Molecular diagnostic approaches for enteric parasites: an issue of relevance for deployed soldiers?

Dear Editor,Recently, Lindrose et al.[1] have conducted a retrospective assessment over 6 years on enteric helminth infections in United States(US)soldiers and their relatives to provide epidemiological insights into this so far neglected topic. A total of 50,000 helminth infections were recorded during the observation period.

Microbiological screenings for infection control in unaccompanied minor refugees： the German Armed Forces Medical Service＇s experience

Background:The German Military Medical Service contributed to the medical screening of unaccompanied minor refugees(UMRs)coming to Germany in 2014 and 2015.In this study,a broad range of diagnostic procedures was applied to identify microorganisms with clinical or public health significance.Previously,those tests had only been used to screen soldiers returning from tropical deployments.This instance is the first time the approach has been studied in a humanitarian context.Methods:The offered screenings included blood cell counts,hepatitis B serology and microscopy of the stool to look for protozoa and worm eggs as well as PCR from stool samples targeting pathogenic bacteria,protozoa and helminths.If individuals refused certain assessments,their decision to do so was accepted.A total of 219 apparently healthy male UMRs coming from Afghanistan,Egypt,Somalia,Eritrea,Syria,Ghana,Guinea,Iran,Algeria,Iraq,Benin,Gambia,Libya,Morocco,Pakistan,and Palestine were assessed.All UMRs who were examined at the study department were included in the assessment.Results:We detected decreasing frequencies of pathogens that included diarrhoea-associated bacteria[Campylobacter(C.)jejuni,enteropathogenic Escherichia(E.)coli(EPEC),enterotoxic E.coli(ETEC),enteroaggregative E.coli(EAEC),enteroinvasive E.coli(EIEC)/Shigella spp.),Giardia(G.)duodenalis,helminths(comprising Schistosoma spp.,Hymenolepis(H.)nana,Strongyloides(S.)stercoralis]as well as hepatitis B virus.Pathogenic microorganisms dominated the samples by far.While G.duodenalis was detected in 11.4%of the assessed UMRs,the incidence of newly identified cases in the German population was 4.5 cases per 100,000 inhabitants.Conclusion:We conclude that the applied in-house PCR screening systems,which have proven to be useful for screening military returnees from tropical deployments,can also be used for health assessment of immigrants from the respective sites.Apparently healthy UMRs may be enterically colonized with a broad variety of pathogenic and apathogenic microorganisms.Increased colonization rates,as shown for G.duodenalis,can pose a hygiene problem in centralized homes for asylum seekers.

Syncope as a health risk for soldiers: Influence of medical history and clinical findings on the sensitivity of head-up tilt table testing

Background: Syncope is a relevant health problem in military environments. Reliable diagnosis is challenging. Tilt table testing is an important tool for syncope diagnosis. The aim of this study was to determine whether signs such as prodromal symptoms, co-morbidity, frequency of syncopal events, body length, body mass index, and electrocardiography(ECG) abnormalities can be used to predict the success of tilt table testing at diagnosing syncope.Methods: Data from 100 patients with histories of syncope or pre-syncope, who were diagnosed using head-up tilt table testing, were retrospectively analyzed in a cross-sectional analysis. The diagnostic procedure was based upon a modified version of the Westminster protocol without any pharmacological provocation. Results: Patients showing pathological reaction patterns during tilt table testing suffered from prodromal symptoms, such as dizziness and sweating, significantly more often. The patients reported more injuries resulting from syncopal events and more previous syncopal events, and the prevalence of co-morbidity was greater among patients presenting negative findings during tilt testing. An asthenic-leptosomal physique was not confirmed as a risk factor for syncopal events as is the case for idiopathic arterial hypotension. However, patients with pathological reaction patterns during tilt table testing were significantly taller. This finding was detected for both females and males. No significant predictors were found in the ECG patterns of patients showing syncope during tilt table testing.Conclusions: Frequency of prior syncope and prodromal symptoms, and increased body length with an otherwise good state of health influence the predictive value of tilt table testing for syncope diagnosis. In particular, if these factors are present, tilt table testing should be considered part of the diagnostic algorithm for soldiers with recurrent syncope.

Infectious diseases during the European Union training mission Mali(EUTM MLI)–a four-year experience

Background: The European Union Training Mission Mali(EUTM MLI) is a multinational military training deployment to the Western African tropical nation of Mali. Based on routinely collected disease and non-battle injury surveillance data, this study quantifies the true impact of infectious diseases for this tropical mission and potential seasonal variations in infectious disease threats.Methods: Categorized health events during the EUTM MLI mission and associated lost working days were reported using the EpiNATO-2 report. Infection-related health events were descriptively analyzed for a 4-year period from the 12 th week in 2013 to the 13 th week in 2017. Aggregated EpiNATO-2 data collected from all missions other than EUTM MLI were used as a comparator.Results: Among the infectious diseases reported by EUTM MLI, non-severe upper respiratory infections and gastrointestinal diseases dominated quantitatively, accounting for 1.65 and 1.42 consultations per 100 person-weeks, respectively. The number of recorded infectious disease-associated lost working days during the whole study interval was 723. Seasonal changes in disease frequency were detectable. More gastrointestinal infections were seen in the rainy season, and more respiratory infections occurred in the dry season; these were associated with peaks of more than 2.5 consultations per 100 person-weeks for both categories.Conclusion: Despite initial concerns focused on tropical infectious diseases during this mission in tropical Mali, upper respiratory tract and gastrointestinal infections predominate. The relatively low number of reported lost working days may indicate that these infections are at the milder end of the spectrum of infectious diseases despite a likely reporting bias.

Screening agars for MRSA:evaluation of a stepwise diagnostic approach with two different selective agars for the screening for methicillin-resistant Staphylococcus aureus(MRSA)

Background: Colonization with methicillin-resistant Staphylococcus aureus(MRSA) poses a hygiene risk that does not spare field hospitals or military medical field camps during military deployments. Diagnostic options for unambiguously identifying MRSA isolates are usually scarce in military environments. In this study, we assessed the stepwise application of two different selective agars for the specific identification of MRSA in screening analyses.Methods: Nasal swabs from 1,541 volunteers were subjected to thioglycollate broth enrichment and subsequently screened on CHROMagar MRSA selective agar for the identification of MRSA. The MRSA identity of suspiciouslooking colonies was confirmed afterwards or excluded by another selective agar, chrom ID MRSA. All isolates from the selective agars with MRSA-specific colony morphology were identified by biochemical methods and mass spectrometry.Results: The initial CHROMagar MRSA screening identified suspicious colonies in 36 out of 1541 samples. A total of 25 of these 36 isolates showed MRSA-like growth on chrom ID agar. Out of these 25 isolates, 24 were confirmed as MRSA, while one isolate was identified as Staphylococcus kloosii. From the 11 strains that did not show suspicious growth on chrom ID agar, 3 were methicillin-sensitive Staphylococcus aureus(MSSA, with one instance of cocolonization with Corynebacterium spp.), 2 were confirmed as MRSA(with 1 instance of co-colonization with MSSA), 2 were lost during passaging and could not be re-cultured, one could not be identified by the applied approaches, and the remaining 3 strains were identified as Staphylococcus saprophyticus, Staphylococcus hominis(co-colonized with Macrococcus caseolyticus) and Staphylococcus cohnii, respectively.Conclusion: The application of the selective agar CHROMagar MRSA alone proved to be too non-specific to allow for a reliable diagnosis of the presence of MRSA. The combined use of two selective agars in a stepwise approach reduced this non-specificity with an acceptably low loss of sensitivity. Accordingly, such a stepwise screening approach might be an option for resource-restricted military medical field camps.

Artificially designed pathogens – a diagnostic option for future military deployments

Background: Diagnostic microbial isolates of bio-safety levels 3 and 4 are difficult to handle in medical field camps under military deployment settings. International transport of such isolates is challenging due to restrictions by the International Air Transport Association. An alternative option might be inactivation and sequencing of the pathogen at the deployment site with subsequent sequence-based revitalization in well-equipped laboratories in the home country for further scientific assessment. Methods: A literature review was written based on a Pub Med search. Results: First described for poliovirus in 2002, de novo synthesis of pathogens based on their sequence information has become a well-established procedure in science. Successful syntheses have been demonstrated for both viruses and prokaryotes. However, the technology is not yet available for routine diagnostic purposes. Conclusions: Due to the potential utility of diagnostic sequencing and sequence-based de novo synthesis of pathogens, it seems worthwhile to establish the technology for diagnostic purposes over the intermediate term. This is particularly true for resource-restricted deployment settings, where safe handling of harmful pathogens cannot always be guaranteed.

Syncope as a health risk for soldiers-influence of medical history and clinical findings on the sensitivity of head-up tilt table testing

Background:Syncope is a relevant health problem in military environments.Reliable diagnosis is challenging.Tilt table testing is an important tool for syncope diagnosis.The aim of this study was to determine whether signs such as prodromal symptoms,co-morbidity,frequency of syncopal events,body length,body mass index,and electrocardiography abnormalities can be used to predict the success of tilt table testing at diagnosing syncope.Methods:Data from 100 patients with histories of syncope or pre-syncope,who were diagnosed using head-up tilt table testing,were retrospectively analyzed in a cross-sectional analysis.The diagnostic procedure was based upon a modified version of the Westminster protocol without any pharmacological provocation.Results:Patients showing pathological reaction patterns during tilt table testing suffered from prodromal symptoms,such as dizziness and sweating,significantly more often.The patients reported more injuries resulting from syncopal events and more previous syncopal events,and the prevalence of co-morbidity was greater among patients presenting negative findings during tilt testing.An asthenic-leptosomal physique was not confirmed as a risk factor for syncopal events as is the case for idiopathic arterial hypotension.However,patients with pathological reaction patterns during tilt table testing were significantly taller.This finding was detected for both females and males.No significant predictors were found in the electrocardiogram patterns of patients showing syncope during tilt table testing.Conclusions:Frequency of prior syncope and prodromal symptoms,and increased body length with an otherwise good state of health influence the predictive value of tilt table testing for syncope diagnosis.In particular,if these factors are present,tilt table testing should be considered part of the diagnostic algorithm for soldiers with recurrent syncope.

Ultrasonography-triggered diagnosis of putrid,ulcero-phlegmonous,hemorrhagic appendicitis and periappendicitis with an atypical symptom pattern:a case report

Background:Asymptomatic and oligosymptomatic appendicitis are rare and challenging diagnoses that should not be missed.Case presentation:A young female patient presented with mild to moderate pain in the middle and lower abdomen,and the results of physical examination,including digital rectal examination,were otherwise non-contributory.Ultrasonography demonstrated a marked increase of the outer appendiceal diameter up to 12.0mm and a trace of free liquid around the terminal ileum.Subsequent surgical exploration and histological examination allowed for a final diagnosis of putrid,ulcero-phlegmonous,hemorrhagic appendicitis and periappendicitis.Conclusion:Ultrasonography is increasingly used for the diagnosis of appendiceal inflammation,particularly in military medical settings.Increases in the outer appendiceal diameter up to>6.0mm under compression have recently been demonstrated to be indicative of acute appendicitis.At a minimum,in cases with doubtful physical examination results,ultrasonography should be considered as an element in the diagnosis of acute appendicitis.