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

Introduction: Virtual health technologies came to the forefront during the COVID-19 Pandemic out of necessity to continue patient care and reduce risk of transmission. The US military began to explore the use of teledentistry in the mid-90s with the technology available at the time. The dental profession is slow at adopting the use of virtual health technologies as a capability to triage, screen, and monitor. Dentist to dentist consults routinely occur in both a civilian and military dental practice via email and phone consults. The idea of teledentistry for the future battlefield requires using existing technology such as advanced digital imaging, cloud technology, and video conferencing to shift towards a real-time virtual encounter. Real-time encounters create opportunities to evaluate a patient at a remote location when a dentist is not physically present. Advance development of virtual health technologies to include teledentistry expands the potential utilization of tele-triage, tele-screening, tele-consult, and tele-monitoring. These capabilities will be useful on the future battlefield during multi-domain operations as part of the Operational Virtual Health (OVH) capability. The application of OVH enables military forces to minimize morbidity and mortality on the battlefield to include prevention of unnecessary medical evacuation.

Methods: Comprehensive literature search was conducted in PubMed for published teledentistry research using military-related and battlefield use of teledentistry keywords.

Results: Two articles were identified that satisfied all inclusion and exclusion criteria.

Conclusion: A review of relevant literature demonstrated a severe paucity of primary sources, highlighting an underdeveloped component of the virtual health capability required to expand access of dental services throughout the military operating environment.

Introduction: Guided bone regeneration (GBR) is the most commonly utilized procedure for augmenting deficient alveolar ridges in support of dental implant placement. In a GBR procedure, barrier membrane dimensions, bone graft volume, and surgical complexity may influence the risk of postsurgical morbidity.

Case presentation: A 25-year-old female in good general health received GBR at two mandibular first molar sites exhibiting horizontal ridge deficiency. High-density polytetrafluoroethylene membranes were intentionally limited in size, and small-volume freeze-dried bone allografts were applied only where clinically beneficial for implant site development. Treatment resulted in clinically favorable ridge augmentation with no appreciable swelling and minimal postoperative discomfort.

Conclusion: At dental implant sites exhibiting modest alveolar ridge deficiency, limiting GBR barrier membrane dimensions and bone graft volumes may enhance patient-centered outcomes while accomplishing clinical goals.

Objective: The objective of this study was to illustrate the efficacy of a novel imaging analysis technology to capture horizontal and vertical dimensional changes following horizontal alveolar ridge augmentation (HRA).

Methods: Cone-beam computed tomography (CBCT) volumes from 65 HRA sites in 57 patients were available for evaluation, employing a three-dimensional analysis software to overlay preoperative and post-augmentation CBCT volumes. Horizontal and vertical alveolar ridge dimensional (HRD/VRD) changes were recorded considering a panel of patient-, site-, and procedure-related explanatory variables.

Results: VRD changes ranged from -2.9 to 3.0 mm, more than half anterior sites losing alveolar ridge height. Mean HRD increase at the 3- and 5-mm levels apical to the alveolar crest amounted to 2.3±1.6 and 2.4±1.3 mm, respectively, membrane fixation and non-resorbable membrane use associated with significantly greater gains.

Conclusions: To date, studies reporting dimensional changes following HRA predominantly rely on serial in situ orofacial caliper recordings omitting vertical alterations. The protocol employed in this study allows simultaneous HRD and VRD evaluations and assures baseline and post-augmentation recordings are made at the same alveolar ridge position. Compared with in situ recording, CBCT overlay analysis may achieve a more complete characterization of dimensional changes following HRA.

Objectives: Obstructive sleep apnea (OSA) is a common health problem that remains an underdiagnosed issue. Screening tools and clinical markers are needed from a variety of providers to determine patients at risk for OSA. Tooth wear could be a good potential identifier of patients at risk of having OSA.

Methods: This is an ambidirectional observational cohort. Participants were identified as retrospectively having undergone a sleep study and then tooth wear data was prospectively collected at patients' annual dental exam. The participants also completed an anonymous questionnaire to determine correlations with possible confounding factors.

Results: A total of 107 individuals were included in the analyses. No significant differences in wear were found between participants with an Apnea-Hypopnea Index (AHI) less than 5 and those with AHI ≥ 5 for any of the teeth examined (all P > 0.05). Overall, both groups had median tooth wear scores of 2 (IQR 1). Similarly, no differences in tooth wear were found between participants based on their body mass index (BMI) classification or consumption data (all P > 0.05).

Conclusion: Sleep is a complicated entity with many possible confounding factors. There is no correlation between AHI and tooth wear in the selected military cohort. Dentists should screen patients for possible medical and dental conditions whenever tooth wear is detected. Further research is needed to determine if tooth wear could be used as a potential identifier of patients at risk for OSA.

Introduction: Traumatic Brain Injury (TBI) is a prevalent health issue in the US and even more prevalent amongst members of the armed forces. The purpose of this project was to evaluate the association between history of TBI and rates of dental treatment performed, endodontic therapy, and high caries risk.

Methods: This was a retrospective medical and dental records study. The first 100 of a chosen dental hygienist's patients in 2016 who were seen for dental prophylaxis appointments were chosen as subjects. Armed Forces Health Longitudinal Technology Application (AHLTA) and Corporate Dental System (CDS) records were used to gather information on these subjects including rank, age, gender, duty status, tobacco use, history of TBI, total number of dental procedures, total Dental Weighted Value (DWV), number of endodontic procedures, endodontic DWV, high caries risk categorization, total days dental fitness class 1, and total days dental fitness class 3. From these subjects, a "TBI group" and a "Non-TBI group" were formed. T-Test analyses were performed to compare these groups to each other in categories of total number of dental procedures, total DWV, total days dental fitness class 1, and total days class 3. Relative risks ratio analysis was used to compare these groups in terms of high caries risk categorization.

Results: Eight out of 100 subjects had a history of TBI. All TBI events were mild. Six subjects had 1 event, 1 had 2 events, and 1 had 4 events. The TBI group had a statistically higher mean number of dental procedures (P=0.00000025) and mean total DWV (P=0.0000062) compared to the non-TBI group. No subjects from the TBI group had an endodontic procedure. The TBI group had lower mean days in dental fitness class 1 and more mean days in dental fitness class 3, but the results were not statistically significant. The TBI group had lower high caries risk categorization rates than the non-TBI group, but the results were not statistically significant.

Conclusions: Patients with a history of TBI had a significantly higher number of dental procedures performed and DWV generated compared to patients without a history of TBI.

Background: Sports injuries are an important non-battle cause of attrition and morbidity among deployed US service members (SMs). Injuries secondary to sport may cause physical disability and prolonged periods of limited duty days. Our objective was to provide a descriptive analysis of sports injuries sustained by US SMs which may assist in the preventive strategies and thereby decrease their burden on the deployed force.

Methods: Using the Department of Defense Trauma Registry's (DoDTR) data between October 2001 and December 2018, a retrospective cross-sectional analysis was conducted. We reported summary statistics of injury characteristics and care provided, stratified by geographic location.

Results: We found 1,578 causalities with sport injuries (4.9% of DoDTR); 1,081 (68.5%) in Iraq and Syria and 497 (31.5%) in Afghanistan. Most casualties had mild injuries (injury severity score: 1-9; n=1,514; 95.9%) and most sustained injuries in the lower extremities (n=741; 47%) followed by upper extremities (n=430; 27.2%). Most injuries were caused by a striking force (n=827; 52.4%) followed by overexertion (n=444; 28.2%), and 512 casualties (32.4%) had a fall incident. About 833 casualties (52.8%) received at least one surgery, and 931 casualties (59%) were hospitalized for two days or more. One casualty died of wound (0.1%).

Conclusions: Sports injuries continue to be an important source of morbidity and attrition and require disproportional medical attention, relative to their mild severity, representing a significant burden to the deployed health care system and impact combat readiness. Further research addressing the prevention of sports injury among deployed US SMs is needed.

Background: Ultrasound is a portable and adaptable imaging modality used widely in the care of trauma patients. The initial exam, known as the "Focused Assessment in Trauma (FAST) exam focused on the evaluation for hemoperitoneum and hemopericardium. In recent years, the exam has expanded to include evaluate for thoracic pathology, including pneumothorax, and is now known as the "Extended Focused Assessment in Trauma" (E-FAST) exam.

Methods: We reviewed after-action reviews (AAR) from the Joint Trauma System Prehospital Trauma Registry from 2013-2014 in which the use of an ultrasound exam was noted. Given the largely unstructured nature of the AARs, we selected relevant information from the free text available.

Results: Our initial dataset contained 705 casualties, of which we identified 45 cases containing the key words with AAR data for review: 39 cases involved the use of the FAST exam, three explicitly described the use of pulmonary ultrasound and they were categorized as E-FAST exams, two cases described the use of point of care echo to evaluate for cardiac standstill, and two cases described the use of ultrasound to evaluate for vascular injury. Of those with vital signs documented, 25% (11) reported at least one episode of tachycardia (≥120/min) and 16% (7) with at least one episode of systolic hypotension (less than 90mmHg). Of the 45 cases reviewed, six were recorded as equivocal, which we interpreted to indicate more training in either performance or interpretation of the exam was needed.

Conclusions: Our findings suggest that training in both the FAST exam and E-FAST has the potential to improve patient care for military trauma patients. A performance improvement system would enable real-time confirmation of findings and feedback for training and quality improvement.

Introduction: Studies assessing early trauma resuscitation have used long-term endpoints, such as 28- or 30-day mortality or Glasgow Outcomes Scores at 6-months. These endpoints are convenient but may not accurately reflect the effect of early resuscitation. We sought expert opinion and consensus on endpoints and definitions of variables needed to conduct a Department of Defense- (DoD) funded study to epidemiologically assess combat-relevant mortality and morbidity due to timeliness of resuscitation among critically injured civilians internationally.

Methods: We conducted an online modified Delphi process with an international panel of civilian and US military experts. In several iterative rounds, experts reviewed background information, appraised relevant scientific evidence, provided comments, and rendered a vote on each variable. A-priori, we set consensus at ≥80% concordant votes.

Results: Twenty panelists participated with a 100% response rate. Eight items were presented, with the following outputs for the epidemiologic study: Assess mortality within 7-days of injury; assess multi-organ failure using SOFA scores measured early (at day 3) and late (at day 7); assess traumatic brain injury mortality early (≤7-days) and late (28-days); hybrid (anatomic and physiologic) injury severity scoring is optimal; capture comorbidities per the US National Trauma Data Standard list with specific additions; assign resuscitative interventions to one of five standardized phases of trauma care; and, use a novel trauma death categorization system.

Conclusions: A modified Delphi process yielded expert-ratified definitions and endpoints of variables necessary to conduct a combat-relevant epidemiologic study assessing outcomes due to early trauma resuscitation. Outputs may also benefit other groups conducting trauma resuscitation research.

Background: Correct diagnosis of pneumothorax in trauma patients is essential. Under-diagnosis can lead to development of life-threatening tension pneumothorax, but overdiagnosis leads to placement of unnecessary chest tubes with potential related morbidity and pain. It is unclear from previous work if there is a benefit to switching from the phased array (low frequency) probe to the linear (high frequency) probe. Is the improvement in image quality worth the time lost changing probes?

Methods: We compared the sensitivity and specificity of a low frequency and high frequency ultrasound probe for the detection of pneumothorax. Images were obtained using swine models and were interpreted by Emergency Medicine residents, attendings, and physician assistants.

Results: We found a specificity of 89% and sensitivity of 99% for the low frequency probe and specificity of 96% and sensitivity of 99% for the high frequency probe. There was a statistically different specificity between the two probes, suggesting that the linear probe may be the superior probe for confirming the presence of pneumothorax.

Conclusion: We conclude switching to the linear probe for the thoracic portion of the Extended-Focused Assessment in Trauma will lead to more accurate diagnosis of pneumothorax and decreased false-positive exams.

Airway management is a foremost priority for combat medics treating battlefield casualties, as a compromised airway is the second leading cause of potentially survivable death on the battlefield, accounting for 1 in 10 preventable combat deaths. Effective suction is a critical component of airway clearance. However, currently available commercial devices are too heavy and bulky for combat medics to carry, and/or lack sufficient power to be useful. Clinical decision support systems (DSS) can close the gap between existing commercial devices and their clinical use and enhance combat medic clinical performance by providing the right "tooth-to-tail" tools to accomplish the task of clearing the airway. Our DSS approach will provide a focused, real-time set of guidelines and recommendations that are tailored to the combat medic. Our proposal will create a knowledge-based algorithm and clinical guideline regarding the use of suction, delivering to the combat medic the "right information, to the right person, in the right format, through the right channel at the right time."