Medical journal (Fort Sam Houston, Tex.)最新文献

Objective: We document a military patient presenting with a diffuse set of symptoms suggestive of chronic Lyme disease (CLD) and the subsequent empiric treatment and health complications arising therein. The lay medical community, spurred by the internet, has ascribed these diffuse symptoms to various illnesses including CLD without confirmatory serological evidence of any underlying disease. With a growing community of patient advocates, CLD has become an illness with broad and highly generalized list of clinical symptoms and an absence of agreed-upon confirmatory laboratory tests. Further complicating matters, diagnostic criteria and treatment protocols differ between the Infectious Diseases Society of America and the International Lyme and Associated Diseases Society guidelines. Clinicians also face serious challenges in diagnosing and treating patients who present with generalized symptoms and close to 50 diagnostic tests for Lyme disease available in North America. Further complicating the picture for military patients seeking medical confirmation of a disease and resolution of their symptoms, medical fitness boards use putative diagnoses as prima faciae evidence in disability. Here a military patient with a long list of complaints that defy any clear or easy diagnosis and treatment is discussed. However, these symptoms taken together with selectively summed notes in the medical record in the absence of convincing and clear laboratory confirmation are suggestive of CLD and its complications, but no resolution was ultimately reached. With the presumptive determination of a medical disability due to CLD by the medical board, the medical dismissal of this service member from active duty occurred.

Objectives: Introduction: Medical readiness is an integral component of total readiness and a prime indicator of an individual's overall fitness to deploy. Promoting medical readiness is the prime directive for military medical departments; however, there are few studies evaluating specific factors of care delivery that will improve medical readiness. In this study, we evaluated one of the common patient perceptions that access to routine and specialty care will have a positive effect on military medical readiness. Surprisingly, there appeared to be a reverse relationship between a patient's perception of access to care and the correlation to their medical readiness.

Materials and methods: This study uses the Joint Outpatient Experience Survey data of Army active duty soldiers (December 2017 through May 2018) to investigate the relationship between access to care and medical readiness. Medical readiness scores were examined a month before and a month after a medical encounter. Medical Readiness Categories (MRC) were collected from the Army Medical Operational Data System Mainframe. Respondents of the survey were matched to MRC data. Comparisons were made using chi-square tests and Wilcoxon rank-sum non-parametric tests to determine whether there were differences in readiness and patient experience ratings before and after the encounter. Logistic regressions were also conducted to predict the odds of non-readiness based on the type of health care visit.

Results: Soldiers who were medically non-ready were more likely to be above age 35 years or have specialty care encounters. Results indicated those meeting all medical readiness requirements or having minor medical issues that could be resolved quickly, generally rated access to care slightly lower compared to those who were medically non-ready. Musculoskeletal Injuries (MSKIs) are the leading cause of medical non-readiness. As a result, this study explored access to care for MSKIs. Although there were no statistical differences in access ratings for those with MSKIs compared to those without MSKIs, there were statistically significant differences in self-reported health. Individuals with MSKIs tended to report poorer health status. Those with specialty care visits had 1.79 times significantly greater odds (p is less than .05) of being non-medically ready compared to those with primary care. For visits related to MSKI (e.g., physical medicine, orthopedic, or chiropractic etc.), those with an orthopedic or occupational therapy visit had 1.25 and 1.59 significantly greater odds (p is less than .05) of being considered not medically ready compared to all other MSKI related visits before the encounter. However, after the encounter, those with orthopedic care had significantly higher odds of improved readiness.

Conclusions: Findings from this study help contextualize who is considered medically non-ready as well as

Objective: Examine incidence rates of Type 2 Diabetes Mellitus (T2DM) in a military population over a tenyear period and whether demographic characteristics differ within the same population.

Methods: Diagnostic data and demographic variables from 23,821 active duty service members between 2006 and 2015 were analyzed from the Defense Medical Epidemiological Database.

Results: The incidence rates of new onset cases ranged from .22 (per 1,000 service members) in 2015 to a high of 1.46 (per 1,000 service members) in 2006 for T2DM without complications and .00 (per 1,000 service members) in 2007 to a high of .29 (per 1,000 service members) in 2015 for T2DM with complications. The one-sample chi-square test showed the observed, and expected frequencies differed significantly for all demographic variables tested.

Conclusions: Although there was a significant increase in the diagnosis of T2DM with complications in 2015, the overall downtrend is similar to that of the general US population. Older age and higher rank were more likely to be associated with the diagnosis of T2DM with and without complications, again suggestive of similar trends with the general US population. Continued efforts towards early diagnosis and treatment of these service members are needed to address this problem regarding military readiness.

Physical therapists (PT) have an integral role in supporting readiness of the Army warfighter. With an increased demand for active duty PTs and the transition to Defense Health Agency (DHA), more direct commission PTs and new graduates as first lieutenants will see themselves positioned in brigade combat teams (BCT). Traditionally, this role is given to a captain due to experience. Additionally, working in a forward deployed or rotational environment brings its own challenges encountered very seldom while in garrison. For example, military treatment facility (MTF) support for outlying clinics ensures continued ease of access to care for musculoskeletal conditions. Whereas in rotational environments, battalions are spread out across large geographic regions, thereby limiting continuity of care. As a brigade (BDE) PT, finding solutions is imperative to overcome these challenges, minimize the negative consequences of limited access, and find ways to address musculoskeletal (MSK) conditions requiring care.

Isolated atrophy of the pectoralis major muscle (PMM) secondary to traumatic lesion of the medial pectoral nerve is a known entity in the field of neuromuscular electrodiagnostics. Recent literature has begun describing a Pectoral Gap Phenomenon in which this atrophy occurs bilaterally as an overuse injury, leading to a marked concavity in the central chest wall musculature. While there is limited information in science journals on this topic, social media posts on weight lifting discuss the topic frequently. We report a case in which a soldier's body armor crushed the lateral medial and pectoral nerves against the anterior chest wall causing permanent upper body weakness. To optimize military medical readiness, awareness of this disorder and the pathophysiology causing it should spread so as to mitigate this potential for significant disability.

Background: Median mononeuropathy at or distal to the wrist, or carpal tunnel syndrome (CTS), is the most common peripheral nerve compression disorder in the upper extremity. Neurophysiological classification systems for patients with CTS have been developed and implemented to provide health care providers an enhanced system of electrophysiological evaluation with a grading scale, so that they may evaluate their patients with CTS within a system that confers relative severity. Electrophysiological data collected within these classification systems includes either nerve conduction studies (NCS), or both NCS and electromyography (EMG) test results. The purpose of this study was to assess the utilization of neurophysiological classification systems in determining interventions for patients with carpal tunnel syndrome (CTS).

Methods: To assess the utilization of neurophysiological classification systems in determining interventions for patients with CTS, an on-line survey of referring providers to NCS/EMG (electrophysiological testing) clinics was developed. These clinical sites were asked to submit three referring providers of their NCS/EMG services. The survey was emailed to the referring providers with a letter of introduction that included an overview and purpose of the study and specifically stated their responses were completely anonymous and analyzed data would be in an aggregate form.

Results: Of the 35 referring providers of NCS/EMG services for their patients with CTS contacted to participate in this study, 14 providers completed the on-line survey (40%). This included 12 physicians (MD), one osteopathic physician (DO), and one nurse practitioner (NP). Twelve of the referring providers (85.7%) were familiar with clinical electrophysiological classification systems for patients with CTS. Nine referring providers use a neurophysiological classification system (Greathouse Ernst Hall Shaffer (GEHS) and Bland-six; GEHS only-two; alternate system-one). Five respondents did not use a neurophysiological classification system, two of which were not familiar with these classification systems. The nine providers who use a neurophysiological classification system for their patients with CTS found these systems useful in assessing patient prognosis, treatment planning, and communicating back to referral services. The most preferable treatments for the very mild and mild (sensory only; sensory and motor) classifications were splinting followed by oral medication and injection. Splinting and surgery (open and endoscopic) were the interventions of choice for the moderate/severe and severe electrophysiological classifications.

Conclusion: Referring providers of NCS/EMG services completed an on-line survey to assess the utilization of neurophysiological classification systems in determining interventions for patients with CTS. The most preferable treatments for the very

Objective: The aim of this study was to compare area under the curve (AUC), frequency, and odds of return of spontaneous circulation (ROSC) when epinephrine was administered in hypovolemic and normovolemic cardiac arrest models.

Methods: Twenty-eight adult swine were randomly assigned to 4 groups: HIO Normovolemia Group (HIONG); HIO Hypovolemia Group (HIOHG); IV Normovolemia (IVNG); and IV Hypovolemia Group (IVHG). Swine were anesthetized. The HIOH and IVH subjects were exsanguinated 35% of their blood volume. Each was placed into arrest. After 2 minutes, cardiopulmonary resuscitation was initiated. After another 2 minutes, 1 mg of epinephrine was given by IV or HIO routes; blood samples were collected over 5 minutes and analyzed by high-performance liquid chromatography. Subjects were defibrillated every 2 minutes.

Results: The AUC in the HIOHG was significantly less than both the HIONG (p = 0.047) and IVHG (p = 0.021). There were no other significant differences in the groups relative to AUC (p > 0.05). HIONG had a significantly higher occurrence of ROSC compared to HIOHG (p = 0.018) and IVH (p =0.018) but no other significant differences (p > 0.05). The odds of ROSC were 19.2 times greater for HIONG compared to the HIOHG.

Conclusion: The study strongly supports the effectiveness of HIO administration of epinephrine and should be considered as a first-line intervention for patients in cardiac arrest related to normovolemic causes. However, our findings do not support using HIO access for epinephrine administration for patients in cardiac arrest related to hypovolemic reasons.

Objective: Few studies have investigated the relationship between patient experience and diabetes medication adherence among Military Health System (MHS) beneficiaries. We explored the link between patient experience survey ratings and adherence to diabetes medication. The hypothesis was that adherent patients would report better provider-patient experience than non-adherent patients.

Methods: Data included 2,599 patient surveys and pharmacy refill records. Adherence was determined using proportion of days covered (PDC) methodology where a patient must have had medications available 80% or more of the time during the observation period. Analysis involved multivariable logistic regression.

Results: Medication adherence was 60.2%. Regarding patient experience, those who were with their provider for 5 years or more had greater odds of adherence (OR 1.86[95%CI 1.19, 2.90]) Most of the patients in this study had high morbidity and high care utilization. Patient characteristics that significantly (p is less than 0.05) differentiated adherent versus non-adherent patients were race, mental health status, multiple medication use, glycated hemoglobin (HbA1c) levels, and health utilization.

Conclusion: Two key factors of adherence that emerged from this study are that moderate (OR 2.54[95%CI 1.35, 4.75]) and elevated (OR 2.35[95%CI 1.29, 4.30]) HbA1c and patients with 7+ health care providers (OR 1.56[95%CI 1.06,2.29]) had greater odds of adherence. Findings suggest that ability to see provider when needed and provider continuity support adherence to treatment. The practice implications of this study are health practitioners can leverage patient experience and pharmacy data to identify patterns of adherence among patients in the MHS.

Purpose: Proximal femoral bone stress injuries (BSI), especially those involving the femoral neck (FNBSI), pose a risk to military medical readiness. There is currently no optimal physical examination technique or test item cluster that substantially influences the clinical diagnosis of FNBSI. Consequently, a lower threshold to order diagnostic imaging is employed by clinicians who manage military populations at risk for FNBSI. A viable physical examination technique or cluster of techniques is needed to better inform this clinical decision process and reduce the associated diagnostic imaging burden. This project assessed the perceived clinical utility of several novel physical examination techniques intended to identify proximal femoral bone stress injuries.

Methods: Thirteen FNBSI-specific physical examination techniques were evaluated using standardized grading criteria, evaluating safety, reliability, and credibility. Based on group consensus, two weight-bearing techniques- forward lunge and tap (FLT), rear lunge reach and tap (RLRT)-and three non-weight-bearing techniques- proximal femoral shear test, 45-degree compress and percuss, and the side-lying scissor test-were each determined to possess a parsimonious cluster of desirable examination properties. A one-hour, multimedia presentation accompanied by live demonstrations was presented to 13 clinicians. Each clinician rated the physical examination techniques based on the following five criteria: patient safety, likely to identify only bone pathology, accuracy regardless of symptom duration or acuity, performed in the mid-range of available motion, and reliability. These criteria were individually weighted from 1 (strongly disagree) to 5 (strongly agree), yielding a possible maximum score of 25. Each physical examination technique was also given a yes or no rating for overall credibility. The minimum acceptable value was set a priori at 80% yes votes.

Results: All clinicians in attendance were physical therapists with an average of 5.9 (SD: 4.4) years of experience managing patients with FNBSI. All attendees either agreed or strongly agreed all techniques would be safe to use with patients suspected of having a FNBSI. The highest overall scoring test based on the five criteria was the FLT with a score of 21. The only two tests to exceed the 80% benchmark for overall credibility were the FLT (92.3%) and the RLRT (83.3%). There were no overall statistically significant differences within each individual criterion except for the safety criterion. However, post hoc pairwise comparisons revealed no statistically significant differences.

Conclusions: A minimum of two of the novel physical examination techniques (FLT, RLRT) appear to have sufficient credibility to warrant further evaluation based on voting results from an experienced group of clinicians. A concurrent criterion validity study to assess the dia

Objective: The purpose of this report was to document clinical responses to Nd:YAG laser energy in patients with surgical injury to terminal branches of the trigeminal nerve.

Background: Limited evidence from in vitro, animal, and human studies suggests infrared laser energy may positively influence recovery after peripheral or cranial nerve injury, although clinical effects of neodymiumdoped yttrium aluminum garnet (Nd:YAG) lasers remain unstudied in this context.

Methods: We applied Nd:YAG laser energy in the treatment of three consecutive patients presenting with altered neurosensory function following various oral and maxillofacial procedures. The time interval between surgical injury and laser photobiomodulation ranged from one week to two years.

Results: All patients exhibited reduction in the area of diminished sensation and partial recovery of normal neurosensory function. The two patients with long-standing neurosensory deficiency experienced near complete recovery of intraoral sensation, with residual zones of diminished sensation from the perioral skin.

Conclusions: Although all patients in this case series demonstrated clinical improvements compared with baseline, controlled studies are needed to determine whether Nd:YAG laser energy accelerates or enhances recovery of neurosensory function after surgical nerve injury. Studies establishing the relative efficacies of Nd:YAG and diode lasers appear warranted.