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Ateş O, Ancar C, Çağlar C. Importance of injury severity in the choice of treatment and its impact on prognosis in gunshot fractures. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02495-x. [PMID: 38466401 DOI: 10.1007/s00068-024-02495-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 02/27/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE The management of femur and tibia fractures resulting from gunshot injuries is a challenge for orthopedic surgeons. One-stage and two-stage treatments are applied according to the anatomical location and severity of the injury. In this study, the importance of injury severity and anatomical location was evaluated in the choice of treatment method and its impact on prognosis in cases of lower extremity gunshot fractures. METHODS A total of 124 patients who met the study criteria were evaluated. They were grouped separately according to the anatomical location of the injury (femur, n = 73; tibia, n = 51) and the surgical method (one-stage, n = 77; two-stage, n = 47). The demographic characteristics of the patients, fracture classification, presence of neurological or vascular damage at the time of diagnosis, anatomical location of the injury, surgical procedure, and follow-up time were recorded. The time of union and the presence of malunion were evaluated radiologically. Finally, patients were assessed clinically with the New Injury Severity Score (NISS) and leg length discrepancy (LLD) calculated through measurements made on lower extremity orthoroentgenograms. RESULTS The rate of vascular injury and the number of Gustilo-Anderson type IIIB and IIIC cases were significantly higher in the two-stage treatment group (p = 0.001 and p = 0.000, respectively). The infection rate was also higher in the two-stage group; therefore, time to union was significantly longer (p = 0.004 and p = 0.05, respectively). LLD was higher among patients who received two-stage treatment (p = 0.015). According to the NISS scale used in clinical assessment, better scores were obtained for the one-stage group (p = 0.002). In comparisons made according to anatomical location, no significant difference was found between femur and tibia injuries. CONCLUSION Regardless of anatomical location and treatment method, injuries of higher severity such as Gustilo-Anderson type IIIB and IIIC are correlated with higher rates of complications such as vascular injury, postoperative infection, delayed union, and LLD. Furthermore, in cases of severe injuries, a two-stage approach is commonly favored.
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Affiliation(s)
- Okan Ateş
- Department of Orthopaedics and Traumatology, Gazi Yaşargil Training and Research Hospital, Ankara, Turkey
| | - Cahit Ancar
- Department of Orthopaedics and Traumatology, Gazi Yaşargil Training and Research Hospital, Ankara, Turkey
| | - Ceyhun Çağlar
- Department of Orthopaedics and Traumatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey.
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Beucler N, Haikal C, Kaya JM. A Penetrating Lumbar Spine Injury With Misleading Neurological Symptoms. Mil Med 2023; 188:e440-e444. [PMID: 33852015 DOI: 10.1093/milmed/usab137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 01/11/2023] Open
Abstract
Penetrating spinal injuries require specific neurosurgical attention. To date, there are no guidelines regarding emergency neurosurgical management of such injuries and the decision whether to operate is made individually, based on the neurological examination and the analysis of any imaging available. We report the case of a 22-year-old patient who sustained two gunshots in the thighs and one in the lumbar spine. Clinical examination revealed neurological deficit in both legs prevailing on the right side. Discussion between the radiologist and the neurosurgeon concluded to an injury to the left S1 nerve root within the spinal canal, and to the right sciatic nerve. Thus, there was no need for a decompressive laminectomy. In the light of the current literature, penetrating spinal injuries rarely require an extensive surgical exploration; indications for such a procedure include incomplete neurological deficit with persistent neurological compression, cerebrospinal fluid leakage, and obvious instability. Furthermore, penetrating spinal injuries are rarely encountered, even for military neurosurgeons. Their surgical management and especially the need for laminectomy, stabilization, and dural sac watertight closure are still a matter of debate. An expert consensus statement would give food to surgeons facing penetrating spinal injuries.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France.,Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, Ile-de-France 75230, France
| | - Christelle Haikal
- Radiology Department, Timone University Hospital, APHM, Marseille, Provence-Alpes-Côte d'Azur 13005, France
| | - Jean-Marc Kaya
- Neurosurgery Department, Nord University Hospital, APHM, Marseille, Provence-Alpes-Côte d'Azur 13015, France
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Stevenson T, Carr DJ, Harrison K, Critchley R, Gibb IE, Stapley SA. Ballistic research techniques: visualizing gunshot wounding patterns. Int J Legal Med 2020; 134:1103-1114. [PMID: 32060625 PMCID: PMC7181419 DOI: 10.1007/s00414-020-02265-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/31/2020] [Indexed: 11/29/2022]
Abstract
There are difficulties associated with mapping gunshot wound (GSW) patterns within opaque models. Depending on the damage measurement parameters required, there are multiple techniques that can provide methods of "seeing" the GSW pattern within an opaque model. The aim of this paper was to test several of these techniques within a cadaveric animal limb model to determine the most effective. The techniques of interest were flash X-ray, ultrasound, physical dissection, and computed-tomography (CT). Fallow deer hind limbs were chosen for the model with four limbs used for each technique tested. Quarantined 7.62 × 39 mm ammunition was used for each shot, and each limb was only shot once, on an outdoor range with shots impacting at muzzle velocity. Flash X-ray provided evidence of yaw within the limb during the projectile's flight; ultrasound though able to visualise the GSW track, was too subjective and was abandoned; dissection proved too unreliable due to the tissue being cadaveric so also too subjective; and lastly, CT with contrast provided excellent imaging in multiple viewing planes and 3D image reconstruction; this allowed versatile measurement of the GSW pattern to collect dimensions of damage as required. Of the different techniques examined in this study, CT with contrast proved the most effective to allow precise GSW pattern analysis within a cadaveric animal limb model. These findings may be beneficial to others wishing to undertake further ballistic study both within clinical and forensic fields.
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Affiliation(s)
- Tom Stevenson
- Impact and Armour Group, Centre for Defence Engineering, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK.
- Cranfield Forensic Institute, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK.
| | - Debra J Carr
- Defence and Security Accelerator, Porton Down, Salisbury, SP4 0JQ, UK
| | - Karl Harrison
- Cranfield Forensic Institute, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK
| | - Richard Critchley
- Impact and Armour Group, Centre for Defence Engineering, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK
| | - Iain E Gibb
- Centre for Defence Radiology, at c/o Sickbay, HMS Nelson, HMNB Portsmouth, Hampshire, PO1 3HH, UK
| | - Sarah A Stapley
- Royal Centre for Defence Medicine, ICT Building, Research Park, St Vincent Drive, Birmingham, B15 2SQ, UK
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Stevenson T, Carr DJ, Gibb IE, Stapley SA. Preliminary effect of projectile yaw on extremity gunshot wounding in a cadaveric animal model: a serendipitous study. Int J Legal Med 2020; 134:1149-1157. [PMID: 32162008 PMCID: PMC7181544 DOI: 10.1007/s00414-020-02271-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/01/2020] [Indexed: 11/12/2022]
Abstract
Gunshot wounding (GSW) is capable of causing devastating tissue injuries by delivering kinetic energy (KE) through the contact surface area of a projectile. The contact surface area can be increased by yaw, deformation and fragmentation, all of which may be caused by any intermediate layers struck by the projectile prior to entering its target. This study aims to describe whether projectile yaw occurring before penetration of a cadaveric animal limb model causes greater damage with or without clothing layers present using 5.45 × 39 mm projectiles. In total, 12 fallow deer hind limbs were shot, further divided into 4 with no clothing layers (Cnil), 4 with a single clothing layer (Cmin) and 4 with maximum clothing layers (Cmax) as worn on active duty by UK military personnel. Contrast computed tomography (CT) of limbs was used to measure permanent cavity size and the results were compared using analysis of variance (ANOVA). No significant differences were found among clothing states for each series of measurements taken, with greater cavity sizes noted in all clothing states. This is in contrast to previous work looking at symmetrically flying projectiles in the same model, where a larger permanent cavity was found only with Cmax present. Projectile yaw is therefore likely to be a key variable with regard to causation of damage within this extremity wound model.
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Affiliation(s)
- Tom Stevenson
- Impact and Armour Group, Centre for Defence Engineering, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK.
- Cranfield Forensic Institute, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK.
| | - Debra J Carr
- Impact and Armour Group, Centre for Defence Engineering, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK
- Defence and Security Accelerator, Porton Down, Salisbury, SP4 0JQ, UK
| | - Iain E Gibb
- Centre for Defence Radiology, at c/o Sickbay HMS Nelson, HMNB Portsmouth, Hampshire, PO1 3HH, UK
| | - Sarah A Stapley
- Royal Centre for Defence Medicine, ICT Building, Research Park, St Vincent Drive, Birmingham, B15 2SQ, UK
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Stevenson T, Carr DJ, Gibb IE, Stapley SA. The effect of military clothing on gunshot wound patterns in a cadaveric animal limb model. Int J Legal Med 2019; 133:1825-33. [PMID: 31414201 DOI: 10.1007/s00414-019-02135-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/26/2019] [Indexed: 11/04/2022]
Abstract
The majority of injuries in survivors of gunshot wounds (GSW) are typically to the extremities. Novel wound ballistic research is encouraged to try and capture corporate knowledge on the management of these injuries gained during recent conflicts and understand the wounding patterns seen. With recent work examining the effect of UK military clothing on extremity GSW patterns in a synthetic model, a model with greater biofidelity is needed for ballistic testing. The aim of this study was to assess the effect of UK military clothing on GSW patterns within a cadaveric animal limb model using two types of ammunition commonly used in recent conflicts—7.62 × 39 mm and 5.45 × 39 mm. In total, 24 fallow deer hind limbs were shot, 12 by 7.62 mm projectiles and the remaining 12 shot by 5.45 mm projectiles, further divided into four with no clothing layers (Cnil), four with a single clothing layer (Cmin) and four with maximum clothing layers (Cmax) as worn on active duty by UK military personnel. Limbs were analysed after ballistic impact using contrast CT scanning to obtain measurements of permanent cavity damage, and results were compared using analysis of variance (ANOVA). Results showed significantly different damage measurements within limbs with Cmax for both ammunition types compared with the other clothing states. This may result in GSWs that require more extensive surgical management, and invites further study.
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Grosset A, Pfister G, de l’Escalopier N, Plang S, Russo A, Murison J, Mathieu L, Rigal S. Risk factors and failures in the management of limb injuries in combat casualties. International Orthopaedics (SICOT) 2019; 43:2671-80. [DOI: 10.1007/s00264-019-04329-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/31/2019] [Indexed: 11/25/2022]
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Stevenson T, Carr DJ, Stapley SA. The effect of military clothing on gunshot wounding patterns in gelatine. Int J Legal Med 2019; 133:1121-31. [PMID: 30488352 DOI: 10.1007/s00414-018-1972-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 11/13/2018] [Indexed: 11/13/2022]
Abstract
With no two gunshot wounds (GSW) being the same, novel research into wound ballistics is challenging. It is evident that the majority of previous wound ballistic research has been conducted without the presence of clothing. Whilst the effect of clothing on wound contamination has been explored, there is a paucity of literature examining the effect of clothing on GSW patterns. The aim of this study was to test the effect of Multi-Terrain Pattern (MTP) UK military clothing on GSW patterns within calibrated blocks of 10% by mass gelatine, using two types of ammunition commonly used in recent conflicts—7.62 × 39 mm and 5.45 × 39 mm. In total, 36 blocks were shot, 18 by each projectile type, further divided into 6 with no clothing layers (Cnil), 6 with a single clothing layer (Cmin) and 6 with maximum clothing layers (Cmax) worn on active duty. Blocks were analysed with high-speed video and dissection to capture measurements of damage, and results compared using analysis of variance (ANOVA). Results showed significantly different damage measurements within blocks with Cmax for both ammunition types compared to the other clothing states. This may result in GSWs that require more extensive surgical management, inviting further study.
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Stevenson T, Carr DJ, Penn-Barwell JG, Ringrose TJ, Stapley SA. The burden of gunshot wounding of UK military personnel in Iraq and Afghanistan from 2003-14. Injury 2018; 49:1064-1069. [PMID: 29609973 DOI: 10.1016/j.injury.2018.03.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/24/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Gunshot wounding (GSW) is the second most common mechanism of injury in warfare after explosive injury. The aim of this study was to define the clinical burden of GSW placed on UK forces throughout the recent Iraq and Afghanistan conflicts. METHODS This study was a retrospective review of data from the UK Military Joint Theatre Trauma Registry (JTTR). A JTTR search identified records within the 12 year period of conflict between 19 Mar 2003 and 27 Oct 2014 of all UK military GSW casualties sustained during the complete timelines of both conflicts. Included cases had their clinical timelines and treatment further examined from time of injury up until discharge from hospital or death. RESULTS There were 723 casualties identified (177 fatalities, 546 survivors). Median age at the time of injury was 24 years (range 18-46 years), with 99.6% of casualties being male. Most common anatomical locations for injury were the extremities, with 52% of all casualties sustaining extremity GSW, followed by 16% GSW to the head, 15% to the thorax, and 7% to the abdomen. In survivors, the rate of extremity injury was higher at 69%, with head, thorax and abdomen injuries relatively lower at 5%, 11% and 6% respectively. All GSW casualties had a total of 2827 separate injuries catalogued. A total of 545 casualties (523 survivors, 22 fatalities) underwent 2357 recorded surgical procedures, which were carried out over 1455 surgical episodes between admission to a deployed medical facility and subsequent transfer to the Royal Centre for Defence Medicine (RCDM) in the UK. This gave a median of 3 (IQR 2-5) surgical procedures within a median of 2 (IQR 2-3) surgical episodes per casualty. Casualties had a combined length of stay (LoS) of 25 years within a medical facility, with a mean LoS in a deployed facility of 1.9 days and 14 days in RCDM. CONCLUSION These findings define the massive burden of injury associated with battlefield GSW and underscore the need for further research to both reduce wound incidence and severity of these complex injuries.
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Affiliation(s)
- T Stevenson
- Cranfield Forensic Institute, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK.
| | - D J Carr
- Impact and Armour Group, Centre for Defence Engineering, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK, now at Defence and Security Accelerator, Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK
| | | | - T J Ringrose
- Centre for Simulation and Analytics, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK
| | - S A Stapley
- Royal Centre for Defence Medicine, Birmingham, UK
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Mahoney P, Carr D, Arm R, Gibb I, Hunt N, Delaney RJ. Ballistic impacts on an anatomically correct synthetic skull with a surrogate skin/soft tissue layer. Int J Legal Med 2018; 132:519-30. [PMID: 29185026 DOI: 10.1007/s00414-017-1737-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/10/2017] [Indexed: 11/18/2022]
Abstract
The aim of this work was to further develop a synthetic model of ballistic head injury by the addition of skin and soft tissue layers to an anatomically correct polyurethane skull filled with gelatine 10% by mass. Six head models were impacted with 7.62 x 39 mm full metal jacket mild steel core (FMJ MSC) bullets with a mean velocity of 652 m/s. The impact events were filmed with high-speed cameras. The models were imaged pre- and post-impact using computed tomography. The models were assessed post impact by two experienced Home Office pathologists and the images assessed by an experienced military radiologist. The findings were scored against real injuries. The entry wounds, exit wounds and fracture patterns were scored positively, but the synthetic skin and soft tissue layer was felt to be too extendable. Further work is ongoing to address this.
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Abstract
BACKGROUND Terrorist attacks have outreached to Europe with more and more attacks on civilians. Derived from war surgery experience and from lessons learned from major incidents, it seems mandatory for every surgeon to improve understanding of the special circumstances of trauma following a terrorist attack and its' management. METHOD A short literature review is followed by outlining the damage control surgery (DCS) principle for each organ system with practical comments from the perspective of a specialized hepatobiliary (HPB) surgery unit. CONCLUSION Every surgeon has to become familiar with the new entities of blast injuries and terrorist attack trauma. This concerns not only the medical treatment but also tailoring surgical treatment with a view to a lack of critical resources under these circumstances. For liver and pancreatic trauma, simple treatment strategies are a key to success.
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Affiliation(s)
- G A Stavrou
- Allgemein- und Viszeralchirurgie, Chirurgische Onkologie, Asklepios Klinik Barmbek, Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Rübenkamp 220, 29221, Hamburg, Deutschland.
| | - M J Lipp
- Allgemein- und Viszeralchirurgie, Chirurgische Onkologie, Asklepios Klinik Barmbek, Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Rübenkamp 220, 29221, Hamburg, Deutschland
| | - K J Oldhafer
- Allgemein- und Viszeralchirurgie, Chirurgische Onkologie, Asklepios Klinik Barmbek, Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Rübenkamp 220, 29221, Hamburg, Deutschland
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Mahoney PF, Carr DJ, Miller D, Teagle M. The effect of helmet materials and simulated bone and tissue layers on bullet behaviour in a gelatine model of overmatch penetrating head injury. Int J Legal Med 2017; 131:1765-1776. [PMID: 28815306 PMCID: PMC5635073 DOI: 10.1007/s00414-017-1665-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 08/07/2017] [Indexed: 11/30/2022]
Abstract
The aim of this work was to simulate an overmatch ballistic event against a head wearing a helmet. The experiments were designed to understand how layers of bone (or synthetic bone), synthetic skin and currently used helmet materials influence the behaviour of full metal jacket mild steel core (FMJ MSC) 7.62 × 39 mm bullets, impacting on targets with a mean velocity of 650 m/s. Bullet behaviour within 10% (by mass) gelatine blocks was assessed by measurements made of the temporary cavity within the blocks using high-speed video and of the permanent cavity by dissecting blocks post firing. While ANOVA did not find significant difference at the 0.05 level in the mean values of most of the measurements, there was a significant difference in neck length within the gelatine blocks. The addition of material layers did produce greater variability in the temporary cavity measurements under some of the conditions. One of the synthetic bone polymers with a synthetic skin layer produced similar results within the gelatine blocks to the horse scapulae (with residual tissue) and may be suitable for future ballistic experiments.
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Affiliation(s)
- Peter F Mahoney
- Royal Centre for Defence Medicine, ICT Centre, Research Park, Birmingham, B15 2SQ, UK. .,Centre for Defence Engineering, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK.
| | - Debra J Carr
- Centre for Defence Engineering, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK
| | - David Miller
- Small Arms Experimental Range, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK
| | - Michael Teagle
- Small Arms Experimental Range, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, SN6 8LA, UK
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