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Objective: While there have been many publications regarding trauma care in the deployed environment, there is little discussion on the management of the more mundane maladies. This article examines the role of elective surgical intervention for inguinal hernia repairs within theater. Current U.S. policy transports service members out of theater for elective repair and convalescence. In these times of limited man power, this can represent a significant loss of the fighting strength.Methods: Between January 2006 and July 2006, military surgeons at the 47th Combat Support Hospital in Iraq repaired 11 inguinal hernias. All patients were encouraged to resume normal duty and physical training as soon as possible. A post-procedure questionnaire was completed 6-12 months after surgery.Results: Four repairs were completed with the Prolene Hernia System (PHS; Ethicon, West Somerville, NJ) and seven repairs using the plug and patch method (C. R. Bard, Inc., Murray Hill, NJ). Ten patients were available for follow-up. There were no wound infections, nerve injuries, or recurrences. Patients returned to full duty within 3 days to 6 weeks.Conclusions: Based on our experience and the feedback from our patients, no complications were noted in this small population of elective hernia repairs. Further prospective trials with long term follow-up are needed to confirm these initial findings. [ABSTRACT FROM AUTHOR]

Objective: To examine the experience of the 48th Combat Support Hospital (CSH) while deployed to Afghanistan, with an emphasis on trauma care.Materials and Methods: Before redeployment, a retrospective review was performed on the medical records of all patients treated at the 48th CSH from December 6, 2002 through June 7, 2003.Results: During the 6-month period, 10,679 patients were evaluated and/or treated. There were 477 hospital admissions (adults, 387; children, 90; trauma, 204) and 634 operating room procedures. The most common mechanisms of injury were land mines/unexploded ordinance (74 = 36%) and gunshot wounds (41 = 20%). Extremities were the most common site. A total of 358 cases was performed on 168 trauma patients (mean, 2 cases per patient; range, 1-12). There were 63 complications in 40 trauma patients and 11 patients died.Conclusions: The 48th CSH supported military and humanitarian operations with an ongoing process of re-evaluation, adaptation, and medical education that resulted in low morbidity and mortality rates. [ABSTRACT FROM AUTHOR]

Objective: The objective was to examine the safety and efficacy of the 48th Combat Support Hospital's use of diagnostic endoscopy in Afghanistan.Methods: A retrospective review was performed on the medical records of all endoscopy patients treated at the 48th Combat Support Hospital in Bagram, Afghanistan, from December 6, 2002 through June 7, 2003.Results: Twenty-four patients (male, 21; female, 3; mean age, 35 years) underwent 28 endoscopic procedures as follows: colonoscopy, 14; esophagogastroduodenoscopy (EGD), 13; and flexible sigmoidoscopy, 1. Four patients underwent both EGD and colonoscopy. There were no complications. Of the 18 U.S. military patients, 3 (15%) were evacuated for further evaluation and/or treatment and 1 (5%) patient underwent an elective screening colonoscopy. For 14 of 17 U.S. military personnel (82%), the endoscopic procedures obviated evacuation from Afghanistan.Conclusions: Diagnostic colonoscopy and EGD were valuable and safe adjuncts that precluded evacuations out of theater for 82% of military patients. Endoscopy should be used when U.S. military operations necessitate the deployment of large numbers of forces for protracted periods. [ABSTRACT FROM AUTHOR]

Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. The treatment for airway obstruction is intubation or advanced airway adjunct, which has a known risk of aspiration. We sought to describe the variables associated with aspiration pneumonia after prehospital airway intervention., Methods: This is a sub-analysis of previously described data from the Department of Defense Trauma Registry (DoDTR) from 2007 to 2020. We included casualties that had at least one prehospital airway intervention with documentation of subsequent aspiration pneumonia or pneumonia within three days of the intervention. We used a generalized linear model with Firth bias estimates to test for associations., Results: There were 1,509 casualties that underwent prehospital airway device placement. Of these, 41 (2.7%) met inclusion criteria into the aspiration pneumonia cohort. The demographics had no statistical difference between the groups. The non-aspiration cohort had fewer median ventilator days (2 versus 6, p < 0.001), intensive care unit days (2 versus 7, p < 0.001, and hospital days [3 versus 8, p < 0.001]). Survival was lower in the non-aspiration cohort (74.2% versus 90.2%, p = 0.017). The administration of succinylcholine was higher in the non-aspiration cohort (28.0% versus 12.2%, p = 0.031). In our multivariable model, only the administration of succinylcholine was significant and was associated with lower probability of aspiration pneumonia (odds ratio 0.56)., Conclusion: Overall, the incidence of aspiration pneumonia was low in our cohort. The administration of succinylcholine was associated with a lower odds of developing aspiration pneumonia., (2023.)

Background: Nonalcoholic fatty liver disease (NAFLD) is associated with hepatic as well as systemic insulin resistance even in the absence of type 2 diabetes. The extent and pathways through which hepatic inflammation modulates insulin sensitivity in NAFLD are only partially understood. We explored the contribution of hepatic interleukin (IL)-1 signalling in a novel conditional knockout mouse model and expand the knowledge on this signalling pathway with regard to its liver-specific functions., Methods: A high-fat, high-carbohydrate diet (HFD) over 12 weeks was used in male hepatocyte-specific IL-1 receptor type 1 (IL-1R1) knockout mice (Il1r1 Hep-/- ) and wild-type (WT) littermates., Results: Both genotypes developed an obese phenotype and accompanying macrovesicular hepatic steatosis. In contrast to WT mice, microvesicular steatosis and ballooning injury was less pronounced in HFD-fed Il1r1 Hep-/- mice, and alanine aminotransferase remained in the normal range. This was paralleled by the suppression of injurious and proinflammatory hepatic c-Jun N-terminal kinases and extracellular signal-regulated kinases signalling, stable peroxisome proliferator activated receptor gamma coactivator-1alpha and farnesoid X receptor-alpha expression and preservation of mitochondrial function. Strikingly, despite HFD-feeding Il1r1 Hep-/- mice remained highly insulin sensitive as indicated by lower insulin levels, homeostatic model assessment for insulin resistance, higher glucose tolerance, more stable hepatic insulin signalling cascade, and less adipose tissue inflammation compared to the WT., Conclusions: The current data highlights that hepatocyte IL-1R1 contributes to hepatic and extrahepatic insulin resistance. Future liver-directed therapies in NAFLD could have effects on insulin sensitivity when improving hepatic inflammation and IL-1R1 signalling., (© 2022 The Authors. Clinical and Translational Medicine published by John Wiley & Sons Australia, Ltd on behalf of Shanghai Institute of Clinical Bioinformatics.)

There are no established ground medical-evacuation systems within Special Operations Command Africa (SOCAFRICA), given the austere and varied environments. Transporting the injured casualty requires ingenuity and modification of existing vehicles. The Expeditionary Resuscitative Surgical Team (ERST) assigned to SOCAFRICA used four unconventional means for ground evacuation. This is a retrospective review of the various modes of ground transportation used by the ERST-3 during deployment with SOCAFRICA. All handcarried litter and air evacuation platforms were excluded. Over 9 months, four different ground casualty platforms were used after they were modified: (1) Mine-Resistant Ambush-Protected All-Terrain Vehicle (MAT-V; Oshkosh Defense); (2) MRZR-4 ("Razor"; Polaris Industries); (3) nonstandard tactical vehicles, (NSTVs; Toyota HiLux); and (4) John Deere TH 6x4 ("Gator"). Use of all vehicle platforms was initially rehearsed and then they were used on missions for transport of casualties. Each of the four methods of ground evacuation includes a description of the talon litter setup, the necessary modifications, the litter capacity, the strengths and weaknesses, and any summary recommendations for that platform. Understanding and planning for ground casualty evacuation is necessary in the austere environment. Although each modified vehicle was used successfully to transfer the combat casualty with an ERST team member, consideration should be given to acquisition of the MAT-V medical-specific vehicle. Understanding the currently available modes of ground casualty evacuation transport promotes successful transfer of the battlefield casualty to the next echelon of care., (2019.)

Background Drugged driving, or driving under the influence of any drug, is a growing public health concern, especially with the recent legislation legalizing marijuana use in certain states in the USA. We sought to gain a better understanding of the surgeons' perspective regarding marijuana (MJ) and alcohol (ETOH) and the relationship of recent laws to identification of MJ and ETOH in trauma victims. Methods Members of a national trauma surgical organization were asked to participate in an Institutional Review Board (IRB)-approved, web-based survey which centered on attitudes, knowledge, and beliefs regarding ETOH and MJ as they related to injury. Two Level I trauma center registries (located in TX and CA) were queried for the incidence of motor vehicular collision (MVC) and the presence of ETOH (defined as > 0.08 g/dL) or MJ from 2006 thru 2012. Results A total of 127 trauma surgeons participated in the survey. The majority were male (84%, n = 107) and with a median age of 52. Most were in surgical practice for greater than 11 years (78%, n = 99) and worked at a Level I trauma center (78%, n = 99) in an academic institution (65%, n = 83). MJ was illegal in the states where most of the participants were in practice (79%, n = 100), but 90% (n = 114) of respondents from states where MJ is legal stated they have not seen an increase in MVC since MJ was legalized. At the TX trauma center, only 4% of patients involved in a vehicular trauma tested positive for MJ, 21% of patients had the presence of ETOH, and 3% had both. For both MJ and also ETOH, the incidence remained the same each year. In CA, there was little yearly variation in the incidence of patients that tested positive for MJ (23%), ETOH (50%), and both (7%). In addition, the incidence of MJ was essentially unchanged after the decriminalization law was passed in 2010. Conclusion The prevalence of cannabis and alcohol varies among the states studied, TX and CA. The impact of decriminalization of marijuana did not seem to affect the incidence of drugged driving with marijuana in CA., Competing Interests: The authors have declared that no competing interests exist.

Background Despite evidence that helmet use decreases motorcycle-associated injuries and mortality, the use of motorcycle helmets is not universal. As trauma surgeons are frequently the primary providers responsible for motorcycle crash victims, we sought to gain a better understanding of trauma surgeons' perspectives on helmet use with motorcycles. Methods Members of the American Association for the Surgery of Trauma (AAST) were asked to participate in a survey that centered on attitudes, knowledge, and beliefs regarding motorcycle helmet use, associated injuries, and related costs. Demographic data were analyzed. In addition, we performed a literature search to attempt to clarify the current data on this subject. Results A total of 127 surgeons participated. The majority were male (64%, n=81), in academic practice (67%, n=85), and worked at a Level I trauma center (80%, n=102). Of those that owned a motorcycle, 100% wear a helmet when riding. Seven percent (n=9) of respondents believe helmet use increases cervical spine injury, although the majority (78%, n=99) disagree. In regards to head injuries and helmet use, most (93%, n=118) believe that helmets decrease the severity of head injury, improve outcomes (98%, n=124), and impact long-term disability (93%, n=118). Ninety percent (n=114) of surgeons believe that state legislation mandating motorcycle helmet use increases helmet utilization, and 82% (n=104) believe that the decision to wear a helmet should not be a personal decision. The majority (83%, n=106) of trauma surgeons agreed that helmet use would likely lead to a major reduction in motorcycle-related health care costs. Conclusions North American trauma surgeons wear helmets when they ride motorcycles and believe that these devices are highly protective, leading to a reduction in brain injury and the subsequent health care costs., Competing Interests: The authors have declared that no competing interests exist.

Background In the United States, there is a constant debate between the proponents of the right to bear arms and those desiring to reduce the epidemic of gun violence. We sought to capture the trauma surgeons' perspective on gun control. Methods We presented an on-line based survey to the members of the American Association for the Surgery of Trauma (AAST). Survey questions were chosen to reflect the popular media poll questions as well as trauma-specific perspectives. We compared the trauma surgeons' perspectives to that of the general populace from a poll conducted by the New York Times (NYT). Results A total of 120 trauma surgeons responded to the survey. The age group ranged from 34 to 82 years, and the median age was 51. Most respondents were male (64%, n = 67) and worked at a Level I trauma center (80%,  n  = 96) in an academic setting (67%, n  = 80). About half of the responding surgeons owned a household firearm (40%; n  = 48 of the AAST members vs. 47%; n  = 521 of the general populace). Sixty-one percent of the trauma surgeons ( n  = 73) and 53% ( n  = 588) of the NYT respondents favor stricter gun control laws. While 80% ( n  = 888) of the NYT respondents felt that mental health screening and treatment would decrease gun violence, only 56% ( n = 67) of surgeons felt that mental health screening would be beneficial. The majority (90%, n  = 999) of the NYT poll respondents favor a law restricting the sale of guns only by licensed dealers. Only (66%, n  = 79) of the trauma surgeons were in agreement with the stricter gun sale legislation by licensed dealers. Conclusion Trauma surgeons appear to share similar views with the general American populace regarding gun violence and injury control., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Firearm-related injuries account for 20% of all injury-related deaths and are responsible for 105,000 injuries annually. The occurrence of bullet emboli to the heart is exceedingly rare. Given the rarity of emboli, controversy exists over management. The primary endpoint of this study is to establish a management algorithm for venous bullet emboli to the heart., Materials and Methods: A literature search was performed using PubMed and Google Scholar with the following search terms: cardiac bullet embolus, cardiac missile embolus, and bullet embolus. Any discoverable case report(s) or series after 1960 were included in the review. The following data points were collected: age, sex, presentation, imaging, foreign body entry site, foreign body destination site, management, and outcomes., Results: Fifty-four articles met our search criteria. A total of 62 patients with thoracic venous bullet emboli were identified with the following distributions: right atrium (9.7%), right ventricle (54.8%), pulmonary arterial tree (32.3%), and intra-thoracic inferior vena cava (3.2%). Only 11.3% of patients had symptoms directly related to the cardiac venous emboli; however, all patients with acute symptoms underwent immediate intervention. Of those patients with bullet emboli to the pulmonary arterial tree, 45% were observed; whereas, only 20% with emboli to the right heart were observed. Those without signs or symptoms usually underwent an intervention (72.7%). Endovascular retrieval was successful in 53% of attempts. Of the endovascular attempts that failed, 28.6% were observed and 71.4% underwent open retrieval. Those who were asymptomatic and observed had no reported adverse sequelae during the follow-up. No mortalities were discovered in this review., Conclusion: Bullet emboli can prove to be a clinical challenge. Adjuncts such as X-ray, computed tomography, transthoracic, and/or transesophageal echocardiography help establish the emboli location. While observation in the asymptomatic patient is reasonable in some circumstances, most patients undergo removal. Removal of bullet cardiac emboli is safe with the availability of modern techniques., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.)

Controversy exists regarding the appropriate timing for placement of permanent intra-abdominal mesh after inadvertent enterotomy during elective hernia repair. The aim of this study was to examine mesh placement at variable postoperative periods and the subsequent risk of infection. Fifty rodents were divided into five groups. Groups one to four underwent laparotomy, enterotomy, and repair. Physiomesh® was placed at the index operation one, three, or seven days postoperatively in Groups 1, 2, 3, and 4. Group 5 underwent mesh placement only. Necropsy with mesh harvest was performed seven days after placement. Cultures of mesh were obtained and Fisher's exact test was used to compare groups. Bacterial growth postsonication was identified in 30, 30, 50, and 90 per cent versus 20 per cent in controls. Compared with controls, there was significantly increased risk of mesh infection when it was placed seven days after enterotomy (P = 0.006). There was no significant difference in bacterial growth when mesh was placed at the time of enterotomy, one or three days later. The risk of bacterial contamination of permanent mesh placed immediately after inadvertent enterotomy during elective hernia repair is as safe as placing mesh at one or three days. Placing mesh at seven days significantly increased the risk of mesh contamination.

Nonalcoholic steatohepatitis (NASH) is a silent liver disease that can lead to inflammation and subsequent scaring. If left untreated, cirrhosis may ensue. Morbidly obese patients are at an increased risk of NASH. We report the prevalence and predictors of NASH in patients undergoing morbid obesity surgery. A retrospective review was conducted on morbidly obese patients undergoing weight reduction surgery from September 2005 through December 2008. A liver biopsy was performed at the time of surgery. Patients who had a history of hepatitis infection or previous alcohol dependency were excluded. Prevalence of NASH was studied. Predictors of NASH among clinical and biochemical variables were analyzed using multivariate regression analysis. One hundred thirteen patients were analyzed (84% female; mean age, 42.6 ± 11.4 years; mean body mass index, 45.1 ± 5.7 kg/m(2)). Sixty-one patients had systemic hypertension (54%) and 35 patients had diabetes (31%). The prevalence of NASH in this study population was 35 per cent (40 of 113). An additional 59 patients (52%) had simple steatosis without NASH. Only 14 patients had normal liver histology. On multivariate analysis, only elevated aspartate aminotransferase (AST) (greater than 41 IU/L) was the independent predictor for NASH (odds ratio, 5.85; confidence interval, 1.06 to 32.41). Patient age, body mass index, hypertension, diabetes, hypercholesterolemia, and abnormal alanine aminotransferase did not predict NASH. NASH is a common finding in obese population. Abnormal AST was the only predictive factor for NASH.

Purpose: The aim of this study was to analyze the surgical management and associated complications of penetrating rectal injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom., Methods: A retrospective review was performed using the Joint Theater Trauma Registry. U.S. military personnel injured in Iraq and Afghanistan from October 2003 to November 2008 were included. The surgical management of rectal injuries was evaluated, specifically looking at the utilization of diversion with ostomy, distal washout, and presacral drainage. Complications were compared between the treatment groups., Results: 57 patients who sustained a penetrating rectal injury were included in this study. Surgical management included diversion and ostomy alone in 34 patients (60%), diversion and distal washout in 11 patients (19%), diversion and drainage in 8 patients (14%), and diversion, distal washout, and drainage in 4 patients (7%). Complications were identified in 21% of patients. There were no deaths in the study group. Logistical regression failed to show a correlation between postoperative complications with either distal washout (p = 0.33) or presacral drainage (p = 0.9)., Conclusions: The majority of patients were successfully managed with fecal diversion alone, suggesting that drainage and distal washout may be unnecessary steps in the management of high-velocity, penetrating rectal injuries., (Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.)

Primary spontaneous pneumothorax from subpleural bleb disease is an uncommon occurrence in pediatric patients. This is a rare case of monozygotic twins presenting at alternating intervals with a single-sided spontaneous pneumothorax, only to have it surgically corrected, and to present later with a subsequent contralateral pneumothorax. A review of familial spontaneous pneumothoraces occurring in children was queried for congenital or genetic syndromes. We concluded that a vast majority of pneumothoraces in children, like adults, are not spontaneous and not familial linked. While they are rare, some congenital syndromes have been identified. The HLA haplotype A2 B40, the gene encoding folliculin, Alph-1-antitrypsin, Marfan's syndrome, Ehlers-Danlos syndrome and Birt-Hogg-Dube syndrome have all been associated with familial spontaneous pneumothoraces. Physicians need to counsel family members to ensure appropriate observation and expedited treatment is not delayed.

Background: Bochdalek hernias are a very rare form of diaphragmatic hernias. There are no robust studies that reveal the true natural history of this disease process. The aim of this study was to summarize clinically relevant data for the purpose of assisting surgeons with the work-up, diagnosis, and treatment of adult patients with Bochdalek hernia., Methods: A literature search was performed using PubMed, Google scholar, EMBASE and the following keywords: Bochdalek hernia, congenital diaphragmatic hernia, and posterolateral hernia. All case reports and series after 1955 that pertained to adults were included in the review. The following data points were queried: age, sex, presentation, studies utilized during work-up, laterality, surgical approach, hernia sac management, specific minimally invasive surgical techniques, and follow-up., Results: A total of 124 articles comprising 173 patients met the inclusion criteria. Based on the data provided, several conclusions regarding this disease process can be made. Most patients present with symptoms related to their hernia (86%). Pain is the most common complaint (69%). While laparotomy is the most widely used surgical approach (38%), minimally invasive surgical techniques have gained popularity since their first report in 1995. Laparoscopic repair can be performed with a low complication rate (7%) and short hospital stay (4 days)., Conclusions: Using modern surgical techniques to include laparoscopy, repair can be performed safely, with a short hospital stay, and with minimal morbidity or mortality.

Arterial line catheterization in the critically ill patient is often an arduous task. Here we identify risk factors in the critical care patient that may predict a more difficult arterial catheter insertion. We also describe our ultrasound technique and review of the literature with regard to location of access, complications, and the use of ultrasound guidance.

Purpose: The increase in mortality noted in African Americans with colon cancer is attributed to advanced stage at presentation and disparities in treatment received. The aim of this study was to assess the influence of race on the treatments and survival of colon cancer patients in an equal-access healthcare system., Methods: This retrospective cohort study included African American and white patients with colon cancer treated at Department of Defense facilities. Disease stage, surgery performed, chemotherapy used, and overall survival were evaluated., Results: Of the 6958 colon cancer patients identified, 1115 were African American. African Americans presented more frequently with stage IV disease, 23% vs 17% for whites (P < .001). There was no difference in surgical resection rates for African American or whites (85.8% vs 85.5%, respectively; chi2, P > .05). There was no difference in the use of systemic chemotherapy for stage III colon cancer (73.5% for African Americans vs 72.2% for whites; chi2, P > .05) or stage IV colon cancer (56.3% for African Americans vs 54.4% for whites; chi2, P > .05). The overall 5-year survival rate was similar for African American and white patients (56.1% vs 58.5%, respectively; log-rank, P > .05). After adjusting for gender, age, tumor grade, and stage, African American race was not a risk factor for survival in Cox proportional hazard analysis (hazard ratio, 0.981; 95% confidence interval, 0.888-1.084)., Conclusions: In an equal-access healthcare system, African American race is not associated with an increase in mortality. African American patients undergo surgery and chemotherapy is administered at rates equal to whites for all stages of colon cancer.

Background: Improved survival is associated with an increased number of lymph nodes (LNs) examined. The aim of this study was to assess whether the examination of >or=12 LNs is associated with more accurate colon cancer staging., Methods: We queried the Department of Defense Automated Central Tumor Registry database for stage I-III colon cancer patients. Logistic regression analysis was performed to determine whether the examination of >or=12 LNs is associated with increased rates of LN-positive colon cancer. Kaplan-Meier and Cox proportional hazard analysis was performed to evaluate the effect of number of LNs examined on survival., Results: The rate of LN-positive colon cancer is significantly higher with increasing number of LNs examined (1-3 LNs examined: 31% vs. >12 LNs examined: 41%, P<.001). Logistic regression analysis adjusting for patients, tumor, and hospital characteristics showed that examination of >or=12 LNs is associated with a >30% increase in detecting a LN-positive colon cancer (odds ratio, 1.350; 95% confidence interval, 1.175-1.511). The evaluation of >or=12 LNs is associated with improved survival in LN-negative colon cancer patients (P<.001)., Conclusions: Our study demonstrates that the proportion of LN-positive colon cancer is far higher when >or=12 LNs are examined. Examination of >or=12 LNs may improve staging accuracy and outcome with optimal use of systemic chemotherapy.

Background: Morgagni hernias are a very rare form of diaphragmatic hernias. No robust studies have been performed to show the true natural history of this disease process. This study aimed to summarize clinically relevant data with respect to Morgagni hernias in adults. These data should help surgeons workup, diagnose, and treat Morgagni hernias in adult patients., Methods: A literature search was performed using PubMed, Google scholar, and the following key words: Morgagni, Larrey, retrosternal, retrocostoxiphal, retrochondrosternal, parasternal, substernal, anterior diaphragmatic, and subcostosternal. All case reports and series after 1951 that pertained to adults were included in the review. The following data points were queried: age, sex, presentation, studies used during workup, laterality, surgical approach, hernia sac management, specific laparoscopic techniques, and follow-up evaluation., Results: These criteria were met by 135 articles representing 298 patients. Based on the data provided, several conclusions regarding this disease process can be drawn. Most patients (72%) present with symptoms related to their hernia. Pulmonary complaints are the most common symptoms (36%). Men present earlier in life than women. Thoracotomy is the most widely used surgical approach (49%). However, laparoscopic repair has gained popularity since its first report in 1992. Laparoscopic surgeons usually repair the defect with mesh (64%) and do not remove the hernia sac (69%). Laparoscopic repair can be performed with a low complication rate (5%) and a short hospital stay (3 days). Outcomes of other surgical approaches also are reported., Conclusions: Using modern surgical techniques including laparoscopy, repair of Morgagni hernia can be performed safely with a short hospital stay and with little morbidity or mortality.