Landstuhl Regional Medical Center

Recent results for classical Be stars are reviewed and links to general astrophysics are presented. Classical Be stars are B‐type stars close to the main sequence that exhibit line emission over the photospheric spectrum. The excess is attributed to a circumstellar gaseous component that is commonly accepted to be in the form of an equatorial disk. Since 1988, when the last such review was published, major progress has been made. The geometry and kinematics of the circumstellar environment can be best explained by a rotationally supported relatively thin disk with very little outflow, consistent with interferometric observations. The presence of short‐term periodic variability is restricted to the earlier type Be stars. This variation for at least some of these objects has been shown to be due to nonradial pulsation. For at least one star, evidence for a magnetic field has been observed. The mechanisms responsible for the production and dynamics of the circumstellar gas are still not constrained. Observations of nonradial pulsation beating phenomena connected to outbursts point toward a relevance of pulsation, but this mechanism cannot be generalized. Either the evidence that Be stars do not form a homogeneous group with respect to disk formation is growing or the short‐term periodic variability is less important than previously thought. The statistics of Be stars investigated in open clusters of the Milky Way and the Magellanic Clouds has reopened the question of the evolutionary status of Be stars. The central B star is a fast rotator, although theoretical developments have revived the question of how high rotational rates are, so the commonly quoted mean value of about 70%–80% of the critical velocity may just be a lower limit. Be stars are in a unique position to make contributions to several important branches of stellar physics, e.g., asymmetric mass‐loss processes, stellar angular momentum distribution evolution, astroseismology, and magnetic field evolution.

BACKGROUND: Blast-related traumatic brain injuries have been common in the Iraq and Afghanistan wars, but fundamental questions about the nature of these injuries remain unanswered. METHODS: We tested the hypothesis that blast-related traumatic brain injury causes traumatic axonal injury, using diffusion tensor imaging (DTI), an advanced form of magnetic resonance imaging that is sensitive to axonal injury. The subjects were 63 U.S. military personnel who had a clinical diagnosis of mild, uncomplicated traumatic brain injury. They were evacuated from the field to the Landstuhl Regional Medical Center in Landstuhl, Germany, where they underwent DTI scanning within 90 days after the injury. All the subjects had primary blast exposure plus another, blast-related mechanism of injury (e.g., being struck by a blunt object or injured in a fall or motor vehicle crash). Controls consisted of 21 military personnel who had blast exposure and other injuries but no clinical diagnosis of traumatic brain injury. RESULTS: Abnormalities revealed on DTI were consistent with traumatic axonal injury in many of the subjects with traumatic brain injury. None had detectable intracranial injury on computed tomography. As compared with DTI scans in controls, the scans in the subjects with traumatic brain injury showed marked abnormalities in the middle cerebellar peduncles (P<0.001), in cingulum bundles (P=0.002), and in the right orbitofrontal white matter (P=0.007). In 18 of the 63 subjects with traumatic brain injury, a significantly greater number of abnormalities were found on DTI than would be expected by chance (P<0.001). Follow-up DTI scans in 47 subjects with traumatic brain injury 6 to 12 months after enrollment showed persistent abnormalities that were consistent with evolving injuries. CONCLUSIONS: DTI findings in U.S. military personnel support the hypothesis that blast-related mild traumatic brain injury can involve axonal injury. However, the contribution of primary blast exposure as compared with that of other types of injury could not be determined directly, since none of the subjects with traumatic brain injury had isolated primary blast injury. Furthermore, many of these subjects did not have abnormalities on DTI. Thus, traumatic brain injury remains a clinical diagnosis. (Funded by the Congressionally Directed Medical Research Program and the National Institutes of Health; ClinicalTrials.gov number, NCT00785304.).

AIMS: Perfusion-cardiac magnetic resonance (CMR) has emerged as a potential alternative to single-photon emission computed tomography (SPECT) to assess myocardial ischaemia non-invasively. The goal was to compare the diagnostic performance of perfusion-CMR and SPECT for the detection of coronary artery disease (CAD) using conventional X-ray coronary angiography (CXA) as the reference standard. METHODS AND RESULTS: In this multivendor trial, 533 patients, eligible for CXA or SPECT, were enrolled in 33 centres (USA and Europe) with 515 patients receiving MR contrast medium. Single-photon emission computed tomography and CXA were performed within 4 weeks before or after CMR in all patients. The prevalence of CAD in the sample was 49%. Drop-out rates for CMR and SPECT were 5.6 and 3.7%, respectively (P = 0.21). The primary endpoint was non-inferiority of CMR vs. SPECT for both sensitivity and specificity for the detection of CAD. Readers were blinded vs. clinical data, CXA, and imaging results. As a secondary endpoint, the safety profile of the CMR examination was evaluated. For CMR and SPECT, the sensitivity scores were 0.67 and 0.59, respectively, with the lower confidence level for the difference of +0.02, indicating superiority of CMR over SPECT. The specificity scores for CMR and SPECT were 0.61 and 0.72, respectively (lower confidence level for the difference: -0.17), indicating inferiority of CMR vs. SPECT. No severe adverse events occurred in the 515 patients. CONCLUSION: In this large multicentre, multivendor study, the sensitivity of perfusion-CMR to detect CAD was superior to SPECT, while its specificity was inferior to SPECT. Cardiac magnetic resonance is a safe alternative to SPECT to detect perfusion deficits in CAD.

We report the detection of a point-like source of very high energy (VHE) -rays coincident within 1 of Sgr A * , obtained with the HESS array of Cherenkov telescopes. The -rays exhibit a power-law energy spectrum with a spectral index of -2.2 0.09 0.15 and a flux above the 165 GeV threshold of (1.82 0.22) 10 -7 m -2 s -1 . The measured flux and spectrum differ substantially from recent results reported in particular by the CANGAROO collaboration.

BACKGROUND: We investigated an outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus complex infection among US service members injured in Iraq. METHODS: The investigation was conducted in Iraq and Kuwait, in the 2 military hospitals where the majority of injured service members were initially treated. After initially characterizing the outbreak, we evaluated 3 potential sources of infection for the period March 2003 to December 2004. The evaluation included screening samples that were obtained from the skin of patients for the presence of colonization and assessing the soil and health care environments for the presence of A. baumanii-calcoaceticus complex organisms. Isolates obtained from samples from patients in US Military treatment facilities, as well as environmental isolates, were genotypically characterized and compared using pulsed-field gel electrophoresis. RESULTS: A. baumanii-calcoaceticus complex organisms were present on the skin in only 1 (0.6%) of 160 patients who were screened and in 1 (2%) of 49 soil samples. A. baumanii-calcoaceticus complex isolates were recovered from treatment areas in 7 of the 7 field hospitals sampled. Using pulsed-field gel electrophoresis, we identified 5 cluster groups in which isolates from patients were related to environmental isolates. One cluster included hospitalized patients who had not been deployed to Iraq. Among the clinical isolates, only imipenem, polymyxin B, and colistin demonstrated reliable in vitro antimicrobial activity. Generally, the environmental isolates were more drug susceptible than were the clinical isolates. CONCLUSIONS: Our findings suggest that environmental contamination of field hospitals and infection transmission within health care facilities played a major role in this outbreak. On the basis of these findings, maintaining infection control throughout the military health care system is essential. Novel strategies may be required to prevent the transmission of pathogens in combat field hospitals.

BACKGROUND: Incomplete or delayed fasciotomies are associated with muscle necrosis and death in civilian trauma. Combat explosions severely damage tissue and distort normal anatomy making fasciotomies challenging. Rapid air evacuation may delay treatment of patients with evolving extremity compartment syndrome. We investigated the impact of fasciotomy revision and delayed compartment release on combat casualties after air evacuation. METHODS: A retrospective review was performed of combat casualties who underwent fasciotomies in Iraq, Afghanistan, or at Landstuhl Regional Medical Center between January 1, 2005 and August 31, 2006. Outcomes were rates of muscle excision, major amputation, and mortality. RESULTS: A total of 336 patients underwent 643 fasciotomies. Most were to the lower leg (49%) and forearm (23%). Patients who underwent a fasciotomy revision had higher rates of muscle excision (35% vs. 9%, p < 0.01) and mortality (20% vs. 6%, p < 0.01) than those who did not receive a revision. The anterior and deep compartments of the lower leg were the most commonly unopened. Patients who underwent fasciotomy after evacuation had higher rates of muscle excision (25% vs. 11%), amputation (31 vs. 15%), and mortality (19% vs. 5%) than patients who received their fasciotomies in the combat theater (p < 0.01). Patients who underwent revisions or delayed fasciotomies had higher Injury Severity Score and larger burns as well as lower systolic blood pressure, acidosis, and more pressor use during air evacuation. These patients also received more blood products at Landstuhl Regional Medical Center. CONCLUSION: Fasciotomy revision was associated with a fourfold increase in mortality. The most common revision procedures were extension of fascial incisions and opening new compartments. The most commonly unopened compartment was the anterior compartment of the lower leg. Patients who underwent delayed fasciotomies had twice the rate of major amputation and a threefold higher mortality.

Abstract. Diurnal measurements of total water potential and stomatal opening were made at six sites. Pressure‐volume curves were established on parallel leaf samples. In eastern Austria, the species investigated were Cornus mas L., Cornus sanguinea L., Crateagus monogyna Jacq., Sorbus aria (L.) Crantz and Viburnum lantana L. in southern France Crateagus monogyna , and in southern Turkey Crateagus monogyna and Olea europaea L. Osmotic adjustment, defined as a change in osmotic potential larger than the passive change resulting from the loss of cell water, was relatively small from day to day or week to week in mature, non‐senescing leaves. Cornus sanguinea was an exception. A recently suggested method for the demonstration of diurnal active osmotic adjustment seems not to be reliable without further independent corroboration. Changes in the leaf water potential threshold for stomatal closure were either insignificant when the pressure‐volume characteristics of the plant material were stable, or significant when shifts in such parameters as the turgor loss point occurred ( Cornus sanguinea ).

BACKGROUND: Among patients presenting with axial low back pain, facet arthropathy accounts for approximately 10-15% of cases. Facet interventions are the second most frequently performed procedures in pain clinics across the United States. Currently, there are no uniformly accepted criteria regarding how best to select patients for radiofrequency denervation. METHODS: A randomized, multicenter study was performed in 151 subjects with suspected lumbar facetogenic pain comparing three treatment paradigms. Group 0 received radiofrequency denervation based solely on clinical findings; group 1 underwent denervation contingent on a positive response to a single diagnostic block; and group 2 proceeded to denervation only if they obtained a positive response to comparative blocks done with lidocaine and bupivacaine. A positive outcome was predesignated as > or =50% pain relief coupled with a positive global perceived effect persisting for 3 months. RESULTS: In group 0, 17 patients (33%) obtained a successful outcome at 3 months versus eight patients (16%) in group 1 and 11 (22%) patients in group 2. Denervation success rates in groups 0, 1, and 2 were 33, 39, and 64%, respectively. Pain scores and functional capacity were significantly lower at 3 months but not at 1 month in group 2 subjects who proceeded to denervation compared with patients in groups 0 and 1. The costs per successful treatment in groups 0, 1, and 2 were $6,286, $17,142, and $15,241, respectively. CONCLUSIONS: Using current reimbursement scales, these findings suggest that proceeding to radiofrequency denervation without a diagnostic block is the most cost-effective treatment paradigm.

OBJECTIVE: Advances in regional anesthesia, specifically continuous peripheral nerve blocks (CPNBs), have greatly improved pain outcomes for wounded soldiers in Iraq and Afghanistan. pain management practice variations, however, do exist, depending on the availability of pain-trained military professionals deployed to combat support hospitals. an exploratory study was undertaken to examine pain and other outcomes during evacuation and at landstuhl regional medical center (lrmc), germany. DESIGN: a mixed-methods, semistructured interview survey design was conducted on a convenience sample of wounded u.s. soldiers evacuated from iraq and afghanistan to lrmc. setting and patients. a total of 110 wounded soldiers evacuated from IRAQ and Afghanistan from July 2007 to February 2008 completed a pain survey at LRMC. Data were collected on demographics, injury mechanism, last 24-hour average, least, and worst, and pain now by using a 0-10 scale, and percent pain relief (from 0% [No relief] to 100% [Complete relief]). Similar items and measures of anxiety, distress, and worry during flight transport were measured (from 0 [None] to 10 [Extreme]). Responses were analyzed by using descriptive and correlational statistics, multiple linear regression, Mann-Whitney U-tests, and t-tests. The Walter Reed Army Medical Center, Human Use Committee approved this investigation. RESULTS: Participants were typically male (99.1%), Caucasian (80%), and injured from improvised explosive devices (60%) and gunshots (21.8%). Average and worst pain scores were inversely correlated with pain relief during transport (r = -0.58 and r = -0.46, respectively; P < 0.001), and low to moderately positively correlated with increased anxiety, distress, and worry during transport (P < 0.05). Average percent pain relief achieved was 45.2% +/- 26.6% during transport and 64.5% +/- 23.5% while at LRMC (P < 0.001). Participants with CPNB catheters placed at LRMC reported significantly less pain right now (P = 0.031) and better pain relief (P = 0.029) than soldiers without CPNBs. CONCLUSIONS: Our findings underscore the value of early aggressive pain management after major combat injuries. Increased pain was associated with increased anxiety, distress, and worry during transport, suggesting the need for psychological management along with analgesia. Regional anesthesia techniques while at LRMC contributed to better pain outcomes.

BACKGROUND: Major advances in combat casualty care have led to increased survival of patients with complex extremity trauma. Invasive fungal wound infections (IFIs) are an uncommon, but increasingly recognized, complication following trauma that require greater understanding of risk factors and clinical findings to reduce morbidity. METHODS: The patient population includes US military personnel injured during combat from June 2009 through December 2010. Case definition required wound necrosis on successive debridements with IFI evidence by histopathology and/or microbiology (Candida spp excluded). Case finding and data collected through the Trauma Infectious Disease Outcomes Study utilized trauma registry, hospital records or operative reports, and pathologist review of histopathology specimens. RESULTS: A total of 37 cases were identified: proven (angioinvasion, n=20), probable (nonvascular tissue invasion, n=4), and possible (positive fungal culture without histopathological evidence, n=13). In the last quarter surveyed, rates reached 3.5% of trauma admissions. Common findings include blast injury (100%) during foot patrol (92%) occurring in southern Afghanistan (94%) with lower extremity amputation (80%) and large volume blood transfusion (97.2%). Mold isolates were recovered in 83% of cases (order Mucorales, n=16; Aspergillus spp, n=16; Fusarium spp, n=9), commonly with multiple mold species among infected wounds (28%). Clinical outcomes included 3 related deaths (8.1%), frequent debridements (median, 11 cases), and amputation revisions (58%). CONCLUSIONS: IFIs are an emerging trauma-related infection leading to significant morbidity. Early identification, using common characteristics of patient injury profile and tissue-based diagnosis, should be accompanied by aggressive surgical and antifungal therapy (liposomal amphotericin B and a broad-spectrum triazole pending mycology results) among patients with suspicious wounds.

We report the detection of TeV -rays from the shell-type supernova remnant RX J0852.0-4622 with data of 3.2 h of live time recorded with HESS in February 2004. An excess of (700 60) events from the whole remnant with a significance of 12 was found. The observed emission region is clearly extended with a radius of the order of 1 and the spatial distribution of the signal correlates with X-ray observations. The spectrum in the energy range between 500 GeV and 15 TeV is well described by a power law with a photon index of = 2.1 0.1 stat 0.2 syst and a differential flux at 1 TeV of 1 TeV = (2.1 0.2 stat 0.6 syst ) 10 -11 cm -2 s -1 TeV -1 . The integral flux above 1 TeV was measured to be (E > 1 TeV) = (1.9 0.3 stat 0.6 syst ) 10 -11 cm -2 s -1 , which is at the level of the flux of the Crab nebula at these energies. More data are needed to draw firm conclusions on the magnetic field in the remnant and the type of the particle population creating the TeV -rays.

<h3>Importance</h3> Recovery after concussion varies, with adolescents taking longer (approximately 30 days) than adults. Many factors have been reported to influence recovery, including preinjury factors, perceptions about recovery, comorbid conditions, and sex. However, 1 factor that may play a role in recovery but has received little attention from researchers is the timeliness of clinical evaluation and care. <h3>Objective</h3> To investigate the association of time since injury with initiation of clinical care on recovery time following concussion. <h3>Design, Setting, and Participants</h3> This retrospective, cross-sectional study was conducted in a sports medicine clinic between August 2016 and March 2018. Eligible participants were aged 12 to 22 years and had a diagnosed, symptomatic concussion; patients were excluded if recovery data were incomplete. Participants were divided into 2 groups: those seen within 7 days of the injury (early) vs between 8 and 20 days of the injury (late). Data were analyzed between June 2019 and August 2019. <h3>Exposures</h3> Time from injury (concussion) to initiation of clinical care. <h3>Main Outcomes and Measures</h3> Recovery time; testing with the Post-Concussion Symptom Scale, Immediate Post-Concussion Assessment and Cognitive Testing, and Vestibular/Ocular Motor Screening instruments; demographic factors, medical history, and injury information. <h3>Results</h3> A total of 416 individuals were eligible, and 254 (61.1%) were excluded, leaving 162 (38.9%) in analyses. The early group (98 patients) and late group (64 patients) did not differ in age (mean [SD] age, early, 15.3 [1.6] years; late, 15.4 [1.6] years), number of female patients (early, 51 of 98 [52.0%]; late, 40 of 64 [62.5%]), or other demographic, medical history, or injury information. The groups also were similar on symptom severity, cognitive, ocular, and vestibular outcomes at the first clinic visit. Results from a logistical regression supported being in the late group (adjusted odds ratio, 5.8 [95% CI, 1.9-17.6];<i>P</i> = .001) and visual motion sensitivity symptoms greater than 2 (adjusted odds ratio, 4.5 [95% CI, 1.1-18.0];<i>P</i> = .04) as factors significantly associated with recovery time. <h3>Conclusions and Relevance</h3> Findings suggest that earlier initiation of clinical care is associated with faster recovery after concussion. Other factors may also influence recovery time. Further research is needed to determine the role of active rehabilitation and treatment strategies, as well as demographic factors, medical history, and injury characteristics on the current findings.

INTRODUCTION: Severe trauma with concomitant chest injury is frequently associated with acute lung failure (ALF). This report summarizes our experience with extracorporeal lung support (ELS) in thoracic trauma patients treated at the University Medical Center Regensburg. METHODS: A retrospective, observational analysis of prospectively collected data (Regensburg ECMO Registry database) was performed for all consecutive trauma patients with acute pulmonary failure requiring ELS during a 10-year interval. RESULTS: Between April 2002 and April 2012, 52 patients (49 male, three female) with severe thoracic trauma and ALF refractory to conventional therapy required ELS. The mean age was 32±14 years (range, 16 to 72 years). Major traffic accident (73%) was the most common trauma, followed by blast injury (17%), deep fall (8%) and blunt trauma (2%). The mean Injury Severity Score was 58.9±10.5, the mean lung injury score was 3.3±0.6 and the Sequential Organ Failure Assessment score was 10.5±3. Twenty-six patients required pumpless extracorporeal lung assist (PECLA) and 26 patients required veno-venous extracorporeal membrane oxygenation (vv-ECMO) for primary post-traumatic respiratory failure. The mean time to ELS support was 5.2±7.7 days (range, <24 hours to 38 days) and the mean ELS duration was 6.9±3.6 days (range, <24 hours to 19 days). In 24 cases (48%) ELS implantation was performed in an external facility, and cannulation was done percutaneously by Seldinger's technique in 98% of patients. Cannula-related complications occurred in 15% of patients (PECLA, 19% (n=5); vv-ECMO, 12% (n=3)). Surgery was performed in 44 patients, with 16 patients under ELS prevention. Eight patients (15%) died during ELS support and three patients (6%) died after ELS weaning. The overall survival rate was 79% compared with the proposed Injury Severity Score-related mortality (59%). CONCLUSION: Pumpless and pump-driven ELS systems are an excellent treatment option in severe thoracic trauma patients with ALF and facilitate survival in an experienced trauma center with an interdisciplinary treatment approach. We encourage the use of vv-ECMO due to reduced complication rates, better oxygenation and best short-term outcome.

Members of the genus Acinetobacter are ubiquitous in soil and water and are an important cause of nosocomial infections. A rapid method is needed to genotype Acinetobacter isolates to determine epidemiology and clonality during infectious outbreaks. Multilocus PCR followed by electrospray ionization mass spectrometry (PCR/ESI-MS) is a method that uses the amplicon base compositions to genotype bacterial species. In order to identify regions of the Acinetobacter genome useful for this method, we sequenced regions of six housekeeping genes (trpE, adk, efp, mutY, fumC, and ppa) from 267 isolates of Acinetobacter. Isolates were collected from infected and colonized soldiers and civilians involved in an outbreak in the military health care system associated with the conflict in Iraq, from previously characterized outbreaks in European hospitals, and from culture collections. Most of the isolates from the Iraqi conflict were Acinetobacter baumannii (189 of 216 isolates). Among these, 111 isolates had genotypes identical or very similar to those associated with well-characterized A. baumannii isolates from European hospitals. Twenty-seven isolates from the conflict were found to have genotypes representing different Acinetobacter species, including 8 representatives of Acinetobacter genomospecies 13TU and 13 representatives of Acinetobacter genomospecies 3. Analysis by the PCR/ESI-MS method using nine primer pairs targeting the most information-rich regions of the trpE, adk, mutY, fumC, and ppa genes distinguished 47 of the 48 A. baumannii genotypes identified by sequencing and identified at the species level at least 18 Acinetobacter species. Results obtained with our genotyping method were essentially in agreement with those obtained by pulse-field gel electrophoresis analysis. The PCR/ESI-MS genotyping method required 4 h of analysis time to first answer with additional samples subsequently analyzed every 10 min. This rapid analysis allows tracking of transmission for the implementation of appropriate infection control measures on a time scale previously not achievable.

In Brief Objective: The objective of this study is to characterize modern point-of-injury (POI) en-route care platforms and to compare mortality among casualties evacuated with conventional military retrieval (CMR) methods to those evacuated with an advanced medical retrieval (AMR) capability. Background: Following a decade of war in Afghanistan, the impact of en-route care capabilities from the POI on mortality is unknown. Methods: Casualties evacuated from POI to one level III facility in Afghanistan (July 2008–March 2012) were identified from UK and US trauma registries. Groups comprised those evacuated by a medically qualified provider-led, AMR and those by a medic-led CMR capability. Outcomes were compared per incremental Injury Severity Score (ISS) bins. Results: Most casualties (n = 1054; 61.2%) were in the low-ISS (1–15) bracket in which there was no difference in en-route care time or mortality between AMR and CMR. Casualties in the mid-ISS bracket (16–50) (n = 583; 33.4%) experienced the same median en-route care time (minutes) on AMR and CMR platforms [78 (58) vs 75 (93); P = 0.542] although those on AMR had shorter time to operation [110 (95) vs 117 (126); P < 0.001]. In this mid-ISS bracket, mortality was lower in the AMR than in the CMR group (12.2% vs 18.2%; P = 0.035). In the high-ISS category (51–75) (n = 75; 4.6%), time to operation was lower in the AMR than the CMR group (66 ± 77 vs 113 ± 122; P = 0.013) but there was no difference in mortality. Conclusions: This study characterizes en-route care capabilities from POI in modern combat. Conventional platforms are effective in most casualties with low injury severity. However, a definable injury severity exists for which evacuation with an AMR capability is associated with improved survival. The greatest opportunity to improve the survivability of wartime injury exists in the prehospital setting. This study examines US and UK point-of-injury en-route care capabilities aboard distinct rotary wing platforms in southern Afghanistan. Severely injured casualties evacuated aboard an advanced medical retrieval platform were associated with a lower mortality.

Objectives: In select burn intensive care units, high-frequency percussive ventilation is preferentially used to provide mechanical ventilation in support of patients with acute lung injury, acute respiratory distress syndrome, and inhalation injury. However, we found an absence of prospective studies comparing high-frequency percussive ventilation with contemporary low-tidal volume ventilation strategies. The purpose of this study was to prospectively compare the two ventilator modalities in a burn intensive care unit setting. Design: Single-center, prospective, randomized, controlled clinical trial, comparing high-frequency percussive ventilation with low-tidal volume ventilation in patients admitted to our burn intensive care unit with respiratory failure. Setting: A 16-bed burn intensive care unit at a tertiary military teaching hospital. Patients: Adult patients ≥18 yrs of age requiring prolonged (>24 hrs) mechanical ventilation were admitted to the burn intensive care unit. The study was conducted over a 3-yr period between April 2006 and May 2009. This trial was registered with ClinicalTrials.gov as NCT00351741. Interventions: Subjects were randomly assigned to receive mechanical ventilation through a high-frequency percussive ventilation-based strategy (n = 31) or a low-tidal volume ventilation-based strategy (n = 31). Measurements and Main Results: At baseline, both the high-frequency percussive ventilation group and the low-tidal volume ventilation group had similar demographics to include median age (interquartile range) (28 yrs [23–45] vs. 33 yrs [24–46], p = nonsignificant), percentage of total body surface area burn (34 [20–52] vs. 34 [23–50], p = nonsignificant), and clinical diagnosis of inhalation injury (39% vs. 35%, p = nonsignificant). The primary outcome was ventilator-free days in the first 28 days after randomization. Intent-to-treat analysis revealed no significant difference between the high-frequency percussive ventilation and the low-tidal volume ventilation groups in mean (± sd) ventilator-free days (12 ± 9 vs. 11 ± 9, p = nonsignificant). No significant difference was detected between groups for any of the secondary outcome measures to include mortality except the need for “rescue” mode application (p = .02). Nine (29%) in the low-tidal volume ventilation arm did not meet predetermined oxygenation or ventilation goals and required transition to a rescue mode. By contrast, two in the high-frequency percussive ventilation arm (6%) required rescue. Conclusions: A high-frequency percussive ventilation-based strategy resulted in similar clinical outcomes when compared with a low-tidal volume ventilation-based strategy in burn patients with respiratory failure. However, the low-tidal volume ventilation strategy failed to achieve ventilation and oxygenation goals in a higher percentage necessitating rescue ventilation.

Importance: This is the first multisite, randomized clinical trial of stellate ganglion block (SGB) outcomes on posttraumatic stress disorder (PTSD) symptoms. Objective: To determine whether paired SGB treatments at 0 and 2 weeks would result in improvement in mean Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) total symptom severity scores from baseline to 8 weeks. Design, Setting, and Participants: This multisite, blinded, sham-procedure, randomized clinical trial used a 2:1 SGB:sham ratio and was conducted from May 2016 through March 2018 in 3 US Army Interdisciplinary Pain Management Centers. Only physicians performing the procedures and the procedure nurses were aware of the intervention (but not the participants or assessors); their interactions with the participants were scripted and limited to the 2 interventions. Active-duty service members on stable psychotropic medication dosages who had a PTSD Checklist-Civilian Version (PCL-C) score of 32 or more at screening were included. Key exclusion criteria included a prior SGB treatment, selected psychiatric disorders or substance use disorders, moderate or severe traumatic brain injury, or suicidal ideation in the prior 2 months. Interventions: Paired right-sided SGB or sham procedures at weeks 0 and 2. Main Outcomes and Measures: Improvement of 10 or more points on mean CAPS-5 total symptom severity scores from baseline to 8 weeks, adjusted for site and baseline total symptom severity scores (planned a priori). Results: Of 190 screened individuals, 113 (59.5%; 100 male and 13 female participants; mean [SD] age, 37.3 [6.7] years) were eligible and randomized (74 to SGB and 39 to sham treatment), and 108 (95.6% of 113) completed the study. Baseline characteristics were similar in the SGB and sham treatment groups, with mean (SD) CAPS-5 scores of 37.6 (11.2) and 39.8 (14.4), respectively (on a scale of 0-80); 91 (80.0%) met CAPS-5 PTSD criteria. In an intent-to-treat analysis, adjusted mean total symptom severity score change was -12.6 points (95% CI, -15.5 to -9.7 points) for the group receiving SGB treatments, compared with -6.1 points (95% CI, -9.8 to -2.3 points) for those receiving sham treatment (P = .01). Conclusions and Relevance: In this trial of active-duty service members with PTSD symptoms (at a clinical threshold and subthreshold), 2 SGB treatments 2 weeks apart were effective in reducing CAPS-5 total symptom severity scores over 8 weeks. The mild-moderate baseline level of PTSD symptom severity and short follow-up time limit the generalizability of these findings, but the study suggests that SGB merits further trials as a PTSD treatment adjunct. Trial Registration: ClinicalTrials.gov identifier: NCT03077919.

A total of 659 consecutive patients underwent venography for the evaluation of idiopathic left varicocele before sclerotherapy. In 484 cases no valves of the left spermatic vein could be demonstrated, while 172 patients demonstrated competent valves or absent insertions of the left spermatic vein at the typical point on the left renal vein plus retrograde flow over persistent intercardinal anastomoses. Stenosis of the renal vein occurred in 103 patients (15.7%). In only 3 patients was stenosis observed in the course of the left iliac vein, suggestive of the so-called distal nutcracker phenomenon. We propose that during embryogenesis disturbances in the development of the secondary venous system may result in the idiopathic left varicocele.

Very high energy (>100 GeV) gamma-ray emission has been detected for the first time from the composite supernova remnant G 0.9+0.1 using the HESS instrument. The source is detected with a significance of 13, and a photon flux above 200 GeV of (5.7 0.7 stat 1.2 sys ) 10 -12 cm -2 s -1 , making it one of the weakest sources ever detected at TeV energies. The photon spectrum is compatible with a power law (dN/dE E - ) with photon index = 2.40 0.11 stat 0.20 sys . The gamma-ray emission appears to originate in the plerionic core of the remnant, rather than the shell, and can be plausibly explained as inverse Compton scattering of relativistic electrons.

The Supernova Remnant MSH 15-52 has been observed in very high energy (VHE) -rays using the HESS 4-telescope array located in Namibia. A -ray signal is detected at the 25 sigma level during an exposure of 22.1 h live time. The image reveals an elliptically shaped emission region around the pulsar PSR B1509-58, with semi-major axis 6 in the NW-SE direction and semi-minor axis 2 . This morphology coincides with the diffuse pulsar wind nebula as observed at X-ray energies by ROSAT. The overall energy spectrum from 280 GeV up to 40 TeV can be fitted by a power law with photon index = 2.27 0.03 stat 0.20 syst . The detected emission can be plausibly explained by inverse Compton scattering of accelerated relativistic electrons with soft photons.