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An older adult patient was admitted with epigastric pain and vomiting and found to have an abdominal mass, increased cholestatic liver enzymes and markedly elevated serum lactate dehydrogenase (LDH). Imaging revealed extensive liver metastases of unknown primary but also an unusual splenic metastasis diagnosed by liver biopsy as malignant melanoma. The patient became lethargic and developed mental status changes associated with asterixis, abnormal EEG, and increased serum ammonia levels. All reversed with high-dose lactulose and had no alternative explanation other than an unusual hepatic encephalopathy secondary to portosystemic shunts bypassing the extensively metastatic liver., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

We demonstrate new, large-mode area (LMA) gain fibers with ∼25 µm mode-field diameter, and increased higher-order mode loss that enable diffraction limited, pulsed fiber lasers operating at high average power with high pulse energy. We achieved 1.6 mJ, ns pulses, with 1.2 kW average power and 370 kW peak power in one of the new Yb-doped gain fibers. In a second, higher absorption fiber, we demonstrate 2 mJ pulse energy with peak power of >420 kW at an average power of 660 W. To the best of our knowledge these are the highest demonstrated energies, powers and peak powers for any nanosecond diffraction-limited, all-fiber laser. The TMI thresholds of two of these fibers were measured to be 1.8 kW and 1 kW respectively.

Background: Current casualty care training modalities present several challenges, including limited simulation facilities, instructor dependence, lack of standardization, documentation of trainees' performance and training personalization. The study presents the design, development and preliminary evaluation of a novel hybrid training platform to address these challenges., Methods: A mixed reality platform was chosen and developed to address field operators' requirements. The platform is easy to operate and can be set up by laypeople within 20-min in multiple environments. Individual-level training documentation is generated autonomously following each session, evaluating 30 aspects of performance. From this, a unique aggregated dataset emerges as a substrate for executives' dashboards and intelligent planning of future sessions., Results: An evaluation process took part using simulator-based training in different stages along the project using a questionnaire (Likert-scale based). Fifty military physicians took part in an identical head injury scenario requiring airway management by endotracheal intubation and were immediately surveyed., Conclusion: TrauMR is an agile hybrid training that harbors the potential to address many of the emerging challenges of training for prehospital care in combat and civilian environments.

Introduction: Shoulder dislocation occurs when the head of the humerus disengages from the glenoid bone. About 95% of shoulder dislocations are traumatic, while the other 5% are not trauma-related in a patient with predisposing factors such as generalized ligamentous laxity. Ninety percent of shoulders dislocate anteriorly from direct force on the arm in the "ABER" position (Abduction- External Rotation). Usually, dislocations are accompanied by injuries to the shoulder that may lead to recurrent anterior shoulder instability and in the long-run, osteoarthritis of the shoulder joint. In the case of traumatic shoulder dislocation in the younger population or competitive sport players, accompanied with bone injury on X-ray's (Bony Bankart or Hill-Sachs), surgical treatment is recommended as soon as possible to avoid recurring dislocation and further joint damage. There are several options to treat recurrent shoulder instability, including soft tissue procedures, bone procedures, and a combination of these procedures. Surgery can be performed by an open or arthroscopic approach.

"Whiplash"-type injuries are commonly encountered and often cause neck pain, neck stiffness, and headaches. However, these injuries can have rare and poorly recognized complications, such as the development of a prevertebral hematoma leading to acute respiratory failure in the emergency department, followed by severe, life-threatening dysphagia and recurrent aspirations. In the patient described herein, a whiplash injury was accompanied by vocal cord paralysis and dysphonia (vagus nerve), dysgeusia (glossopharyngeal nerve, vagus nerve), and upper esophageal spasm (cricopharyngeal muscle, vagus nerve). It is unlikely that this was a complication of cervical fusion surgery. Instead, a combined stretch-induced lower cranial nerve injury, possibly on the exit of these nerves through the jugular foramen, seems to be a likely, but underappreciated mechanism occurring in rare instances of whiplash injuries., Competing Interests: Conflicts of interest The authors have no conflicts of interest to declare., (© 2022 The Korean Society of Traumatology.)

Competing Interests: Competing interests: None declared.