventional combat group. There was no statistically significant difference (p=0.27). The median CBRN pain score was 2.0 (IQR 2.0-3.5). The median control pain score was 4.0 (IQR 3-6). This was a statistically significant difference (p=0.002). CONCLUSION: C-A-Ts applied to simulated casualties in CBRN IPE at the midthigh are at least as efficacious as those applied to the midthigh in a conventional combat dress state. The pain experienced was less in CBRN IPE than when in a conventional combat dress state.

A systematic review of the evidence base for the Lightning Process.

BACKGROUND: The Lightning Process (LP), a mind-body training programme, has been applied to a range of health problems and disorders. Studies and surveys report a range of outcomes creating a lack of clarity about the efficacy of the intervention. OBJECTIVE: This systematic review evaluates the methodological quality of existing studies on the LP and collates and reviews its reported efficacy. DATA SOURCES: Five databases, PsycINFO, PubMed, CINAHL, Embase, ERIC (to September 2018), and Google and Google Scholar were searched for relevant studies. STUDY SELECTION: Studies of the LP in clinical populations published in peer-reviewed journals or in grey literature were selected. Reviews, editorial articles and studies/surveys with un-reported methodology were excluded. DATA EXTRACTION: Searches returned 568 records, 21 were retrieved in full text of which 14 fulfilled the inclusion criteria (ten quantitative studies/surveys and four qualitative studies). DATA SYNTHESIS AND CONCLUSIONS: The review identified variance in the quality of studies across time; earlier studies demonstrated a lack of control groups, a lack of clarity of aspects of the methodology and potential sampling bias. Although it found a variance in reported patient outcomes, the review also identified an emerging body of evidence supporting the efficacy of the LP for many participants with fatigue, physical function, pain, anxiety and depression. It concludes that there is a need for more randomised controlled trials to evaluate if these positive outcomes can be replicated and generalised to larger populations.

Acute and subacute effects of a synthetic kisspeptin analog, C6, on serum concentrations of luteinizing hormone, follicle stimulating hormone, and testosterone in prepubertal bull calves.

Kisspeptin (KP) is a neuropeptide integral in regulating puberty and gonadotropin releasing hormone. Compound 6 (C6), a KP analog, is more potent in vitro, has a longer half-life, and may have greater therapeutic applications than KP. To determine the acute and subacute effects of KP and C6 on serum concentrations of luteinizing hormone (LH), follicle stimulating hormones (FSH), and testosterone (T), prepubertal bull calves [12.1 ±â€¯1.1 (SD) weeks of age; 91.2 ±â€¯10.8 kg BW] were assigned to one of three treatment groups [Saline (n = 4), KP (n = 4; 20 nmoles), or C6 (n = 4; 20 nmoles). Treatments were administered intramuscularly once daily for four consecutive days. Blood samples were collected every 15 min for 6 h immediately following treatment administration on Day 1 (acute) and Day 4 (subacute). Serum concentrations of LH, FSH, and T were determined by radioimmunoassay. For each day, effects of treatment, time, and interactions on LH and FSH concentrations and pulse parameters were analyzed using procedures for repeated measures with JMP Software (SAS Inst. Inc., Cary, NC). There was a treatment × time interaction during Day 1 (P < 0.0001) and Day 4 (P = 0.02) such that LH concentrations were greatest following administration of C6 (albeit diminished during Day 4). Number of LH pulses were least (P = 0.02) and LH nadirs were highest (P = 0.04) following administration of C6 (P = 0.02). There was no effect of treatment (P = 0.95) or treatment × time interaction (P = 0.10) on serum FSH concentrations during Day 1. During Day 4 FSH concentrations (P = 0.02) and number of FSH pulses (P = 0.02) were least following administration of C6. There was no effect of treatment (P = 0.33), time (P = 0.19) or treatment × time interaction (P = 0.44) on T concentrations. In conclusion, acute and subacute C6 increased LH concentrations and subacute C6 decreased FSH concentrations and pulse parameters. Despite suppression of FSH with subacute daily administration of C6, altered frequency and timing of treatment with KP analogs may have application to affect the onset of puberty in livestock.

Surveillance of Arboviruses in Primates and Sloths in the Atlantic Forest, Bahia, Brazil.

From 2006 through 2014, we conducted seroepidemiological surveys on non-human primates and sloths to investigate the possible circulation of arboviruses in Bahia Atlantic Forest, Brazil. We collected a total of 196 samples from 103 Leontopithecus chrysomelas, 7 Sapajus xanthosternos, 22 Bradypus torquatus and 7 Bradypus variegatus. Serum samples were tested using neutralization test and hemagglutination inhibition test to detect total antibodies against 26 different arboviruses. The overall prevalence of arboviruses was 36.6% (51/139), with the genus Flavivirus having the highest prevalence (33.1%; 46/139), followed by Phlebovirus (5.0%; 7/139), Orthobunyavirus (4.3%; 6/139) and Alphavirus (0.7%; 1/139). Monotypic reactions suggest that the wild animals were exposed naturally to at least twelve arboviruses. Added results from the neutralization test, animals were exposed to thirteen arboviruses. Most of these viruses are maintained in transmission cycles independent of human hosts, although antibodies against dengue virus serotypes 1, 2 and 3 were found in this study. To our knowledge, this is the first study reporting exposure to arboviruses in L. chrysomelas, S. xanthosternos and B. torquatus. Our results also highlight that the Southern Bahia Atlantic Forest has a variety of vertebrate hosts and potential vectors, which may support the emergence or re-emergence of arboviruses, including those pathogenic to humans.

Prospective use of unmanned aerial vehicles for military medical evacuation in future conflicts.

In order to continue to deliver outstanding medical care on the battlefield, the UK Defence Medical Services must continue to adapt, overcome and actively embrace change. One potential area is the rapid proliferation and sophistication of automated and remote systems such as unmanned aerial vehicles (UAVs). UAVs are already used to deliver blood to remote military locations in Afghanistan and defibrillators to those that need them in the USA and Sweden. An area of future opportunity would be to facilitate rapid evacuation of wounded personnel from high intensity, high threat, remote and austere areas directly to specialist care. Such a capability would reduce threat to human life while allowing rapid extraction of casualties from high risk or inaccessible environments straight back to Role 3 care, all of which in these situations is either not possible or carries too much risk using conventional aerial assets. The article aims to highlight a potential future capability, stimulate debate and reflection, all of which is essential for innovation and future organisational development. The potential uses and benefits of UAVs are highlighted including both the challenges and rewards of utilising UAVs for casualty evacuation. Key benefits are reduced risk to human life, cost, ability to insert into areas conventional aircraft cannot and the rapidity of transfer. Challenges are likely to be airspace management, decisions on appropriate level of care to deliver during transit and ultimately user acceptability. The article also highlights that in order to maximise our ability to exploit new technologies, all arms and trades within the military must be involved in collective research and development. Furthermore, sensible corroboration with private companies will further enhance our ability to acquire products that best serve our needs.

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.

Group O low titre only emergency donor panels for small combat teams.

INTRODUCTION: Military elements increasingly operate in small teams in remote areas with no immediate blood product support. Planners and operators may endorse collection of fresh whole blood from pretested donors in emergency situations. The biggest risk of transfusion is the accidental use of ABO incompatible blood which can be fatal. The risk may be mitigated by using only group O LOw (OLO) titre donors with plasma containing low levels of the naturally occurring antibody to group A and B red cells. This paper reviews the ABO blood group distribution in potential blood donors from a high readiness UK medical regiment and explores the feasibility of using only group OLO donors in small teams. METHODS: A retrospective review of routine volunteer blood donor samples was undertaken at 6 monthly intervals during a 2-year period. Personnel were tested in groups when available during training to create multiple donor panels to simulate small teams. RESULTS: 206 donation samples were collected from 157 potential donors. All donors were acceptable based on the lifestyle questionnaire, serology and microbiology screen. Of the 206 samples reviewed, 85 (41%) were group O (D pos and D neg). 14 group O (16.5%) were shown to have high titre of anti-A or B. Therefore, 71, that is, 34% overall were suitable as OLO donors. The donor panel size varied from 15 to 44. The absolute number of OLO donors in each panel ranged from 4 to 17 and the number of O neg donors was 0-3. CONCLUSION: A third of samples were suitable as OLO donors; however, there were insufficient 'universal' donors within smaller subgroups (<10). In this situation, we recommend the careful use of both group O and group A donors or the use of a buddy-buddy blood group matrix.

STAT4 expression and activation is increased during mitosis in vitro and in vivo in skin- and mucosa-derived cell types: implications in neoplastic and inflammatory skin diseases.

BACKGROUND: The signal transducer and activator of transcription-4 (STAT4/Stat4) is a transcription factor known to convey signals from interleukin-12, interleukin-23, and interferon-alpha/beta to the nucleus, resulting in activation of dendritic cells, T-helper cell differentiation and production of interferon-gamma. OBJECTIVE: To demonstrate a novel role for STAT4 in cell mitosis. RESULTS: Phosphoserine STAT4 (pSerSTAT4) is increased in cells undergoing mitosis and is distributed throughout the cytoplasm during this stage of the cell cycle, whilst phosphotyrosine STAT4 (pTyrSTAT4) is confined to the chromosomal compartment. This distinct pattern of pSerSTAT4 during mitosis is seen in vitro in human keratinocytes and in other cell types. This is also present in vivo in cells undergoing mitosis in normal skin, psoriasis and squamous cell carcinoma. Inhibition of STAT4 phosphorylation by lisofylline and depletion of STAT4 by RNA interference results in a delay in progression of mitosis and leads to a reduction in cells completing cytokinesis. CONCLUSION: Our data demonstrate that STAT4 plays a role in enabling the normal and timely division of cells undergoing mitosis.

The impact of sleep deprivation in military surgical teams: a systematic review.

BACKGROUND: Fatigue in military operations leads to safety and operational problems due to a decrease in alertness and performance. The primary method of counteracting the effects of sleep deprivation is to increase nightly sleep time, which in operational situations is not always feasible. History has taught us that surgeons and surgical teams are finite resources that cannot operate on patients indefinitely. METHODS: A systematic review was conducted using the search terms 'sleep' and 'deprivation' examining the impact of sleep deprivation on cognitive performance in military surgical teams. Studies examining outcomes on intensive care patients and subjects with comorbidities were not addressed in this review. RESULTS: Sleep deprivation in any 'out-of-hours' surgery has a significant impact on overall morbidity and mortality. Sleep deprivation in surgeons and surgical trainees negatively impacts cognitive performance and puts their own and patients' health at risk. All published research lacks consensus when defining 'sleep deprivation' and 'rested' states. It is recognised that it would be unethical to conduct a well-designed randomised controlled trial, to determine the effects of fatigue on performance in surgery; however, there is a paucity between surrogate markers and applying simulated results to actual clinical performance. This requires further research. Recommended methods of combating fatigue include: prophylactically 'sleep-banking' prior to known periods of sleep deprivation, napping, use of stimulant or alerting substances such as modafinil, coordinated work schedules to reduce circadian desynchronisation and regular breaks with enforced rest periods. CONCLUSIONS: A forward surgical team will become combat-ineffective after 48 hours of continuous operations. This systematic review recommends implementing on-call periods of no more than 12 hours in duration, with adequate rest periods every 24 hours. Drug therapies and sleep banking may, in the short term, prevent negative effects of acute sleep deprivation.

Contrast sonovenography - Is this the answer to complex deep vein thrombosis imaging?

BACKGROUND: Deep vein thrombosis (DVT) is a potentially fatal condition causing significant morbidity and mortality in the patient population. Ultrasound (USS) is the mainstay for detecting DVT. This can sometimes be difficult in hostile limbs due to factors such as large body habitus and oedema. This pilot study investigated contrast-enhanced ultrasound (CEUS) as a viable method to improve visualisation of the venous system of the lower limb. METHODS: Patients at high risk for DVT were selected after an initial negative USS. A follow-up scan was performed 1 week later utilising standard B-mode imaging with a curvilinear 3-5 MHz transducer array. After the fundamental scan, intravenous Sonovue™ contrast was administered and visualisation of the proximal limb veins and visualisation gains in distance were mapped onto a proforma. RESULTS: Twelve patients were selected. Visualisation was not improved in the common femoral vein (CFV) but increases in full visualisation were demonstrated in the femoral vein (FV) and popliteal vein (Pop V) from (n = 8) 67% and (n = 10) 83-100% in both veins, respectively. Significant gains in visualisation distance were observed in the posterior tibial vein (PTV) (p = 0.0005) and peroneal vein (Per V) (p = 0.02) with increased full visualisation of the Per V from (n = 3) 25% to (n = 7) 58%. CONCLUSION: CEUS is a viable and clinically safe method for increasing visualisation of the deep venous system. It has the potential to improve visualisation of the lower limb venous system, reducing follow-up costs and diagnostic uncertainty for patients and the clinician.

Demystifying damage control in musculoskeletal trauma.

Trauma care has evolved rapidly over the past decade. The benefits of operative fracture management in major trauma patients are well recognised. Concerns over early total care arose when applied broadly. The burden of additional surgical trauma could constitute a second hit, fuelling the inflammatory response and precipitating a decline into acute respiratory distress syndrome, sepsis and multiple organ dysfunction syndrome. Temporary external fixation aimed to deliver the benefits of fracture stabilisation without the risk of major surgery. This damage control orthopaedics approach was advocated for those in extremis and a poorly defined borderline group. An increasing understanding of the physiological response to major trauma means there is now a need to refine our treatment options. A number of large scale retrospective reviews indicate that early definitive fracture fixation is beneficial in the majority of major trauma patients. It is recommended that patients are selected appropriately on the basis of their response to resuscitation. The hope is that this approach (dubbed 'safe definitive fracture surgery' or 'early appropriate care') will herald an era when care is individualised for each patient and their circumstances. The novel Damage Control in Orthopaedic Trauma Surgery course at The Royal College of Surgeons of England aims to equip senior surgeons with the insights and mindset necessary to contribute to this key decision making process as well as also the technical skills to provide damage control interventions when needed, relying on the improved techniques of damage control resuscitation and advances in the understanding of early appropriate care.