Characterization of the response to primary blast injury

Lung injuries, predominantly arising from blast exposure, are a clinical problem in a significant minority of current military casualties. This special feature consists of a series of articles on lung injury. This first article examines the mechanism of the response to blast lung (primary blast injury to the lung). Subsequent articles examine the incidence of blast lung, clinical consequences and current concepts of treatment, computer (in silico) modelling of lung injury and finally chemical injuries to the lungs. Blast lung is caused by a shock wave generated by an explosion causing widespread damage in the lungs, leading to intrapulmonary haemorrhage. This, and the ensuing inflammatory response in the lung, leads to a compromise in pulmonary gas exchange and hypoxia that can worsen over several hours. There is also a characteristic cardio-respiratory effect mediated via an autonomic reflex causing apnoea (or rapid shallow breathing), bradycardia and hypotension (the latter possibly also due to the release of nitric oxide). An understanding of this response, and the way it modifies other reflexes, can help the development of new treatment strategies for this condition and for the way it influences the patient's response to concomitant injuries.     

Blast injury research models

Blast injuries are an increasing problem in both military and civilian practice. Primary blast injury to the lungs (blast lung) is found in a clinically significant proportion of casualties from explosions even in an open environment, and in a high proportion of severely injured casualties following explosions in confined spaces. Blast casualties also commonly suffer secondary and tertiary blast injuries resulting in significant blood loss. The presence of hypoxaemia owing to blast lung complicates the process of fluid resuscitation. Consequently, prolonged hypotensive resuscitation was found to be incompatible with survival after combined blast lung and haemorrhage. This article describes studies addressing new forward resuscitation strategies involving a hybrid blood pressure profile (initially hypotensive followed later by normotensive resuscitation) and the use of supplemental oxygen to increase survival and reduce physiological deterioration during prolonged resuscitation. Surprisingly, hypertonic saline dextran was found to be inferior to normal saline after combined blast injury and haemorrhage. New strategies have therefore been developed to address the needs of blast-injured casualties and are likely to be particularly useful under circumstances of enforced delayed evacuation to surgical care.     

Blast injuries to the lung: epidemiology and management

Lung injury is frequently a component of the polytrauma sustained by military personnel surviving blast on the battlefield. This article describes a case series of the military casualties admitted to University Hospital Birmingham's critical care services (role 4 facility), during the period 1 July 2008 to 15 January 2010. Of the 135 casualties admitted, 107 (79.2%) were injured by explosive devices. Plain chest films taken soon after arrival in the role 4 facility were reviewed in 96 of the 107 patients. In 55 (57.3%) films a tracheal tube was present. One or more radiological abnormalities was present in 66 (68.75%) of the films. Five patients met the consensus criteria for the definition of adult respiratory distress syndrome (ARDS). The majority of casualties with blast-related lung injury were successfully managed with conventional ventilatory support employing a lung protective strategy; only a small minority received non-conventional support at any time in the form of high-frequency oscillatory ventilation. Of those casualties who survived to be received by the role 4 facility, none subsequently died as a consequence of lung injury.     

Local Government Reform and the Health Services

The shock wave generated by an explosion (“blast wave”) may cause injury in any or all of the following: (1) direct impact on the tissues of variations in environmental pressure; (2) flying glass and other debris set in motion by it; (3) propulsion of the body. Injuries in the first category affect gas-containing organs (ears, lungs and intestines), and acute death is attributed to air forced into the coronary vessels via damaged pulmonary alveoli. It is estimated that overpressure sufficient to cause lung injury may occur up to five miles from a 20-megaton nuclear explosion. The greatest single hazard from blast is, however, flying glass, and serious wounding from this cause is possible up to 12 miles from an explosion of this magnitude.     

口腔颌面部爆炸伤的研究现状

口腔颌面部爆炸伤是指由致伤物爆炸所造成的口腔颌面部组织损伤,两种主要致伤因素是冲击波和高速破片,较一般火器伤而言,爆炸伤的致伤机制及致伤特点都有不同之处。对爆炸伤害的物理机制和病理生理反应方面研究有助于改进防护及改善治疗策略。本文在简述口腔颌面部爆炸伤的致伤因素和损伤特点的基础上,着重综述了动物模型和有限元模型的研究方法及结果,旨在为以后的模型研究提供思路和参考。     

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.     

冲击波负压对大鼠肺致伤效应的初步观察

观察了不同的冲击波负压峰值对大鼠肺的影响。各种条件下的冲击波负压值可由负压发生装置来模拟调节,这种装置可满足化爆、核爆和爆炸性减压下负压参数的一般要求,参数稳定,重复性好。冲击波负压峰值范围为-13～-90kPa,下降时间为1～90ms,持续时间为14～2 000ms。6组Wistar系大鼠,分别暴露在-47.2～-84.0kPa的冲击波负压环境中,伤后立即解剖动物,重点观察肺伤情。实验结果显示,在上述冲击波负压环境中,肺可出现从无伤至极重度伤;出血、充血以及肺表面压痕酷似肺冲击伤的病理表现。随着冲击波负压峰值的变化,各组肺伤情亦随着变化,冲击波负压峰值(△P)和减压倍数(P_i/P_a)分别与肺出血面积和动物死亡率相关显著或非常显著。本实验提示,一定条件下的冲击波负压具有明显的致伤作用,且伤情变化范围与超压所致肺伤情变化范围相同,超压和冲击波负压在一定条件下可通过伤情指标等效。     

Computational modelling of lung injury: is there potential for benefit?

State-of-the-art medical care of the victims of current conflicts is generating large quantities of quality clinical data as a by-product. Observational research based on these data is beginning to have a profound influence on the clinical management of both military and civilian trauma patients. Computational modelling based on these datasets may offer the ability to investigate clinical treatment strategies that are practically, ethically or scientifically impossible to investigate on the front line. This article reviews the potential of this novel technology to aid development of treatment for blast lung and other unresolved medical scenarios.     

Hypoxia enhances unilateral lung injury by increasing blood flow to the injured lung

We hypothesized that in unilateral lung injury, bilateral hypoxic ventilation would induce vasoconstriction in the normal lung, redirect blood flow to the injured lung, and cause enhanced edema formation. Unilateral left lung injury was induced by intrabronchial instillation of 1.5 ml/kg of 0.1 N HCl. After HCl injury, blood flow to the injured left lung decreased progressively from 0.70 +/- 0.04 to 0.37 +/- 0.05 l/min and percent of flow to the injured left lung (QL/QT) decreased from 37.7 +/- 2.2 to 23.6 +/- 2.2% at 240 min. Exposure to hypoxia (12% O2) for three 10-min episodes did not affect QL/QT in normal animals, but after unilateral HCl injury, it caused blood flow to the injured left lung to increase significantly. A concomitant decrease in blood flow occurred to the noninjured right lung, resulting in a significant increase in QL/QT. The enhanced blood flow to the injured lung was associated with a significant increase in the wet-to-dry lung weight ratio in the dependent regions of the injured lung. These findings demonstrate that in unilateral HCl-induced lung injury, transient hypoxia can enhance blood flow to the areas of injury and increase lung edema formation.     

Prediction of globe rupture caused by primary blast: a finite element analysis

Although a human eye comprises less than 0.1% of the frontal body surface area, injuries to the eye are found to be disproportionally common in survivors of explosions. This study aimed to introduce a Lagrangian–Eulerian coupling model to predict globe rupture resulting from primary blast effect. A finite element model of a human eye was created using Lagrangian mesh. An explosive and its surrounding air domain were modelled using Eulerian mesh. Coupling the two models allowed simulating the blast wave generation, propagation and interaction with the eye. The results showed that the peak overpressures caused by blast wave on the corneal apex are 2080, 932.1 and 487.3 kPa for the victim distances of 0.75, 1.0 and 1.25 m, respectively. Higher stress occurred at the limbus, where the peaks for the three victim distances are 25.5, 14.1 and 6.4 MPa. The overpressure threshold of globe rupture was determined as 2000 kPa in a small-scale explosion. The findings would provide insights into the mechanism of primary blast-induced ocular injuries.     

Outbreak of acute respiratory disease caused by human adenovirus type 7 in a military training camp in Shaanxi,China

Outbreaks of ARD associated with HAdV have been reported in military populations in many countries. Here, we report an ARD outbreak caused by HAdV‐7 in a military training camp in Shaanxi Province, China, from February to March of 2012. Epidemic data and samples from the patients were collected, and viral nucleotides from samples and viral isolations were detected and sequenced. IgG and IgA antibodies against HAdV, and the neutralization antibodies against the viral strain isolated in this outbreak, were detected. Epidemiological study showed that all personnel affected were males with an average age of 19.1 years. Two peaks appeared on the epicurve and there was an 8‐day interval between peaks. Laboratory results of viral nucleotide detection carried out with clinical specimens were positive for HAdV (83.33%, 15/18). Further study through serum antibody assay, virus isolation and phylogenetic analysis showed that HAdV‐7 was the etiological agent responsible for the outbreak. IgA antibody began to appear on the 4th day after the onset and showed 100% positivity on the 8th day. The virus strain in the present outbreak was highly similar to the virus isolated in Hanzhong Shaanxi in 2009. We conclude that HAdV‐7 was the pathogen corresponding to the outbreak, and this is the first report of an ARD outbreak caused by HAdV‐7 in military persons in China. Vaccine development, as well as enhanced epidemiological and virological surveillance of HAdV infections in China should be emphasized.     

Family perceptions of post-deployment healthcare needs of Iraq/Afghanistan military personnel

Nearly 40 000 service members returning from Iraq and Afghanistan have suffered traumatic injuries, with over 300 000 at risk for post-traumatic stress disorder (PTSD) or other psychiatric problems. These veterans face numerous post-deployment health concerns, sharing substantial burdens with their families. Although many rely upon community-based health care, little is known about how these individuals present at family medicine clinics for perceived medical and psychological issues. We surveyed 347 patients during visits at six clinics, and respondents reported whether they,a family member or a close acquaintance had been deployed since 2001. Patients identified traumatic military experiences, plus any attributable health or social problems. The mean patient age was 47.5 years, with 71% women and 55% Hispanic individuals. Nearly one-quarter reported family members serving overseas while 52% knew someone deployed. Significant events included nearby explosion (21%) or combat injury (9%), along with a variety of other incidents. Among the half of individuals perceiving significant health or social ramifications, the most prevalent consequences were PTSD, depression and alcohol abuse. Divorce or marital problems were noted by13%, while many reported employment, legal or other difficulties. This study offers insights into post-deployment needs of military personnel and subsequent problems reported by family members. A high prevalence of traumatic combat events translated into serious health needs, plus social disruptions for veterans and their loved ones. As the long-term problems disclosed by returning service personnel continue to ripple across community clinics and other health systems, effective treatment planning mandates coordinated attention from multiple providers and service organisations.     

某军校学员心理健康情况调查分析

目的：了解军校学员心理健康状况,为军校心理辅导工作提供理论依据,提高军校教育管理水平,有效预防学员在校期间由于压力、情绪等因素造成的心理问题。方法：使用DXC-6型多项群体心理测评仪,对某军校不同年级1332名学员进行卡特尔16种人格个性因素测验。结果：①1332名被测试学员16PF得分总体呈现”五高三低”。②不同年级的学员在16PF多项因子上得分有差异（P〈0．05）。研究生在C、M、O等因子得分明显高于大三学员,而在A、F、H等得分明显低于大三学员（P〈0．05）;研究生在C因子得分明显高于大四学员（P〈0．05）,F、G、Y2因子得分明显低于大四学员（P〈0．05）,而在A、M、O、H这些因子的得分差异无统计学意义（P〉0．05）;大三学员在A、H、X2等得分明显高于大四学员,而在M、O、Q1等得分明显低于大四学员（P〈0．05）。结论：军校学员的整体心理健康水平良好;本科学员（尤其是大三学员）的心理健康水平明显优于研究生;大三的学员在乐群性、敢为性、实验性、忧虑性等方面优于大四学员,和大四学员相比,大三学员更喜欢探索新生事物。     

Viral gastroenteritis associated with genogroup II norovirus among U.S. military personnel in Turkey, 2009

The present study demonstrates that multiple NoV genotypes belonging to genogroup II contributed to an acute gastroenteritis outbreak at a US military facility in Turkey that was associated with significant negative operational impact. Norovirus (NoV) is an important pathogen associated with acute gastroenteritis among military populations. We describe the genotypes of NoV outbreak occurred at a United States military facility in Turkey. Stool samples were collected from 37 out of 97 patients presenting to the clinic on base with acute gastroenteritis and evaluated for bacterial and viral pathogens. NoV genogroup II (GII) was identified by RT-PCR in 43% (16/37) stool samples. Phylogenetic analysis of a 260 base pair fragment of the NoV capsid gene from ten stool samples indicated the circulation of multiple and rare genotypes of GII NoV during the outbreak. We detected four GII.8 isolates, three GII.15, two GII.9 and a sole GII.10 NoV. Viral sequences could be grouped into four clusters, three of which have not been previously reported in Turkey. The fact that current NoV outbreak was caused by rare genotypes highlights the importance of norovirus strain typing. While NoV genogroup II is recognized as causative agent of outbreak, circulation of current genotypes has been rarely observed in large number of outbreaks.     

Effects of military activity on breeding birds

United States military bases provide habitat for a diverse suite of wildlife species despite intense anthropogenic disturbance inherent in training activities. Little research has examined how military activity affects wildlife reproduction. We compared parental investment, reproductive success, offspring and adult quality, and stress hormone concentrations of northern cardinals (Cardinalis cardinalis) breeding in areas that differed 10-fold in levels of on-ground military activity. We found no evidence of direct impacts of military activity on cardinals, nor did the reproductive success of several other passerine species appear to be affected. However, we observed American crows (Corvus brachyrhynchos) much less frequently in areas of high military activity, and cardinals nesting in those areas were less responsive to crow models. The apparent displacement of this nest predator suggests that military activity could indirectly benefit some wildlife. Although these results are promising for the conservation of birds that depend on military bases for breeding habitat, further assessment of direct and indirect effects of military training on a wider array of species is required before concluding that such activity is benign. © 2012 The Wildlife Society.     

Factor analysis of teacher professional development in Chinese military medical universities

Background and purpose: Teacher professional development potentially enhances teachers’ professional morale, knowledge, skills and autonomy, which helps improve the quality of education. The military medical university is an important medical education institution in China; however, studies of teacher professional development within military medical universities are still lacking. This study aimed to explore the factors that influence teacher professional development in Chinese military medical universities. Methods: We interviewed 19 experts from China’s Third Military Medical University to identify factors that affect teacher professional development and used these factors to prepare a questionnaire. The data were collected through a random, anonymous questionnaire survey of 371 teachers at three military universities in China, analysed by exploratory factor analysis and verified by confirmatory factor analysis (CFA). Results: We obtained five main factors, which explained 66.691% of the total variance and were found to have a good data fitting according to the CFA results. Conclusions: Teaching experience, shared vision, policy and material security, professional competence and psychological motivation primarily affect teacher professional development in Chinese military medical universities. We can only achieve teacher professional development goals through comprehensive consideration, coordinated arrangement and content improvement of these five factors.     

The potential of military training areas for bird conservation in a central European landscape

European biodiversity has suffered from serious declines during the past few decades, with alterations of land use practices resulting in a loss of fine-scale habitat heterogeneity being a dominant driver. This heterogeneity was maintained by extensive landscape management, which has gradually been replaced by either intensive exploitation or land abandonment. It has been suggested that military training can generate habitat heterogeneity that may support the existence of species of conservation concern, but studies rigorously testing the real importance of military training areas for biodiversity are lacking. Here we address this issue by analyses of two datasets. First, we compared land cover classes between all large military training areas (MTAs) and surrounding control areas (CAs) of the same size in the Czech Republic using multivariate redundancy analysis. We found that the difference in land cover between MTAs and CAs was significant and represented the strongest gradient in land cover classes: from various farmland and artificial habitats typical for CAs to forest and scrubland-grassland mosaic typical for MTAs. Second, we selected one of these areas and compared bird species richness between the MTA and the nearby CA using generalized linear mixed effects models. We found that the number of species of conservation concern was significantly higher in the MTA than in the CA. With respect to habitats, bird species richness was significantly higher in the MTA than in the CA for open habitats, but not for forest habitats. Our results are thus consistent with the view that military training creates areas that are different from the surrounding landscape in terms of land cover, and that this difference translates to a suitability for species of conservation concern. It is remarkable that the positive influence of military training is confined to open habitats, which are subject to the most intensive military activities and also suffer the highest degree of deterioration in European landscapes.     

Evaluation of the efficacy of chloroquine chemoprophylaxis for vivax malaria among Republic of Korea military personnel

Chloroquine has been used massively for vivax malaria prophylaxis and treatment in the Republic of Korea (ROK) military personnel from 1997. Although prophylaxis is generally regarded as successful among ROK military, prophylaxis failure has been repeatedly reported. Before the prophylaxis program was started on July 4th 2011, which was completed on October 16th 2011, by the ROK military, more than 60% of malaria cases were attributed to new infection or long-latency relapse. During the prophylaxis program, the authors re-examined the efficiency of chloroquine chemoprophylaxis in ROK military during the last 6 months of 2011 by measuring compliance and whole blood chloroquine levels in 41 malaria patients immediately before instituting antimalarial therapy between July and December. Three patients (7.3%) showed good compliance, and had whole blood total chloroquine levels above the minimally inhibitory concentration (100 ng/mL). However, 28 (69.3%) of these 41 patients when admitted to hospital showed poor or no compliance with prophylaxis; 4 of the 28 (14.3%) were stationed outside the mass prophylaxis region, and 5 (17.9%) subjects were infected after the prophylaxis program had finished. These findings indicate that the current malaria control program should be carefully reconsidered, in terms of, individual instruction, current chemoprophylaxis program regimens, and schedules to improve the efficacy of prophylaxis in the ROK military.     

Blue whales respond to simulated mid-frequency military sonar

Mid-frequency military (1–10 kHz) sonars have been associated with lethal mass strandings of deep-diving toothed whales, but the effects on endangered baleen whale species are virtually unknown. Here, we used controlled exposure experiments with simulated military sonar and other mid-frequency sounds to measure behavioural responses of tagged blue whales (Balaenoptera musculus) in feeding areas within the Southern California Bight. Despite using source levels orders of magnitude below some operational military systems, our results demonstrate that mid-frequency sound can significantly affect blue whale behaviour, especially during deep feeding modes. When a response occurred, behavioural changes varied widely from cessation of deep feeding to increased swimming speed and directed travel away from the sound source. The variability of these behavioural responses was largely influenced by a complex interaction of behavioural state, the type of mid-frequency sound and received sound level. Sonar-induced disruption of feeding and displacement from high-quality prey patches could have significant and previously undocumented impacts on baleen whale foraging ecology, individual fitness and population health.     

Physical trauma and tungsten toxicity reduce the efficiency of biolistic transformation

A cell suspension culture of tobacco (Nicotiana tabacum L.) was used as a model to study injury to cells during biolistic transformation. Lawns of cells were bombarded with tungsten particles that were coated with a plasmid containing the β-glucuronidase and the neomycin phosphotransferase II genes. When a gunpowder-driven biolistic device was used, numerous transiently expressing cells were focused around the epicenter of the blast which was manifested by a hole blown in the filter paper supporting the cells. However, transformed cells nearest the blast epicenter were injured and could not be recovered as stable transformants. The injury was primarily caused by physical trauma to the cells from gas blast and acoustic shock generated by the device. Postlaunch baffles or meshes placed in the gunpowder device reduced cell injury and increased the recovery of kanamycin-resistant colonies 3.5- and 2.5-fold, respectively. A newly developed helium-driven device was more gentle to the cells and also increased the number of transformants. Cell injury could be further moderated by using a mesh and a prelaunch baffle in the helium device. Toxicity of the tungsten microprojectiles also contributed to cell injury. Gold microprojectiles were not toxic and resulted in fourfold more kanamycin-resistant colonies than when similar quantities of similarly sized tungsten particles were used.