Nail changes following upper extremity transplantation(UET)cannot be overlooked as they possess diagnostic and prognostic relevance in allotransplantation of upper limbs.This comprehensive review explores nail and nai...Nail changes following upper extremity transplantation(UET)cannot be overlooked as they possess diagnostic and prognostic relevance in allotransplantation of upper limbs.This comprehensive review explores nail and nail bed related changes encountered in UET recipients in the literature.The differential diagnosis of nail abnormalities in UET includes a wide range of systemic,local and iatrogenic conditions other than immune responses to the allograft.It requires interdisciplinary evaluation by primary transplant surgeons,pathologists,dermatologists and immunologists.The possible underlying mechanisms of nail pathology in UET and the management are discussed.It also underscores the importance of onychodystrophy and need for timely intervention and to improve outcomes in UET recipients.展开更多
Background:The impact of sleep disorders on active-duty soldiers’medical readiness is not currently quantified.Patient data generated at military treatment facilities can be accessed to create research reports and th...Background:The impact of sleep disorders on active-duty soldiers’medical readiness is not currently quantified.Patient data generated at military treatment facilities can be accessed to create research reports and thus can be used to estimate the prevalence of sleep disturbances and the role of sleep on overall health in service members.The current study aimed to quantify sleep-related health issues and their impact on health and nondeployability through the analysis of U.S.military healthcare records from fiscal year 2018(FY2018).Methods:Medical diagnosis information and deployability profiles(e-Profiles)were queried for all active-duty U.S.Army patients with a concurrent sleep disorder diagnosis receiving medical care within FY2018.Nondeployability was predicted from medical reasons for having an e-Profile(categorized as sleep,behavioral health,musculoskeletal,cardiometabolic,injury,or accident)using binomial logistic regression.Sleep e-Profiles were investigated as a moderator between other e-Profile categories and nondeployability.Results:Out of 582,031 soldiers,48.4%(n=281,738)had a sleep-related diagnosis in their healthcare records,9.7%(n=56,247)of soldiers had e-Profiles,and 1.9%(n=10,885)had a sleep e-Profile.Soldiers with sleep e-Profiles were more likely to have had a motor vehicle accident(p OR(prevalence odds ratio)=4.7,95%CI 2.63–8.39,P≤0.001)or work/duty-related injury(p OR=1.6,95%CI 1.32–1.94,P≤0.001).The likelihood of nondeployability was greater in soldiers with a sleep e-Profile and a musculoskeletal e-Profile(p OR=4.25,95%CI 3.75–4.81,P≤0.001)or work/dutyrelated injury(p OR=2.62,95%CI 1.63–4.21,P≤0.001).Conclusion:Nearly half of soldiers had a sleep disorder or sleep-related medical diagnosis in 2018,but their sleep problems are largely not profiled as limitations to medical readiness.Musculoskeletal issues and physical injury predict nondeployability,and nondeployability is more likely to occur in soldiers who have sleep e-Profiles in addition to these issues.Addressing sleep problems may prevent accidents and injuries that could render a soldier nondeployable.展开更多
The objectives of this review were to 1)summarize the available evidence on the impact of hearing loss on quality of life(QOL)among U.S.active-duty service members,2)describe the QOL instruments that have been used to...The objectives of this review were to 1)summarize the available evidence on the impact of hearing loss on quality of life(QOL)among U.S.active-duty service members,2)describe the QOL instruments that have been used to quantify the impact of hearing loss on quality of life,3)examine national population-level secondary databases and report on their utility for studying the impact of hearing loss on QOL among active-duty service members,and 4)provide recommendations for future studies that seek to quantify the impact of hearing loss in this population.There is a lack of literature that addresses the intersection of hearing impairment,the military population,and quality of life measures.For audiological research,U.S.military personnel offer a unique research population,as they are exposed to noise levels and blast environments that are highly unusual in civilian work settings and can serve as a model population for studying the impact on QOL associated with these conditions.This review recommends conducting a study on the active-duty service member population using a measurement instrument suitable for determining decreases in QOL specifically due to hearing loss.展开更多
Background: In combat operations, patients with traumatic injuries require expeditious evacuation to improve survival. Studies have shown that long transport times are associated with increased morbidity and mortality...Background: In combat operations, patients with traumatic injuries require expeditious evacuation to improve survival. Studies have shown that long transport times are associated with increased morbidity and mortality. Limited data exist on the influence of transport time on patient outcomes with specific injury types. The objective of this study was to determine the impact of the duration of time from the initial request for medical evacuation to arrival at a medical treatment facility on morbidity and mortality in casualties with traumatic extremity amputation and noncompressible torso injury(NCTI).Methods: We completed a retrospective review of MEDEVAC patient care records for United States military personnel who sustained traumatic amputations and NCTI during Operation Enduring Freedom between January 2011 and March 2014. We grouped patients as traumatic amputation and NCTI(AMP+NCTI), traumatic amputation only(AMP),and neither AMP nor NCTI(Non-AMP/NCTI). Analysis was performed using chi-squared tests, Fisher's exact tests,Cochran-Armitage Trend tests, Shapiro-Wilks tests, Wilcoxon and Kruskal-Wallis techniques and Cox proportional hazards regression modeling.Results: We reviewed 1267 records, of which 669 had an injury severity score(ISS) of 10 or greater and were included in the analysis. In the study population, 15.5% sustained only amputation injuries(n=104, AMP only), 10.8% sustained amputation and NCTI(n=72, AMP+NCTI), and 73.7% did not sustain either an amputation or an NCTI(n=493,Non-AMP/NCTI). AMP+NCTI had the highest mortality(16.7%) with transport time greater than 60 min. While the AMP+NCTI group had decreasing survival with longer transport times, AMP and Non-AMP/NCTI did not exhibit the same trend.Conclusions: A decreased transport time from the point of injury to a medical treatment facility was associated with decreased mortality in patients who suffered a combination of amputation injury and NCTI. No significant association between transport time and outcomes was found in patients who did not sustain NCTI. Priority for rapid evacuation of combat casualties should be given to those with NCTI.展开更多
Although hepatocellular carcinoma(HCC) primarily arises in the background of liver cirrhosis,the development of HCC in nonalcoholic fatty liver disease(NAFLD) without cirrhosis is increasingly recognized. The pathogen...Although hepatocellular carcinoma(HCC) primarily arises in the background of liver cirrhosis,the development of HCC in nonalcoholic fatty liver disease(NAFLD) without cirrhosis is increasingly recognized. The pathogenesis of NAFLD associated non-cirrhotic HCC is distinct from that of cirrhotic HCC because the metabolic syndrome(MS) along with obesity and insulin resistance(IR) underlie several unique mechanisms that promote tumorigenesis. IR associated with MS,NAFLD,and type 2 diabetes mellitus lead to the release of multiple pro-inflammatory cytokines,including tumor necrosis factor alpha,interleukin-6,leptin and resistin,as well as decreased amounts of adiponectin. These processes favor the development of hepatic steatosis and inflammation within the liver,which precede HCC development. Nevertheless,further investigation is necessary to elucidate the determinants for development of HCC in patients with NAFLD in the absence of cirrhosis.展开更多
Indirect traumatic optic neuropathy(ITON) refers to optic nerve injury resulting from impact remote to the optic nerve. The mechanism of injury is not understood, and there are no confirmed protocols for prevention, m...Indirect traumatic optic neuropathy(ITON) refers to optic nerve injury resulting from impact remote to the optic nerve. The mechanism of injury is not understood, and there are no confirmed protocols for prevention, mitigation or treatment. Most data concerning this condition comes from case series of civilian patients suffering blunt injury, such as from sports- or motor vehicle-related concussion, rather than military-related ballistic or blast damage. Research in this field will likely require the development of robust databases to identify patients with ITON and follow related outcomes, in addition to both in-vivo animal and virtual human models to study the mechanisms of damage and potential therapies.展开更多
AIMTo assess the effect of sofosbuvir (SOF) based regimens on glycemic and lipid control. METHODSThis is a retrospective analysis of hepatitis C virus (HCV)-infected patients treated and cured with a SOF regimen [SOF/...AIMTo assess the effect of sofosbuvir (SOF) based regimens on glycemic and lipid control. METHODSThis is a retrospective analysis of hepatitis C virus (HCV)-infected patients treated and cured with a SOF regimen [SOF/ribavirin/interferon, SOF/simeprevir, or SOF/ledipasvir (LDV) ± ribavirin] from January 2014 to March 2015. Patients with hemoglobin A1C (HbA1C) and lipid panels within six months before and six months after therapy were identified and included in our study. Due to the known hemolytic effect of ribavirin, HbA1C was obtained a minimum of three months post-treatment for the patients treated with a ribavirin regimen. Medical history, demographics, HCV genotype, pre-therapy RNA, and liver biopsies were included in our analysis. The patients who started a new medication or had an adjustment of baseline medical management for hyperlipidemia or diabetes mellitus (DM) were excluded from our analysis. RESULTSTwo hundred and thirty-four patients were reviewed, of which 60 patients met inclusion criteria. Sixty-three point three percent were male, 26.7% were Caucasian, 41.7% were African American and 91.7% were infected with hepatitis C genotype 1. Mean age was 60.6 ± 6.7 years. Thirty-nine patients had HbA1C checked before and after treatment, of which 22 had the diagnosis of DM type 2. HbA1C significantly decreased with treatment of HCV (pretreatment 6.66% ± 0.95% vs post-treatment 6.14% ± 0.65%, P vs 0.71% ± 0.83%, P = 0.070). Fifty-two patients had pre- and post-treatment lipid panels; there was a significant increase in low-density lipoprotein (LDL) and total cholesterol (TC) after treatment (LDL: 99.5 ± 28.9 mg/dL vs 128.3 ± 34.9 mg/dL, P vs 199.7 ± 40.0 mg/dL, P P = 0.684). CONCLUSIONEradication of HCV with a SOF regimen resulted in a significant drop in HbA1C and an increase in LDL and TC post therapy.展开更多
Recent randomized clinical trials have established the efficacy of Comprehensive Behavioral Intervention for Tics(CBIT) in treating children and adults with Tourette syndrome and persistent tic disorders. However, the...Recent randomized clinical trials have established the efficacy of Comprehensive Behavioral Intervention for Tics(CBIT) in treating children and adults with Tourette syndrome and persistent tic disorders. However, the standard CBIT protocol uses a weekly outpatient treatment format(i.e., 8 sessions over 10 wk), which may be inconvenient or impractical for some patients, particularly patients, who are required to travel long distances in order to receive care. In contrast, an intensive outpatient program may increase accessibility to evidence-based behavioral treatments for Tourette syndrome and other persistent tic disorders by eliminating the necessity of repeated travel. This case series evaluated the use of an intensive outpatient program CBIT(IOP CBIT) for the treatment of 2 preadolescent males(ages 10 and 14 years) with Tourette syndrome. The IOP CBIT treatment protocol included several hours of daily treatment over a 4-d period. Both children evi-denced notable reductions in their tics and maintained treatment gains at follow-up. Moreover, both patients and their parents expressed treatment satisfaction with the IOP CBIT format. This case series addresses an important research gap in the behavioral treatment of tic disorders literature. The patients' treatment outcomes indicate that IOP CBIT is a promising treatment that warrants more systematic investigation.展开更多
Background:Junctional hemorrhage surpassed extremity hemorrhage as the leading cause of preventable death after the resurgence of limb tourniquets during the recent conflicts in Afghanistan and Iraq.Junctional tourniq...Background:Junctional hemorrhage surpassed extremity hemorrhage as the leading cause of preventable death after the resurgence of limb tourniquets during the recent conflicts in Afghanistan and Iraq.Junctional tourniquets(JTQs)were developed in response to this injury pattern.Published data for JTQ efficacy are limited and do not incorporate nonmedical,military first responders.We compared the time for effective placement and scores for device satisfaction between two different JTQs,stratified by combat lifesaver(CLS)and combat medics.Methods:We performed a prospective,randomized,crossover trial utilizing the SAM ’ Medical Junctional Tourniquet(SJT)and Junctional Emergency Treatment Tool(JETTTM).Investigators simple randomized CLS and combat medics to SJT or JETT for their first JTQ application on mannequins with penetrating inguinal injuries.Then,participants immediately placed the other JTQ on another casualty with the same injury.The primary outcome measured was time of successful applicatio n.Success was defined as proper JTQ placement and a pressu re reading of at least 180 mmHg.We compared outcomes between CLS and combat medics.Unsuccessful JTQ applications were excluded from the comparative analysis.Results:From June 2015 to August 2015,a total of 227 personnel(133 CLS and 94 combat medics)at Fort Hood,Texas,USA volunteered to participate in the study.Twenty-eight percent(38 of 133)of CLS and 40%(38 of 94)of combat medics placed both JTQs successfully,for a total of 152 applications(76 SJTs and 76 JETTs).We found a significant difference between applications of the JETT between the CLS and combat medics(92.0±37.7 s versus70.5±20.5 s,P=0.004).No other subg roup analyses,whether by device or user,demonstrated a sig nifica nt difference in application time.Both groups preferred the SJT over the JETT.CLS disagreed with combat medics that the JETT could be easily applied by one person(median 3.0[2.0,4.0]versus median 4.0[3.0,5.0];P=0.006).Conclusions:Overall,success rates for both the SJT and JETT were low.Improved training is needed to increase successful application of junctional tourniquets before widespread implementation.Combat lifesavers and combat medics prefer the SJT over the JETT.展开更多
To systematically review the syndrome of giant gastric lipomas, report 2 new illustrative cases.Literature systematically reviewed using PubMed for publications since 1980 with following medical subject heading/keywor...To systematically review the syndrome of giant gastric lipomas, report 2 new illustrative cases.Literature systematically reviewed using PubMed for publications since 1980 with following medical subject heading/keywords: (“giant lipoma”) AND (“gastric”) OR [(“lipoma”) and (“gastric”) and (“bleeding”)]. Two authors independently reviewed literature, and decided by consensus which articles to incorporate. Computerized review of pathology/endoscopy records at William Beaumont Hospitals, Royal Oak and Troy, Michigan, January 2005-December 2015, revealed 2 giant gastric lipomas among 117110 consecutive esophagogastroduodenoscopies (EGDs), which were thoroughly reviewed, including re-review of original endoscopic photographs, radiologic images, and pathologic slides.展开更多
To assess dietary myo-inositol in reducing stem cell activation in colitis, and validate pβ-catenin<sup>S552</sup> as a biomarker of recurrent dysplasia.METHODSWe examined the effects of dietary myo-inosi...To assess dietary myo-inositol in reducing stem cell activation in colitis, and validate pβ-catenin<sup>S552</sup> as a biomarker of recurrent dysplasia.METHODSWe examined the effects of dietary myo-inositol treatment on inflammation, pβ-catenin<sup>S552</sup> and pAkt levels by histology and western blot in IL-10<sup>-/-</sup> and dextran sodium sulfate-treated colitic mice. Additionally, we assessed nuclear pβ-catenin<sup>S552</sup> in patients treated with myo-inositol in a clinical trial, and in patients with and without a history of colitis-induced dysplasia.RESULTSIn mice, pβ-catenin<sup>S552</sup> staining faithfully reported the effects of myo-inositol in reducing inflammation and intestinal stem cell activation. In a pilot clinical trial of myo-inositol administration in patients with a history of low grade dysplasia (LGD), two patients had reduced numbers of intestinal stem cell activation compared to the placebo control patient. In humans, pβ-catenin<sup>S552</sup> staining discriminated ulcerative colitis patients with a history of LGD from those with benign disease.CONCLUSIONEnumerating crypts with increased numbers of pβ-catenin<sup>S552</sup> - positive cells can be utilized as a biomarker in colitis-associated cancer chemoprevention trials.展开更多
Objective: The purpose of this work is to examine the usefulness of the topological approach for analysis of current density maps during ST-T interval in detection of coronary artery disease (CAD) in patients with pro...Objective: The purpose of this work is to examine the usefulness of the topological approach for analysis of current density maps during ST-T interval in detection of coronary artery disease (CAD) in patients with proved CAD but normal results of routine tests. Materials and Methods: The patient group included 123 patients. Coronary angiography was done due to chest pain. The control group consisted of 124 healthy volunteers. The MCG test was done by 4-channels MCG system installed at unshielded setting. An integral topological index Kideal, consisting of 4 parameters, has been counted. Results and Conclusions: It is shown that Kideal was higher in patient group compared to control one. Sensitivity was 87%, and specificity was 64%. The topological analysis of MCG current density maps is a valuable tool in noninvasive detection of CAD in difficult-to-diagnose patients with uninformative results of routine tests.展开更多
Traumatic axonal injury is a progressive process evoked by shear forces on the brain, gradually evolving from focal axonal alteration and cumulating in neural disconnection. Clinical classifiers and conventional neuro...Traumatic axonal injury is a progressive process evoked by shear forces on the brain, gradually evolving from focal axonal alteration and cumulating in neural disconnection. Clinical classifiers and conventional neuroimaging are limited in traumatic axonal injury detection, outcome prediction, and treatment guidance. Diffusion weighted imaging is an advanced magnetic resonance imaging (MRI) technique that is sensitive to the movement of water molecules, providing additional information on the micro-structural arrangement of tissue. Quantitative analysis of diffusion metrics can aid in the localization of axonal injury and/or de(dys)myelination caused by trauma. Diffusion MRI tractography is an extension of diffusion weighted imaging, and can provide additional information about white matter pathways and the integrity of brain neural networks. Both techniques are able to detect the early micro-structural changes caused by Traumatic Brain Injury (TBI), and can be used to increase understanding of the mechanisms of brain plasticity in recovery after brain injury and possibly optimize treatment planning of patients with Traumatic Brain Injury. This review focuses on the theoretical basis and applied advanced techniques of diffusion weighted imaging, their limitations and applications, and future directions in the application to TBI.展开更多
Background: Dietary supplement use(protein/amino acids, weight-loss supplements, performance enhancers) is common among U.S. military members. Reported dietary supplement use in deployed troops is limited and is of co...Background: Dietary supplement use(protein/amino acids, weight-loss supplements, performance enhancers) is common among U.S. military members. Reported dietary supplement use in deployed troops is limited and is of concern in settings where troops are exposed to high ambient temperatures, increased physical demands, and dehydration. Our objective was to describe dietary supplement use and adverse events(AEs) among deployed U.S. service members compared with their pre-deployment use.Methods: We conducted an institutional review board(IRB) approved, descriptive study in Afghanistan using a written questionnaire and collected demographic information, dietary supplement use before and during deployment, AEs associated with supplement use, and physical workout routines. Participants were U.S. military personnel of all branches of service deployed to Afghanistan. They were recruited in high-traffic areas in the combat theater. We analyzed the data with descriptive statistics. Paired t-test/Wilcoxon signed-rank test was conducted to examine the before/during deployment changes for continuous data, and Mc Nemar's chi-square test was conducted for categorical data. We constructed separate logistic regression models to determine the best predictors of increases or decreases in dietary supplement use, with demographic information, reasons for using supplements, and education requested/received as covariates in each model. All statistical tests were two-sided at a significance level of 5%(P<0.05).Results: Data were collected on 1685 participants. Ninety-seven of the participants were in the Army or Air Force. The participants were more likely to work out daily or more than once a day during deployment. Thirty-five percent of the participants reported no supplement use before or during deployment. The remaining 65% of participants reported increased use and increased frequency of use of supplements(e.g., daily) during deployment compared with predeployment. Additionally, more people followed label instructions strictly during deployment vs. predeployment. Overall, the frequency of self-reported AEs among supplement users remained consistent before and during deployment. The only significant difference noted was in problems falling or staying asleep, which increased during deployment. In the adjusted logistic regression models, the level of formal education, military branch, occupational specialty, education about dietary supplements, and certain reasons for using supplements(to boost energy, lose weight, gain muscle strength and mass, and as a meal replacement) were significant predictors of changes in supplement use.Conclusion: Deployed U.S. service members were more likely to use dietary supplements, use more than one supplement and use supplements more frequently during deployment than pre-deployment. No serious AEs were reported, but problems falling or staying asleep increased during deployment.展开更多
Objective:To evaluate the impact of prolonged post-thaw embryos culture on pregnancy outcome during frozen embryo transfer cycles.Methods:This prospective cohort study evaluated 324 thaw transfer cycles with 819 embry...Objective:To evaluate the impact of prolonged post-thaw embryos culture on pregnancy outcome during frozen embryo transfer cycles.Methods:This prospective cohort study evaluated 324 thaw transfer cycles with 819 embryos from 269 patients at the Center for Reproductive Endocrinology and Infertility of Hue University Hospital in Vietnam.These frozen embryo transfer cycles were divided into two groups at the time of thawing:the short culture group(2-hour post-thaw culture)and the overnight culture group(overnight culture for 18 h)before the embryo was transferred into the uterus.The rates of embryo intact,grade A embryo at frozen and transfer time and continuing cleavage were recorded.The clinical outcomes including serum beta-human chorionic gonadotropin,clinical pregnancy and implantation rate were evaluated after 14 days,4 weeks,6 weeks,respectively,after embryo transfer.Results:Human chorionic gonadotropin positive occurred in 39.5%of patients in the short culture group compared to 25.9%in the overnight culture group with risk difference(RD)=13.6%,relative risk(RR)=1.343,95%confidence interval(CI)1.085-1.663,P<0.01.Clinical pregnancy rate of the short culture group and overnight culture group was 33.3%and 24.1%,respectively(RD=9.2%,RR=1.242,95%CI 0.996-1.549,P=0.06)and the implantation rate in the short culture group and overnight culture group was 16.5%and 11.0%,respectively(RD=5.5%,RR=1.244,95%CI 1.046-1.479,P=0.01).In women of advanced age(≥35 years)and women who received 3 embryos,pregnancy outcomes were found to be significantly(P<0.05)higher in the short culture than in the overnight culture group.Conclusions:The prolonged post-thaw culture period does not increase pregnancy outcome in comparison with the short culture.展开更多
Leptospirosis is a zoonotic disease with worldwide distribution and increasing prevalence. Infection is caused by the spirochete Leptospira, with common exposure being contaminated fresh water. Most infections are asy...Leptospirosis is a zoonotic disease with worldwide distribution and increasing prevalence. Infection is caused by the spirochete Leptospira, with common exposure being contaminated fresh water. Most infections are asymptomatic, but symptoms range from a mild, self-limiting, non-specific febrile illness to fulminant respiratory and renal failure with a high mortality rate. The combination of jaundice, renal failure, and hemorrhage is known as Weil's disease and is the most characteristic pattern associated with severe leptospirosis. Clinical suspicion alone may be enough to warrant empiric antibiotic treatment in many cases. Serological methods are the most commonly used means of confirming a diagnosis of leptospirosis. The "gold standard" is the microscopic agglutination test. Typical treatment for mild causes is oral doxycycline, though azithromycin and oral penicillins are reasonable alternatives. Intravenous penicillin G has long been the standard of care for severe cases though limited studies show no benefit compared to third generation cephalosporins. We review the clinical presentation, diagnosis, treatment and prevention of leptospirosis.展开更多
Research evidence substantiating benefits of dental self-care habits is surprisingly limited. This study evaluated associations between dental self-care behaviors and oral health, specifically toothbrushing, flossing,...Research evidence substantiating benefits of dental self-care habits is surprisingly limited. This study evaluated associations between dental self-care behaviors and oral health, specifically toothbrushing, flossing, rinsing, chewing xylitol gum, and diet. Soldiers recently deployed to Iraq and Afghanistan had dental examinations and answered questionnaires on dental self-care habits. The DoD Oral Health and Readiness Classification System was used to categorize oral health （see manuscript for definitions）. Correlations were assessed between self-care habits and dental classification. Of 266 soldiers, 43 （16%） were Class 1 （excellent）, 191 （72%） Class 2 （acceptable）, 18 （7%） Class 3 （poor）, and 14 （5%） Class 4 （unknown）. Only 63% of soldiers brushed twice or more per day and only half flossed once or more per day. Dental classification improved with toothbrushing （P = 0.05） and adherence to a Mediterranean diet （P = 0.04）. Flossing trended toward correlation （P = 0.11）. Dental classification did not correlate with mouth rinse or xylitol chewing gum. These research findings help fill an evidence gap that toothbrushing and flossing in addition to a healthful eating pattem are associated with improved oral health.展开更多
The teratogenicity of thalidomide has been known since the early 1960s [1]. Thalidomide is currently used world wide, including the United States, to treat erythema nodosum leprosum, multiple myeloma, refractory Crohn...The teratogenicity of thalidomide has been known since the early 1960s [1]. Thalidomide is currently used world wide, including the United States, to treat erythema nodosum leprosum, multiple myeloma, refractory Crohn’s disease, aphthous stomatitis and HIV wasting syndrome. New cases of thalidomide phocomelia are being reported as well. We report a case of the anesthetic challenges of a 23 year-old parturient with thalidomide phocomelia and review the important anesthetic challenges it presents. Spontaneous vaginal delivery under continuous lumbar epidural was achieved in this challenging patient. However, it required careful planning for reliable intravenous access and the use of magnetic resonance imaging (MRI) of her pelvis and lumbar spine.展开更多
The Mesoamerican Ministers of Health have set 2020 as the target for malaria elimination to be achieved in the region. Imported malaria cases are a potential threat to countries attempting elimination or working to pr...The Mesoamerican Ministers of Health have set 2020 as the target for malaria elimination to be achieved in the region. Imported malaria cases are a potential threat to countries attempting elimination or working to prevent resurgence. We report the first imported Plasmodium ovale infection with molecular confirmation in Central America, which occurred in a Guatemalan soldier that had been deployed in Africa. The obstacles for its diagnosis using the standard microscopy technique and the need to improve its detection are discussed.展开更多
文摘Nail changes following upper extremity transplantation(UET)cannot be overlooked as they possess diagnostic and prognostic relevance in allotransplantation of upper limbs.This comprehensive review explores nail and nail bed related changes encountered in UET recipients in the literature.The differential diagnosis of nail abnormalities in UET includes a wide range of systemic,local and iatrogenic conditions other than immune responses to the allograft.It requires interdisciplinary evaluation by primary transplant surgeons,pathologists,dermatologists and immunologists.The possible underlying mechanisms of nail pathology in UET and the management are discussed.It also underscores the importance of onychodystrophy and need for timely intervention and to improve outcomes in UET recipients.
基金The Department of Defense Military Operational Medicine Research Program(MOMRP)supported this study。
文摘Background:The impact of sleep disorders on active-duty soldiers’medical readiness is not currently quantified.Patient data generated at military treatment facilities can be accessed to create research reports and thus can be used to estimate the prevalence of sleep disturbances and the role of sleep on overall health in service members.The current study aimed to quantify sleep-related health issues and their impact on health and nondeployability through the analysis of U.S.military healthcare records from fiscal year 2018(FY2018).Methods:Medical diagnosis information and deployability profiles(e-Profiles)were queried for all active-duty U.S.Army patients with a concurrent sleep disorder diagnosis receiving medical care within FY2018.Nondeployability was predicted from medical reasons for having an e-Profile(categorized as sleep,behavioral health,musculoskeletal,cardiometabolic,injury,or accident)using binomial logistic regression.Sleep e-Profiles were investigated as a moderator between other e-Profile categories and nondeployability.Results:Out of 582,031 soldiers,48.4%(n=281,738)had a sleep-related diagnosis in their healthcare records,9.7%(n=56,247)of soldiers had e-Profiles,and 1.9%(n=10,885)had a sleep e-Profile.Soldiers with sleep e-Profiles were more likely to have had a motor vehicle accident(p OR(prevalence odds ratio)=4.7,95%CI 2.63–8.39,P≤0.001)or work/duty-related injury(p OR=1.6,95%CI 1.32–1.94,P≤0.001).The likelihood of nondeployability was greater in soldiers with a sleep e-Profile and a musculoskeletal e-Profile(p OR=4.25,95%CI 3.75–4.81,P≤0.001)or work/dutyrelated injury(p OR=2.62,95%CI 1.63–4.21,P≤0.001).Conclusion:Nearly half of soldiers had a sleep disorder or sleep-related medical diagnosis in 2018,but their sleep problems are largely not profiled as limitations to medical readiness.Musculoskeletal issues and physical injury predict nondeployability,and nondeployability is more likely to occur in soldiers who have sleep e-Profiles in addition to these issues.Addressing sleep problems may prevent accidents and injuries that could render a soldier nondeployable.
基金supported by the Air Force Research Laboratory under Contract No.FA8650-12-C-6358
文摘The objectives of this review were to 1)summarize the available evidence on the impact of hearing loss on quality of life(QOL)among U.S.active-duty service members,2)describe the QOL instruments that have been used to quantify the impact of hearing loss on quality of life,3)examine national population-level secondary databases and report on their utility for studying the impact of hearing loss on QOL among active-duty service members,and 4)provide recommendations for future studies that seek to quantify the impact of hearing loss in this population.There is a lack of literature that addresses the intersection of hearing impairment,the military population,and quality of life measures.For audiological research,U.S.military personnel offer a unique research population,as they are exposed to noise levels and blast environments that are highly unusual in civilian work settings and can serve as a model population for studying the impact on QOL associated with these conditions.This review recommends conducting a study on the active-duty service member population using a measurement instrument suitable for determining decreases in QOL specifically due to hearing loss.
基金Department of Defense Joint Program Committee(JPC-6)
文摘Background: In combat operations, patients with traumatic injuries require expeditious evacuation to improve survival. Studies have shown that long transport times are associated with increased morbidity and mortality. Limited data exist on the influence of transport time on patient outcomes with specific injury types. The objective of this study was to determine the impact of the duration of time from the initial request for medical evacuation to arrival at a medical treatment facility on morbidity and mortality in casualties with traumatic extremity amputation and noncompressible torso injury(NCTI).Methods: We completed a retrospective review of MEDEVAC patient care records for United States military personnel who sustained traumatic amputations and NCTI during Operation Enduring Freedom between January 2011 and March 2014. We grouped patients as traumatic amputation and NCTI(AMP+NCTI), traumatic amputation only(AMP),and neither AMP nor NCTI(Non-AMP/NCTI). Analysis was performed using chi-squared tests, Fisher's exact tests,Cochran-Armitage Trend tests, Shapiro-Wilks tests, Wilcoxon and Kruskal-Wallis techniques and Cox proportional hazards regression modeling.Results: We reviewed 1267 records, of which 669 had an injury severity score(ISS) of 10 or greater and were included in the analysis. In the study population, 15.5% sustained only amputation injuries(n=104, AMP only), 10.8% sustained amputation and NCTI(n=72, AMP+NCTI), and 73.7% did not sustain either an amputation or an NCTI(n=493,Non-AMP/NCTI). AMP+NCTI had the highest mortality(16.7%) with transport time greater than 60 min. While the AMP+NCTI group had decreasing survival with longer transport times, AMP and Non-AMP/NCTI did not exhibit the same trend.Conclusions: A decreased transport time from the point of injury to a medical treatment facility was associated with decreased mortality in patients who suffered a combination of amputation injury and NCTI. No significant association between transport time and outcomes was found in patients who did not sustain NCTI. Priority for rapid evacuation of combat casualties should be given to those with NCTI.
文摘Although hepatocellular carcinoma(HCC) primarily arises in the background of liver cirrhosis,the development of HCC in nonalcoholic fatty liver disease(NAFLD) without cirrhosis is increasingly recognized. The pathogenesis of NAFLD associated non-cirrhotic HCC is distinct from that of cirrhotic HCC because the metabolic syndrome(MS) along with obesity and insulin resistance(IR) underlie several unique mechanisms that promote tumorigenesis. IR associated with MS,NAFLD,and type 2 diabetes mellitus lead to the release of multiple pro-inflammatory cytokines,including tumor necrosis factor alpha,interleukin-6,leptin and resistin,as well as decreased amounts of adiponectin. These processes favor the development of hepatic steatosis and inflammation within the liver,which precede HCC development. Nevertheless,further investigation is necessary to elucidate the determinants for development of HCC in patients with NAFLD in the absence of cirrhosis.
文摘Indirect traumatic optic neuropathy(ITON) refers to optic nerve injury resulting from impact remote to the optic nerve. The mechanism of injury is not understood, and there are no confirmed protocols for prevention, mitigation or treatment. Most data concerning this condition comes from case series of civilian patients suffering blunt injury, such as from sports- or motor vehicle-related concussion, rather than military-related ballistic or blast damage. Research in this field will likely require the development of robust databases to identify patients with ITON and follow related outcomes, in addition to both in-vivo animal and virtual human models to study the mechanisms of damage and potential therapies.
文摘AIMTo assess the effect of sofosbuvir (SOF) based regimens on glycemic and lipid control. METHODSThis is a retrospective analysis of hepatitis C virus (HCV)-infected patients treated and cured with a SOF regimen [SOF/ribavirin/interferon, SOF/simeprevir, or SOF/ledipasvir (LDV) ± ribavirin] from January 2014 to March 2015. Patients with hemoglobin A1C (HbA1C) and lipid panels within six months before and six months after therapy were identified and included in our study. Due to the known hemolytic effect of ribavirin, HbA1C was obtained a minimum of three months post-treatment for the patients treated with a ribavirin regimen. Medical history, demographics, HCV genotype, pre-therapy RNA, and liver biopsies were included in our analysis. The patients who started a new medication or had an adjustment of baseline medical management for hyperlipidemia or diabetes mellitus (DM) were excluded from our analysis. RESULTSTwo hundred and thirty-four patients were reviewed, of which 60 patients met inclusion criteria. Sixty-three point three percent were male, 26.7% were Caucasian, 41.7% were African American and 91.7% were infected with hepatitis C genotype 1. Mean age was 60.6 ± 6.7 years. Thirty-nine patients had HbA1C checked before and after treatment, of which 22 had the diagnosis of DM type 2. HbA1C significantly decreased with treatment of HCV (pretreatment 6.66% ± 0.95% vs post-treatment 6.14% ± 0.65%, P vs 0.71% ± 0.83%, P = 0.070). Fifty-two patients had pre- and post-treatment lipid panels; there was a significant increase in low-density lipoprotein (LDL) and total cholesterol (TC) after treatment (LDL: 99.5 ± 28.9 mg/dL vs 128.3 ± 34.9 mg/dL, P vs 199.7 ± 40.0 mg/dL, P P = 0.684). CONCLUSIONEradication of HCV with a SOF regimen resulted in a significant drop in HbA1C and an increase in LDL and TC post therapy.
文摘Recent randomized clinical trials have established the efficacy of Comprehensive Behavioral Intervention for Tics(CBIT) in treating children and adults with Tourette syndrome and persistent tic disorders. However, the standard CBIT protocol uses a weekly outpatient treatment format(i.e., 8 sessions over 10 wk), which may be inconvenient or impractical for some patients, particularly patients, who are required to travel long distances in order to receive care. In contrast, an intensive outpatient program may increase accessibility to evidence-based behavioral treatments for Tourette syndrome and other persistent tic disorders by eliminating the necessity of repeated travel. This case series evaluated the use of an intensive outpatient program CBIT(IOP CBIT) for the treatment of 2 preadolescent males(ages 10 and 14 years) with Tourette syndrome. The IOP CBIT treatment protocol included several hours of daily treatment over a 4-d period. Both children evi-denced notable reductions in their tics and maintained treatment gains at follow-up. Moreover, both patients and their parents expressed treatment satisfaction with the IOP CBIT format. This case series addresses an important research gap in the behavioral treatment of tic disorders literature. The patients' treatment outcomes indicate that IOP CBIT is a promising treatment that warrants more systematic investigation.
文摘Background:Junctional hemorrhage surpassed extremity hemorrhage as the leading cause of preventable death after the resurgence of limb tourniquets during the recent conflicts in Afghanistan and Iraq.Junctional tourniquets(JTQs)were developed in response to this injury pattern.Published data for JTQ efficacy are limited and do not incorporate nonmedical,military first responders.We compared the time for effective placement and scores for device satisfaction between two different JTQs,stratified by combat lifesaver(CLS)and combat medics.Methods:We performed a prospective,randomized,crossover trial utilizing the SAM ’ Medical Junctional Tourniquet(SJT)and Junctional Emergency Treatment Tool(JETTTM).Investigators simple randomized CLS and combat medics to SJT or JETT for their first JTQ application on mannequins with penetrating inguinal injuries.Then,participants immediately placed the other JTQ on another casualty with the same injury.The primary outcome measured was time of successful applicatio n.Success was defined as proper JTQ placement and a pressu re reading of at least 180 mmHg.We compared outcomes between CLS and combat medics.Unsuccessful JTQ applications were excluded from the comparative analysis.Results:From June 2015 to August 2015,a total of 227 personnel(133 CLS and 94 combat medics)at Fort Hood,Texas,USA volunteered to participate in the study.Twenty-eight percent(38 of 133)of CLS and 40%(38 of 94)of combat medics placed both JTQs successfully,for a total of 152 applications(76 SJTs and 76 JETTs).We found a significant difference between applications of the JETT between the CLS and combat medics(92.0±37.7 s versus70.5±20.5 s,P=0.004).No other subg roup analyses,whether by device or user,demonstrated a sig nifica nt difference in application time.Both groups preferred the SJT over the JETT.CLS disagreed with combat medics that the JETT could be easily applied by one person(median 3.0[2.0,4.0]versus median 4.0[3.0,5.0];P=0.006).Conclusions:Overall,success rates for both the SJT and JETT were low.Improved training is needed to increase successful application of junctional tourniquets before widespread implementation.Combat lifesavers and combat medics prefer the SJT over the JETT.
文摘To systematically review the syndrome of giant gastric lipomas, report 2 new illustrative cases.Literature systematically reviewed using PubMed for publications since 1980 with following medical subject heading/keywords: (“giant lipoma”) AND (“gastric”) OR [(“lipoma”) and (“gastric”) and (“bleeding”)]. Two authors independently reviewed literature, and decided by consensus which articles to incorporate. Computerized review of pathology/endoscopy records at William Beaumont Hospitals, Royal Oak and Troy, Michigan, January 2005-December 2015, revealed 2 giant gastric lipomas among 117110 consecutive esophagogastroduodenoscopies (EGDs), which were thoroughly reviewed, including re-review of original endoscopic photographs, radiologic images, and pathologic slides.
基金Supported by Veterans Affairs Merit Award,No.IO1CX001353(to Barrett TA)National Institutes of Health,No.2R01DK095662-06A1(to Barrett TA)+3 种基金the National Cancer Institute at the National Institutes of Health,No.N01-CN-35157(to Bergan R)the Training Program in Oncogenesis and Developmental Biology through the National Cancer Institute,No.NCI T32 CA080621(to Bradford EM)an Institutional Development Award from the National Institute of General Medical Sciences of the National Institutes of Health,No.8 P20GM103527-05American Physiological Society STEP-UP Fellowship(to Thompson CA)
文摘To assess dietary myo-inositol in reducing stem cell activation in colitis, and validate pβ-catenin<sup>S552</sup> as a biomarker of recurrent dysplasia.METHODSWe examined the effects of dietary myo-inositol treatment on inflammation, pβ-catenin<sup>S552</sup> and pAkt levels by histology and western blot in IL-10<sup>-/-</sup> and dextran sodium sulfate-treated colitic mice. Additionally, we assessed nuclear pβ-catenin<sup>S552</sup> in patients treated with myo-inositol in a clinical trial, and in patients with and without a history of colitis-induced dysplasia.RESULTSIn mice, pβ-catenin<sup>S552</sup> staining faithfully reported the effects of myo-inositol in reducing inflammation and intestinal stem cell activation. In a pilot clinical trial of myo-inositol administration in patients with a history of low grade dysplasia (LGD), two patients had reduced numbers of intestinal stem cell activation compared to the placebo control patient. In humans, pβ-catenin<sup>S552</sup> staining discriminated ulcerative colitis patients with a history of LGD from those with benign disease.CONCLUSIONEnumerating crypts with increased numbers of pβ-catenin<sup>S552</sup> - positive cells can be utilized as a biomarker in colitis-associated cancer chemoprevention trials.
文摘Objective: The purpose of this work is to examine the usefulness of the topological approach for analysis of current density maps during ST-T interval in detection of coronary artery disease (CAD) in patients with proved CAD but normal results of routine tests. Materials and Methods: The patient group included 123 patients. Coronary angiography was done due to chest pain. The control group consisted of 124 healthy volunteers. The MCG test was done by 4-channels MCG system installed at unshielded setting. An integral topological index Kideal, consisting of 4 parameters, has been counted. Results and Conclusions: It is shown that Kideal was higher in patient group compared to control one. Sensitivity was 87%, and specificity was 64%. The topological analysis of MCG current density maps is a valuable tool in noninvasive detection of CAD in difficult-to-diagnose patients with uninformative results of routine tests.
文摘Traumatic axonal injury is a progressive process evoked by shear forces on the brain, gradually evolving from focal axonal alteration and cumulating in neural disconnection. Clinical classifiers and conventional neuroimaging are limited in traumatic axonal injury detection, outcome prediction, and treatment guidance. Diffusion weighted imaging is an advanced magnetic resonance imaging (MRI) technique that is sensitive to the movement of water molecules, providing additional information on the micro-structural arrangement of tissue. Quantitative analysis of diffusion metrics can aid in the localization of axonal injury and/or de(dys)myelination caused by trauma. Diffusion MRI tractography is an extension of diffusion weighted imaging, and can provide additional information about white matter pathways and the integrity of brain neural networks. Both techniques are able to detect the early micro-structural changes caused by Traumatic Brain Injury (TBI), and can be used to increase understanding of the mechanisms of brain plasticity in recovery after brain injury and possibly optimize treatment planning of patients with Traumatic Brain Injury. This review focuses on the theoretical basis and applied advanced techniques of diffusion weighted imaging, their limitations and applications, and future directions in the application to TBI.
文摘Background: Dietary supplement use(protein/amino acids, weight-loss supplements, performance enhancers) is common among U.S. military members. Reported dietary supplement use in deployed troops is limited and is of concern in settings where troops are exposed to high ambient temperatures, increased physical demands, and dehydration. Our objective was to describe dietary supplement use and adverse events(AEs) among deployed U.S. service members compared with their pre-deployment use.Methods: We conducted an institutional review board(IRB) approved, descriptive study in Afghanistan using a written questionnaire and collected demographic information, dietary supplement use before and during deployment, AEs associated with supplement use, and physical workout routines. Participants were U.S. military personnel of all branches of service deployed to Afghanistan. They were recruited in high-traffic areas in the combat theater. We analyzed the data with descriptive statistics. Paired t-test/Wilcoxon signed-rank test was conducted to examine the before/during deployment changes for continuous data, and Mc Nemar's chi-square test was conducted for categorical data. We constructed separate logistic regression models to determine the best predictors of increases or decreases in dietary supplement use, with demographic information, reasons for using supplements, and education requested/received as covariates in each model. All statistical tests were two-sided at a significance level of 5%(P<0.05).Results: Data were collected on 1685 participants. Ninety-seven of the participants were in the Army or Air Force. The participants were more likely to work out daily or more than once a day during deployment. Thirty-five percent of the participants reported no supplement use before or during deployment. The remaining 65% of participants reported increased use and increased frequency of use of supplements(e.g., daily) during deployment compared with predeployment. Additionally, more people followed label instructions strictly during deployment vs. predeployment. Overall, the frequency of self-reported AEs among supplement users remained consistent before and during deployment. The only significant difference noted was in problems falling or staying asleep, which increased during deployment. In the adjusted logistic regression models, the level of formal education, military branch, occupational specialty, education about dietary supplements, and certain reasons for using supplements(to boost energy, lose weight, gain muscle strength and mass, and as a meal replacement) were significant predictors of changes in supplement use.Conclusion: Deployed U.S. service members were more likely to use dietary supplements, use more than one supplement and use supplements more frequently during deployment than pre-deployment. No serious AEs were reported, but problems falling or staying asleep increased during deployment.
文摘Objective:To evaluate the impact of prolonged post-thaw embryos culture on pregnancy outcome during frozen embryo transfer cycles.Methods:This prospective cohort study evaluated 324 thaw transfer cycles with 819 embryos from 269 patients at the Center for Reproductive Endocrinology and Infertility of Hue University Hospital in Vietnam.These frozen embryo transfer cycles were divided into two groups at the time of thawing:the short culture group(2-hour post-thaw culture)and the overnight culture group(overnight culture for 18 h)before the embryo was transferred into the uterus.The rates of embryo intact,grade A embryo at frozen and transfer time and continuing cleavage were recorded.The clinical outcomes including serum beta-human chorionic gonadotropin,clinical pregnancy and implantation rate were evaluated after 14 days,4 weeks,6 weeks,respectively,after embryo transfer.Results:Human chorionic gonadotropin positive occurred in 39.5%of patients in the short culture group compared to 25.9%in the overnight culture group with risk difference(RD)=13.6%,relative risk(RR)=1.343,95%confidence interval(CI)1.085-1.663,P<0.01.Clinical pregnancy rate of the short culture group and overnight culture group was 33.3%and 24.1%,respectively(RD=9.2%,RR=1.242,95%CI 0.996-1.549,P=0.06)and the implantation rate in the short culture group and overnight culture group was 16.5%and 11.0%,respectively(RD=5.5%,RR=1.244,95%CI 1.046-1.479,P=0.01).In women of advanced age(≥35 years)and women who received 3 embryos,pregnancy outcomes were found to be significantly(P<0.05)higher in the short culture than in the overnight culture group.Conclusions:The prolonged post-thaw culture period does not increase pregnancy outcome in comparison with the short culture.
文摘Leptospirosis is a zoonotic disease with worldwide distribution and increasing prevalence. Infection is caused by the spirochete Leptospira, with common exposure being contaminated fresh water. Most infections are asymptomatic, but symptoms range from a mild, self-limiting, non-specific febrile illness to fulminant respiratory and renal failure with a high mortality rate. The combination of jaundice, renal failure, and hemorrhage is known as Weil's disease and is the most characteristic pattern associated with severe leptospirosis. Clinical suspicion alone may be enough to warrant empiric antibiotic treatment in many cases. Serological methods are the most commonly used means of confirming a diagnosis of leptospirosis. The "gold standard" is the microscopic agglutination test. Typical treatment for mild causes is oral doxycycline, though azithromycin and oral penicillins are reasonable alternatives. Intravenous penicillin G has long been the standard of care for severe cases though limited studies show no benefit compared to third generation cephalosporins. We review the clinical presentation, diagnosis, treatment and prevention of leptospirosis.
文摘Research evidence substantiating benefits of dental self-care habits is surprisingly limited. This study evaluated associations between dental self-care behaviors and oral health, specifically toothbrushing, flossing, rinsing, chewing xylitol gum, and diet. Soldiers recently deployed to Iraq and Afghanistan had dental examinations and answered questionnaires on dental self-care habits. The DoD Oral Health and Readiness Classification System was used to categorize oral health （see manuscript for definitions）. Correlations were assessed between self-care habits and dental classification. Of 266 soldiers, 43 （16%） were Class 1 （excellent）, 191 （72%） Class 2 （acceptable）, 18 （7%） Class 3 （poor）, and 14 （5%） Class 4 （unknown）. Only 63% of soldiers brushed twice or more per day and only half flossed once or more per day. Dental classification improved with toothbrushing （P = 0.05） and adherence to a Mediterranean diet （P = 0.04）. Flossing trended toward correlation （P = 0.11）. Dental classification did not correlate with mouth rinse or xylitol chewing gum. These research findings help fill an evidence gap that toothbrushing and flossing in addition to a healthful eating pattem are associated with improved oral health.
文摘The teratogenicity of thalidomide has been known since the early 1960s [1]. Thalidomide is currently used world wide, including the United States, to treat erythema nodosum leprosum, multiple myeloma, refractory Crohn’s disease, aphthous stomatitis and HIV wasting syndrome. New cases of thalidomide phocomelia are being reported as well. We report a case of the anesthetic challenges of a 23 year-old parturient with thalidomide phocomelia and review the important anesthetic challenges it presents. Spontaneous vaginal delivery under continuous lumbar epidural was achieved in this challenging patient. However, it required careful planning for reliable intravenous access and the use of magnetic resonance imaging (MRI) of her pelvis and lumbar spine.
文摘The Mesoamerican Ministers of Health have set 2020 as the target for malaria elimination to be achieved in the region. Imported malaria cases are a potential threat to countries attempting elimination or working to prevent resurgence. We report the first imported Plasmodium ovale infection with molecular confirmation in Central America, which occurred in a Guatemalan soldier that had been deployed in Africa. The obstacles for its diagnosis using the standard microscopy technique and the need to improve its detection are discussed.
