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Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. These challenges are magnified while forward deployed in austere or hostile environments. This Joint Trauma System Clinical Practice Guideline provides recommendations for the treatment and medical management of casualties with moderate to severe head injuries in an environment where personnel, resources, and follow-on care are limited. These guidelines have been developed by acknowledging commonly recognized recommendations for neurosurgical and neuro-critical care patients and augmenting those evaluations and interventions based on the experience of neurosurgeons, trauma surgeons, and intensivists who have delivered care during recent coalition conflicts., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objectives: The objective of this study is to describe the United States and allied military medical response during the withdrawal from Afghanistan., Background: The military withdrawal from Afghanistan concluded with severe hostilities resulting in numerous civilian and military casualties. The clinical care provided by coalition forces capitalized on decades of lessons learned and enabled unprecedented accomplishments., Methods: In this retrospective, observational analysis, casualty numbers, and operative information was collected and reported from military medical assets in Kabul, Afghanistan. The continuum of medical care and the trauma system, from the point of injury back to the United States was captured and described., Results: Prior to a large suicide bombing resulting in a mass casualty event, the international medical teams managed distinct 45 trauma incidents involving nearly 200 combat and non-combat civilian and military patients over the preceding 3 months. Military medical personnel treated 63 casualties from the Kabul airport suicide attack and performed 15 trauma operations. US air transport teams evacuated 37 patients within 15 hours of the attack., Conclusion: Lessons learned from the last 20 years of combat casualty care were successfully implemented during the culmination of the Afghanistan conflict. Ultimately, the effort, teamwork, and system adaptability exemplify not only the attitudes and character of service members who provide modern combat casualty care but also the paramount importance of the battlefield learning health care system. A continued posture to maintain military surgical preparedness in unique environments remain crucial as the US military prepares for the future.Retrospective observational analysis., Level of Evidence: Therapeutic/Care Management; Level V., (Copyright © 2023 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Abstract: Introduction : COVID-19-induced coagulopathy (CIC) can increase the risk of thromboembolism without underlying clotting disorders, even when compared with other respiratory viruses. Trauma has a known association with hypercoagulability. Trauma patients with concurrent COVID-19 infection potentially have an even greater risk of thrombotic events. The purpose of this study was to evaluate venous thromboembolism (VTE) rates in trauma patients with COVID-19. Methods : This study reviewed all adult patients (≥18 years of age) admitted to the Trauma Service from April through November 2020 for a minimum of 48 hours. Patients were grouped based off COVID-19 status and compared for inpatient VTE chemoprophylaxis regimen, thrombotic complications defined as deep vein thrombosis, pulmonary embolism, myocardial infarction, and cerebrovascular accident, intensive care unit (ICU) length of stay, hospital length of stay, and mortality. Results : A total of 2,907 patients were reviewed and grouped into COVID-19-positive (n = 110) and COVID-19-negative (n = 2,797) groups. There was no difference in terms of receiving deep vein thrombosis chemoprophylaxis or type, but a longer time to initiation in the positive group ( P = 0.0012). VTE occurred in 5 (4.55%) positive and 60 (2.15%) negative patients without a significant difference between the groups, as well as no difference in type of VTE observed. Mortality was higher ( P = 0.009) in the positive group (10.91%). Positive patients had longer median ICU LOS ( P = 0.0012) and total LOS ( P < 0.001). Conclusion : There were no increased rates of VTE complications between COVID-19-positive and -negative trauma patients, despite a longer time to initiation of chemoprophylaxis in the COVID-19-positive group. COVID-19-positive patients had increased ICU LOS, total LOS, and mortality, which are likely due to multifactorial causes but primarily related to their underlying COVID-19 infection., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by the Shock Society.)

Determine seasonal, annual, and decadal patterns of abundance in reptile species and assemblages occupying central Bold Park (~338 ha), an isolated urban bushland remnant in Perth, Southwestern Australia. Fenced pitfall trapping in four sampling sites, representing different habitats and fire history, over the primary reptile activity period for 35 consecutive years with over 17,000 individuals captured during 3300 days of sampling; the trapping regime was modified for the last 28 years. Sampling occurred in one of 35 global biodiversity hotspots that has a Mediterranean climate experiencing a 15% decline from the century average rainfall over the last 50 years. Twenty-nine species were recorded, with 16 captured in 32 or more years and accounting for nearly 97% of all captures; the six most common for 81%. Three taxa became locally extinct. Activity predominates in warmer and dryer months (October to April), peaking in November-December. Species richness remained relatively constant between years with around 73% of known taxa captured annually. Assemblages did not change when analyzing the presence/absence data but moved through five statistically significant assemblages analyzing relative abundance data. Over the last 28 years, relative abundance was significantly and positively correlated with annual rainfall residuals, uniquely for the 4 years preceding annual sampling, resulting in significant changes in total assemblages and significantly similar patterns in four sample sites; the presence/absence data indicated only minor assemblage changes across sites. The number of species recorded annually remained relatively constant, but relative abundance illustrated significant temporal changes in assemblages over decades. The modeled relationship between relative abundance and annual rainfall residuals for 4 years preceding annual sampling is supported by known ecological responses and reptile demographics within this Mediterranean climate. Maintenance of urban biodiversity should consider impacts of a significantly drying climate exacerbating the extinction debt already inherent in isolated bushland populations experiencing limited immigration., Competing Interests: None., (© 2022 The Authors. Ecology and Evolution published by John Wiley & Sons Ltd.)

Background: Military experience has shown low-titer O whole blood (LTOWB) to be safe and beneficial in the resuscitation of hemorrhaging trauma patients. However, few civilian centers use LTOWB for trauma resuscitation. We evaluated the early experience and safety of a LTOWB program at a level 1 civilian trauma center., Methods: We retrospectively reviewed our trauma registry from January 2018 to June 2020 for patients admitted in shock (defined as ≥1 of the following: heart rate, >120 beats per minute; systolic blood pressure, <90 mm Hg; or shock index, >0.9) who received blood products within 24 hours. Patients were grouped by resuscitation provided: LTOWB (group 1), component therapy (CT; group 2), and LTOWB-CT (group 3). Safety, outcomes, and variables associated with LTOWB transfusion and mortality were analyzed., Results: 216 patients were included: 34 in Group 1, 95 in Group 2, and 87 in Group 3. Patientsreceiving LTOWB were more commonly male (p<0.001) and had a penetrating injury (p=0.005). Groups 1 and 3 had higher median ISS scores compared to Group 2 (19 and 20 vs 17; p=0.01). Group 3 received more median units of blood product in the first 4h (p<0.001) and in the first 24h (p<0.001). There was no difference between groups in 24h mortality or transfusion-related complications (all p>0.05). Arrival ED SBP was associated with LTOWB transfusion (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.95-1.00, p=0.03). ED lactate was independently associated with 24h mortality. (OR 1.27, CI 1.02-1.58, p=0.03). LTOWB transfusion was not associated with mortality (p=0.49). Abstract., Conclusion: Severely injured patients received LTOWB-CT and more overall product units but had similar 24 h mortality when compared with the LTOWB or CT groups. No increase in transfusion-related complications was seen after LTOWB transfusion. Low-titer O whole blood should be strongly considered in the resuscitation of trauma patients at civilian centers., Level of Evidence: Retrospective, therapeutic, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The care of trauma patients in combat operations is handwritten on a five-page flow sheet. The process requires the manual scanning and uploading of paper documents to bridge the gap between electronic and paper record management. There is an urgent operational need for an information technology solution that will enable medics to better capture patient treatment information, which will improve long-term health care without impacting short-term care responsibilities., Methods: We conducted a process improvement project to evaluate the ability of T6 Health Systems Mobile Application to improve combat casualty care data collection at a deployed trauma hospital. We performed a head-to-head comparison of the completeness and accuracy of data capture of electronic versus handwritten records to determine noninferiority., Results: During the 90-day pilot, there were 131 trauma evaluations of which 53 casualty resuscitations (40.5%) were also documented in the electronic application. We compared completeness and accuracy of admit, prehospital, primary survey, secondary survey, interventions, and trends data. We found an overall 13% increase in data capture at 96% accuracy compared with the written record, suggesting that the electronic record was superior. Completion of electronic documentation compared with paper by section was statistically significantly higher for admitting data, 119.7% (p < 0.0001); prehospital, 116.2% (p = 0.0039); primary, 109.6% (p < 0.001); and secondary, 125.5% (p < 0.001). We also had the medical evacuation teams document prehospital and en route care and then synchronize the record in the trauma bay, allowing the trauma teams there to continue documenting on the same casualty record, likely contributing to superiority because teams did not have to redocument based on an oral report., Conclusion: Our pilot program in the deployed environment demonstrated a mobile technology that actually enhanced the completeness and accuracy of paper trauma documentation that has the capability of providing patient-specific decision support and real-time data analysis., Level of Evidence: Care Management, level IV.

Historical population contraction and expansion events associated with Pleistocene climate change are important drivers of intraspecific population structure in Australian arid-zone species. We compared phylogeographic patterns among arid-adapted Dasyuridae ( Sminthopsis and Planigale ) with close phylogenetic relationships and similar ecological roles to investigate the drivers of phylogeographic structuring and the importance of historical refugia. We generated haplotype networks for two mitochondrial (control region and cytochrome b) and one nuclear (omega-globin) gene from samples distributed across each species range. We used Φ ST to test for a genetic population structure associated with the four Pilbara subregions, and we used expansion statistics and Bayesian coalescent skyline analysis to test for signals of historical population expansion and the timing of such events. Significant population structure associated with the Pilbara and subregions was detected in the mitochondrial data for most species, but not with the nuclear data. Evidence of population expansion was detected for all species, and it likely began during the mid-late Pleistocene. The timing of population expansion suggests that these species responded favorably to the increased availability of arid habitats during the mid-late Pleistocene, which is when previously patchy habitats became more widespread. We interpret our results to indicate that the Pilbara region could have acted as a refugium for small dasyurids.

Background: Adenosine, lidocaine, and magnesium (ALM) is a cardioplegic agent shown to improve survival by improving cardiac function, tissue perfusion, and coagulopathy in animal models of shock. We hypothesized prehospital ALM treatment in hemorrhagic shock would improve survival compared to current Tactical Combat Casualty Care (TCCC) resuscitation beyond the golden hour., Methods: Swine were randomized to: (1) TCCC, (2) 2 mL·kg vehicle control (VC), (3) 2 mL·kg ALM + drip, (4) 4 mL·kg ALM + drip, 5) 4 mL·kg ALM + delayed drip at 0.5 mL·kg·h, 6) 4 mL/kg VC, 7) 4 mL·kg ALM for 15 minutes + delayed drip at 3 mL·kg·h. Animals underwent pressure controlled hemorrhage to mean arterial pressure (MAP) of 30 mm Hg (S = 0). Treatment was administered at T = 0. After 120 minutes of simulated prehospital care (T = 120) blood product resuscitation commenced. Physiologic variables were recorded and laboratories were drawn at specified time points., Results: Tactical Combat Casualty Care demonstrated superior survival to all other agents. The VC and ALM groups had lower MAPs and systolic blood pressures compared with TCCC. Except for the VC groups, lactate levels remained similar with correction of base deficit after prehospital resuscitation in all groups. Kidney function and liver function remained comparable across all groups. Compared with baseline values, TCCC demonstrated significant hypocoagulability., Conclusion: Adenosine, lidocaine, and magnesium, as administered in this study, are inferior to current Hextend-based resuscitation for survival from prolonged hemorrhagic shock in this model. In survivors, ALM groups had lower systolic blood pressures and MAPs, but provided a protective effect on coagulopathy as compared to TCCC. Adenosine, lidocaine, and magnesium do not appear to be a suitable low volume replacement to current TCCC resuscitation. The reduced coagulopathy compared to TCCC warrants future studies of ALM, perhaps as a therapeutic adjunct.

Islands present a unique scenario in conservation biology, offering refuge yet imposing limitations on insular populations. The Kimberley region of northwestern Australia has more than 2500 islands that have recently come into focus as substantial conservation resources. It is therefore of great interest for managers to understand the driving forces of genetic structure of species within these island archipelagos. We used the ubiquitous bar-shouldered skink (Ctenotus inornatus) as a model species to represent the influence of landscape factors on genetic structure across the Kimberley islands. On 41 islands and 4 mainland locations in a remote area of Australia, we genotyped individuals across 18 nuclear (microsatellite) markers. Measures of genetic differentiation and diversity were used in two complementary analyses. We used circuit theory and Mantel tests to examine the influence of the landscape matrix on population connectivity and linear regression and model selection based on Akaike's information criterion to investigate landscape controls on genetic diversity. Genetic differentiation between islands was best predicted with circuit-theory models that accounted for the large difference in resistance to dispersal between land and ocean. In contrast, straight-line distances were unrelated to either resistance distances or genetic differentiation. Instead, connectivity was determined by island-hopping routes that allow organisms to minimize the distance of difficult ocean passages. Island populations of C. inornatus retained varying degrees of genetic diversity (NA = 1.83 - 7.39), but it was greatest on islands closer to the mainland, in terms of resistance-distance units. In contrast, genetic diversity was unrelated to island size. Our results highlight the potential for islands to contribute to both theoretical and applied conservation, provide strong evidence of the driving forces of population structure within undisturbed landscapes, and identify the islands most valuable for conservation based on their contributions to gene flow and genetic diversity., (© 2015 Society for Conservation Biology.)

The exposure of indigenous humans and native fauna in Australia and the Wallacea zoogeographical region of Indonesia to exotic Salmonella serovars commenced during the colonial period and has accelerated with urbanization and international travel. In this study, the distribution and prevalence of exotic Salmonella serovars are mapped to assess the extent to which introduced infections are invading native wildlife in areas of high natural biodiversity under threat from expanding human activity. The major exotic Salmonella serovars, Bovismorbificans, Derby, Javiana, Newport, Panama, Saintpaul and Typhimurium, isolated from wildlife on populated coastal islands in southern temperate areas of Western Australia, were mostly absent from reptiles and native mammals in less populated tropical areas of the state. They were also not recorded on the uninhabited Mitchell Plateau or islands of the Bonaparte Archipelago, adjacent to south-eastern Indonesia. Exotic serovars were, however, isolated in wildlife on 14/17 islands sampled in the Wallacea region of Indonesia and several islands off the west coast of Perth. Increases in international tourism, involving islands such as Bali, have resulted in the isolation of a high proportion of exotic serovar infections suggesting that densely populated island resorts in the Asian region are acting as staging posts for the interchange of Salmonella infections between tropical and temperate regions.

This study investigated allozyme and morphometric variability within the genus Cynopterus, with particular emphasis on C. nusatenggara, which is endemic to Wallacea, the area encompassing the Oriental-Australian biogeographic interface. The genetic distances between Cynopterus species are small by mammalian standards and suggest that this genus has undergone a recent series of speciation events. The genetic distance between populations of C. nusatenggara is strongly correlated with both the contemporary sea-crossing distance between islands and the estimated sea crossing at the time of the last Pleistocene glacial maximum, 18,000 b.p. This observation, together with low levels of population substructure within islands as shown by F-statistics, indicates that the sea is a primary and formidable barrier to gene exchange. The genetic distance and the great-circle geographical distance between the populations of C. nusatenggara are not correlated, although a principal-coordinates analysis of genetic distance reveals relationships between the populations that are similar to their geographical arrangement. A strong negative correlation exists between the level of heterozygosity within island populations of C. nusatenggara and the minimum sea-crossing distance to the nearest large source population. This is interpreted as reflecting an isolation effect of the sea, leading to reduced heterozygosity in populations that have larger sea barriers between them and the large source islands. Independently of this, heterozygosity is negatively associated with longitude, which in turn is associated with systematic changes in the environment such as a gradual decline in rainfall from west to east. The association between heterozygosity and longitude is interpreted as reflecting an association between genetic and environmental variance and supports the niche-width theory of genetic variance. Morphometric variability did not show any of the main effects demonstrated in the genetic data. Furthermore, there was no evidence that, at the level of individuals, genetic and morphometric variability were associated., (© 1995 The Society for the Study of Evolution.)

Screening for salmonellae was conducted on five occasions within a year on mammals from many different habitats in the Mitchell Plateau area of the tropical Kimberley Division of Western Australia. Some data were obtained from reptiles. Forty-two Salmonella serotypes, two Edwardsiella and one Arizona strain were isolated. Marsupials harbour significantly more (1.6 times) Salmonella serotypes than eutherians. Eleven Salmonella serotypes and one Arizona strain were isolated from reptiles. All Salmonella strains were common to the mammalian species. Varanid lizards showed higher prevalence of salmonellae than other reptilian families. Top carnivores (reptile and marsupial) show relatively high numbers of Salmonella serotypes and prevalence levels. Four mammalian species showed marked seasonal variation in the prevalence of salmonellae and three species in the number of serotypes isolated. Pooled mammalian community data for individual survey sites showed similar seasonal variation which reflected the pattern seen in the predominant host species on the site. Significant seasonal variation in the prevalence of salmonella was concurrent in three of the host species showing maximum prevalence in the wet season (January-summer) followed by a declining prevalence to the end of the dry season (October). Prevalence in the fourth species was also high in January, but continued to increase after the wet season (April) before decreasing as the dry season progressed (July and October). Dendrograms of association showed that the salmonella 'community' does not associate according to any systematic category of the hosts and no evidence of such communities was found using other criteria, such as site or coastal vs inland locations. No evidence was found for host or site specificity of given serotypes. Multiple serotype infections by salmonella were common, with up to three present in mammals and reptiles, and they occurred at random. When hosts in coastal habitats were compared with those in inland sites higher, lower or no difference was found in the prevalence of salmonella, depending upon which host was considered. Sites with similar mammals and vegetation sometimes showed marked differences in salmonella prevalence at a given time. Generally a given Salmonella serotype was lost from the host within congruent to 3 months. Surveys for salmonellae should be designed to include a range of species, replicated vegetation types and, especially, be repeated in several seasons. Edwardsiella tarda was isolated twice from a carnivorous marsupial.