Floods are increasing with climate change, and evacuating medically vulnerable people receiving home healthcare remains challenging. Patients dependent on medical devices and long-term care face complex challenges throughout the evacuation process. However, key factors influencing successful evacuation and effective support strategies remain underexamined. This study aimed to identify such factors and essential support measures across evacuation phases. Semi-structured interviews were conducted with 13 participants-family caregivers, healthcare providers, and municipal officials-from July 2022 to March 2023 in 3 Japanese regions. Snowball sampling was used via medical administrative institutions. Thematic analysis followed COREQ guidelines, focusing on three phases: preparation, evacuation, and post-evacuation. Ethics approval was obtained (MG2022-01). Preparation showed heterogeneous readiness: some services had hazard maps and manuals/BCPs, whereas household engagement was limited and operationalization was constrained by resources. During evacuation, participants described transport and staffing limitations, difficulty in moving medical equipment, and uncertainty about feasible options, with occasional consideration of vertical evacuation. Post-evacuation challenges centered on shelter sanitation and supplies, continuity of medical support, and coordination of support systems. A three-phase, multi-stakeholder perspective clarifies how constraints accumulate and informs coordinated planning among municipalities, home-care teams, and families. Limitations include a small, region-specific sample and no direct patient interviews.
Surgical smoke exposes approximately 500,000 perioperative personnel annually and contains ultrafine particulate matter, carcinogens, and viable biologic material that cannot be fully mitigated by surgical personal protective equipment or N95 respirators. Adequate protection requires removing smoke at the source through smoke evacuation devices and air filtration. Within the Military Health System (MHS), implementation is challenged by staff turnover, equipment variability, knowledge gaps, and competing operational demands. This integrative review synthesizes evidence to inform a quality improvement initiative aimed at optimizing smoke evacuation practices in a Military Treatment Facility. An integrative review was conducted using PubMed/MEDLINE, CINAHL, and Embase (2015-2025). Initial searches yielded 486 articles; after removal of duplicates and screening, 44 studies met the inclusion criteria. Two reviewers independently appraised each study using a Rapid Critical Appraisal checklist, with verification by a third reviewer. Data extraction was completed by paired reviewers and synthesized into thematic categories. Evidence consistently supports source-level removal of surgical smoke using smoke evacuation devices positioned within 2 inches of the surgical site and equipped with ultra-low particulate air filtration. Key barriers included limited knowledge, inconsistent equipment availability, workflow concerns, and a lack of standardized policies. Education interventions, leadership engagement, and multidisciplinary implementation improved compliance. COVID-19 heightened awareness of aerosol hazards, influencing early increases in smoke evacuation use. Despite strong evidence of harm, compliance across healthcare settings remains low, and little research examines long-term sustainment, leadership impacts, or operational considerations unique to the MHS. Evacuation of surgical smoke at the source is the most effective method to protect perioperative staff and patients. Standardized policies, sustained education, leadership support, and integration into MHS workflows are essential to overcoming persistent barriers. Implementing and sustaining smoke evacuation programs across the MHS will enhance force health protection and align military perioperative practice with evolving national safety standards.
The optimal surgical management of bilateral chronic subdural hematoma (bCSDH) remains debated, particularly whether and when to evacuate unilaterally or bilaterally at index surgery. This study aimed to determine the incidence and predictors of later contralateral surgery after initial unilateral evacuation of bCSDH. We conducted a population-based retrospective cohort study of adults (≥18 years) treated for bCSDH at Karolinska University Hospital (2006 - 2023). Standard surgical approach was single burr-hole craniostomy followed by 24-h subgaleal drainage. The primary outcome was evacuation of the initially non-operated hematoma within 6 months. Candidate predictors included preoperative clinical and radiological variables, as well as intraoperative treatment-related variables. Univariable analyses and backward stepwise multivariable logistic regression identified independent predictors. Of 861 bCSDH cases, 401 underwent initial unilateral evacuation. Of these, later contralateral surgery was required in 46/401 (11%) at a median of 21 days (IQR 12 - 31) after the index procedure. Non-operated hematoma volume at index surgery was the only predictor of later contralateral evacuation (adjusted OR 1.01 per mL, p = 0.022), with a Nagelkerke pseudo-R2 value of 21%, and an AUC of 56%. In this population-based study, 11% of patients with bCSDH required contralateral surgery following unilateral evacuation, with a median time to surgery of 21 days. Non-operated hematoma volume at index surgery was statistically associated with later contralateral surgery, although its predictive performance was limited. These findings may help inform individualized postoperative surveillance strategies, particularly in patients with larger non-operated hematoma volumes.
In emergency evacuation scenarios, ensuring the safe and prompt evacuation of passengers is of utmost importance. Although emergency evacuation signs hold significant meaning, passengers often hesitate to comply with them during emergencies. Therefore, it is crucial to understand the psychological decision-making process that passengers undergo in these critical situations. This study focuses on subway fire emergencies and examines the psychological decision-making mechanisms influencing passengers' evacuation sign compliance (ESC) intention. To achieve this, a psychological mechanism framework model based on the protection action decision model (PADM) and the heuristic-systematic model (HSM) is constructed. The study adopts a questionnaire survey to establish a structural equation model for passengers' ESC intention, followed by mediation and moderation analyses of the predictive factors. The research findings reveal that passengers' ESC intention is positively correlated with risk perception (RP), hazard-related attributes, information seeking (IS), and systematic information processing (SIP), while being negatively associated with resource-related attribute (RRA) perception. The mediation analysis indicates that both IS and SIP act as mediators in the relationship between RP and ESC intention. Furthermore, SIP serves as a mediator between IS and ESC intention. The moderation analysis demonstrates that the importance of RRAs intensifies the negative association between RRAs and ESC intention. This research enhances our understanding of the psychological mechanisms underlying passengers' ESC intention and provides practical suggestions for subway engineering design and emergency management.
This study aimed to investigate the clinical efficacy of modified intraoperative gas evacuation combined with immediate postoperative pressure and local cold compress in reducing postoperative seroma formation following laparoscopic TAPP repair of larger inguinal hernias. This single-center, prospective, observational real-world study analyzed clinical data from 196 patients with larger inguinal hernias admitted to our hospital between January 2025 and August 2025. Based on perioperative management differences, patients were divided into two groups: the control group (n = 98) underwent TAPP repair with routine postoperative care, including inguinal compression bandaging applied upon ward transfer. The experimental group (n = 98) received standard care plus strict intraoperative preperitoneal and scrotal gas evacuation, followed by immediate postoperative inguinal compression bandaging and intermittent cold compress application. The operative time, postoperative pain VAS scores, postoperative scrotal distension VAS scores, and incidence of postoperative seroma were compared between the two groups of patients. A total of 196 patients were included. Early postoperative distension and acute pain in the Experimental group were significantly lower than in the Control group (p < 0.05), while no significant difference was observed long-term (p > 0.05); Only 2 cases (2.0%) in the Experimental group developed postoperative seroma, significantly lower than the 9 cases (9.2%) in the Control group (p < 0.05). Postoperative comfort in the Experimental group was superior to that in the Control group. For patients with larger inguinal hernias, meticulous management involving thorough intraoperative gas evacuation to eliminate dead space, combined with early postoperative pressure and cold compress, can significantly reduce the risk of postoperative seroma, alleviate postoperative pain, and is worthy of clinical promotion.
Aeromedical evacuation (AE) is a critical capability of military medical support systems, allowing patients to be transferred rapidly from forward medical facilities to higher levels of care while maintaining medical supervision during transport. Despite its importance, published information describing AE activities from Level 2 field hospitals operating in United Nations peacekeeping missions remains limited. A retrospective descriptive study was performed to examine AE missions conducted from the Vietnamese Level 2 Field Hospital deployed in Bentiu, South Sudan within the United Nations Mission, between July 2023 and December 2025. Data were extracted from mission documentation, including MEDEVAC logs and flight reports. Collected variables included patient demographics, mission characteristics, and medical interventions performed during transport. Associations between operational factors and the performance of in-flight interventions were evaluated using Fisher's exact test and the Mann-Whitney U test. Thirty AE missions were analyzed. The average patient age was 41.8 ± 8.8 years, and 25 (83.3%) were male. Medical conditions accounted for 16 (53.3%) of evacuations, followed by trauma, 8 (26.7%). Median flight time was 75 minutes (IQR 70-112.5). In-flight medical interventions were performed in 22 (73.3%) of missions, most commonly continuous physiologic monitoring, 16 (53.3%), intravenous medication administration, 14 (46.7%), and oxygen therapy, 12 (40.0%). Special flights and missions with ≥2 accompanying medical personnel were significantly associated with in-flight interventions (P = .01 and P = .032). No in-flight mortality occurred. Aeromedical evacuation from a Level 2 field hospital was operationally feasible and clinically safe. The frequent need for in-flight interventions highlights the importance of appropriate patient stabilization, escort team composition, and mission planning in deployed operational environments.
Pelvic floor physical therapy (PFPT) is recommended for conditions including constipation and fecal incontinence. There is limited evidence exploring characteristics of physical therapy practices, attitudes toward treating evacuation disorders, and potential barriers to care that may influence treatment outcomes. Therefore, a better understanding of these aspects of PFPT is needed. The purpose of this study was to survey PFPT practices, using the Chicagoland area as a microcosm. We aimed to explore practice characteristics, available treatment modalities, and attitudes toward treatment of evacuation disorders. We conducted a cross-sectional phone and email-based survey of pelvic floor physical therapists across 17 counties in the Chicagoland area. Of 149 eligible contacts, there were 48 respondents representing 58 total PFPT practices. Mixed methods were used to aggregate data quantitatively and perform mapping analysis and thematic analysis. There were geographic disparities in PFPT provider density. Most practices served all gender identities but consisted primarily of female therapists. Levels of PFPT-specific training and certification varied. Respondents felt that education on lifestyle, including diet, was an important therapeutic goal. Biofeedback in a variety of forms was used by most respondents (81%); some suggested that biofeedback was not as effective for chronic constipation as other therapies. Themes of potential barriers to satisfactory outcomes included delayed and vague referrals from other clinicians, as well as patient misinformation and inappropriate expectations. This study provides preliminary insights to guide further work on improving access to PFPT and improving treatment outcomes for bowel symptoms. To strengthen collaboration, we suggest that referring clinicians actively communicate and develop networks with local PFPT offices, and offer earlier, more detailed PFPT referrals to patients.
On 27 September 2024, at the 67th Annual Meeting of the Japan Radiation Research Society at the Kitakyushu International Conference Center in Kokura City, the program organizers held a symposium titled 'Symposium on Evacuation and Shelter-in-place Strategies in Nuclear Disasters: Preventing Disaster-Related Deaths.' This symposium aimed to examine practical disaster-prevention strategies at the operational level in disaster-affected areas during nuclear disasters and featured presentations and general discussions with four speakers. The topics included evacuation during the Great East Japan Earthquake and Fukushima Daiichi nuclear power plant accident; ethical problems regarding medical policy during the coronavirus disease 2019 pandemic; on-site issues in supporting areas affected by the Noto Peninsula earthquake; and estimates of the effect of reducing radiation exposure by shelter-in-place in four scenarios during a nuclear disaster. The discussion provided insights into decision-making processes during nuclear disasters. The symposium concluded that government must collaborate with medical and nursing care professionals to develop specific disaster-prevention measures. These plans should be tailored to the particular circumstances of the disaster and the unique conditions of each facility.
Arteriovenous shunting involving the middle meningeal artery (MMA) has been reported after cranial trauma, neurosurgical procedures, and endovascular interventions. However, its angiographic frequency and characteristics after chronic subdural hematoma (cSDH) surgery remain poorly defined. This study aimed to assess the frequency and angiographic features of MMA arteriovenous shunting in patients undergoing MMA embolization after surgical evacuation of cSDH. We retrospectively analyzed consecutive patients who underwent selective and superselective MMA angiography during MMA embolization after surgical evacuation of cSDH between January 2020 and March 2023. Angiograms were reviewed for angiographic evidence of arteriovenous shunting, shunt morphology, flow characteristics, venous drainage, relationship to embolization, and angiographic closure after embolization. Surgical technique was classified as burr-hole craniotomy or formal craniotomy. Thirty patients met the inclusion criteria. Angiographic evidence of MMA arteriovenous shunting was identified in 11 patients (36.7%). Shunting was significantly more frequent after craniotomy than after burr-hole craniotomy (90.9% vs. 5.3%, Fisher's exact test, p < 0.001). Most shunts were detectable before microcatheter advancement, while superselective angiography improved visualization of shunt morphology and venous drainage. All shunts demonstrated low-flow angiographic characteristics without cortical venous reflux. Post-embolization control angiography demonstrated disappearance of the angiographic shunt in all affected patients. Low-flow arteriovenous shunting involving the MMA is a frequent angiographic finding in patients undergoing MMA embolization after cSDH surgery, particularly following craniotomy. These findings provide systematic angiographic characterization of a previously underrecognized postoperative vascular phenomenon. The clinical relevance of such shunting remains uncertain and warrants prospective investigation.
During 2014-2020, the Florida Department of Health in Sarasota County (DOH-Sarasota) developed a program to prepare for weather-related disaster impacts on the county's Access and Functional Needs (AFN) population, with a special focus on emergency communication and evacuation. This case report presents a retrospective evaluation of the planning process used to engage diverse stakeholders, build inter-agency collaborations, and integrate disaster and health policies to enhance community resilience. DOH-Sarasota fashioned their multi-tiered approach on agency-facing and community-engaged activities by implementing FEMA's Whole Community approach to better understanding AFN communities, to engage and empower both AFN residents and the organizations that serve them, and to strengthen AFN community assets in the context of hurricane preparedness. DOH-Sarasota's planning process aimed to build critical new partnerships, incorporate the perspectives of AFN groups in the planning process, and establish critical resource networks. Vulnerability is not uniform and understanding this diversity of needs is necessary to better target resources and expand opportunities for more representation in decision-making. By finding opportunities to gather and share knowledge in sustained and reflexive ways, the case study is a translatable example of how public health and emergency management agencies can expand their capacities and policies to integrate, collaborate, educate and innovate towards increased community resilience for AFN populations.
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Open-framework gallium phosphates (GaPO4) are generally considered unstable, often collapsing during calcination for the removal of organic structure-directing agents (OSDAs). We developed an effective and simple method to remove dipropylamine (DPA), an OSDA, from GaPO4-LTA (a gallium phosphate with the LTA-type framework) by heating it at 623 K in vacuo, thus avoiding combustion. Following this proposed methodology, the LTA-type framework persisted successfully under an inert atmosphere, although it exhibited signs of strain. Porosity after this treatment was characterized by Ar adsorption-desorption measurements. The isotherms showed Type I curves without hysteresis, characteristic of purely microporous materials. The material exhibited a Brunauer-Emmett-Teller specific area of 428 m2/g and a micropore volume of 0.150 cm3/g. These values suggest the presence of approximately 30 wt % nonporous phase within the sample. GaPO4-LTA exhibited weaker attractive interactions with Ar and N2 adsorbates compared to LTA-type aluminosilicates (Ca-form A and Na-form ZK-4). Thermogravimetry-mass spectrometry revealed that DPA desorbs intact, offering a new route for the recovery and reuse of OSDAs.
Wartime conditions have exacerbated the importance of infection prevention and control (IPC) practices and their impact on patient prognosis. While microflora contamination occurs at the time of injury, multiple subsequent invasive procedures potentially place patients at a higher risk of acquiring nosocomial flora. This study aimed to evaluate whether the region of trauma, the length of the evacuation chain, or the previous healthcare facility impact the risk of acquiring ESKAPE pathogens upon admission to a rear hospital, and to assess the consequences of these pathogens on wound microflora and patient prognosis. A retrospective cohort study was conducted at the Feofaniya Clinical Hospital of the State Administration of Affairs, which serves as a rear hospital in Ukraine's medical evacuation chain. Combatants treated in the Surgical Intensive Care Unit (ICU) were selected for analysis. Medical records were reviewed to obtain geographical details of the trauma region, the approximate route and duration of evacuation, injury type, and microbiological results from wound swabs collected upon ICU admission. Binary logistic regression analysis was performed to identify factors associated with the primary outcome. A total of 264 male combatants admitted between February 2022 and December 2024 were included (mean age: 38.1 years). The median time from injury to admission at the rear hospital was 7 days. The most frequent regions of trauma were Donetsk (57.1%) and Kharkiv (12.2%), with patients primarily evacuated via hospitals in the Dnipro region and the Kharkiv Northern region military medical center. Blast injuries predominated (70.3%), followed by gunshot wounds (22.4%). Initial microbiological screening revealed ESKAPE pathogens in 63.8% of blast injury cases and 62.7% of gunshot wounds. While the prevalence of ESKAPE-positive swabs slightly decreased from 66.0% in 2022 to 58.2% in 2023, it rose to 59.3% in 2024, remaining the dominant finding. Logistic regression analysis indicated that the geographic region of trauma, evacuation route, and duration of evacuation did not significantly affect the risk of ESKAPE pathogen presence upon admission (\(p > 0.05\)). However, the presence of ESKAPE pathogens at admission was a significant independent predictor of mortality (aOR 22.39; 95% CI 2.97-168.55; \(p = 0.003\)). Our study demonstrated that neither the specific geographical region of injury nor the medical evacuation route significantly influenced the microbiological profile of combat-related wounds upon admission to a rear hospital. ESKAPE pathogens are highly prevalent in the initial wound swabs of combatants and serve as a critical independent predictor of increased in-hospital mortality. Not applicable.
Delayed evacuation creates a critical gap between point-of-injury care and definitive surgical management in battlefield trauma. Although Damage Control Orthopedics (DCO) is an established strategy for physiologically unstable trauma patients, it is usually implemented after evacuation and depends on higher-level medical support. We propose Battlefield Monitoring and Stabilization (BMS) as a forward-deployed conceptual framework for earlier battlefield care. BMS emphasizes temporary stabilization, hemorrhage-oriented intervention, basic physiological support, and portable monitoring before evacuation and definitive treatment. Proposed applications include point-of-injury stabilization, prolonged field care, and en-route casualty management. Several enabling components, including a rapidly assembled pelvic stabilization device, are under development. Relevant evaluation domains include fixation speed, hemostatic performance, monitoring accuracy, portability, and environmental adaptability. Further validation is warranted.
Floods are frequent climate-related disasters in Bangladesh, threatening physical safety, livelihoods, and mental health. Women are particularly vulnerable due to gendered roles, economic dependence, and caregiving duties. However, research on women's mental health outcomes following recent flash floods is limited. A community-based cross-sectional study was conducted among 504 women aged 18 years and above in Fulgazi and Sonagazi upazilas of Feni District, Bangladesh, following the 2024 flash flood. Participants were recruited purposively from flood-affected communities, and data were collected at the beginning of 2025. Data were collected via face-to-face interviews using a structured questionnaire, and mental health was assessed using the DASS-21. Severe depression (71.1%), anxiety (48.8%), and stress (60.6%) were reported. Women aged 18-25 years reported lower depression and anxiety, while those aged over 55 years showed higher anxiety. Engagement in income-generating activities was associated with lower levels of depression, anxiety, and stress. Perceived social life satisfaction was strongly associated with satisfaction, whereas dissatisfaction was associated with higher psychological distress. Chronic disease status was significantly associated with mental health, with women having chronic conditions reporting higher anxiety, and those experiencing flood-related illness showing elevated depression, anxiety, and stress. Flood-related exposures also played a key role; the perceived lack of safety was associated with higher anxiety. Access to socioeconomic support during the flood was associated with lower anxiety and stress, while access to safe drinking water reduced anxiety. Food security and evacuation experiences also influenced outcomes, with the absence of food scarcity linked to lower depression and non-evacuation associated with higher depression. High levels of depression, anxiety, and stress were observed among women in flood-affected areas of Feni, Bangladesh, highlighting the need for gender-sensitive mental health support in disaster-prone settings.
Prolonged evacuation intervals, infrastructure disruption, and contested environments increasingly prevent timely access to surgical care for casualties with ongoing hemorrhage or contamination. Prior operational reports, including the Joint Medical Augmentation Unit experience, have shown that emergency life- and limb-saving surgical intervention can occur in flight when required. The present article addresses a different problem: how to train teams for intentional fixed-wing transport of a casualty whose operative needs may begin, continue, or recur during evacuation. This observational descriptive report summarizes 5 single-flight C-130 simulation iterations conducted during the West Virginia National Guard Ridge Healer exercises from 2024 to the present. Each iteration included up to 1 hour of in-flight scenarios with 1 surgical casualty and at least 2 critical care casualties using perfused wearable cut suits on live role players. Common operative tasks included splenectomy, small bowel resection, vascular ligation, and temporary abdominal closure. After-action reviews led by Ridge Healer staff informed the identification of recurrent themes through repeated faculty observation, participant discussion, and iterative curriculum refinement. Across the 5 iterations, several recurrent adaptations improved procedural flow and team safety. These included loading the most unstable surgical casualty first and positioning that patient forward in the aircraft, using voice-activated communication systems, employing standing operative posture on stanchion-mounted litters, favoring staplers and clips over hand-sewn techniques, rehearsing rapid turbulence bailout procedures, and standardizing temporary abdominal closure and handoff documentation methods. Participant feedback consistently emphasized loadout streamlining as the highest-yield operational adjustment, and teams reported subsequent changes to loadouts and team composition, including greater reliance on hemostatic clips, bowel staplers, and cross-trained personnel rather than a dedicated assistant role. Simulation-based training for in-flight damage control surgery during fixed-wing transport is feasible and yields practical lessons in ergonomics, communication, staffing, and procedural simplification. These observations should be interpreted as descriptive lessons learned from repeated exercise iterations rather than as proof of clinical efficacy or claims that in-flight surgery itself is unprecedented.
As forces prepare for large scale combat environments (LSCO), military medicine must adapt by building an in-theater system capable of providing prolonged casualty care under direct threat, moving away from reliance on access to specialty providers and rapid evacuation. This new approach needs to address mental health (MH) conditions by equipping front-line personnel with MH skills. This work aimed to evaluate the effectiveness of the BH GEAR training, which teaches MH prevention, identification and management skills to soldiers without prior MH training. Soldiers (n = 545) from seven U.S. Army units participated in the study from October 2022-April 2024, attended the training, and completed pre- and post-training surveys on the same day. The six-hour training provided instruction on conducting MH assessments, signs and symptoms of illnesses, interventions to prevent or manage concerns, and considerations for managing medical evacuations. Analyses examined satisfaction with the training, self-report of skills learned, and changes in scope of practice, knowledge and confidence utilizing the skills. Most participants (89%) rated the training as relevant and useful, and learned how to assess for (93%) and provide interventions for (91%) MH concerns. Post-training, participants experienced significant increases in MH-related scope of work, knowledge, and confidence. This work shows that completion of a one-day training is associated with increased MH skill knowledge and anticipated confidence using these skills with military service members. Integrating this training into military curriculums will increase the availability of support during current and future operations, ultimately sustaining readiness and lessening the impact of mental health challenges.
Transoral robotic thyroidectomy (TORT) relies on continuous carbon dioxide (CO2) insufflation to maintain the operative workspace, introducing a spectrum of gas-related complications. The newly introduced da Vinci 5 (DV5) system features an integrated, actively regulated insufflation and smoke evacuation system that differs fundamentally from prior-generation platforms. The platform-specific safety profile of the DV5 in TORT remains largely uncharacterized. A 50-year-old male with papillary thyroid carcinoma (PTC) of the left thyroid lobe underwent transoral robotic left hemithyroidectomy with central lymph node dissection using the DV5 system. Insufflation was maintained at 8 mmHg with a flow rate of 20 L/min; the procedure was uneventful. Upon post-anesthesia care unit (PACU) admission, the patient was stable (SpO2 99%), but developed acute chest pain and oxygen desaturation (SpO2 <90%) approximately 20 minutes later. Emergency chest radiography demonstrated bilateral pneumothorax requiring immediate bilateral chest tube insertion. Subsequent computed tomography (CT) confirmed pneumoretroperitoneum and pneumoperitoneum along the perirenal spaces without visceral injury, consistent with extensive CO2 migration along cervicofascial planes. The patient recovered with conservative management and was discharged without sequelae on postoperative day four. Final pathology confirmed pT1N0M0 PTC. Extensive multicavitary gas migration can occur following TORT even under standard insufflation settings and without direct organ injury. The DV5's integrated airflow regulation may alter intraoperative pressure gradients in way that differ from prior platforms. Surgeons adopting DV5 for TORT should consider reducing insufflation pressure to 6 mmHg, restricting automated smoke evacuation during deep dissection, and extending PACU monitoring for at least 60 minutes post-extubation. Multidisciplinary collaboration with system specialists is essential during platform adoption.
Forward trauma care remains a critical gap in emergency responses to armed conflict, particularly where conventional medical evacuation is disrupted. Trauma Stabilization Points (TSPs) were introduced in previous conflicts to bring life-saving care closer to the point of injury. To improve standards and adaptability, the World Health Organization convened a Technical Working Group to develop operational guidance for TSPs, drawing on diverse field experiences, including the ongoing Gaza deployments. Between February and July 2024, three TSPs were established in Gaza, managing over 4,000 consultations. Initially focused on trauma stabilization and referral, these sites quickly adapted to minor injuries and non-traumatic conditions, reflecting population needs and access challenges. Referral rates varied across sites due to hospital proximity, ambulance availability, and shifting frontlines. Security threats limited forward deployment and safe patient access, requiring high mobility and rapid relocation. Experience from Gaza highlighted key operational principles: locating TSPs near the point of injury; integrating within a functioning trauma referral pathway supported by evacuation capacity and hospital readiness; maintaining clear clinical functions and staffing standards; and using standardized documentation for quality assurance and continuity. Lessons from Gaza aligned with those from other conflict zones, emphasizing challenges such as insecurity, fragmented oversight, and disrupted referral systems. The guidance recognizes the need for adaptable models that balance mobility with advanced interventions, including damage control resuscitation in austere settings. The Gaza experience, together with lessons from other conflict settings, is shaping the development of flexible, context-sensitive operational guidance for TSPs. This guidance aims to support emergency care actors and national authorities in determining when and how to deploy TSPs in complex emergencies, balancing core trauma functions with the realities of modern warfare.
Hematoma formation is a common complication following gender-affirming mastectomy, yet the contribution of perioperative hemodynamics to hematoma risk in this population remains unclear. A retrospective cohort study was performed of transgender patients undergoing bilateral gender-affirming mastectomy by a single surgeon from 2016 to 2023. Hematoma was defined as a postoperative collection requiring surgical evacuation. MAP was calculated at baseline, preoperatively, intraoperatively, and within one hour postoperatively. Group comparisons and multivariable logistic regression were used to assess predictors of hematoma formation. Among 216 patients, 8 (3.7%) developed hematomas requiring evacuation. Patients who developed hematoma had significantly lower intraoperative MAP than those without hematoma (73.5 ± 7.2 vs. 83.9 ± 8.6 mmHg, p = 0.004). In addition, the increase in MAP from the intraoperative to postoperative period was significantly greater in the hematoma group (25.6 ± 15.0 vs. 5.85 ± 12.6 mmHg, p = 0.007). On multivariable logistic regression, the intraoperative-to-postoperative MAP increase was a strong independent predictor of hematoma formation (OR 1.14 per mmHg increase, p < 0.001). Optimizing perioperative hemodynamic stability may be an important modifiable factor in reducing hematoma formation and improving outcomes after gender-affirming top surgery.