Objective: To estimate the risk of malignancy in gallbladder polyps of incremental sizes detected during transabdominal ultrasound (TAUS). Methods: We searched databases including MEDLINE, Embase, and Cochrane Library for eligible studies recording the polyp size from which gallbladder malignancy developed, confirmed following cholecystectomy, or by subsequent follow-up. Primary outcome was the risk of gallbladder cancer in patients with polyps. Secondary outcome was the effect of polyp size as a prognostic factor for cancer. Risk of bias was assessed using the Quality in Prognostic Factor Studies (QUIPS) tool. Bayesian meta-analysis estimated the median cancer risk according to polyp size. This study is registered with PROSPERO (CRD42020223629). Results: 82 studies published since 1990 reported primary data for 67,837 patients. 67,774 gallbladder polyps and 889 cancers were reported. The cumulative median cancer risk of a polyp measuring 10 mm or less was 0.60% (99% credible range 0.30-1.16%). Substantial heterogeneity existed between studies (I-2 = 99.95%, 95% credible interval 99.86-99.98%). Risk of bias was generally high and overall confidence in evidence was low. 13 studies (15.6%) were graded with very low certainty, 56 studies (68.3%) with low certainty, and 13 studies (15.6%) with moderate certainty. In studies considered moderate quality, TAUS monitoring detected 4.6 cancers per 10,000 patients with polyps less than 10 mm. Conclusion: Malignant risk in gallbladder polyps is low, particularly in polyps less than 10 mm, however the data are heterogenous and generally low quality. International guidelines, which have not previously modelled size data, should be informed by these findings. Advances in knowledge This large systematic review and meta-analysis has shown that the mean cumulative risk of small gallbladder polyps is low, but heterogeneity and missing data in larger polyp sizes (>10 mm) means the risk is uncertain and may be higher than estimated. Studies considered to have better methodological quality suggest that previous estimates of risk are likely to be inflated.

AIM: To provide an updated systematic review concerning the impact of endoscopic ultrasound (EUS) in the modern era of oesophageal cancer staging. MATERIALS AND METHODS: To update the previous systematic review, databases including MEDLINE and EMBASE were searched and studies published from 2005 onwards were selected. Studies reporting primary data in patients with oesophageal or gastro-oesophageal junction cancer who underwent radiological staging and treatment, regardless of intent, were included. The primary outcome was the reported change in management after EUS. Secondary outcomes were recurrence rate and overall survival. Two reviewers extracted data from included articles. This study was registered with PROSPERO (CRD42021231852). RESULTS: Eighteen studies with 11,836 patients were included comprising 2,805 patients (23.7%) who underwent EUS compared to 9,031 (76.3%) without EUS examination. Reported change of management varied widely from 0% to 56%. When used, EUS fine-needle aspiration precluded curative treatment in 37.5%-71.4%. Overall survival improvements ranged between 121 and 639 days following EUS intervention compared to patients without EUS. Smaller effect sizes were observed in a randomised controlled trial, compared to larger differences reported in observational studies. CONCLUSION: Current evidence for the effectiveness of EUS in oesophageal cancer pathways is conflicting and of limited quality. In particular, the extent to which EUS adds value to contemporary cross-sectional imaging techniques is unclear and requires formal re-evaluation. Crown Copyright (c) 2022 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. All rights reserved.

Social determinants of health (SDOH) impact patients' health outcomes, yet screening methods in emergency departments (EDs) are inconsistent. Patients who seek care in EDs may be at greater risk for adverse SDOH than those seen by their primary care physician (PCP), but little comparable data is available. The authors sought to identify SDOH among ED Fast Track patients during the COVID-19 pandemic at an urban, safety-net hospital, measure preferred methods of resource referrals and barriers to accessing resources, and compare the prevalence of adverse SDOH among of ED Fast Track patients to that of adult PCP clinic patients. ED Fast Track patients were screened using a validated SDOH screener, and asked about the impact of COVID-19 on their SDOH. This was a convenience sample conducted from 1/15/21 to 4/13/21 and determined to be exempt by the IRB. Trained study staff completed screening and provided a printed resource guide. A two-week follow-up telephone survey assessed for barriers to resource connection. ED Fast Track patient data was then compared to concurrent SDOH data for adult PCP clinic patients, which collected the same validated SDOH screening data but was self-reported. Among 414 adult ED Fast Track patients, 296 (71.5%) screened positive for at least one adverse SDOH, most commonly education (38.41%), food (35.0%), and housing insecurity (20.5%). Most (56.8%) endorsed COVID-19 affecting their SDOH. Fewer patients (36/156, 23.1%) reported attempting to connect with a resource. Barriers to accessing resources included having no time to call or visit the resource (59%), not recalling being given the resource guide (41%) or having lost it (28%). When compared to adult PCP clinic patients (Table 1), ED Fast Track patients were 10 times more likely to report at least one adverse SDOH (OR 10.0, 95% CI 6.9-14.4), 13 times more likely to report housing needs (OR 13.1, 95% CI 5.2-32.7), 8 times more likely to have food insecurity (OR 8.2, 95% CI 4.7-14.1) and 11 times more likely to have employment difficulty (OR 11.1, 95% CI 5.7-21.6). Most ED Fast Track patients reported at least one adverse SDOH negatively impacted by the COVID-19 pandemic. Providing printed resource guides at ED discharge may be insufficient for linking patients to resources. ED Fast Track patients were far more likely to report adverse SDOH than adult PCP clinic patients based on the unadjusted odds ratio analyses. This finding, however, is limited by the negative impact of COVID-19 on ambulatory SDOH screening rate, and a potential selection bias as patients with adverse SDOH may have experienced difficulty accessing their PCP clinics. This finding further emphasizes the need to standardize and expand SDOH screening and strengthen further resources from EDs.

These guidelines are an update of the 2017 recommendations developed between the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery and other Interventional Techniques (EAES), International Society of Digestive Surgery–European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE). A targeted literature search was performed to discover recent evidence concerning the management and follow-up of gallbladder polyps. The changes within these updated guidelines were formulated after consideration of the latest evidence by a group of international experts. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. • These recommendations update the 2017 European guidelines regarding the management and follow-up of gallbladder polyps.

Abstract Background Gastric cancer (GC) treatment levies substantial financial burden on health services. Potentially curative surgery with or without chemotherapy is offered to patients with locoregional disease. This study aimed to examine treatment costs related to life-years gained in patients having potentially curative treatment (gastrectomy) and those receiving best supportive care (BSC). Methods Some 398 consecutive patients with GC were classified according to treatment modality (116 BSC, 282 gastrectomy). Cost calculations for 1 year’s treatment from referral were made according to network diagnostic, staging and treatment algorithms. Primary outcome was overall survival (OS). Results GC median survival after BSC was 8 months, costing €5413, compared with gastrectomy median survival of 34 months, costing €22 753 for 1 year’s treatment: cost per life-year gained €9319. Cost incurred for stage I GC was €22 434, stage II €23 498, stage III €22 445, and stage IV €22 032. Based on these values, the cost per quality adjusted life-year (QALY) for BSC for stage I GC was –€8335 stage II –€8952, stage III –€11 317, and stage IV –€25 669. Conclusion Potentially curative treatment that included gastrectomy improved OS four-fold compared with BSC and was cost-effective at national thresholds of readiness to pay per QALY.

Objectives Electrically Assisted Pedal Cycles (EAPCs) are pedal bikes that are fitted with a motor that travel at higher speeds than conventional bicycles. Recent international data shows that there is an association with increased severity of injury, particularly in paediatric populations. Currently, EAPCs are subject to the same legislation regarding helmet use as pedal bikes in the UK and EU which does not mandate the use of a helmet. Here we examine safety concerns surrounding EAPCs in the context of existing EU and UK legislation to assess whether changes to these should be made by public health bodies to mitigate the increased risk of injury. Methods A retrospective international literature review looking at electric bicycle-related trauma and legislation was conducted using a systematic search of internet databases. Peer-reviewed articles and online resources were reviewed based on relevance to the above objective. Results EAPCS can travel at up to 17.5 mph, resulting in higher speeds of travel and collision. The use of EAPCs has been associated with increased severity of head injuries. Bicycle helmets have been shown to reduce the severity of head injury in accidents involving both EAPCs and pedal cycles. Healthcare providers should pay extra attention to the possibility of severe injuries when a patient had a bicycle accident with an EAPC, especially in paediatric populations. Conclusions Given that EAPCS have been associated internationally with increased severity of head injuries we propose that existing EU and UK legislation may not be fit for purpose with respects to increased EAPC usage and criteria for impact protection of existing helmets. Further research and audit with more accurate recording of data associated with EAPCs use and associated injuries would inform enhanced regulation regarding EAPC usage in the future.

BACKGROUND:Inflammation has an important role in cancer survival, yet whether serum markers of inflammation predict response to potentially curative neoadjuvant chemotherapy (NAC) in oesophageal adenocarcinoma (OAC) is controversial. This study aimed to determine whether the systemic inflammatory response (SIR) is associated with response to NAC and survival.METHODS:Consecutive patients with OAC planned for surgery with curative intent received blood neutrophil and lymphocyte measurements at diagnosis to calculate the neutrophil to lymphocyte ratio (NLR). Pathological variables including pTNM stage, differentiation, vascular invasion and Mandard tumour regression grade (TRG) were recorded. TRGs 1 and 2 were taken to represent a good response, and the primary outcome was overall survival.RESULTS:During follow-up of 136 patients, 36 patients (26·5 per cent) had recurrence and 69 (50·7 per cent) died. Receiver operating characteristic (ROC) curve analysis of NLR before NAC predicted poor TRG (area under the ROC curve 0·71, 95 per cent c.i. 0·58 to 0·83; P = 0·002). In univariable analysis, pT category (P < 0·001), pN category (P < 0·001), poor differentiation (P = 0·006), margin positivity (P = 0·001), poor TRG (P = 0·014) and NLR (dichotomized at 2·25; P = 0·017) were associated with poor overall survival, and NLR retained independent significance in multivariable analysis (hazard ratio 2·26, 95 per cent c.i. 1·03 to 4·93; P = 0·042).CONCLUSION:The pretreatment NLR was associated with a pathological response to NAC and overall survival in patients with OAC.ANTECEDENTES:La inflamación juega un importante papel en la supervivencia por cáncer, aunque aún no se sabe si los marcadores séricos de inflamación predicen la respuesta a la quimioterapia neoadyuvante (neoadjuvant chemotherapy, NAC) potencialmente curativa en el adenocarcinoma de esófago (oesophageal adenocarcinoma, OAC). Este estudio se propuso determinar si la respuesta inflamatoria sistémica (systemic inflammatory response, SIR) estaba asociada con la respuesta a la NAC y a la supervivencia. MÉTODOS: A pacientes consecutivos con OAC en los que se planificó cirugía con intención curativa se les determinó neutrófilos y linfocitos en sangre en el momento del diagnóstico para calcular la tasa neutrófilo-linfocito (neutrophil-lymphocyte ratio, NLR). Se registraron variables patológicas que incluían el estadio pTNM, diferenciación tumoral, invasión vascular y grado de regresión tumoral (tumour regression grade, TRG) de Mandard. Los grados TRG 1 y 2 fueron considerados como una buena respuesta y el resultado primario fue la supervivencia global (overall survival, OS).RESULTADOS:Durante el seguimiento de 136 pacientes, 36 pacientes (26,5%) presentaron recidiva y 69 pacientes (50,7%) fallecieron. El análisis de las características operativas del receptor (receiver-operator-characteristic, ROC) de NLR antes de la NAC predijo una pobre TRG (área bajo la curva ROC, AUC 0,71, i.c. del 95% 0,58-0,83, P = 0,002). En el análisis univariable, el estadio pT (P < 0,001), el estadio pN (P < 0,001), una pobre diferenciación tumoral (P = 0,006), un margen positivo (P = 0,001), una pobre TRG (P = 0,014) y la NLR (dicotomizada a 2,25, P = 0,017) se asociaron con una pobre OS, pero solamente la NLR (cociente de riesgos instantáneos, hazard ratio, HR 2,28, i.c. del 95% 1,03-4,93, P = 0,042) conservó la significación estadística como variable independiente en el análisis multivariable. CONCLUSIÓN: La NLR antes del tratamiento se asoció con respuesta patológica del OAC a la NAC y OS.

Memory impairment is a common, disabling effect of traumatic brain injury. In healthy individuals, successful memory encoding is associated with activation of the dorsal attention network as well as suppression of the default mode network. Here, in traumatic brain injury patients we examined whether: (i) impairments in memory encoding are associated with abnormal brain activation in these networks; (ii) whether changes in this brain activity predict subsequent memory retrieval; and (iii) whether abnormal white matter integrity underpinning functional networks is associated with impaired subsequent memory. Thirty-five patients with moderate-severe traumatic brain injury aged 23-65 years (74% males) in the post-acute/chronic phase after injury and 16 healthy control subjects underwent functional MRI during performance of an abstract image memory encoding task. Diffusion tensor imaging was used to assess structural abnormalities across patient groups compared to 28 age-matched healthy controls. Successful memory encoding across all participants was associated with activation of the dorsal attention network, the ventral visual stream and medial temporal lobes. Decreased activation was seen in the default mode network. Patients with preserved episodic memory demonstrated increased activation in areas of the dorsal attention network. Patients with impaired memory showed increased left anterior prefrontal activity. White matter microstructure underpinning connectivity between core nodes of the encoding networks was significantly reduced in patients with memory impairment. Our results show for the first time that patients with impaired episodic memory show abnormal activation of key nodes within the dorsal attention network and regions regulating default mode network activity during encoding. Successful encoding was associated with an opposite direction of signal change between patients with and without memory impairment, suggesting that memory encoding mechanisms could be fundamentally altered in this population. We demonstrate a clear relationship between functional networks activated during encoding and underlying abnormalities within the structural connectome in patients with memory impairment. We suggest that encoding failures in this group are likely due to failed control of goal-directed attentional resources.

BACKGROUND:Propensity score (PS) regression analysis can be used to minimize differences between cohorts in order to perform comparisons The aim of this study was to use PS analysis to examine the outcomes of oesophageal adenocarcinoma (OAC) treatment with surgery alone or neoadjuvant chemotherapy (NAC) followed by surgery (NACS), to see whether the benefits seen in a randomized trial (MRC OE02) were reproducible in a UK cancer network clinical practice.METHODS:Consecutive patients undergoing potentially curative treatment for OAC in a regional cancer network were studied. Multiple regression models, including PS analysis, were developed to account for confounding factors. Primary outcome measures were disease-free (DFS) and overall (OS) survival.RESULTS:A cohort of 440 patients was included in a regression analysis controlling for confounders (176 surgery alone, 264 NACS). NACS was associated with a higher positive margin status rate compared with surgery alone (42·4 versus 26·7 per cent respectively; P < 0·001), an inferior 5-year DFS rate (32·1 versus 56·9 per cent; P < 0·001) and a worse 5-year OS rate (27·5 versus 47·3 per cent; P < 0·001). On regression adjustment based on propensity scores, NACS was not associated with DFS (P = 0·220) or OS (P = 0·431). The Mandard tumour regression grade (TRG) score was significantly associated with DFS (hazard ratio (HR) 0·21, 95 per cent c.i. 0·07 to 0·70) and OS (HR 0·27, 0·13 to 0·59). Five-year DFS and OS rates related to TRG were 64 and 62 per cent respectively for 25 good responders versus 8·0 and 8·6 per cent for 127 poor responders (P < 0·001).CONCLUSION:The prescription of NAC to all patients with OAC risks delay in effective treatment of patients who are relatively chemoresistant, given the variability in pathological response. Identification of patients with OAC who may derive the most benefit from NAC should be the focus.

Background During the COVID-19 pandemic, aerosol-generating procedures such as upper gastrointestinal endoscopy (UGIE) have been considered high risk. We designed a novel acrylic box (endoscopy box (EBOX)) with the intention of limiting aerosol and droplet spread during such procedures. We evaluated clinical utility, impact on the endoscopy team and also assessed the impact of the EBOX on macroscopic droplet spread from a simulated cough during UGIE. Methods Clinical utility was evaluated prospectively via EBOX use on 15 patients undergoing endoscopic retrograde cholangiopancreatography (13) or endoscopic ultrasound (2). Feedback was recorded from the endoscopy team regarding ease of positioning, impact of the EBOX on procedural performance and cleaning. A cough was simulated via explosion of a hyperinflated balloon containing 0.75 mL of ultraviolet disclosing lotion within the oral cavity of a mannequin, with and without the EBOX. Macroscopic spread was then evaluated with a ultraviolet torch. Results Three endoscopists and the team members found that the EBOX did not hamper the procedure and felt it was a useful adjunct to full personal protective equipment (PPE). Simulated cough without the EBOX identified macroscopic spread up to 2.3 m away from the patient’s mouth as well as onto key areas such as the exposed neck of the endoscopist, which is not considered in current PPE guidance. Simulated cough using the EBOX significantly reduced macroscopic spread onto key areas of the healthcare workers. Conclusions The EBOX is a valuable adjunct to recommended PPE for UGIE, but still allows these procedures to be performed in the standard manner.

BACKGROUND:Intracranial lipomas are rare, benign lesions, of congenital origin commonly found incidentally on imaging studies.METHODS:We describe a case of interpeduncular lipoma in an 18 year-old female presenting with a painful left complete oculomotor (IIIrd) nerve palsy and associated headache, which to the best of our knowledge has not been reported in an adult patient.RESULTS:Following eye patching and steroid treatment, at 6-week follow-up the patient's pain had significantly improved however the complete IIIrd nerve palsy remained.CONCLUSIONS:Evidence suggests improvement will occur regardless with conservative management independent of radiological changes to the lipoma.

Background: The main complication of external ventricular drains (EVD) is infection. Implementation of evidence-based guidelines for central venous catheter (CVC) care resulted in significant declines in infections. We tested a comparable approach to EVD infection rates. Methods: An initial retrospective study evaluated the existing EVD infection rate, and identified contributory risk factors. Based on our results, and in corroboration with existing literature, an EVD care bundle was developed and implemented. A prospective study was then conducted to identify improvement. Results: A total of 275 EVDs (120 pre- and 155 post-EVD care bundle) inserted over a period of 1532 days were included. Pre-care bundle, the infection rate was 27%, with the predominant factor associated with infection being number cerebrospinal fluid sampling episodes. Following introduction of the EVD care bundle, the infection rate declined to 10% (p < 0.001) with the incidence from 21 to 9 cases per 1,000 EVD-days (p = 0.003). The infection rate was not found to be significantly associated with the number of accesses during this period (p = 0.910). Conclusions: Introduction of a well-implemented EVD care bundle can significantly decrease EVD infection rates.

Surgeon‐level operative mortality is widely seen as a measure of quality after gastric and oesophageal resection. This study aimed to evaluate this alongside a compound‐level outcome analysis.

AIM:Enhanced prognostic models are required to improve risk stratification of patients with oesophageal cancer so treatment decisions can be optimised. The primary aim was to externally validate a published prognostic model incorporating PET image features. Transferability of the model was compared using only clinical variables. METHODS:This was a Transparent Reporting of a multivariate prediction model for Individual Prognosis Or Diagnosis (TRIPOD) type 3 study. The model was validated against patients treated with neoadjuvant chemoradiotherapy according to the Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS) trial regimen using pre- and post-harmonised image features. The Kaplan-Meier method with log-rank significance tests assessed risk strata discrimination. A Cox proportional hazards model assessed model calibration. Primary outcome was overall survival (OS). RESULTS:Between 2010 and 2015, 449 patients were included in the development (n = 302), internal validation (n = 101) and external validation (n = 46) cohorts. No statistically significant difference in OS between patient quartiles was demonstrated in prognostic models incorporating PET image features (X2 = 1.42, df = 3, p = 0.70) or exclusively clinical variables (age, disease stage and treatment; X2 = 1.19, df = 3, p = 0.75). The calibration slope β of both models was not significantly different from unity (p = 0.29 and 0.29, respectively). Risk groups defined using only clinical variables suggested differences in OS, although these were not statistically significant (X2 = 0.71, df = 2, p = 0.70). CONCLUSION:The prognostic model did not enable significant discrimination between the validation risk groups, but a second model with exclusively clinical variables suggested some transferable prognostic ability. PET harmonisation did not significantly change the results of model validation.

Purpose: A positive circumferential resection margin (CRM) is regarded as a poor prognostic indicator in oesophageal cancer (OC) but its prediction can be challenging. MRI is used to predict a threatened CRM in rectal cancer but is not commonly performed in OC unlike PET/CT, which is now routinely used. Therefore, this study assessed the additional predictive value of PET-defined tumour variables compared with EUS and CT T-stage. The prognostic significance of CRM status was also assessed. Materials and Methods: This retrospective study included 117 consecutive patients [median age 64.0 (range 24-78), 102 males, 110 adenocarcinomas, 6 squamous cell carcinoma (SCC), 1 neuro-endocrine] treated between 1st March 2012 and 31st July 2015. A binary logistic regression model tested 5 staging variables; EUS T-stage (<= T2 vs >= T3), CT T-stage (<= T2 vs >= T3), PET metabolic tumour length (MTL), PET metabolic tumour width (MTW) and the maximum standardised uptake value (SUVmax). Results: The CRM was positive in 43.6%. Sixty-seven (57.3%) patients received neo-adjuvant chemotherapy (NACT), 31 patients (26.5%) underwent surgery alone and 19 patients (16.2%) had neo-adjuvant chemoradiotherapy (NACRT). Median overall survival (OS) was 36.0 months (95% confidence interval (CI) 24.1-47.9) and the 2-year OS was 55.4%. A binary logistic regression model showed EUS >= T3 tumours were independently and significantly more likely to have a positive CRM than EUS <= T2 tumours (HR 5.188, 95% CI 1.265-21.273, p = 0.022). CT T-stage, PET MTL, PET MTW and SUVmax were not significantly associated with CRM status (p = 0.783, 0.852, 0.605 and 0.413, respectively). There was a significant difference in OS between CRM positive and negative groups (X-2 4.920, df 1, p = 0.027). Conclusion: Advanced EUS T-stage is associated with a positive CRM, but PET-defined tumour variables are unlikely to provide additional predictive information. This study demonstrates the continued benefit of EUS as part of a multi-modality OC staging pathway.

Lymph node metastases are a major prognostic indicator in oesophageal cancer. Radiological staging largely influences treatment decisions and is becoming more reliant on PET and CT. However, the sensitivity of these modalities is suboptimal and is known to under-stage disease. The primary aim of this study was to validate a published prognostic model in oesophageal cancer patients staged N0 with PET/CT, which showed that EUS nodal status was an independent predictor of survival. The secondary aim was to assess the prognostic significance of pathological lymph node metastases in this cohort.

PET/CT is now integral to the staging pathway for potentially curable esophageal cancer (EC), primarily to identify distant metastases undetected by computed tomography. The aim of this study was to analyze the effect of PET/CT introduction on survival and assess patterns of recurrence after esophagectomy.

This retrospective cohort study developed a prognostic model incorporating PET texture analysis in patients with oesophageal cancer (OC). Internal validation of the model was performed.

INTRODUCTION:The evolution of medical practice is resulting in increasing subspecialisation, with head, face and neck (HFN) trauma in a civilian environment usually managed by a combination of surgical specialties working as a team. However, the full combination of HFN specialties commonly available in the NHS may not be available in future UK military-led operations, necessitating the identification of a group of skill sets that could be delivered by one or more deployed surgeons. METHOD:A systematic review was undertaken to identify those surgical procedures performed to treat acute military head, face, neck and eye trauma. A multidisciplinary consensus group was convened following this with military HFN trauma expertise to define those procedures commonly required to conduct deployed, in-theatre HFN surgical combat trauma management. RESULTS:Head, face, neck and eye damage control surgical procedures were identified as comprising surgical cricothyroidotomy, cervico-facial haemorrhage control and decompression of orbital haemorrhage through lateral canthotomy. Acute in-theatre surgical skills required within 24 hours consist of wound debridement, surgical tracheostomy, decompressive craniectomy, intracranial pressure monitor placement, temporary facial fracture stabilisation for airway management or haemorrhage control and primary globe repair. Delayed in-theatre procedures required within 5 days prior to predicted evacuation encompass facial fracture fixation, delayed lateral canthotomy, evisceration, enucleation and eyelid repair. CONCLUSIONS:The identification of those skill sets required for deployment is in keeping with the General Medical Council's current drive towards credentialing consultants, by which a consultant surgeon's capabilities in particular practice areas would be defined. Limited opportunities currently exist for trainees and consultants to gain experience in the management of traumatic head, face, neck and eye injuries seen in a kinetic combat environment. Predeployment training requires that the surgical techniques described in this paper are covered and should form the curriculum of future military-specific surgical fellowships. Relevant continued professional development will be necessary to maintain required clinical competency.