Military surgeon最新文献

Excessive gaming may be associated with sleep deprivation and self-harm. One active duty member committed self-injurious behavior to avoid work-related consequences. It was discovered that the patient participated in a video-gaming binge throughout an entire 72-hour weekend liberty. The patient experienced severe sleep deprivation to the point where he overslept and failed to report to work. He injured himself and fabricated a robbery and assault to avoid disciplinary consequences. Military health care providers should consider excessive gaming in patients presenting with sleep issues, self-harm, and disciplinary problems. As the prevalence of gaming increases, the military leadership should be aware that excessive gaming can degrade force readiness.

Background: Artemisinin and its derivatives have potential antidiabetic effects. There is no evaluation of reported studies in the literature on the treatment of diabetic nephropathy (DN), one of the commonest diabetic microangiopathies, with artemisinins. Here, we aimed to evaluate preclinical evidence for the efficacy and possible mechanisms of artemisinins in reducing diabetic renal injury.

Methods: We conducted an electronic literature search in fourteen databases from their inception to November 2021. All animal studies assessing the efficacy and safety of artemisinins in DN were included, regardless of publication or language. Overall, 178 articles were screened according to predefined inclusion and exclusion criteria. Finally, 18 eligible articles were included in this systematic review. The SYstematic Review Center for Laboratory animal Experimentation (SYRCLE) risk-of-bias tool was used to assess the risk of bias in the included studies. The primary outcomes were kidney function, proteinuria, and renal pathology. Secondary endpoints included changes in fasting plasma glucose (FPG) levels, body weight, and relevant mechanisms.

Results: Of the 18 included articles involving 418 animal models of DN, 1, 2, 6, and 9 used dihydroartemisinin, artemether, artesunate, and artemisinin, respectively. Overall, artemisinins reduced indicators of renal function, including blood urea nitrogen (P < 0.00001), serum creatinine (P < 0.00001), and kidney index (P = 0.0001) compared with control group treatment. Measurements of proteinuria (P < 0.00001), microalbuminuria (P < 0.05), and protein excretion (P = 0.0002) suggested that treatment with artemisinins reduced protein loss in animals with DN. Artemisinins may lower blood glucose levels (P = 0.01), but there is a risk of weight gain (P < 0.00001). Possible mechanisms of action of artemisinins include delaying renal fibrosis, reducing oxidative stress, and exerting antiapoptotic and anti-inflammatory effects.

Conclusion: Available evidence suggests that artemisinins may be protective against renal injury secondary to diabetes in preclinical studies; however, high-quality and long-term trials are needed to reliably determine the balance of benefits and harms.

Objectives: To evaluate facility postoperative opioid prescribing patterns in comparison to published guidelines and adherence to opioid safety mandates.

Methods: This quality analysis was performed between November 2019 and March 2020. Patients were identified to have been opioid naïve prior to receiving a new opioid prescription postoperatively during the study period. Patient charts were reviewed, and patients were contacted to collect desired data. Statistical analysis was performed to evaluate distributions of morphine equivalent daily dose and opioid day supply prescribed across study subpopulations.

Results: Ninety-four of 100 prescriptions evaluated were determined to be within quantity or duration recommendations of the selected guideline. Statistical analysis found no significantly different distributions between the duration and quantity of opioid prescribed at discharge and patient-specific risk factors. Forty-eight patients did not use the entire quantity of the initial opioid prescription dispensed. Of those patients, 26 still had opioids within the home. Opioid risk review documentation was completed in 19 of 65 patients indicated for documentation.

Conclusion: Most opioid prescriptions provided within the study period aligned with recommendations from author-selected guidelines. However, a review of risk prior to opioid prescribing frequently was not performed. The number of patients utilizing less than 50% of prescribed opioids, and few refills indicate that reductions in opioids prescribed would improve safety for both patients and the surrounding community without increasing the risk for the under-treatment of postoperative pain. Improved prescribing habits and patient safety will be targeted through provider education regarding risk review documentation in opioid naïve patients.

Introduction: Modeling of injury risk from nonlethal weapons including flash-bangs is a critical step in the design, acquisition, and application of such devices for military purposes. One flash-bang design concept currently being developed involves multiple, area-distributed flash-bangs. It is particularly difficult to model the variation inherent in operational settings employing such devices due to the randomness of flash-bang detonation positioning relative to targets. The problem is exacerbated by uncertainty related to changes in the mechanical properties of auditory system tissues and contraction of muscles in the middle ear (the acoustic reflex), which can both immediately follow impulse-noise exposure. In this article, we demonstrate a methodology to quantify uncertainty in injury risk estimation related to exposure to multiple area-distributed flash-bang impulses in short periods of time and analyze the effects of factors such as the number of impulses, their spatial distribution, and the uncertainties in their parameters on estimated injury risk.

Materials and methods: We conducted Monte Carlo simulations of dispersion and timing of a mortar-and-submunition flash-bang device that distributes submunitions over an area, using the Auditory 4.5 model developed by L3 Applied Technologies to estimate the risk of hearing loss (permanent threshold shift) in an exposure area. We bound injury risk estimates by applying limiting assumptions for dose accumulation rules applied to short inter-pulse intervals and varied impulse-noise-intensity exposure characteristic of multi-impulse flash-bangs. The upper bound of risk assumes no trading of risk between the number of impulses and intensity of individual impulses, while the lower bound assumes a perfectly protective acoustic reflex.

Results: In general, the risk to individuals standing in the most hazardous zone of the simulation is quite sensitive to the pattern of submunitions, relative to the sensitivity for those standing farther from that zone. Larger mortar burst radii (distributing submunitions over a wider area) reduce expected peak risk, while increasing the number of submunitions, the intensity of individual impulses, or the uncertainty in impulse intensity increases expected risk. We find that injury risk calculations must factor in device output variation because the injury risk curve in the flash-bang dose regime is asymmetric. We also find that increased numbers of submunitions increase the peak risk in an area more rapidly than scene-averaged risk and that the uncertainty related to dose accumulation in the acoustic reflex regime can be substantial for large numbers of submunitions and should not be ignored.

Conclusions: This work provides a methodology for exploring both the role of device parameters and the choice of dose accumulation rule in estimating the risk of significant injury and associa

Shortness of breath is an important complaint in the austere setting with a broad differential diagnosis. The difficulty of deployed patient movement and lack of diagnostic testing at treatment sites complicates its evaluation. This case highlights a young Soldier presenting with shortness of breath caused by a Morgagni hernia. A 25-year-old deployed male presented with a 1-month history of dyspnea with exertion and right-sided chest tightness. After initial diagnoses of bronchitis, later chest radiographs demonstrated a linear opacity in the right middle lobe (RML). The patient was transferred to a higher level of care where a chest computer tomography scan was consistent with Morgagni hernia. Morgagni hernias can present with a wide variety of clinical complaints, including gastrointestinal symptoms, dyspnea, and chest pain. A lack of familiarity among providers who care for adults and the nonspecific nature of the symptoms frequently cause a diagnostic delay in diagnosis. CXR is helpful in this diagnosis, although this case demonstrates that this hernia may appear similar to RML atelectasis or pneumonia.6 Computed tomography remains the modality of choice to confirm the diagnosis, as well as provide anatomical details and rule out complications. While most experts agree that Morgagni hernias should be surgically repaired, the optimal surgical technique remains uncertain.3 Despite its rarity, Morgagni hernia is important to consider in a broad range of clinical presentations. Its nonspecific symptoms, combined with radiographs that can mimic other disease entities, can lead to a delay in diagnosis, mistreatment, prolonged patient suffering, and complications.

Introduction: Treatment outcomes for PTSD with current psychological therapies are poor, with very few patients achieving sustained symptom remission. A number of authors have identified physiological and immune disturbances in Post Traumatic Stress Disorder (PTSD) patients, but there is no unifying hypothesis that explains the myriad features of the disorder.

Materials and methods: The medical literature was reviewed over a 6-year period primarily using the medical database PUBMED.

Results: The literature contains numerous papers that have identified a range of physiological and immune dysfunction in association with PTSD. This paper proposes that unrestrained cytokine signaling induces epigenetic changes that promote an evolutionary survival adaptation, which maintains a defensive PTSD phenotype. The brain can associate immune signaling with past threat and initiate a defensive behavioral response. The sympathetic nervous system is pro-inflammatory, while the parasympathetic nervous system is anti-inflammatory. Prolonged cholinergic withdrawal will promote a chronic inflammatory state. The innate immune cytokine IL-1β has pleiotropic properties and can regulate autonomic, glucocorticoid, and glutamate receptor functions, sleep, memory, and epigenetic enzymes. Changes in epigenetic enzyme activity can potentially alter phenotype and induce an adaptation. Levels of IL-1β correlate with severity and duration of PTSD and PTSD can be prevented by bolus administration of hydrocortisone in acute sepsis, consistent with unrestrained inflammation being a risk factor for PTSD. The nervous and immune systems engage in crosstalk, governed by common receptors. The benefits of currently used psychiatric medication may arise from immune, as well as synaptic, modulation. The psychedelic drugs (3,4-Methylenedioxymethamphetamine (MDMA), psilocybin, and ketamine) have potent immunosuppressive and anti-inflammatory effects on the adaptive immune system, which may contribute to their reported benefit in PTSD. There may be distinct PTSD phenotypes induced by innate and adaptive cytokine signaling.

Conclusion: In order for an organism to survive, it must adapt to its environment. Cytokines signal danger to the brain and can induce epigenetic changes that result in a persistent defensive phenotype. PTSD may be the price individuals pay for the genomic flexibility that promotes adaptation and survival.

Introduction: The beneficial effect of rivastigmine, an acetylcholinesterase inhibitor (AChEi), which increases levels of acetylcholine (ACh), was first reported in 2013. This paper replicates those findings and reports sustained symptom remission.

Methods and materials: The high-frequency (HF) component of heart rate variability (HRV) is a measure of cholinergic withdrawal and was measured using a Zephyr Bioharness HR monitor, pre- and post-commencement of treatment. Data analysis was performed using Kubios HRV software. PTSD symptom severity was assessed using the Post-Traumatic Checklist-Civilian (PCL-C).

Results: Low HF HRV was observed in both patients before rivastigmine treatment and reductions in PCL-C scores paralleled increases in HF HRV values. Follow-up revealed low HF HRV values in both patients despite PCL-C scores indicating remission. Sympathetic nervous system hyperactivity was observed in one patient, just before a suicide attempt. Following rivastigmine treatment, the patient had no further suicidal ideation or attempts. Another patient reported worsening of her PTSD symptoms in the peri-menstrual period, which was abolished by rivastigmine. She also experienced symptom relapse following prolonged infections.

Conclusion: Low HF HRV has been reported in PTSD patients, but findings have been inconsistent. Cholinergic withdrawal could explain the disturbances in sleep, learning, and memory seen in PTSD patients. The relapse of symptoms following prolonged infection implicates the immune system as a possible initiator of the disorder. ACh and estrogen have anti-inflammatory properties, supporting a possible role of inflammation in initiating PTSD. The effect of rivastigmine treatment should be tested in properly controlled clinical trials.