Triage has been critical to combat casualty care by determining the order in which wounded soldiers are treated in case of mass casualties and saving as many lives as possible.Changes in the operation mode unfolded in the future will make a huge difference to casualties and combat casualty care.Given the inadequacies of current methods of triage,this article focused on triage in large-scale combat operations in the future.It is recommended that such factors be taken into consideration as the situation on the battlefield:the number and severity of wounded soldiers,health care resources and supplies,and ways of evacuation.Meanwhile,multiple triage methods should be adopted and dynamic evaluations conducted in order to save more lives and enable some previously wounded soldiers to return to the battlefield soon.In this way,combat effectiveness can be maintained,the benefits to wounded soldiers maximized,and the level of combat casualty care improved.

Objective:To analyze the costs and effectiveness of five common screening modes and genetic screening for thalassemia in China in order to find the optimal way and provide evidence for the implementation of thalassemia prevention and control projects in Hunan Province.Methods:From June 2020 to April 2021, 12 971 couples from 14 cities and autonomous prefectures in Hunan Province were selected as the study population. The diagnosis of thalassemia was based on the results of genetic testing. Results of routine blood test and hemoglobin electrophoresis were collected and analyzed. The efficacy of five screening modes, at the cut-off value of <80 fl or 82 fl for the mean corpuscular volume (MCV), was analyzed by positive predictive value, negative predictive value, Jorden index and cost-effectiveness ratio. Sensitivity analysis was used to assess the feasibility of genetic screening at different costs after fixing the costs of routine blood and hemoglobin electrophoresis. The five thalassemia screening models are as follows: Mode 1: The woman had a blood routine test first. If the result was positive, the spouse required a blood routine test. If both results were positive, a thalassemia gene test should be offered to the couple. Mode 2: Both husband and wife were screened by blood routine and hemoglobin electrophoresis. If one or both of them were positive, both would be tested for thalassemia gene. Mode 3: The couple received blood routine tests initially. If either was positive, both should receive hemoglobin electrophoresis testing. If either was positive, both parties will conduct thalassemia gene testing. Mode 4: The woman was screened by blood routine and hemoglobin electrophoresis. If any one of them was positive, the woman would be tested for thalassemia gene. If the gene test result was positive, the spouse should receive thalassemia gene. Mode 5: Both spouses conducted a blood routine test. If either was positive, both would conduct hemoglobin electrophoresis test. If both were positive, both spouses should receive thalassemia gene testing. Gene testing mode: The woman would be tested for thalassemia, and her spouse would have thalassemia test too if her result was positive.Results:When using MCV<80 fl as the cut-off for diagnosing thalassemia, the Youden indices of the five prenatal screening modes in Hunan Province were 0.551, 0.639, 0.898, 0.555 and 0.356, while when using MCV<82 fl as the cut-off, the Youden indices were 0.549, 0.629, 0.851, 0.548 and 0.356. When the MCV cut-off value was <80 fl, the missed diagnosis rates of the five screening modes were 44.44%, 0.00, 0.00, 18.52% and 62.96%, and the cost-effectiveness ratios were 21 709, 250 939, 76 870, 138 463 and 92 860 yuan (RMB)/couple, respectively. When the price of genetic testing was lower than 55 yuan (RMB), the cost-effectiveness ratio of genetic screening was lower than that of Mode 3.Conclusions:MCV<80 fl can be considered as the positive criteria in blood routine screening for thalassemia in Hunan Province, and the cost-effectiveness ratio of Mode 3 (the couple received blood routine tests initially. If either was positive, both should receive hemoglobin electrophoresis testing. If either was positive, both parties will conduct thalassemia gene testing) is the best. Genetic screening has certain advantages with the decreasing price.

Objective To evaluate the function of clinical-diffusion mismatch (CDM) in intraarterial thrombolysis treatment for acute middle cerebral artery occlusion (MCAO) and to evaluate specialty of CDM in predicting the putative penumbra.Methods All 106 acute MCAO patients within 6 hours after onset and examined by magnetic resonance angiography (MRA) were assigned into two groups:the intraartery thrombolysis group (n =36) and without thrombolysis group ( n =70).Both groups were subdivided into CDM sub-group and non-CDM sub-group based on the criteria of CDM:National Institutes of Health Stroke Scale (NIHSS) score ≥8 and ischemic volume on DWI ≤25 ml upon admission.NIHSS scores at the day 30 and 3 month after onset,and infarct volumes on T2 weighted imaging (T2 WI)at day 14 after onset were analyzed and compared between each sub-groups.Results The NIHSS scores in the CDM sub-group at both day 30 and the 3 month were significantly lower than the scores in the non-CDM sub-group among the patients having thrombolysis(3.20 ± 2.40 vs 6.76 ± 4.00,t =- 3.330,P =0.002 ; 2.20 ± 1.70 vs 6.05 ± 4.06,t =3.895,P =0.001 ),but not among the non-thrombolysis patients (5.22 ± 2.95 vs 5.66 ± 3.21,t =- 1.756,P =0.084 ;4.34 ± 2.53 vs 5.34 ± 3.42,t =1.234,P =0.353 ).Among the patients having CDM,the thrombolysis group resulted significant lower NIHSS scores at both day 30 and 3 month follow-up than non-thrombolysis group did (3.20 ±2.40 vs 5.22 ±2.95,t =- 2.210,P =0.034;2.20 ± 1.70 vs 4.34 ± 2.53,t =-3.128,P =0.003 ).However,among the patients of non-CDM,there was no difference in the NIHSS score between the thrombolysis group and the non-thrombolysis group at day 30 and 3 month (6.76±4.00 vs 5.66±3.21,t=1.209,P=0.231;6.05 ± 4.06 vs 5.34 ± 3.42,t =1.234,P=0.460).Among the CDM patients,the T2 WI infarct volume in the thrombolysis group was significantly smaller than that in the non-thrombolysis at day 14 onset ( ( 6.29 ± 4.41 ) ml vs ( 60.25 ± 49.23 ) ml,Z =- 4.848,P =0.001 ).Conclusion CDM may predict the putative penumbra with high specificity and can be applied in the therapy of intra-artery thrombolytic for acute MCAO patients.

Objective To investigate the clinical and imaging differences in acute thrombotic and embolic middle cerebral artery occlusion.Methods The cerebral infarction patients with acute middle cerebral artery trtmk occlusion confirmed by diffusion-weighted imaging (DWI) and magnetic resonance angiography (MRA) within 24 hours of onset were divided into large artery atherosclerosis (LAA) group and the cardioembolism (CE) group according to the TOAST classification criteria.Under the circumstances of not receiving thrombolytic therapy,the infarct volume on DWI,morphological characteristics and the changes of the National Institutes of Health Stroke Scale (NIHSS) scores both at admission and day 14 were compared.Results A total of 102 cerebral infarction patients with acute middle cerebral artery trunk occlusion were included.The age of the CE group was significantly older than that of the LAA group (67.60 ± 9.62 years vs.62.57 ± 10.18 years,P =0.017),and more patients with coronary heart disease (27.27％ vs.2.90％,P=0.001 ).The infarct volume (31.96 ±39.20 ml vs.65.66 ±84.74 ml,P =0.005),the NIHSS score at admission (6.42 ± 3.38 vs.11.67 ±8.50,P=0.007),and the improvement of the disease (i.e.the difference of NIHSS scores between admission and day 14) (1.55 ± 6.43 vs.5.75 ± 9.28,P =0.027) in LAA group were significantly lower than those in the CE group.However,there was no significant difference in the NIHSS score between the 2 groups at day 14 (4.87 ± 6.61 vs.5.97 ± 3.60,P =0.324).The infarct volume was significantly correlated with the NIHSS scores at day 14 (CE group:r=0.625,P=0.001; LAA group:r=0.295,P=0.014).The LAA group was mostly the multiple lesions (71.01％),and the CE group was mostly the single lesions (54.55％) (P =0.016).Conclusion There were differences in morphology of cerebral lesion between the LAA and CE groups.In the early stage after onset,CE caused middle cerebral artery trunk occlusion was more serious and had larger infarct volume,but some patients could naturally significantly improve within a short time after onset.

Objective To assess the feasibility, safety, and efficacy of balloon disruption of thrombus by using a deflated balloon catheter combined with intraarterial thrombolysis for the treatment of acute middle cerebral artery(MCA) occlusion. Methods Five consecutive patients with acute MCA occlusion underwent balloon disruption combined with intra-arterial thrombolysis. The microballoon was inflated in the distal carotid artery and then deflated and advanced just distal to the occlusion site in the MCA. Thereafter, intra-arterial thrombolysis of the MCA was applied and the maximum dosage of urokinase was 500,000 U. Results Complete recanalization was achieved in 3 patients and partial recanalization in 2. All patients got favourable clinical outcome. There was no major intracerebral hemorrhage. Conclusion The penetration of the MCA with a deflated balloon catheter combined with an intra-arterial thrombolysis may be a safe and effective treatment for acute ischemic stroke.