Impact of prehospital medical evacuation (MEDEVAC) transport time on combat mortality in patients with noncompressible torso injury and traumatic amputations: a retrospective study

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.

Pathogenesis of hepatocarcinogenesis in non-cirrhotic nonalcoholic fatty liver disease:Potential mechanistic pathways

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.

Combat lifesaver-trained, first-responder application of junctional tourniquets: A prospective, randomized,crossover trial

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.

Hepatitis C eradication with sofosbuvir leads to significant metabolic changes

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.

Systematic review of giant gastric lipomas reported since 1980 and report of two new cases in a review of 117110 esophagogastroduodenoscopies

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.

Intensive outpatient comprehensive behavioral intervention for tics: A case series

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.

Self-reported dietary supplement use in deployed United States service members pre-deployment vs.during deployment,Afghanistan,2013-2014

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.

Success Rate of Dental Implants Placed in the Atrophic Posterior Maxilla with Intentional Sinus Floor Perforation in Lieu of Indirect Sinus Augmentation: A Retrospective Report of 26 Consecutive Patients and Literature Review

Purpose: To assess surgical success rate of placing dental implants in the atrophic posterior maxilla engaging the maxillary sinus floor in patients with inadequate posterior maxillary alveolar bone height (PMABH). Methods: 26 patients with PMABH of 7 - 10 mm had 39 implants placed between July 2012 and June 2014. These implants were placed protruding apically 1 - 3 mm into the maxillary sinus engaging the sinus floor. At stage one, implants and cover screws were placed, followed by stage two, 5 - 6 months later. The implants were considered osseo-integrated in the absence of symptoms, mobility and inflammation. Periapical radiographs were taken to rule out peri-implant radiolucency. Restorative treatment was completed 2 months thereafter. Patients were scheduled to have a dental exam (6 - 12 months after delivery of prosthesis) and the implants were evaluated clinically and radiographically. A retrospective review was conducted to assess the surgical success rate of this treatment modality. Clinic charts, radiographs and digital implant log were reviewed for all patients with PMABH of 7 - 10 mm who received dental implants in the posterior maxilla to determine the success rate of this treatment modality. Results: 26 patients who had 39 implants placed were included in the study. All implants (100%) were osseo-integrated at the time of uncovering (stage 2). None of the implants (0%) had mobility or inflammation around them. Stage 2 was successfully performed on all 39 implants (100%). All implants (100%) in these patients had been restored, and were in good condition without mobility or inflammation, and had been functioning well 6 - 12 months after restoration. Conclusion: This study suggests that a high success rate can be attained placing dental implants in the posterior maxilla while perforating and engaging the cortical maxillary sinus floor. A future prospective study that compares this technique with the internal sinus lift would likely help elucidate this suggestion.

A Systems Biology Approach for Studying Heterotopic Ossification： Proteomic Analysis of Clinical Serum and Tissue Samples

Heterotopic ossification （HO） refers to the abnormal formation of bone in soft tissue. Although some of the underlying processes of HO have been described, there are currently no clinical tests using validated biomarkers for predicting HO formation. As such, the diagnosis is made radiographically after HO has formed. To identify potential and novel biomarkers for HO, we used isobaric tags for relative and absolute quantitation （iTRAQ） and high-throughput antibody arrays to produce a semi-quantitative proteomics survey of serum and tissue from subjects with （HO ＋） and without （HO-） heterotopic ossification. The resulting data were then analyzed using a systems biology approach. We found that serum samples from subjects experiencing traumatic injuries with resulting HO have a different proteomic expression controls. Subsequent quantitative ELISA identified profile compared to those from the matched five blood serum proteins that were differentially regulated between the HO-- and HO- groups. Compared to HO- samples, the amount of insulin-like growth factor I （IGF1） was up-regulated in HO＋ samples, whereas a lower amount of osteopontin （OPN）, myeloperoxidase （MPO）, runt-related transcription factor 2 （RUNX2）,and growth differentiation factor 2 or bone morphogenetic protein 9 （BMP-9） was found in HO ＋ samples （Welch two sample t-test; P 〈 0.05）. These proteins, in combination with potential serum biomarkers previously reported, are key candidates for a serum diagnostic panel that may enable early detection of HO prior to radiographic and clinical manifestations.