Brooke Army Medical Center Research Articles

Rest and exercise hemodynamic and metabolic findings in active duty soldiers referred for cardiac catheterization to exclude heart disease: Insights from past invasive cardiopulmonary exercise testing using multisensor high fidelity catheters.

This study describes results of iCPET from the past, which used submaximal stress and multisensor high-fidelity catheters to exclude heart disease in a unique population of young adults. There has been resurgence in comprehensive hemodynamic evaluation of complex cardiovascular patients. Although dynamic assessments during cardiac catheterization have become commonplace, there remains limited information regarding left and right heart hemodynamic changes during supine exercise in young adults. The study population was derived from a retrospective review of catheterization records at Brooke Army Medical Center for active duty patients (ages: 19-40 years) in whom hemodynamic waveforms were obtained with multisensor high-fidelity catheters and supine exercise testing (53.1 ± 12.6 watts) and angiography performed to exclude heart disease. We report findings from 41 males and 1 female (ages: 19-40 years) found free of heart disease. Submaximal exercise was associated with ≈ fourfold (P < 0.001) increase in minute ventilation (VE), O2 consumption (VO2 ) and carbon dioxide production (VCO2 ). VE/VCO2 ratio decreased (-16.8 ± 13.9%, P < 0.001) and VE/VCO2 slope was 22.6 ± 0.6 (±SE). Cardiac index (CI) increased with VO2 (ΔCI/ΔVO2 slope = 7.6 ± 2.2). Heart rate increased nearly 10 bpm per 100 mL O2 /min/M2 , whereas, changes in stroke volume were more variable. Pulmonary artery (PA) saturations fell from 77 to 55% (P < 0.001). No change was noted in mean right atrial pressures; PA pressures increased ≈10 mm Hg (P < 0.001). Pulmonary capillary wedge and left ventricular end-diastolic pressures increased ≈2 mm Hg (P < 0.001) but variability noted between individuals. This study provides insight into past practices of invasive cardiopulmonary testing and furthers the understanding of metabolic and hemodynamic changes in a young population during supine submaximal exercise. © 2017 Wiley Periodicals, Inc.

Patient Response to an Integrated Orthotic and Rehabilitation Initiative for Traumatic Injuries: The PRIORITI-MTF Study.

Although limb salvage is now possible for many high-energy open fractures and crush injuries to the distal tibia, ankle, hindfoot, and midfoot, orthotic options are limited. The Intrepid Dynamic Exoskeletal Orthosis (IDEO) is a custom, energy-storing carbon fiber orthosis developed for trauma patients undergoing limb salvage. The IDEO differs from other orthoses in that it allows patients with ankle weakness to have more normal ankle biomechanics and increased ankle power. This article describes the design of a study to evaluate the effectiveness of the IDEO when delivered together with a high-intensity, sports medicine-based approach to rehabilitation. It builds on earlier studies by testing the program at military treatment facilities beyond the Brooke Army Medical Center and the Center for the Intrepid where the device was developed. The PRIORITI-MTF study is a multicenter before-after program evaluation where participants at least 1 year out from a traumatic lower extremity injury serve as their own controls. Participants are evaluated before receiving the IDEO, immediately after 4 weeks of physical therapy with the IDEO and at 6 and 12 months after the completion of physical therapy. Primary outcomes include functional performance, measured using well-validated assessments of speed, agility, power, and postural stability and self-reported functioning using the Short Musculoskeletal Function Assessment (SMFA) and the Veterans Health Survey (VR-12). Secondary outcomes include pain, depression, posttraumatic stress, and satisfaction with the IDEO.

Clonal distribution and associated characteristics of Escherichia coli clinical and surveillance isolates from a military medical center

Antimicrobial-resistant Escherichia coli are a concern for military health services. We studied 100 extended-spectrum beta-lactamase (ESBL)-producing and non-producing E. coli clinical and surveillance isolates from military personnel and civilians at Brooke Army Medical Center (2007–2011). Major E. coli lineages, most prominently ST10 (24%), ST131 (16%), and ST648 (8%), were distributed much as reported for other North American populations. ST131, represented mainly by its resistance-associated ST131-H30 clonal subset, was uniquely associated with a clinical origin, regardless of ESBL status. Thus, clonal background predicted resistance phenotype and clinical versus surveillance origin, and these findings could assist military clinicians and epidemiologists.

My Dad Can Beat Your Dad: Agonists, Antagonists, Partial Agonists, and Inverse Agonists.

Perspectives in Psychiatric CareVolume 53, Issue 2 p. 76-79 Column My Dad Can Beat Your Dad: Agonists, Antagonists, Partial Agonists, and Inverse Agonists Peter C. Kowalski MD, Peter C. Kowalski MD Peter C. Kowalski, MD, is a Child, Adolescent, and Adult Psychiatrist at the Behavioral Health Center of Eastern Idaho Regional Medical Center, Idaho Falls, Idaho, USASearch for more papers by this authorJonathan S. Dowben MD, Jonathan S. Dowben MD Jonathan S. Dowben, MD, is a Staff Psychiatrist, Child and Family, Behavioral Health Service, Brooke Army Medical Center (BAMC), Fort Sam Houston, Texas, USASearch for more papers by this authorNorman L. Keltner EdD, CRNP, Corresponding Author Norman L. Keltner EdD, CRNP normankeltner@gmail.com Norman L. Keltner, EdD, CRNP, is a Professor, School of Nursing (retired), University of Alabama at Birmingham, Birmingham, Alabama, USA Author contact: normankeltner@gmail.com, with a copy to the Editor: e426@twc.comSearch for more papers by this author Peter C. Kowalski MD, Peter C. Kowalski MD Peter C. Kowalski, MD, is a Child, Adolescent, and Adult Psychiatrist at the Behavioral Health Center of Eastern Idaho Regional Medical Center, Idaho Falls, Idaho, USASearch for more papers by this authorJonathan S. Dowben MD, Jonathan S. Dowben MD Jonathan S. Dowben, MD, is a Staff Psychiatrist, Child and Family, Behavioral Health Service, Brooke Army Medical Center (BAMC), Fort Sam Houston, Texas, USASearch for more papers by this authorNorman L. Keltner EdD, CRNP, Corresponding Author Norman L. Keltner EdD, CRNP normankeltner@gmail.com Norman L. Keltner, EdD, CRNP, is a Professor, School of Nursing (retired), University of Alabama at Birmingham, Birmingham, Alabama, USA Author contact: normankeltner@gmail.com, with a copy to the Editor: e426@twc.comSearch for more papers by this author First published: 16 January 2017 https://doi.org/10.1111/ppc.12208 Disclaimer: The views expressed in this article do not represent the views of Brooke Army Medical Center, U.S. Army, Department of Defense, or US government. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume53, Issue2April 2017Pages 76-79 RelatedInformation

Legal Blood Alcohol Testing in the U.S. Military.

To retrospectively analyze multiple years of legal blood alcohol test (LBAT) results as part of a laboratory process improvement plan. We analyzed the LBAT requests received by the Brooke Army Medical Center during calendar years 2013 and 2014. We received 365 samples from 11 installations; 351 were tested and 14 were rejected. Nearly one-third of the tested samples had negligible ethanol levels. One installation was responsible for submitting 10 rejected samples which prompted laboratory intervention. The ability to perform timely LBATs is invaluable to the Department of Defense as the results are more readily accepted in a court of law than routine clinical ethanol test results.

Hepatocellular Carcinoma in the Setting of Non-cirrhotic Nonalcoholic Fatty Liver Disease and the Metabolic Syndrome: US Experience.

Type 2 diabetes mellitus, obesity, and the metabolic syndrome (MS) have been growing in prevalence in the USA and are independent risk factors for the development of hepatocellular carcinoma (HCC). Nonalcoholic fatty liver disease (NAFLD), the hepatic manifestation of the MS, with or without nonalcoholic steatohepatitis (NASH) can predispose to HCC in the absence of cirrhosis or advanced fibrosis. Nevertheless, the US literature investigating non-cirrhotic HCC in the setting of NAFLD/NASH and MS is lacking. To describe a retrospective case series of patients who developed HCC without cirrhosis in the setting of NAFLD/NASH or features of the MS. We identified NAFLD/NASH-associated HCC cases arising in the absence of cirrhosis between January 2010 and September 2012 from a tumor board database at Brooke Army Medical Center (BAMC). Of 44 cases of HCC reviewed, six cases of non-cirrhotic HCC associated with NAFLD/NASH and/or MS were identified. Only one patient underwent partial hepatectomy with curative intent. The other five might have been candidates for potential curative partial hepatectomy or liver transplantation had they been diagnosed earlier. Our case series highlights the development of NAFLD/NASH and MS-associated HCC in the absence of cirrhosis in the US population and raises the important question of HCC screening for this at-risk group.

Editorial introductions

Current Opinion in Infectious Diseases was launched in 1988. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of infectious diseases is divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Paul T. HeathPaul T. HeathPaul T. Heath is a Professor and Honorary Consultant in Paediatric Infectious Diseases at St George's, University of London, UK, and St George's Vaccine Institute in London, UK. His training in paediatrics and infectious diseases was at the Royal Children's Hospital, Melbourne, Australia, the John Radcliffe Hospital, Oxford, UK, and St George's Hospital, London, UK. His particular research interests are in: the epidemiology of vaccine preventable diseases, clinical vaccine trials (particularly in at-risk groups), and in perinatal infections. He has published over 150 original or review papers in these areas. He sits on national committees concerned with neonatal infections, meningitis, group B streptococcus prevention, and on immunisation policies in children. He is a Fellow of the Royal Australasian College of Physicians, a Fellow of the Royal College of Paediatrics and Child Health, a member of the research committee of the European Society of Paediatric Infectious Diseases and a member of the Science Board of the international Brighton Collaboration on vaccine safety. Dennis L. StevensDennis L. StevensDr Stevens received his PhD in Microbiology from Montana State University, USA, and his MD from the University of Utah College of Medicine, USA. Following a residency in internal medicine at the University of Utah, Dr Stevens completed an infectious disease fellowship at Brooke Army Medical Center in San Antonio, Texas, USA. Since 1979 he has been Chief of Infectious Diseases at the Veterans Affairs Medical Center in Boise, Idaho, USA. Dr Stevens is Professor of Medicine at the University of Washington School of Medicine, USA, and his major clinical interests have been in Staphylococcal and Streptococcal toxic shock syndromes and in skin and soft tissue infections, including necrotizing fasciitis and gas gangrene. His research interests are centered around gram positive bacteria and the role of extracellular toxins in the pathogenesis of severe soft tissue infection caused by Streptococcus pyogenes, Clostridium perfringens, and methicillin-resistant Staphylococcus aureus. His current research efforts investigate the mechanisms of toxin induced shock and organ dysfunction, including cardiomyopathy, the effects of toxins on endothelial cells, granulocytes, and platelets, and the importance of the mechanisms of action of antibiotics in treating gram positive infections. Dr Stevens has published over 170 original research papers, 89 book chapters, 143 abstracts and three books: Streptococcal Infections: Clinical Aspects, Microbiology and Molecular Pathogenesis (co-authored with Dr Edward Kaplan), An Atlas of Infectious Diseases: Skin and Soft Tissue, Bone and Joint Infections and Netter's Textbook of Infectious Diseases (co- authored with Dr Elaine Jong). Dr Stevens is a member of the American Society of Microbiology, a Fellow in the American College of Physicians, a Fellow in the Infectious Disease Society of America and a member of the Association of American Physicians. In 2000, Dr Stevens received the Infectious Disease Society of America's Society Citation Award and in 2001 The William Altemier Award from the Surgical Infectious Disease Society. Dr Stevens has served as a consultant for the CDC Working Group on Invasive Group A streptococcal infections and for the WHO and NIH on similar matters. Dr Stevens is currently Chairman of the Infectious Disease Society of America Guidelines Committee on Skin and Soft Tissue Infections.

Ceruloplasmin and Hypoferremia: Studies in Burn and Non-Burn Trauma Patients.

Objective: Normal iron handling appears to be disrupted in critically ill patients leading to hypoferremia that may contribute to systemic inflammation. Ceruloplasmin (Cp), an acute phase reactant protein that can convert ferrous iron to its less reactive ferric form facilitating binding to ferritin, has ferroxidase activity that is important to iron handling. Genetic absence of Cp decreases iron export resulting in iron accumulation in many organs. The objective of this study was to characterize iron metabolism and Cp activity in burn and non-burn trauma patients to determine if changes in Cp activity are a potential contributor to the observed hypoferremia. Material and Methods: Under Brooke Army Medical Center Institutional Review Board approved protocols, serum or plasma was collected from burn and non-burn trauma patients on admission to the ICU and at times up to 14 days and measured for indices of iron status, Cp protein and oxidase activity and cytokines. Results: Burn patients showed evidence of anemia and normal or elevated ferritin levels. Plasma Cp oxidase activity in burn and trauma patients were markedly lower than controls on admission and increased to control levels by day 3, particularly in burn patients. Plasma cytokines were elevated throughout the 14 days study along with evidence of an oxidative stress. No significant differences in soluble transferrin receptor were noted among groups on admission, but levels in burn patients were lower than controls for the first 5 days after injury. Conclusion: This study further established the hypoferremia and inflammation associated with burns and trauma. To our knowledge, this is the first study to show an early decrease in Cp oxidase activity in burn and non-burn trauma patients. The results support the hypothesis that transient loss of Cp activity contributes to hypoferremia and inflammation. Further studies are warranted to determine if decreased Cp activity increases the risk of iron-induced injury following therapeutic interventions such as transfusions with blood that has undergone prolonged storage in trauma resuscitation.

Prehospital and en route analgesic use in the combat setting: a prospectively designed, multicenter, observational study.

Combat injuries result in acute, severe pain. Early use of analgesia after injury is known to be beneficial. Studies on prehospital analgesia in combat are limited and no prospectively designed study has reported the use of analgesics in the prehospital and en route care setting. Our objective was to describe the current use of prehospital analgesia in the combat setting. This prospectively designed, multicenter, observational, prehospital combat study was undertaken at medical treatment facilities (MTF) in Afghanistan between October 2012 and September 2013. It formed part of a larger study aimed at describing the use of lifesaving interventions in combat. On arrival at the MTF, trained on-site investigators enrolled eligible patients and completed standardized data capture forms, which included the name, dose, and route of administration of all prehospital analgesics, and the type of provider who administered the drug. Physiological data were retrospectively ascribed as soon as practicable. The study was prospectively approved by the Brooke Army Medical Center institutional review board. Data were collected on 228 patients, with 305 analgesia administrations recorded. The predominant mechanism of injury was blast (50%), followed by penetrating (41%), and blunt (9%). The most common analgesic used was ketamine, followed by morphine. A combination of analgesics was given to 29% of patients; the most common combination was ketamine and morphine. Intravenous delivery was the most commonly used route (55%). Patients transported by the UK Medical Emergency Response Team (MERT) or U.S. Air Medical Evacuation (Dust-off) team were more likely to receive ketamine than those evacuated by U.S. Pararescue Jumpers (Pedro). Patients transported by Medical Emergency Response Team or Pedro were more likely to receive more than 1 drug. Patients who received only ketamine had a higher pulse rate (p<0.005) and lower systolic blood pressure (p=0.01) than other groups, and patients that received hydromorphone had a lower respiratory rate (p=0.04). In our prospectively designed, multicenter, observational, prehospital combat study, ketamine was the most commonly used analgesic drug. The most frequently observed combination of drugs was ketamine and morphine. The intravenous route was used for 55% of drug administrations.

A Comprehensive Cardiovascular Preventive Clinic: Is it a Concept that is Possible to Implement in the Military System?

Cardiovascular disease has a huge impact on our society and the individuals affected. According to the most recent data published by American Heart Association (2014 Update), Coronary heart disease alone caused about 1 in 6 deaths in the United States in 2010. In 2010, the senior author attempted to explore the concept of truly comprehensive cardiovascular preventive clinics with goal driven protocols and operated by mid-level providers with different backgrounds from clinical pharmacy to advanced nurse practitioners. The concept, design and implementation of the Preventive Cardiology Clinic at Brooke Army Medical Center using a multi-disciplinary approach with evidence based protocols and standard operating procedures in a patient-centered design enhanced patient participation and optimized success in preventive care in a high-risk population. The Preventive Cardiology Clinic resulted in improved identification and screening of cardiovascular patients at risk, improved implementation of preventive therapies and achievement of target goals, significantly affected tobacco cessation success rates that surpasses nationally reported success rates, and improved quality of life. We feel this concept could be easily replicated using existing resources in most military and other medical treatment facilities

Editorial introductions

Current Opinion in Infectious Diseases was launched in 1988. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of infectious diseases is divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Paul T. HeathPaul T. HeathPaul T. Heath is a Professor and Honorary Consultant in Paediatric Infectious Diseases at St George's, University of London and Vaccine Institute in London, UK. His training in paediatrics and infectious diseases was at the Royal Children's Hospital, Melbourne, Australia, the John Radcliffe Hospital, Oxford, UK and St George's Hospital, London, UK. His particular research interests are in the epidemiology of vaccine preventable diseases, in clinical vaccine trials, particularly in at-risk groups, and in perinatal infections and he has published over 150 original or review papers in these areas. He sits on national committees concerned with neonatal infections, meningitis, group B streptococcus prevention and on immunisation policies in children. He is a Fellow of the Royal Australasian College of Physicians, a Fellow of the Royal College of Paediatrics and Child Health, a member of the research committee of the European Society of Paediatric Infectious Diseases and a member of the Science Board of the international Brighton Collaboration on vaccine safety. Dennis L. StevensDennis L. StevensDr Stevens received his PhD in Microbiology from Montana State University, USA and his MD from the University of Utah College of Medicine, USA. Following a residency in internal medicine at the University of Utah, Dr Stevens completed an infectious disease fellowship at Brooke Army Medical Center in San Antonio, Texas, USA and has been Chief of Infectious Diseases at the Veterans Affairs Medical Center in Boise, Idaho, USA, since 1979. Dr Stevens is Professor of Medicine at the University of Washington School of Medicine, USA and his major clinical interests have been in Staphylococcal and Streptococcal toxic shock syndromes and in skin and soft tissue infections including necrotizing fasciitis and gas gangrene. His research interests are centered around gram positive bacteria and the role of extracellular toxins in the pathogenesis of severe soft tissue infection caused by Streptococcus pyogenes, Clostridium perfringens and methicillin-resistant Staphylococcus aureus. Current research efforts investigate the mechanisms of toxin induced shock and organ dysfunction including cardiomyopathy, the effects of toxins on endothelial cells, granulocytes and platelets and the importance of the mechanisms of action of antibiotics in treating gram positive infections. Dr Stevens has published over 170 original research papers, 89 book chapters, 143 abstracts and three books, Streptococcal Infections: Clinical Aspects, Microbiology and Molecular Pathogenesis (co-authored with Dr. Edward Kaplan), An Atlas of Infectious Diseases: Skin and Soft Tissue, Bone and Joint Infections and Netter's Textbook of Infectious Diseases (co- authored with Dr. Elaine Jong). Dr Stevens is a member of the American Society of Microbiology, a Fellow in the American College of Physicians, a Fellow in the Infectious Disease Society of America and a member of the Association of American Physicians. In 2000, Dr Stevens received the Infectious Disease Society of America's Society Citation Award and in 2001, The William Altemier Award from the Surgical Infectious Disease Society. Dr Stevens has served as a consultant for the CDC Working Group on Invasive Group A streptococcal infections and for the WHO and NIH on similar matters. Dr Stevens is currently Chairman of the Infectious Disease Society of America Guidelines Committee on Skin and Soft Tissue Infections.

The Face of the Spine

Dr. Dieckman is Staff Radiologist, Keesler Air Force Base, Biloxi, Mississippi; and Dr. Bui-Mansfield is Chief, Musculoskeletal Radiology Section, Department of Radiology, Brooke Army Medical Center, Fort Sam Houston, Texas, and Associate Professor, Department of Radiology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814; E-mail: [email protected]. After participating in this activity, the diagnostic radiologist should be better able to identify the anatomical landmarks that make up the face of the spine on an AP radiograph, and furthermore develop a systematic approach to the radiographic interpretation of the thoracolumbar spine, aided by the acronym “ABCS.” The authors and all staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no relationships with, or financial interests in, any commercial organizations pertaining to this educational activity. The opinions and assertions contained herein are those of the authors and should not be construed as official or as representing the opinions of the Department of the Army, Department of the Air Force, or the Department of Defense. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This continuing medical education activity expires on June 20, 2014.

Energy Expenditure in Acute Posttraumatic Amputation

Adequate energy intake is a component of successful recovery after injury, yet little is known about the energy requirements in the acute period following traumatic amputation. The purpose of this study was to compare the clinical applicability of resting energy expenditure (REE) measured by a handheld calorimeter and estimated by 3 different predictive equations to that measured by the gold standard, indirect calorimetry using a metabolic cart, during the acute postamputation period of inpatient hospitalization. Indirect calorimetry measured using both a metabolic cart and handheld calorimeter and predicted by 3 equations were used to assess energy needs of eligible subjects admitted to Brooke Army Medical Center with traumatic amputation(s). REE measured by the handheld calorimeter and estimated using 3 predictive equations (Mifflin St. Jeor, Ireton-Jones 1992, and the American College of Chest Physicians [ACCP]) were compared to the gold standard metabolic cart. Each measure was assessed for significant differences and level of clinical acceptability defined as ± 10% REE by metabolic cart. Thirteen male service members with traumatic amputation(s) were included. The majority of subject's measurements using the handheld calorimeter (n = 9, 69%) and 3 predictive equations (Mifflin St. Jeor [n = 7, 54%], Ireton-Jones 1992 [n = 8, 62%], ACCP [n = 7, 54%]) fell outside of the ± 10% range of clinical acceptability. Use of the metabolic cart for measuring energy needs remains optimal in this population.

Prevalence of Supranormal Pulmonary Function Test Values Between a Military and Nonmilitary Cohort

The study objective was to determine differences in the proportion of supranormal pulmonary function tests (PFTs) between active duty (AD) military personnel and a similar non-active duty (non-AD) population. Given the emphasis on cardiovascular fitness in the military, it has been hypothesized that regular exercise in this cohort leads to an increased proportion of supranormal PFTs. We hypothesized that a comparison of PFTs would identify no differences in the ratio of supranormal to normal PFTs between the AD and non-AD populations. A retrospective chart review was conducted of all PFT studies at the Brooke Army Medical Center from 2006 to 2011. Studies were included with either an FVC or FEV1 > 110% of predicted, with both values > 100% of predicted. A comparative analysis was performed for patients between 18 and 50 years of age based on AD status. Further analysis was performed on all ages to determine the distribution of supranormal findings in the entire study population. A total of 16,600 interpreted PFTs were queried. Of those, 4,303 (31.6%) were AD patients, and 9,306 (68.4%) were non-AD patients. From all of the PFTs reviewed, a total of 912 (6.7%) were identified as supranormal. When further analyzed, 381 (9.4%) of AD patients 18-50 years old were supranormal, 175 (12.4%) of non-AD patients 18-50 years old were supranormal, and 356 (4.7%) of non-AD patients older than 50 years were supranormal. This study revealed no significant difference in the proportion of supranormal-to-normal PFTs in an AD versus non-AD duty population of the same age range. Based on these findings, no assumption should be made that supranormal PFTs are more common in military personnel. Interpretation of normal PFTs in AD personnel undergoing evaluation should not differ from that in any typical patient.

Editorial introductions

Current Opinion in Infectious Diseases was launched in 1988. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of infectious diseases is divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Paul T. HeathPaul T. HeathPaul Heath is a Professor and Honorary Consultant in Paediatric Infectious Diseases at St George's, University of London and Vaccine Institute in London, UK. His training in paediatrics and infectious diseases was at the Royal Children's Hospital, Melbourne, Australia, the John Radcliffe Hospital, Oxford, UK and St George's Hospital, London, UK. His particular research interests are in the epidemiology of vaccine preventable diseases, in clinical vaccine trials, particularly in at-risk groups, and in perinatal infections. He sits on national committees concerned with meningitis, group B streptococcus prevention and on immunisation policies in children. He is a Fellow of the Royal Australasian College of Physicians, a Fellow of the Royal College of Paediatrics and Child Health, a member of the education committee of the European Society of Paediatric Infectious Diseases and a member of the Science Board of the international Brighton Collaboration on vaccine safety. Dennis L. StevensDennis L. StevensDr Stevens received his PhD in Microbiology from Montana State University, USA and his MD from the University of Utah College of Medicine, USA. Following a residency in internal medicine at the University of Utah, Dr Stevens completed an infectious disease fellowship at Brooke Army Medical Center in San Antonio, Texas, USA and has been Chief of Infectious Diseases at the Veterans Affairs Medical Center in Boise, Idaho, USA, since 1979. Dr Stevens is Professor of Medicine at the University of Washington School of Medicine, USA and his major clinical interests have been in Staphylococcal and Streptococcal toxic shock syndromes and in skin and soft tissue infections including necrotizing fasciitis and gas gangrene. His research interests are centered around gram positive bacteria and the role of extracellular toxins in the pathogenesis of severe soft tissue infection caused by Streptococcus pyogenes, Clostridium perfringens and methicillin-resistant Staphylococcus aureus. Current research efforts investigate the mechanisms of toxin induced shock and organ dysfunction, the effects of toxins on endothelial cells, granulocytes and platelets and the importance of the mechanisms of action of antibiotics in treating gram positive infections. Dr Stevens has published over 150 original research papers, 60 book chapters, 110 abstracts and two books, Streptococcal Infections: Clinical Aspects, Microbiology and Molecular Pathogenesis (co-authored with Dr. Edward Kaplan) and An Atlas of Infectious Diseases: Skin and Soft Tissue, Bone and Joint Infections. Dr Stevens is a member of the American Society of Microbiology, a Fellow in the American College of Physicians, a Fellow in the Infectious Disease Society of America and a member of the Association of American Physicians. In 2000, Dr Stevens received the Infectious Disease Society of America's Society Citation Award and in 2001, The William Altemier Award from the Surgical Infectious Disease Society. Dr Stevens has served as a consultant for the Centers of Disease Control and PreventionWorking Group on Invasive Group A streptococcal infections and for the World Health Organization and National Institutes of Health on similar matters. Dr Stevens is currently Chairman of the Infectious Disease Society of America Guidelines Committee on Skin and Soft Tissue Infections.

Biofilm formation by clinical isolates and the implications in chronic infections

BackgroundBiofilm formation is a major virulence factor contributing to the chronicity of infections. To date few studies have evaluated biofilm formation in infecting isolates of patients including both Gram-positive and Gram-negative multidrug-resistant (MDR) species in the context of numerous types of infectious syndromes. Herein, we investigated the biofilm forming capacity in a large collection of single patient infecting isolates and compared the relationship between biofilm formation to various strain characteristics.MethodsThe biofilm-forming capacity of 205 randomly sampled clinical isolates from patients, collected from various anatomical sites, admitted for treatment at Brooke Army Medical Center (BAMC) from 2004–2011, including methicillin-resistant/methicillin susceptible Staphylococcus aureus (MRSA/MSSA) (n=23), Acinetobacter baumannii (n=53), Pseudomonas aeruginosa (n=36), Klebsiella pneumoniae (n=54), and Escherichia coli (n=39), were evaluated for biofilm formation using the high-throughput microtiter plate assay and scanning electron microscopy (SEM). Relationships between biofilm formation to clonal type, site of isolate collection, and MDR phenotype were evaluated. Furthermore, in patients with relapsing infections, serial strains were assessed for their ability to form biofilms in vitro.ResultsOf the 205 clinical isolates tested, 126 strains (61.4%) were observed to form biofilms in vitro at levels greater than or equal to the Staphylococcus epidermidis, positive biofilm producing strain, with P. aeruginosa and S. aureus having the greatest number of biofilm producing strains. Biofilm formation was significantly associated with specific clonal types, the site of isolate collection, and strains positive for biofilm formation were more frequently observed to be MDR. In patients with relapsing infections, the majority of serial isolates recovered from these individuals were observed to be strong biofilm producers in vitro.ConclusionsThis study is the first to evaluate biofilm formation in a large collection of infecting clinical isolates representing diverse types of infections. Our results demonstrate: (1) biofilm formation is a heterogeneous property amongst clinical strains which is associated with certain clonal types, (2) biofilm forming strains are more frequently isolated from non-fluid tissues, in particular bone and soft tissues, (3) MDR pathogens are more often biofilm formers, and (4) strains from patients with persistent infections are positive for biofilm formation.

Implementing outcome measures—The military physical therapist’s perspective

Outcome measures are a necessary part of rehabilitation. Various methods and measures have been used to assess patient progress and as criteria for discharge from inpatient care, routine outpatient care, and long-term rehabilitation in a variety of patient populations for many years. In the sports medicine setting, outcome measures become especially important in determining when injured athletes are able to return to the playing field. In a military setting, similar to sports medicine, the use of outcome measures is necessary to help determine when the patient is able to return to duty or deploy. In the case of servicemembers with traumatic limb loss, the ultimate goal for many is to return to Active Duty as a tactical athlete and member of today's Army, Navy, Air Force, Marine Corps, or Coast Guard. Determining the functional level and ability to meet the demands they may face is a challenge for the military healthcare system (MHCS) and more specifically for the providers rehabilitating servicemembers with major limb loss. The Armed Forces Amputee Patient Care Program is composed of three distinct centers: the Military Advanced Training Center (MATC) located at Walter Reed National Medical Center, the Center for the Intrepid (CFI) at Brooke Army Medical Center, and the Comprehensive Combat and Complex Casualty Care (C5) program center at the Naval Medical Center San Diego. Physical therapists caring for servicemembers with amputation at all three centers are particularly invested in making sure that the outcome measures we use systematically are appropriate. One of the challenges we faced early on was that most of the outcome measures used for people with amputation did not adequately measure the higher level of that servicemembers with amputation need to return to duty. The majority of combat-related amputations occur in relatively healthy males under the age of 35, a very different population from the civilian population with amputation, in which the vast majority are older and have comorbidities such as diabetes mellitus, peripheral vascular disease, and cardiovascular conditions. The outcome measures used in the civilian amputee population suffer from a ceiling effect when used to assess the typical young, physically active servicemember with amputation. A new paradigm and approach to testing high-level in people with amputation was needed for use in the military environment. In practice, there are already many sophisticated and instrumented outcome measures in use in the Armed Forces Amputee Patient Care Program. These measures include those obtained in the motion analysis/gait laboratories and the Computer Assisted Rehabilitation Environment virtual reality (VR) systems. Motion analysis is a proven technology, and the use of VR with patients with amputation appears to be useful in both patient treatment and research activities. The benefit to the patients in both of these systems is the real-time feedback they receive relative to weight bearing, lateral weight shifting, agility, pelvic obliquity, and shoulder symmetry. The learning that occurs with regard to agility, base of support, center of gravity, and proprioception is hidden underneath the facade of a video game. Biomechanical testing provides very detailed information on kinetics and kinematics of motion, but requires sophisticated equipment and expertise. These systems do not provide a relatively easy-to-administer test that culminates in a usable summary of abilities similar to the Amputee Mobility Predictor. Self-report measures can be used and are easier to administer than either biomechanical testing or performance-based tests. However, self-report measures, while they can be useful, are generally not strongly associated with actual performance-based measures. Many researchers feel that self-report measures alone do not adequately assess the broad concept of function and that performance-based measures are needed to capture the whole picture. …

Characterization of Midface Fractures Incurred in Recent Wars

Facial injuries sustained by US military personnel during the wars in Iraq and Afghanistan have increased compared with past conflicts. Characterization of midface fractures (orbits, maxilla, zygoma, and nasal bones) sustained on the battlefield is needed to improve our understanding of these injuries, to optimize treatment, and to potentially direct strategic development of protective equipment in the future. The military's Joint Theater Trauma Registry was queried for midface fractures from 2001 to 2011 using International Classification of Diseases, Ninth Revision diagnosis codes. Stratification was then performed, and individual treatment records from Brooke Army Medical Center were reviewed. Analysis of the fracture pattern, treatment, and complications was performed. One thousand seven hundred sixty individuals with midface fractures were identified. Those fractures sustained in battle were characterized by a predominance of open fractures, blast etiology, and associated injuries. Detailed record reviews of the patients treated at our institution revealed 45% of all midface fractures as operative. Thirty-one percent of these were treated at levels III and IV facilities outside the continental United States before arrival at our institution. Patients with midface fractures underwent multiple operations. There was a 30% rate of complication among operative fractures characterized by malalignment, implant exposure, and infection. Midface battle injuries also had a high incidence of orbital fractures and severe globe injuries. Midface fractures sustained in the battlefield have a high complication rate, likely as a result of the blast mechanism of injury with associated open fractures, multiple fractures, and associated injuries. These cases present unique challenges, often requiring both soft tissue and skeletal reconstruction.

Cardiovascular Disease and Nonalcoholic Fatty Liver Disease

We aimed to investigate the prevalence of cardiovascular disease in patients with nonalcoholic steatohepatitis (NASH) versus non-NASH fatty liver. Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular disease, which is a leading cause of death in this patient population. NASH is a subset of NAFLD that carries a higher risk of progression to cirrhosis and its associated complications. We conducted a retrospective chart review of patients with biopsy-confirmed NAFLD, including NASH and non-NASH fatty liver, within the Gastroenterology and Hepatology clinic at Brooke Army Medical Center. Patients with secondary causes of chronic liver disease were excluded. The patients' records were reviewed for the presence of significant cardiovascular disease, which was defined as a history of stroke, unstable angina, myocardial infarction, congestive heart failure, or need for revascularization. Nine hundred thirteen patients were identified and 377 patients met inclusion and exclusion criteria and were included in the final analysis. Of these, 219 patients had biopsies showing the presence of at least grade I NASH. The overall prevalence of cardiovascular disease was 6.63%. After controlling for age, sex, body mass index, and the presence of diabetes, there was no significant increase in the prevalence of cardiovascular disease in the NASH cohort over the non-NASH group. Cardiovascular disease is common among patients with NAFLD. However, no increased risk of cardiovascular disease was found among those patients with NASH as compared with those with non-NASH fatty liver.

Biological Perspectives: Remember the Thyroid

Biological Perspectives: Remember the Thyroid