Military Health System

BACKGROUND: Nonrheumatic valvular diseases are common; however, no studies have estimated their global or national burden. As part of the Global Burden of Disease Study 2017, mortality, prevalence, and disability-adjusted life-years (DALYs) for calcific aortic valve disease (CAVD), degenerative mitral valve disease, and other nonrheumatic valvular diseases were estimated for 195 countries and territories from 1990 to 2017. METHODS: Vital registration data, epidemiologic survey data, and administrative hospital data were used to estimate disease burden using the Global Burden of Disease Study modeling framework, which ensures comparability across locations. Geospatial statistical methods were used to estimate disease for all countries, because data on nonrheumatic valvular diseases are extremely limited for some regions of the world, such as Sub-Saharan Africa and South Asia. Results accounted for estimated level of disease severity as well as the estimated availability of valve repair or replacement procedures. DALYs and other measures of health-related burden were generated for both sexes and each 5-year age group, location, and year from 1990 to 2017. RESULTS: Globally, CAVD and degenerative mitral valve disease caused 102 700 (95% uncertainty interval [UI], 82 700-107 900) and 35 700 (95% UI, 30 500-42 500) deaths, and 12.6 million (95% UI, 11.4 million-13.8 million) and 18.1 million (95% UI, 17.6 million-18.6 million) prevalent cases existed in 2017, respectively. A total of 2.5 million (95% UI, 2.3 million-2.8 million) DALYs were estimated as caused by nonrheumatic valvular diseases globally, representing 0.10% (95% UI, 0.09%-0.11%) of total lost health from all diseases in 2017. The number of DALYs increased for CAVD and degenerative mitral valve disease between 1990 and 2017 by 101% (95% UI, 79%-117%) and 35% (95% UI, 23%-47%), respectively. There is significant geographic variation in the prevalence, mortality rate, and overall burden of these diseases, with highest age-standardized DALY rates of CAVD estimated for high-income countries. CONCLUSIONS: These global and national estimates demonstrate that CAVD and degenerative mitral valve disease are important causes of disease burden among older adults. Efforts to clarify modifiable risk factors and improve access to valve interventions are necessary if progress is to be made toward reducing, and eventually eliminating, the burden of these highly treatable diseases.

OBJECTIVE: To analyze the extent and spatial distribution of white matter hyperintensities (WMH) in brain regions from cognitively normal older individuals (CN) and patients with mild cognitive impairment (MCI) and Alzheimer disease (AD). METHODS: We studied 26 mild AD, 28 MCI, and 33 CN. MRI analysis included quantification of WMH volume, nonlinear mapping onto a common anatomic image, and spatial localization of each WMH voxel to create an anatomically precise frequency distribution map. Areas of greatest frequency of WMH from the WMH composite map were used to identify 10 anatomic regions involving periventricular areas and the corpus callosum (CC) for group comparisons. RESULTS: Total WMH volumes were associated with age, extent of concurrent vascular risk factors, and diagnosis. After correcting for age, total WMH volumes remained significantly associated with diagnosis and extent of vascular risk. Regional WMH analyses revealed significant differences in WMH across regions that also differed significantly according to diagnosis. In post-hoc analyses, significant differences were seen between CN and AD in posterior periventricular regions and the splenium of the CC. MCI subjects had intermediate values at all regions. Repeated measures analysis including vascular risk factors in the model found a significant relationship between periventricular WMH and vascular risk that differed by region, but regional differences according to diagnosis remained significant and there was no interaction between diagnosis and vascular risk. CONCLUSIONS: Differences in white matter hyperintensities (WMH) associated with increasing cognitive impairment appear related to both extent and spatial location. Multiple regression analysis of regional WMH, vascular risk factors, and diagnosis suggest that these spatial differences may result from the additive effects of vascular and degenerative injury. Posterior periventricular and corpus callosum extension of WMH associated with mild cognitive impairment and Alzheimer disease indicate involvement of strategic white matter bundles that may contribute to the cognitive deficits seen with these syndromes.

The military lifestyle often includes continuous operations whether in training or deployed environments. These stressful environments present unique challenges for service members attempting to achieve consolidated, restorative sleep. The significant mental and physical derangements caused by degraded metabolic, cardiovascular, skeletomuscular, and cognitive health often result from insufficient sleep and/or circadian misalignment. Insufficient sleep and resulting fatigue compromises personal safety, mission success, and even national security. In the long-term, chronic insufficient sleep and circadian rhythm disorders have been associated with other sleep disorders (e.g., insomnia, obstructive sleep apnea, and parasomnias). Other physiologic and psychologic diagnoses such as post-traumatic stress disorder, cardiovascular disease, and dementia have also been associated with chronic, insufficient sleep. Increased co-morbidity and mortality are compounded by traumatic brain injury resulting from blunt trauma, blast exposure, and highly physically demanding tasks under load. We present the current state of science in human and animal models specific to service members during- and post-military career. We focus on mission requirements of night shift work, sustained operations, and rapid re-entrainment to time zones. We then propose targeted pharmacological and non-pharmacological countermeasures to optimize performance that are mission- and symptom-specific. We recognize a critical gap in research involving service members, but provide tailored interventions for military health care providers based on the large body of research in health care and public service workers.

BACKGROUND: The role of the angiotensin II type 2 receptor (AT2-R) in left ventricular (LV) remodeling may depend on the underlying stimulus. We hypothesized that cardiac AT2-R overexpression in transgenic (TG) mice would attenuate remodeling after myocardial infarction (MI). METHODS AND RESULTS: Ten wild-type (WT) C57BL/6 mice and 12 TG mice that overexpress the AT2-R in the heart were studied by cardiac MRI at baseline and days 1, 7, and 28 post-MI induced by 1 hour of occlusion of the LAD followed by reperfusion. Short-axis imaging from apex to base was used to determine LV mass index, end-diastolic and end-systolic volume indices (EDVI, ESVI), regional wall thickness and thickening, and ejection fraction (EF). Gadolinium-DTPA was infused 20 minutes before day 1 imaging to assess infarct size. At baseline, heart rate, blood pressure, LV mass index, and EDVI were similar between groups. Baseline ESVI was lower (0.20+/-0.07 versus 0.45+/-0.15 microL/g, P<0.001) and EF higher (82.3+/-4.9% versus 67.7+/-5.3%, P<0.001) in TG than WT. Infarct size was similar (36.6+/-7.2% in WT, 34.0+/-7.8% in TG, P=NS). When controlled for baseline differences, ESVI was significantly less and EF significantly higher at all time points in TG versus WT. At day 28, ESVI was 1.05+/-0.32 microL/g in TG and 1.63+/-0.41 microL/g in WT, P<0.03, and EF was 47.3+/-5.8% versus 34.1+/-9.2%, P<0.003, respectively. Regional wall thickness and thickening were greater in TG both at baseline and at day 28. At day 28, blood pressure and LV dP/dt were higher in TG. CONCLUSIONS: Cardiac AT2-R overexpression improves LV systolic function at baseline and preserves function during post-MI remodeling.

BACKGROUND: Allogeneic mesenchymal stem cells (MSCs) show great potential for the treatment of military and civilian trauma based on their reduced immunogenicity and ability to modulate inflammation and immune function in the recipient. Although generally considered to be safe, MSCs express tissue factor (TF), a potent activator of coagulation. In the current study, we evaluated multiple MSC populations for tissue factor expression and procoagulant activity to characterize safety considerations for systemic use of MSCs in trauma patients who may have altered coagulation homeostasis. METHODS: Multiple MSC populations derived from either human adipose tissue or bone marrow were expanded in the recommended stem cell media. Stem cell identity was confirmed using a well-characterized panel of positive and negative markers. Tissue factor expression on the cell surface was evaluated by flow cytometry with anti-CD142 antibody. Effects on blood coagulation were determined by thromboelastography and calibrated automated thrombogram assays using platelet-poor plasma or whole blood. RESULTS: Mesenchymal stem cells express tissue factor on their surfaces and are procoagulant in the presence of blood or plasma. The adipose-derived MSCs (Ad-MSC) evaluated were more procoagulant and expressed more tissue factor than bone marrow MSCs (BM-MSCs), which showed a greater variability in TF expression. Bone marrow MSCs were identified that exhibited low procoagulant activity, whereas all Ad-MSCs examined exhibited high procoagulant activity. The percentage of cells in a given population expressing surface tissue factor correlates roughly with functional procoagulant activity. Mesenchymal stem cell tissue factor expression and procoagulant activity change over time in culture. CONCLUSIONS: All MSC populations are not equivalent; care should be taken to select cells for clinical use that minimize potential safety problems and maximize chance of patient benefit. Adipose-derived MSCs seem more consistently procoagulant than BM-MSCs, presenting a potential safety concern for systemic administration in coagulopathic patients. Donor variation exists between different cell populations, and culture handling conditions may also determine coagulation activity. Cells must be routinely monitored during preparation to ensure that they retain the desired characteristics before patient administration.

Electrical stimulation to augment or maintain muscle performance has been well documented. The purpose of this preliminary report is to present the results of a single-case study conducted to determine the order of activation of skeletal muscle fibers as a result of electrical stimulation. The subject's quadriceps femoris muscles were electrically stimulated at 80% of maximal isometric torque. Pre-stimulation and immediate post-stimulation muscle biopsy samples were obtained, and a modification of the glucogen-depletion method was used to determine activation of muscle fibers. The pre-stimulation muscle biopsy sample demonstrated uniform periodic acid-Schiff (PAS)-positive staining in all fiber types, whereas the post-stimulation muscle biopsy sample showed glycogen depletion of type II muscle fibers. The most PAS-negative muscle fibers were type IIa skeletal muscle fibers. The results of this single-case study provide evidence that electrical stimulation, as described, selectively activates type II skeletal muscle fibers. The implication of this finding is that, in many chronic diseases, type II fibers are selectively and preferentially affected. Electrical stimulation may be a clinically viable technique to use in patients with type II fiber involvement.

BACKGROUND: Although biphasic, as compared with monophasic, waveform defibrillation for cardiac arrest is increasing in use and popularity, whether it is truly a more lifesaving waveform is unproven. METHODS AND RESULTS: Consecutive adults with nontraumatic out-of-hospital ventricular fibrillation cardiac arrest were randomly allocated to defibrillation according to the waveform from automated external defibrillators administered by prehospital medical providers. The primary event of interest was admission alive to the hospital. Secondary events included return of rhythm and circulation, survival, and neurological outcome. Providers were blinded to automated defibrillator waveform. Of 168 randomized patients, 80 (48%) and 68 (40%) consistently received only monophasic or biphasic waveform shocks, respectively, throughout resuscitation. The prevalence of ventricular fibrillation, asystole, or organized rhythms at 5, 10, or 20 seconds after each shock did not differ significantly between treatment groups. The proportion of patients admitted alive to the hospital was relatively high: 73% in monophasic and 76% in biphasic treatment groups (P=0.58). Several favorable trends were consistently associated with receipt of biphasic waveform shock, none of which reached statistical significance. Notably, 27 of 80 monophasic shock recipients (34%), compared with 28 of 68 biphasic shock recipients (41%), survived (P=0.35). Neurological outcome was similar in both treatment groups (P=0.4). Earlier administration of shock did not significantly alter the performance of one waveform relative to the other, nor did shock waveform predict any clinical outcome after multivariate adjustment. CONCLUSIONS: No statistically significant differences in outcome could be ascribed to use of one waveform over another when out-of-hospital ventricular fibrillation was treated.

Article1 June 1952OBSERVATIONS ON THE VIGOROUS DIAGNOSTIC APPROACH TO SEVERE UPPER GASTROINTESTINAL HEMORRHAGEEDDY D. PALMEREDDY D. PALMERSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-36-6-1484 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptIn the military services, the diagnostic problem presented by the patient with severe upper gastrointestinal hemorrhage is as a rule somewhat more difficult than that encountered in general civilian practice, because ordinarily prior to hemorrhage the patient has been entirely well. Only occasionally is there a history of previously diagnosed abdominal disease to help the clinician locate the source of bleeding. The peace-time Armed Forces ordinarily do not retain men who are discovered to have many of the diseases which may lead to upper gastrointestinal hemorrhage, unless the defect can be cured surgically. Each case of hemorrhage must usually be...Bibliography1. BrownThieme RJET: The results of the conservative treatment of upper gastro-intestinal bleeding, Gastroenterology 14: 369-374, 1950. CrossrefGoogle Scholar2. BrownMeyersPoschDeneen JRSGJLO: Massive hemorrhage from the upper gastrointestinal tract, Arch. Surg. 61: 767-774, 1950. CrossrefGoogle Scholar3. ChaikinTuller NWT: Management of hemorrhage from the upper gastrointestinal tract, Rev. Gastroenterol. 18: 403-412, 1951. MedlineGoogle Scholar4. ChinnWeckesser ABEC: Acute hemorrhage from peptic ulceration: an analysis of 322 cases, Ann. Int. Med. 34: 339-351, 1951. LinkGoogle Scholar5. Costello C: Massive hematemesis: analysis of 300 consecutive cases, Ann. Surg. 129: 289-298, 1949. CrossrefMedlineGoogle Scholar6. Lewison EF: Bleeding peptic ulcer, Internat. Abstr. Surg. 90: 1-30, 1950. Google Scholar7. ThompsonOzsterHeidMorgan HLJMJBFM: Hematemesis: a study of underlying causes, Gastroenterology 7: 320-331, 1946. MedlineGoogle Scholar8. BrownMcHardy DCG: Gastroscopy in hemorrhage of the stomach, New Orleans M. and S. J. 93: 338-341, 1941. Google Scholar9. CaravatiMacMillan CMJM: Obscure hematemesis: gastroscopy, an aid in its diagnosis, Virginia M. Monthly 74: 200-203, 1947. MedlineGoogle Scholar10. CarterZamcheck MGN: Esophagoscopy in upper gastrointestinal bleeding, New England J. Med. 242: 280-283, 1950. CrossrefMedlineGoogle Scholar11. ChevallierMoutier PF: Les hémorragies gastriques et leur contrôl endoscopique, Presse méd. 92: 1814-1815, 1936. Google Scholar12. JobinDugal JBJP: Gastrite hémorragique diagnostic par la gastroscopie, Laval méd. 4: 64-73, 1939. Google Scholar13. Jones FA: Haematemesis and melaena with special reference to bleeding peptic ulcer, Brit. M. J. 2: 441, 477, 1947. CrossrefMedlineGoogle Scholar14. Korbsch R: Ueber Hämatemesis bei chronischer Gastritis, München. med. Wchnschr. 72: 1558-1559, 1925. Google Scholar15. OlsenMoersch AMHJ: The role of gastroscopy in the diagnosis of upper gastrointestinal hemorrhage of obscure origin, Gastroenterology 14: 292-299, 1950. CrossrefMedlineGoogle Scholar16. RomanoMaggi NAL: Importancia de la gastroscopia en el diagnostico de las gastritis hemorragicas, Rev. Asoc. méd. argent. 55: 505-508, 1941. Google Scholar17. ElmerRousuckRyan RAAAJM: Early roentgenologic evaluation in patients with upper gastrointestinal hemorrhage: report of 58 cases, Gastroenterology 16: 552-565, 1950. CrossrefMedlineGoogle Scholar18. Schatzki R: Roentgenologic examination in patients with bleeding from the gastrointestinal tract, New England J. Med. 235: 783-786, 1946. CrossrefMedlineGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: M.C. Washington, D. C.*Received for publication October 12, 1951.From the Gastrointestinal Section, Walter Reed Army Hospital, Washington, D. C. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byEndoscopic hemostasis for nonvariceal upper gastrointestinal bleedingSecondary hæmorrhage complicating gastrectomyGastroenterologische Endoskopie und ChirurgieThe surgeon and endoscopy for gastrointestinal diseaseACUTE GASTROINTESTINAL HEMORRHAGEEmergency upper gastrointestinal endoscopy: Does haste make waste?Progress in the treatment of acute gastroduodenal mucosal lesions (AGML)Acetic acid-induced gastritis in cats changes in blood flow and capillary permeabilityMallory-Weiss SyndromeComparison of emergent endoscopy and upper gastrointestinal series radiography in acute upper gastrointestinal haemorrhage.Two Cases of Gastric Cancer in the Upper Portion with HematoemesisManagement of Bleeding Varices in Cirrhosis: A Critical ExaminationEndoscopy in upper gastrointestinal bleeding then and nowA Controlled Study of the Therapeutic Portacaval ShuntGastritisGastric musocal tears with acute hemorrhage: A possible variant of the Mallory-Weiss syndromeThe Mallory-Weiss syndrome: Some unusual presentations and a suggested new therapyCardial balloon tamponade in the treatment of the Mallory-Weiss syndromeSafety and Effectiveness of the Modified Sengstaken- Blakemore Tube: A Prospective StudyAcute haemorrhagic gastritis: modern concepts based on pathogenesis.EARLY INVESTIGATION OF HÆMATEMESIS AND MELÆNAErroneous diagnosis of hemorrhage from esophageal varicesReassessment of Massive Upper Gastrointestinal Hemorrhage on the Wards of the Boston City HospitalRecurrent Upper Gastrointestinal Hemorrhage in Peptic UlcerThe spectrum of emetogenic injury to the esophagus and stomachMassive Hemorrhage From Esophagogastric TearsThe Mallory-Weiss syndrome and lesionGASTRO–ŒSOPHAGEAL LACERATIONSEmergency Esophagoscopy in the Diagnosis of Upper Gastrointestinal HemorrhageUNEXPLAINED HÆMORRHAGE INTO THE UPPER GASTRO‐INTESTINAL TRACT: THE MALLORY–WEISS SYNDROMESources of bleeding in upper gastrointestinal hemorrhage: A re-evaluationHaematemesis in a Peripheral Scottish HospitalGastrointestinal tract hemorrhageEarly fiberscope endoscopy for upper gastrointestinal bleedingMallory-Weiss Syndrome: A Commonly Overlooked Cause of Upper Gastrointestinal BleedingMultiple Infusions of Posterior Pituitary Extract in the Treatment of Bleeding Esophageal VaricesHAROLD O. CONN, M.D., DONALD J. DALESSIO, M.D.Diagnostic Aids in Localizing the Site of Upper Gastrointestinal HemorrhageThe Emergency Management of Upper Gastrointestinal HemorrhageEARLY ENDOSCOPY AND RADIOLOGY IN THE MANAGEMENT OF HAEMATEMESIS AND MELAENAMucosal tears at the oesophagogastric junction (the Mallory-Weiss syndrome)LYMPHANGIOMA-HAEMANGIOMA OF THE JEJUNUM: A RARE CAUSE OF ALIMENTARY TRACT BLEEDINGWard barium meal examination in acute gastro-intestinal haemorrhageHemorrhagic (Erosive) gastritisEXPERIENCES WITH THE "VIGOROUS DIAGNOSTIC APPROACH" TO UPPER GASTROINTESTINAL HEMORRHAGE*NORMAN M. SCOTT JR., F.A.C.P.Hemorrhage from Erosive Gastritis and its Surgical ImplicationsEndoscopy in acute upper gastrointestinal bleedingMallory-weiss syndromeHematemesis and MelenaGastrointestinal hemorrhage, its diagnosis and treatmentMallory-weiss syndrome: Report of case diagnosed by gastroscopyGastrointestinal Hemorrhage (Excluding Peptic Ulcer and Esophageal Varices)Leukemia, gastroduodenal ulcer, and the problem of massive upper gastrointestinal hemorrhageMassive Hemorrhage in Patients with both Esophageal Varices and Duodenal UlcerChronic Hypertrophic Gastritis.Sources of Upper Gastrointestinal Hemorrhage in Cirrhotic Patients with Esophageal Varices 1 June 1952Volume 36, Issue 6Page: 1484-1491KeywordsArmed forcesGastrointestinal hemorrhageHemorrhage ePublished: 1 December 2008 Issue Published: 1 June 1952 PDF downloadLoading ...

The Management of Acute Compartment Syndrome Clinical Practice Guideline is based on a systematic review of current scientific and clinical research. The purpose of this clinical practice guideline is to guide the clinician's ability to diagnose and treat acute compartment syndrome by providing evidence-based recommendations for key decisions that affect the management of patients with extremity trauma. This guideline contains 15 recommendations including both diagnosis and treatment. In addition, the workgroup highlighted the need for better research in the diagnosis and treatment of acute compartment syndrome.

Occipital neuralgia is a condition manifested by chronic occipital headaches and is thought to be caused by irritation or trauma to the greater occipital nerve (GON). Treatment for occipital neuralgia includes medications, nerve blocks, and pulsed radiofrequency ablation (PRFA). Landmark-guided GON blocks are the mainstay in both the diagnosis and treatment of occipital neuralgia. Ultrasound is being utilized more and more in the chronic pain clinic to guide needle advancement when performing procedures; however, there are no reports of ultrasound used to guide a diagnostic block or PRFA of the GON. We report two cases in which ultrasound was used to guide diagnostic greater occipital nerve blocks and greater occipital nerve pulsed radiofrequency ablation for treatment of occipital neuralgia. Two patients with occipital headaches are presented. In Case 1, ultrasound was used to guide diagnostic blocks of the greater occipital nerves. In Case 2, ultrasound was utilized to guide placement of radiofrequency probes for pulsed radiofrequency ablation of the greater occipital nerves. Both patients reported immediate, significant pain relief, with continued pain relief for several months. Further study is needed to examine any difference in outcomes or morbidity between the traditional landmark method versus ultrasound-guided blocks and pulsed radiofrequency ablation of the greater occipital nerves.

Objective: The aim of this study is to determine objective and subjective changes in mature hypertrophic burn scars treated with a fractional ablative carbon dioxide (CO 2 ) laser. Background: Fractional CO 2 laser treatment has been reported to improve burn scars, with increasing clinical use despite a paucity of controlled, prospective clinical studies using objective measures of improvement. Methods: A multicenter, site-controlled, prospective open-label study was conducted from 2013 to 2016. Objective and patient-reported outcome measures were documented at baseline, at each monthly laser treatment, and 6 months after treatment. Objective measurements employed were: mechanical skin torque to measure viscoelastic properties; ultrasonic imaging to measure scar thickness; and reflectometry to measure erythema and pigmentation. Subjective measures included health-related quality of life, patient and investigator scar assessment scales, and blinded scoring of before and after photographs. Subjects aged 11 years or older with hypertrophic burn scars were recruited. Each subject received 3 monthly treatment sessions with an ablative fractionated CO 2 laser. Results: Twenty-nine subjects were enrolled, of whom 26 received at least 1 fractional CO 2 laser treatment and 22 received 3 treatments. Mean age of those completing all 3 treatments was 28 years. Statistically significant objective improvements in elastic stretch ( P &lt; 0.01), elastic recovery ( P &lt; 0.01), extensibility ( P &lt; 0.01), and thickness ( P &lt; 0.01) were noted. Patient- and physician-reported scar appearance and pain/pruritus were significantly improved ( P &lt; 0.01). There was no regression of improvement for at least 6 months after treatment. Conclusions: Fractional ablative laser treatment provides significant, sustained improvement of elasticity, thickness, appearance, and symptoms of mature hypertrophic burn scars.

BACKGROUND: Conventional autologous skin grafts are associated with significant donor-site morbidity. This study was conducted to determine feasibility, safety, and efficacy of a new strategy for skin grafting based on harvesting small columns of full-thickness skin with minimal donor-site morbidity. METHODS: The swine model was used for this study. Hundreds of full-thickness columns of skin tissue (~700 µm diameter) were harvested using a custom-made harvesting device, and then applied directly to excisional skin wounds. Healing in donor and graft sites was evaluated over 3 months by digital photographic measurement of wound size and blinded, computer-aided evaluation of histological features and compared with control wounds that healed by secondary intention or with conventional split-thickness skin grafts (STSG). RESULTS: After harvesting hundreds of skin columns, the donor sites healed rapidly without scarring. These sites reepithelialized within days and were grossly and histologically indistinguishable from normal skin within 7 weeks. By contrast, STSG donor sites required 2 weeks for reepithelialization and retained scar-like characteristics in epidermal and dermal architecture throughout the experiment. Wounds grafted with skin columns resulted in accelerated reepithelialization compared with ungrafted wounds while avoiding the "fish-net" patterning caused by STSG. CONCLUSION: Full-thickness columns of skin can be harvested in large quantities with negligible long-term donor-site morbidity, and these columns can be applied directly to skin wounds to enhance wound healing.

Throughout history, battlefield medicine has led to advancements in civilian trauma care. In the most recent conflicts of Operation Enduring Freedom in Afghanistan/Operation Iraqi Freedom, one of the most important advances is increasing use of point-of-injury hemorrhage control with tourniquets. Tourniquets are gradually gaining acceptance in the civilian medical world-in both the prehospital setting and trauma centers. An analysis of Emergency Medical Services (EMS) data shows an increase of prehospital tourniquet utilization from 0 to nearly 4,000 between 2008 and 2016. Additionally, bystander educational campaigns such as the Stop the Bleed program is expanding, now with over 125,000 trained on tourniquet placement. Because the medical community and the population at large has broader acceptance and training on the use of tourniquets, there is greater potential for saving lives from preventable hemorrhagic deaths.

BACKGROUND: Vascular complications from resuscitative endovascular balloon occlusion of the aorta (REBOA) have been reported in as high as 13% with some patients requiring lower-extremity amputation. We sought to review our institution series of REBOA and assess our vascular complications. METHODS: Retrospective review of all patients undergoing REBOA from October 2011 through July 2016. Data were gathered from the Memorial Hermann Trauma Registry and the hospital electronic medical records. Operative details and vascular injuries from arterial access for REBOA insertion were recorded. RESULTS: Forty-eight patients underwent REBOA during our study period. Thirty-eight had the 14 Fr. system placed and 10 had the 7 Fr. system placed. Of the 24 surviving the removal of the 14 Fr. sheath, 19 had primary repair of the arteriotomy without vascular complication. The other five required additional vascular procedures to repair arteriotomy with no lower-extremity amputations. There were no vascular complications of sheath removal with the 7 Fr. system, with no amputations. CONCLUSION: Implementation of REBOA can be done safely without increased risk of vascular access complications or limb loss. The 14 Fr. system will more likely require further vascular procedures to address the access site, whereas the 7 Fr. system will not. LEVEL OF EVIDENCE: Therapeutic/care management, level II.

AIM: To determine the uptake of noninvasive multitarget stool DNA (mt-sDNA) in a cohort of colorectal cancer (CRC) screening non-compliant average-risk Medicare patients. METHODS: This cross sectional primary care office-based study examined mt-sDNA uptake in routine clinical practice among 393 colorectal cancer screening non-compliant Medicare patients ages 50-85 ordered by 77 physicians in a multispecialty group practice (USMD Physician Services, Dallas, TX) from October, 2014-September, 2015. Investigators performed a Health Insurance Portability and Accountability Act compliant retrospective review of electronic health records to identify mt-sDNA use in patients who were either > 10 years since last colonoscopy and/or > 1 year since last fecal occult blood test. Test positive patients were advised to get diagnostic colonoscopy and thereafter patients were characterized by the most clinically significant lesion documented on histopathology of biopsies or excisional tissue. Descriptive statistics were employed. Key outcome measures included mt-sDNA compliance and diagnostic colonoscopy compliance on positive cases. RESULTS: Over 12 mo, 77 providers ordered 393 mt-sDNA studies with 347 completed (88.3% compliance). Patient mean age was 69.8 (50-85) and patients were 64% female. Mt-sDNA was negative in 85.3% (296/347) and positive in 14.7% (51/347). Follow-up colonoscopy was performed in 49 positive patients (96.1% colonoscopy compliance) with two patients lost to follow up. Index findings included: colon cancer (4/49, 8.2%), advanced adenomas (21/49, 42.9%), non-advanced adenomas (15/49, 30.6%), and negative results (9/49, 18.4%). The positive predictive value for advanced colorectal lesions was 51.0% and for any colorectal neoplasia was 81.6%. The mean age of patients with colorectal cancer was 70.3 and all CRC's were localized Stage I (2) and Stage II (2), three were located in the proximal colon and one was located in the distal colon. CONCLUSION: Mt-sDNA provided medical benefit to screening noncompliant Medicare population. High compliance with mt-sDNA and subsequent follow-up diagnostic colonoscopy identified patients with clinically critical advanced colorectal neoplasia.

The ongoing war has convinced a new generation of clinicians that whole blood (WB) benefits bleeding patients.1-4 As with many changes in civilian trauma care, the use of WB has transitioned from a wartime practice to the civilian world, becoming routine at many centers.5 At last count, 19 leading trauma centers are using this approved product as their first line transfusion, with some starting prehospital (both ground and air ambulance) and continuing into the Emergency Department (ED) and Operating Room. Seheult and colleagues have been leaders in this civilian effort, along with a multinational group of collaborators.6-13 The Pittsburgh group instituted low titer group O WB (LTOWB) transfusion protocols in 2014 and has systematically documented their approach and outcomes in multiple studies over the last 4 years.6-10 In this issue of TRANSFUSION, Seheult and colleagues report a retrospective, observational study of their recent experience, performed in a rigorous fashion, with appropriate analysis and without overstating their results.6 They show that civilian trauma patients receiving WB plus components did as well or better than patients matched by propensity score who received components and no WB. There were trends toward lower mortality and faster lactate normalization in the LTOWB group, as well as early and higher (closer to 1:1) transfusion ratios in the LTOWB group. Previously, this same group has shown that the fears of hemolysis are unfounded, similar to the results from the military studies, albeit with larger number of transfused WB units.9 These results will encourage other donor centers, blood banks, and clinicians caring for bleeding patients to collaboratively establish WB programs. Furthermore, these and additional unpublished data will set the stage for randomized studies of WB. The WB story is a fascinating example of evolution of clinical care. WB was the standard transfusion product for 50 years and obviously was a balanced approach to transfusion. In the early 1970s it essentially disappeared from clinical use, replaced with unbalanced component therapy, in which plasma to red blood cell (RBC) ratios often reached 1:10, with platelets given even less often. This drastic change occurred without supporting outcome data in bleeding patients. Interestingly, it was during this era that acute respiratory distress syndrome, multiple organ failure, abdominal compartment syndrome, and profound coagulopathy became common. We started caring for patients in the mid 1980s and it was routine to see patients with overt clinical coagulopathy. Over the last decade clinicians around the world have reversed this iatrogenic resuscitation error and are now transfusing bleeding patients in a balanced fashion, with amounts of plasma, platelets, cryoprecipitate, and RBCs that attempt to replicate WB. At the same time, the deleterious effects of even small amounts of crystalloid have become widely recognized, and plasma is used as the primary resuscitation fluid. Cannon and colleagues have promulgated clinical guidelines supporting early balanced resuscitation in patients predicted to receive a massive transfusion.14 Early blood product transfusion, within minutes of injury, yields better outcomes and patients now rarely suffer from a clinically apparent coagulopathy.15, 16 Results with this early and balanced method are superior to the previous approach. However, blood banks and bedside clinicians all report difficulty with coordinating the preparation, thawing, checking, delivering, and transfusing all these products at the same time and in the correct order. Frankly it's just hard to do. WB is easier and exposes the recipient to far fewer donors potentially making it safer from a number of angles, including human error. But WB is scary, it is “new,” represents change, upsets the routine between donor center and blood bank, will alter current inventory levels, is shrouded in myth, and frankly is just inconvenient. But all indications suggest it's a superior product. It is one component that delivers plasma, platelets, fibrinogen, and RBCs in the correct ratio, in one bag, at one time, with a shelf life that can extend to 35 days.12 Placing RBCs and thawed/liquid plasma on ambulances and in the ED has been associated with improved survival; however, with different expiration dates this has proved cumbersome to manage. Platelets have even shorter expiration dates (4 days) and different storage requirements than plasma and RBCs, while cryoprecipitate requires thawing before it can be transfused. WB eliminates these issues, providing one component, minimally “processed,” stored in its native milieu that delivers all these critical elements in one bag, greatly simplifying the storage, delivery transfusion, and administrative issues surrounding transfusion of the bleeding patient. WB is easily carried prehospital, for the first time in two generations providing for patients the highest quality of all elements in blood critical to hemorrhage control within minutes of injury. Transfusing patients with WB while they are bleeding, irrespective of the patient's location, is now possible and is the definition of patient-centered care.17, 18 The logistical advantage of WB versus attempting to recreate WB with component therapy is clear. The nursing personnel that “check the blood” at the bedside are some of the strongest proponents of WB, as they must contend daily with the paperwork and order of transfusion chaos that exists at the bedside while attempting to “recreate” WB from components (Fig. 1). WB simplifies these issues by decreasing the paperwork and eliminating the ratio/order question. It is well known that administrative errors are the most common transfusion misadventure and WB will likely decrease those errors. There is great concern about alloimunization with WB.19-21 Is this an area that is also tradition versus data based? The bedside clinicians are not cavalier about this issue; however, we are trying to weigh a risk-to-benefit equation of alloimunization in patients that at best have a 25% mortality within the next 105 minutes. For example, only a small minority of female patients of childbearing age are transfused. The risk of alloimunization by transfusing O+ LTWB to a Rh− woman of child bearing age is commonly reported at 22% (3%–30%) and an even smaller risk for her future child.19-21 If she is in hemorrhagic shock and requires a laparotomy, her mortality is more than 40%. If immediate transfusion of WB can lower that mortality, is it in her best interest to do so? How do we balance the risk of alloimunization with the larger potential benefit of having O+ LTWB available prehospital and in the ED for all genders of hemorrhagic shock patients, versus trying to manage only an O− LTWB supply? WB is not the answer for all patients, and in fact, it will be used in a very small number of patients. As bleeding slows and transfusion becomes guided by laboratory values, component therapy will be utilized. It is interesting to consider if using WB early will result in earlier hemostasis and decrease the overall number of blood products transfused. While WB was the standard product transfused in civilian hospitals until the mid 1970s, and is still an approved product, most blood centers have lost the expertise to produce LTOWB. There are issues with the computer systems, cost, impact on other products, supply of O− versus O+ LTWB, what is the right titer, what is the right titer method, leukoreduced or not, platelet-sparing filter or not, 21-day or 35-day storage, and what to do with expiring WB? While challenging, we are convinced that these issues are answerable. Nineteen centers have already started and more are on the way. A similar challenge comes with training bedside clinicians in the use of WB. Two generations of civilian clinicians have not been trained (except those who served in the military) on when and how to use WB; the textbooks, training courses, and registries will need to be updated. There are approximately 5000 hospitals in the United States. While RBCs are widely available, many (most?) cannot meet the standard of infusing RBCs, plasma, platelets and cryoprecipitate immediately upon arrival of a patient in hemorrhagic shock. There are approximately 35,000 ambulances in the United States. Today few carry any blood products, although recent data support improved outcomes with prehospital transfusion.22, 23 In these situations, every minute really does count. Even if those products are available in the blood bank, it often takes 30–40 minutes to prepare and deliver them to the bedside, during which a substantial percentage of bleeding patients will die.16, 24-26 The standard can be met by providing all hospitals with WB. How many ambulances will carry WB? Some are today, more will tomorrow. Many will say this vision is impossible and entirely unrealistic. What would they say if their loved one was transported or admitted to one of the many hospitals that can't provide that standard? More than 150,000 patients die after injury every year in the United States and bleeding is the leading cause of potentially preventable cause of death. When viewed as a public health crisis, WB is an intervention than can be used to help address those potentially preventable deaths at every level of care. The time is now to make WB widely available. The authors have disclosed no conflicts of interest.

OBJECTIVES: Traumatic brain injury (TBI) can cause adverse physiologic changes in fluid content within the brain, which may lead to changes in tissue elasticity (eg, stiffness). This study evaluated the ability of ultrasonic shear wave elastography to observe these changes in the brain after TBI in vivo. METHODS: Mice and rats received a mild TBI or sham surgery and were imaged acutely or 24 hours after injury using shear wave elastography, and the hemispheric stiffness values were compared. RESULTS: Stiffness values were consistent across brain hemispheres of sham TBI rodents. By 24 hours after TBI, relative brain tissue stiffness values for mice and rats each decreased ipsilaterally and increased contralaterally, both relative to each other and compared to sham TBI rodents (P < .05). The absolute tissue elasticity value increased for rats (P < .05) but not for mice. CONCLUSIONS: Differences between intrahemispheric stiffness values of rodent brains by 24 hours after mild TBI may reflect the observed edema and hemorrhage ipsilateral to TBI and the known reduction of cerebral blood flow in both brain hemispheres. If these hypotheses hold true, ultrasonic shear wave elastography may offer a method for detecting adverse changes in fluid content within the brain after mild TBI.

BACKGROUND: Trauma is the leading cause of death among casualties between 1 and 44 years. A large proportion of trauma deaths occurs even before arriving at a medical facility. The paucity of prehospital data is a major reason for the lagging development of prehospital trauma care research. This study aims to describe the Israel Defense Forces Prehopistal Trauma Registry, the steps taken to improve data collection and quality, the resulting trends, and the registry's contribution to policymaking. METHODS: This study explores the quantity and quality of point of injury and prehospital data in the registry between the years 1997 and 2018. We assessed the number of recorded casualties per year, casualties characteristics, and documentation variables in the registry, with a specific focus on documentation of vital signs throughout the years. RESULTS: Overall, 17,905 casualties were recorded. Most casualties were young males (88.6%)-military personnel (52.7%), Syrian refugees (16.2%), Israeli civilians (11.5%), and Palestinians (9.0%). The median number of annual records from 2006 onward was significantly higher compared with before 2006 (1,000 [IQR, 792-1,470] vs. 142 [IQR, 129-156]). Between 2010 and 2018, documentation rate increased in all vital signs investigated including heart rate (56.3% vs. 1.0%), level of consciousness (55.1% vs. 0.3%), respiratory rate (51.8% vs. 0.3%), blood oxygen saturation (50.0% vs. 1.0%), Glasgow Coma Scale (48.2% vs. 0.4%), systolic blood pressure (45.7% vs. 0.8%), and pain (19.1% vs. 0.5%). CONCLUSION: Point of injury and prehospital documentation are rare yet essential for ongoing improvement of combat casualty care. The Israel Defense Forces Trauma Registry is one of the largest and oldest prehospital computerized military trauma registries in the world. This study shows a major improvement in the quantity and then in the quality of prehospital documentation throughout the years that affected guidelines and policy. Further work will focus on improving data completeness and accuracy. LEVEL OF EVIDENCE: Retrospective study, level III.

INTRODUCTION: Youth with autism spectrum disorder (ASD) face high rates of unemployment, with unique challenges for military-dependent and -connected youth with ASD. This paper reports preliminary findings from Year One of a randomized waitlist controlled trial investigating the efficacy of the Project SEARCH + ASD Supports (PS + ASD) intervention model for military-dependent and -connected youth with ASD. METHODS: Treatment group participants (n = 6) participated in internships at a military installation in the southeastern United States; waitlist group participants (n = 8) received special education transition services at their local high schools. Employment outcome data were collected at 12 months for both groups. RESULTS: Fourteen unique internship experiences were developed across seven business partner organizations on the military installation during Year One. Five of six PS + ASD treatment group participants obtained competitive integrated employment for an overall employment rate of 83.3%. Four of the positions were federal jobs. None of the waitlist group participants obtained competitive integrated employment during the same period. CONCLUSIONS: Initial results are promising and suggest that the PS + ASD model may help to meet the transition needs of military-dependent and -connected youth with ASD and the employment needs of local military communities.

OBJECTIVE: Clinicians have anecdotally noted that combat-related invasive fungal wound infections (IFIs) lead to residual limb shortening, additional days and operative procedures before initial wound closure, and high early complication rates. We evaluated the validity of these observations and identified risk factors that may impact time to initial wound closure. DESIGN: Retrospective review and case-control analysis. SETTING: Military hospitals. PATIENTS/PARTICIPANTS: US military personnel injured during combat operations (2009-2011). The IFI cases were identified based on the presence of recurrent, necrotic extremity wounds with mold growth in culture, and/or histopathologic fungal evidence. Non-IFI controls were matched on injury pattern and severity. In a supplemental matching analysis, non-IFI controls were also matched by blood volume transfused within 24 hours of injury. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Amputation revision rate and loss of functional levels. RESULTS: Seventy-one IFI cases (112 fungal-infected extremity wounds) were identified and matched to 160 control patients (315 non-IFI extremity wounds). The IFI wounds resulted in significantly more changes in amputation level (P < 0.001). Additionally, significantly (P < 0.001) higher number of operative procedures and longer duration to initial wound closure were associated with IFI. A shorter duration to initial wound closure was significantly associated with wounds lacking IFIs (Hazard ratio: 1.53; 95% confidence interval, 1.17-2.01). The supplemental matching analysis found similar results. CONCLUSIONS: Our analysis indicates that IFIs adversely impact wound healing and patient recovery, requiring more frequent proximal amputation revisions and leading to higher early complication rates. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.