Walter Reed Army Medical Center Research Articles

1171. Epidemiology of Old World Cutaneous Leishmaniasis among Members of the U.S. Military

Abstract Background Cutaneous leishmaniasis (CL) is a threat to U.S. Military personnel as they deploy to endemic areas. As treatment may require evacuation, CL undermines operations. Elucidating the epidemiology of CL in this population is key for prevention. Methods We retrospectively reviewed data from a CL sodium stibogluconate treatment trial at Walter Reed Army Medical Center, Washington DC. 412 military members with parasitologically confirmed CL and deployment to Southwest Asia from May 2002 - August 2004 enrolled. Subjects’ CL lesions were counted and measured. 334 subjects completed a risk survey. Given no control group, we used number of CL lesions (NL), total lesion area (TLA), and lesion location as outcomes to assess CL risks. Non-parametric tests and logistic regression were used as appropriate. Results Permethrin treated bed net use was associated with lower NL (p = 0.000), TLA (p = 0.024), and odds of head/face lesion (OR 0.12, p = 0.047). Sleeping in a combat uniform was associated with lower TLA (p = 0.000) and odds of leg/foot lesion (OR 0.39, p = 0.023). Use of a permethrin treated uniform (p = 0.002) and N,N-diethyl-meta-toluamide (DEET) insect repellent at night (p = 0.046) were associated with lower NL. Noting unit members with similar lesions was associated with higher NL (p = 0.007) and odds of head/face lesion (OR 12.1, p = 0.019). National Guard status followed by Active Duty was associated with higher NL (p = 0.002) and TLA (p = 0.000) than Reserve. Sleeping in a building was associated with higher TLA (p = 0.008) and odds of arm lesion (OR 2.28, p = 0.016). Sleeping near animal burrows was associated with higher NL (p = 0.031). Sleeping on a cot (p = 0.006), certain ethnicities (p = 0.020) and certain military occupational specialties (p =0.038) were associated with higher TLA. Increasing age (p = 0.001) and years of service (p = 0.000) were positively correlated with TLA. Conclusion This is the largest group of U.S. Military members with CL reported and provides insight into risks for CL which will guide preventive efforts to reduce the burden of illness in this population. The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. Disclosures Naomi E. Aronson, M.D., Elsevier: Royalties as text editor, honoraria for chapter writing|UpToDate: royalties for writing chapters.

Risk Factors for Failure of Final Anatomic Surgical Reattachment in Retinal Detachments From Combat Ocular Trauma.

The goal of this study was to determine the anatomic outcome of traumatic retinal detachment (RD) from combat ocular trauma. Retrospective study of patients sustaining a traumatic RD in Operation Iraqi Freedom and Operation Enduring Freedom who were evacuated to Walter Reed Army Medical Center from 2001 to 2011. The Fisher exact test, Wilcoxon rank sum test, and Agresti and Coull methods were used for analyses. There were 143 eyes of 134 patients in which a traumatic RD developed, of a total of 890 eyes of 652 patients in the Walter Reed Ocular Trauma Database. Based on our results, predictors for failure to reattach the retina include maculaoff status (P = .0002), open-globe injury (P = .03), proliferative vitreoretinopathy postoperatively (P = .002), and presence of hyphema (P = .02). Intraocular foreign body and time to initial retinal surgery did not increase risk for failure. Thirty-four percent (34%) of eyes failed to be reattached. Traumatic RD due to injury sustained in a combat zone resulted in poor prognosis, with 82.09% of eyes with RD having a best-corrected visual acuity worse than 20/200. The anatomic success of RD repair was shown to be 65.71%, likely owing to the severity of the injuries, concomitant systemic injuries, and delayed surgical intervention. [Ophthalmic Surg Lasers Imaging Retina 2022;53:493-501.].

Editorial introductions.

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one 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 obstetrics and gynecology is divided into nine 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 Journal's Section Editors for this issue. SECTION EDITORS Matthew T. SiedhoffMatthew T. SiedhoffMatthew T. Siedhoff completed his medical degree at Stanford University, USA and obstetrics and gynecology residency training at New York University, USA. He then went on to complete an AAGL fellowship in Minimally Invasive Gynecologic Surgery (MIGS) at the University of North Carolina at Chapel Hill (UNC), USA, and received a master's degree in clinical research from UNC's Gillings School of Public Health during fellowship. As faculty at UNC, he served as MIGS fellowship and division director. He joined Cedars-Sinai in Los Angeles, USA, at the end of 2015. The MIGS practice has rapidly grown to include three providers, and Dr Siedhoff now serves as the Vice Chair for Gynecology for the department. He performs advanced laparoscopic surgery for a range of gynecologic conditions, with special interest and expertise in large fibroids and complicated endometriosis. His research interests focus on surgical outcomes and he has published important trials on topics such as bowel preparation and opportunistic salpingectomy, as well as decision analysis research on uterine tissue extraction. He is very involved with AAGL Elevating Gynecologic Surgery, serving as course faculty in the United States and internationally. He has served as President for its fellowship board and on the editorial board for its journal, the Journal of Minimally Invasive Gynecologic Surgery, as well as its video platform, SurgeryU. He is currently a site reviewer for the fellowship. He has helped organize and lead local simulation sessions on suturing, hysteroscopy, laparoscopy, and tissue extraction at Cedars-Sinai and similar work in national and international courses. He has served as the course chair for the past five years of the fellowship in MIGS boot camp, which includes cadaveric instruction, low- and high-fidelity simulation, and simulated skills training such as managing hemorrhage and providing patients with difficult news. Nisse V. ClarkNisse V. ClarkNisse V. Clark is a board-certified obstetrician and gynecologist. She completed her medical school at Loyola University in Chicago, Illinois, USA, and her residency training at Tufts University in Boston, Massachusetts, USA. Afterwards, she completed a fellowship in Minimally Invasive Gynecologic Surgery (MIGS) at Brigham and Women's Hospital in Boston, Massachusetts, USA. During fellowship, she completed a Master of Public Health at Harvard T.H. Chan School of Public Health, USA. Currently, she directs MIGS at Massachusetts General Hospital and is a faculty member at Harvard Medical School in Boston, Massachusetts, USA. She devotes most of her time to caring for women with complex gynecologic conditions, with a focus on laparoscopic procedures for fibroids and endometriosis. She is an avid clinical researcher with multiple publications evaluating outcomes of gynecologic surgery. She is also an active member of the American Association of Gynecologic Laparoscopists (AAGL) as both a committee chair and member. Ruben AlveroRuben AlveroDr Ruben Alvero is Professor of Obstetrics and Gynecology at Stanford University School of Medicine, USA and the Division Director of Reproductive Endocrinology and Infertility at the Lucille Packard Children's Hospital in Palo Alto, California, USA. He graduated from Harvard College and received his medical degree from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, USA. He completed his residency at the Walter Reed Army Medical Center and his fellowship in Reproductive Endocrinology and Infertility (REI) at the National Institutes of Health. Previously, Dr Alvero was Professor and Division Director at the University of Colorado, USA and Brown University, USA, Fellowship Director in REI at Brown, and Residency Program Director of Obstetrics and Gynecology at the University of Colorado. A 27-year veteran of the United States Army, he retired as a Colonel. A native Spanish speaker, Dr Alvero is devoted to the care of underserved populations.

Circumference Method Estimates Percent Body Fat in Male US Service Members with Lower Limb Loss

BackgroundThe Department of Defense circumference method (CM) is used to estimate percent body fat (%BF) in evaluation of health, physical fitness, appearance, and military readiness; however, the CM has not been validated in individuals with lower limb loss. ObjectiveTo evaluate the agreement between CM and dual-energy X-ray absorptiometry (DXA) for measuring %BF in individuals with lower limb loss. DesignThis study is part of a larger cross-sectional comparison study, and this analysis was included as a secondary objective. Two methods of measuring %BF included CM and DXA, with DXA as the reference standard for this study. Participants/settingThis study was conducted at Walter Reed Army Medical Center. Data were collected from summer 2010 to summer 2011. One hundred individuals, 50 with and 50 without lower limb loss, were screened for this study; three individuals with limb loss and two without limb loss had incomplete data, and one individual (female, without limb loss) lacked a comparison participant. All participants were recruited from a military medical center, and data were collected in a clinic research laboratory. Main outcome measuresMeasurements of %BF were compared between methods for each group. Statistical analyses performedMeasurements of %BF were compared using paired t-tests and intraclass correlation coefficient. Agreement and bias were assessed with Bland-Altman analysis. Receiver operating characteristic analysis was used to determine the diagnostic accuracy of the CM to identify participants with %BF levels in the obese category (≥25%). ResultsA statistically significant difference was found between %BF methods in the group with limb loss (1.7%; P = 0.001) and the group without limb loss (1.4%; P = 0.005), with DXA consistently higher than CM. However, the intraclass correlation coefficient estimates for the agreement between %BF by CM and DXA were 0.848 (95% confidence interval [CI]: 0.683–0.922; P < 0.001) and 0.828 (CI: 0.679–0.906; P < 0.001), for the groups with and without limb loss, respectively, suggesting that CM has good to near excellent agreement with DXA for estimating %BF in these groups. Receiver operating characteristic analysis indicated that the area under the curve supported predictive ability to detect obesity-based %BF in males with and without limb loss. ConclusionsAlthough a statistically significant difference was found between methods for individuals with limb loss, there was also good agreement between the methods, suggesting that CM may be a useful tool for estimating %BF in individuals with lower limb loss. The CM may be a useful and field expedient method for assessing %BF in a clinical setting when DXA is not available.

Open-globe wounds in operation Iraqi Freedom and Operation Enduring Freedom: risk factors for poor visual outcomes and enucleation.

To determine the rates and types of open-globe wounds in soldiers admitted to Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries. Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were patients who suffered open-globe injuries. Open-globe injuries were classified by type of wound: corneal, corneo-scleral or scleral, or type of open-globe injury: perforating, rupture, penetrating or intraocular foreign body. The primary analysis assessed the effect on final visual acuity (VA) and the risk of enucleation. In this study, 285 (32.02%) open-globe injuries were recorded in 890 eyes in the data set. Corneal wounds were noted in 127 (44.56%) eyes, corneo-scleral wounds in 78 (27.37%) and scleral wounds in 129 (45.26%) eyes. The involvement of both the corneal and sclera was associated with poorer visual outcome (BCVA < 20/200) compared to injuries with an injury confined to either the cornea or scleral alone (p = 0.038). At a wound length of greater than approximately 14 mm, patients had 75% chance of having a poor final VA. Enucleation was performed in 64 (22.46%) eyes of patients with wounds. The type of wound was not found to be predictive of enucleation in multivariate analysis, but rather the type of open-globe injury was predictive. Perforating (OR: 1.58, 95% CI: 1.43-1.72) and globe rupture injuries (OR: 1.49, 95% CI: 1.33-1.66) were more likely to undergo enucleation. Open-globe injuries occur frequently in combat ocular trauma. Poor final VA was noted most with corneo-scleral wounds with approximately 50% of patients having a final VA less than 20/200.

Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study.

Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. A retrospective cohort study. Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. Not applicable. Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Editorial introductions

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one 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 obstetrics and gynecology is divided into nine 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 Journal's Section Editors for this issue. SECTION EDITORS Joseph AquilinaJoseph AquilinaJoseph Aquilina, FRCOG, MFFP, is a consultant obstetrician and gynaecologist at Barts Health NHS Trust based St. Bartholomew's and the Royal London Hospitals, UK, and Honorary Senior Lecturer in Obstetrics and Gynaecology at Queen Mary University of London, UK. He is the Lead Clinician for Fetal Medicine Clinical Academic Group and runs a one-stop menstrual disorders clinic at St Bartholomew's Hospital. Mr Aquilina obtained his primary medical degree in Malta and then moved to the UK for his basic postgraduate training in Bristol, and in London at King's College and Greenwich Hospitals, UK. He subsequently undertook research and subspecialty training in feto-maternal medicine/gynaecological ultrasound as a lecturer at St.Bartholomew's and Royal London Medical School, Queen Mary Westfield College, based at Homerton Hospital, UK. He is recognised as a preceptor for training in gynaecological scanning by the Royal College of Obstetricians and Gynaecologists, UK. His special interests include polycystic ovarian syndrome, prediction of pre-eclampsia and the application of ultrasound in the diagnosis and management of benign gynaecological conditions. Ruben AlveroRuben AlveroDr Ruben Alvero is Professor of Obstetrics and Gynecology at Stanford Medical School, USA, and is the Division Director of Reproductive Endocrinology and Infertility at the Lucille Packard Children's Hospital, USA. He is Board Certified in obstetrics and gynecology, and in reproductive endocrinology and infertility. He is a fellow of the American College of Obstetrics and Gynecology and the American College of Surgeons. Following undergraduate training at Harvard College, USA (BA, Economics, 1980), Dr Alvero received his medical degree from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, USA, in 1986. He completed his residency in Obstetrics and Gynecology at Walter Reed Army Medical Center, USA (1990), and a fellowship in Reproductive Endocrinology and Infertility at the National Institutes of Health, USA (NIH, 1995). Dr Alvero was the Division Director for Infertility Services at the National Naval Medical Center, Bethesda, USA, and Walter Reed Army Medical Center and faculty in the NIH-sponsored fellowship in Reproductive Endocrinology and Infertility. Dr Alvero remained a reserve Colonel in the US Army Medical Corps until 2012, and during 27 years in the Army was mobilized several times for missions around the world, including service in Iraq, Kuwait, Mongolia, Germany and various locations in the United States. Dr Alvero was Professor of Obstetrics and Gynecology and Vice Chair for Education at the University of Colorado Health Sciences Center, USA, and the Director of the Assisted Reproductive Technologies, and founding member of the Center for Surgical Innovation. Dr Alvero was Residency Program Director in Obstetrics and Gynecology at the University of Colorado, USA. He was subsequently Division and Fellowship Director at Brown University, USA. The Council in Residency Education in Obstetrics and Gynecology awarded him its National Faculty Award for Excellence three times. He has been NIH-funded, most recently as part of the Reproductive Medicine Network. Dr Alvero is currently the Vice President of the Society for Reproductive Endocrinology, the national organization of fertility specialists and will take over as President in October 2020. Dr Alvero's clinical interests include IVF, polycystic ovary syndrome, endometriosis and robotic surgery. Dr Alvero's research interests include non-invasive evaluation of embryo quality, cost-effectiveness analysis, and the role of critical thinking in medical education. A fluent Spanish-speaker, Dr Alvero is also dedicated to improving the health of the Latinx community.

ADMISSION SERUM ALBUMIN IS ASSOCIATED WITH HOSPITAL-ACQUIRED VTE IN A COHORT OF SOLDIERS WOUNDED IN OPERATION ENDURING FREEDOM AND OPERATION IRAQI FREEDOM

SESSION TITLE: Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Define the association between serum albumin and in-hospital venous thromboembolism (VTE) and compare the differences between patients wounded in Afghanistan (OEF) and Iraq (OIF) and the general hospital population. METHODS: We conducted a prospective, observational study of patients admitted to the Walter Reed Army Medical Center (WRAMC) between September 2009 and March of 2011. The primary outcome was in-hospital VTE events. Daily data abstraction was performed for each admission, to include patient characteristics, percentage time on thromboprophylaxis, and measurements of laboratory values, including serum albumin. RESULTS: There were 6559 adult patients admitted for more than two days during this period. A total of 160 VTE events were observed, with incidences of 2.42% and 4.89% for all admissions and trauma due to deployment related war injuries respectively. At least one serum albumin was measured in 66.3% of admissions. Overall, despite high adherence to chemical prophylaxis, compared to a serum albumin of 3.5-4.5 mg/dL, an initial albumin of less than 2.5 mg/dL was associated an increased risk of VTE, hazard ratio 6.3 (95% CI 3.7-10.7, p value <0.001). The relationship between serum albumin was particularly evident in those with deployment-related injuries (HR 20.4, 2.8- 149.0, p value = 0.003). In multivariate cox regression, serum albumin was independently associated with in-hospital VTE. CONCLUSIONS: Patients with a low admission serum albumin were more than six times as likely to have an in-hospital VTE. The effect size was even greater among wounded soldiers returning from OEF and OIF. This association likely highlights serum albumin as a negative acute phase reactant and as a marker of a pro-inflammatory and hyper-coagulable state. Further research is needed to fully explain this association and how it may be utilized to predict and prevent in-hospital VTE. CLINICAL IMPLICATIONS: Hypoalbuminemia was associated in-hospital VTE risk and while this has been recognized in other subgroups (e.g. subjects with cancer and nephrotic syndrome), it has not been observed in the individualized with severe traumatic injuries. Knowledge of this risk factor, may improve our ability to prevent VTE in this population. DISCLOSURES: My spouse/partner as a Employee relationship with United Health Group Please note: $20001 - $100000 by Aaron Holley, source=Web Response, value=stock options Provided educational content on nebulized tiotropium relationship with CHEST Please note: approximately 4 months (Jan-Apr 2019) Added 04/30/2020 by Aaron Holley, source=Web Response, value=Honoraria Write pieces on journal articles to be published online relationship with WebMD Please note: 5 years Added 04/30/2020 by Aaron Holley, source=Web Response, value=Consulting fee Agreed to design COPD web and game-based educational content relationship with CHEST Please note: Hasn't started yet, will occur this Spring Added 04/30/2020 by Aaron Holley, source=Web Response, value=Honoraria No relevant relationships by Michael McMahon, source=Web Response

Ocular Trauma in Operation Iraqi Freedom and Operation Enduring Freedom from 2001 to 2011: A Bayesian Network Analysis

ABSTRACT Purpose To update the epidemiology of ocular injuries in soldiers admitted to Walter Reed Army Medical Center (WRAMC) from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Methods Data were collected in the Walter Reed Ocular Trauma Database. A Bayesian Network Analysis was completed to better understand the relationships between different ocular demographic variables, injuries, surgeries, ocular trauma scores (OTS) and visual outcomes. Results There were 890 consecutive globe or adnexal combat injuries, or both, sustained by 652 United States soldiers treated at WRAMC between 2001 and 2011.The primary mechanism of injury was improvised explosive device (62.47%). Many patients (62.0%) had final visual acuity (VA) grades of 1–2 (20/15 – 20/200), while 29.9% of patients had final VA grades of 3–5 (less than 20/200), and 8.1% had unknown final VA grades. Bayesian Network Analysis revealed that the injury variables of Retina (47.9%), Lens (44.6%), Posterior Segment (43.7%) and Anterior Segment (40.3%), and the surgical variables of Enucleation (97.6%) and cataract extraction and posterior capsule intraocular lens placement (CEPCIOL; 43.3%) all had probabilities greater than 40% for a poor final VA, while all other variables were less than 40%. Conclusion Modern-day combat trauma results in complicated ocular injuries causing 30% of patients to be left legally blind in their injured eye. It is critical to maintain a wide variety of deployable, specialty trained ophthalmologists to ensure the best visual outcomes for wounded warriors and to maintain mission readiness.

Editorial introductions

Editorial introductions

How the parcellation theory of comparative forebrain specialization emerged from the Division of Neuropsychiatry at the Walter Reed Army Institute of Research

ABSTRACT The Golgi method gave birth to modern neuroscience. The Nauta method, developed in a novel Army think tank at the Walter Reed Army Medical Center, was the next major breakthrough before neuroscience emerged as a separate discipline. Dr. Walle Nauta’s (1916–1994) method allowed for the first time the ability to trace interneuronal connections accurately to their termination. The think tank, created by Dr. David Rioch (1900–1985), provided a unique intellectual environment for interdisciplinary neuroscience research, the first of its kind. Rioch hired exceptional senior faculty and recruited outstanding young investigators who were drafted into the Army, typically after finishing their M.D.s or Ph.D.s, and were interested in brain research. Many of these young investigators went on to illustrious careers in neuroscience. I worked with Walle Nauta at a time when the technique was first being applied to nonmammalian vertebrate brains. Along with other Army draftees, I was encouraged to pursue my own research interests. This led me on a quest to understand interspecific variability of connections in relation to evolution and ontogeny of the brain. By 1980, I had found that the variability of all known connections could be explained by a theory to the effect that new structures such as the neocortex were not formed by one system invading another and mingling, as Clarence Luther Herrick (1858–1904) had proposed, but by selective proliferation and differentiation sometimes involving the select loss of connections to reduce cross-modality interference as in the case of the parcellation and differentiation of cortical areas. The resulting parcellation theory predicts that elements of a primordial neocortex existed from the beginning of vertebrate evolution and did not originate by an invasion of nonolfactory modalities into the olfactory lobe, as commonly believed before the introduction of the Nauta method. This theory would not have been created if it were not for the brilliant environment that was Walter Reed in the 1960s.

Orbital Fractures and Associated Ocular Injuries in Operation Iraqi Freedom and Operation Enduring Freedom Referred to a Tertiary Care Military Hospital and the Effect on Final Visual Acuity.

To update the incidence of orbital fractures in U.S. Soldiers admitted to the former Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any U.S. Soldier or Department of Defense civilian with an orbital fracture injured in Operation Iraqi Freedom/Operation Enduring Freedom. Primary outcome measures were final visual acuity and the effect of orbital fracture, number of fractures, and anatomic location of fracture on final visual acuity. Eight-hundred ninety eye injuries occurred in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. Orbital fractures occurred in 304 eyes (34.2%). A single wall was fractured in 140 eyes (46.05%), 2 in 99 (32.6%) eyes, 3 in 31 (10.2%), 4 in 28 (9.2%), and unknown in 6 (1.9%) eyes. Roof fractures were found in 74 (24.34%), medial wall in 135 (44.41%), lateral wall in 109 (35.9%), and floor fractures in 217 (71.4%). Final visual acuity was analyzed and 140 (46.05%) eyes had greater than 20/40 vision, 17 (5.59%) were 20/50 to 20/200, 26 (8.5%) were count fingers to light perception, and 95 (31.3%) were no light perception. In logistic regression analysis, roof (p = 0.001), medial (p = 0.009), and lateral fractures (p = 0.016) were significantly associated with final visual acuity less than 20/200, while floor fractures were not (p = 0.874). Orbital fracture and all fracture subtypes were significantly associated with traumatic brain injury, retrobulbar hematoma, optic nerve injury, but not for vitreous hemorrhage, commotio, hyphema, and choroidal rupture. Fracture repair was noted in 45 (14.8%). Orbital fractures occurred in a third of Operation Iraqi Freedom/Operation Enduring Freedom eyes of ocular trauma patients referred to one tertiary care military hospital. This resulted in approximately 40% of these eyes remaining legally blind after injury.Orbital fractures occur commonly during combat trauma and a significant number are legally blind despite appropriate treatment.

Hyphema in Open-Globe Versus Closed-Globe Injuries in Operation Iraqi Freedom and Enduring Freedom: 2001-2011.

The goal of this study is to update the incidence of hyphema in Operation Iraqi (OIF) and Enduring Freedom (OEF). We wanted to assess associated ocular injuries and final visual acuity (VA) in open-globe versus closed-globe injuries with a hyphema. We performed a retrospective review of the Walter Reed Ocular Trauma Database (WRTOD) to identify U.S. Service members and DoD civilians with hyphema who were evacuated to Walter Reed Army Medical Center between 2001 and 2011. Primary outcome measures were the final VA and differences in concomitant ocular injuries in open-globe hyphema and closed-globe hyphema. 168 of 890 eyes (18.9%) in the WROTD had a hyphema. Closed-globe injuries were noted in 64 (38.1%) eyes and open-globe injuries in 104 (61.9%) eyes. A final VA of less than 20/200 was noted in 88 eyes (51.8%). Eyes with hyphema were more likely to have traumatic cataract formation (odds ratio (OR) 6.2, 95% confidence interval (CI) 4.2-9.2, P<0.001), retinal detachment (OR 4.2, CI 2.8-6.4, P<0.001), angle recession (OR 8.1, CI 2.9-24.3, P<0.001), and final VA of less than 20/200 (OR 3.7, CI 2.6-5.4, P<0.001). Traumatic cataract formation (OR 7.4, CI 2.9-18.7, P<0.001), retinal detachment (OR 6.1, CI 2.1-17.5, P<0.001), and a final VA less than 20/200 (OR 6.1, CI 2.4-15.4 P<0.001) were statistically more likely to occur with an open-globe hyphema than with a closed-globe hyphema. Close follow-up in patients with hyphema is important due to the associated development of traumatic cataract and retinal detachment and poor final visual outcome.

Demographic and Clinical Characteristics of Military Service Members Hospitalized Following a Suicide Attempt versus Suicide Ideation.

Psychiatric hospitalization for a suicide attempt (SA), rather than suicide ideation (SI) alone, is a stronger risk indicator for eventual suicide death. Yet, little is known about demographic and clinical characteristics differentiating those admitted for SA versus SI. Understanding these differences has implications for assessment and treatment. A retrospective review of electronic medical records (EMRs) was performed on service members (n = 955) admitted for SA or SI at the Walter Reed Army Medical Center between 2001–2006. Service members hospitalized for SA were younger compared to those hospitalized for SI. The proportion of women admitted for SA was significantly higher than those admitted for SI whereas their male counterparts showed the opposite pattern. Patients admitted for SA, versus SI, had significantly higher prevalence of adjustment disorder with mixed disturbance of emotion and conduct (MDEC), personality disorder not otherwise specified (PDNOS), and borderline personality disorder (BPD). Patients admitted for SI had significantly higher prevalence of adjustment disorder with depressed mood and deferred Axis II diagnosis, compared to those admitted for SA. There were no significant between-group differences in the average or median number of documented prior suicide attempts. Findings highlight the need for more standardized assessment, diagnostic decision-making, and documentation practices for all patients.

Enucleations and Eviscerations for Combat Ocular Trauma Performed During Operations Iraqi and Enduring Freedom: 2001 to 2011.

To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011. The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification. One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%). Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.

Lateral Canthotomy and Cantholysis in Operations Iraqi Freedom and Enduring Freedom: 2001–2011

To describe outcomes and associated ocular injuries of lateral canthotomy and cantholysis (LCC) as performed in combat ocular trauma. Data from the Walter Reed Ocular Trauma Database of patients requiring LCC during Operations Iraqi Freedom and Enduring Freedom was reviewed as a retrospective cohort. Primary outcome measures included final visual acuity (VA) and Ocular Trauma Score. Secondary outcome measures were associated injuries and timing of surgery. Thirty-six LCCs were recorded on a total of 890 eyes (4.04 %) in the Walter Reed Ocular Trauma Database. Eighteen out of 36 eyes (50.00%) had a final VA of the affected eye of 20/200 or worse vision. From the initial available VA measured either at the time of injury or at Walter Reed Army Medical Center, 13 eyes (40.63%) had no change in VA, 15 eyes (46.88%) had improvement, and 4 (12.5%) had a decrease in VA (n = 32, data unavailable for 4 eyes). Ocular Trauma score 0-65 was noted in 14 (38.9%) and 66-100 (61.1%). Retinal detachment (6, 16.67%), optic nerve injuries (7, 19.44%), orbital fractures (20, 55.56%), and retrobulbar hematoma (25, 69.44%) were commonly associated injuries. Of the 36 LCC, 18 (50.00%) were performed as the first surgery performed at the combat support hospital, 13 (36.11%) as the second, 4 (11.11%) as the third, and 1 (2.78%) as the fourth. The largest subgroup of patients had an improvement in VA associated with performance of LCC; however, half of patients remained with a final VA of equal to or worse than 20/200 due to severe ocular trauma.

Impact of Statins on Cardiovascular Outcomes Following Coronary Artery Calcium Scoring

BackgroundCompared with traditional risk factors, coronary artery calcium (CAC) scores improve prognostic accuracy for atherosclerotic cardiovascular disease (ASCVD) outcomes. However, the relative impact of statins on ASCVD outcomes stratified by CAC scores is unknown. ObjectivesThe authors sought to determine whether CAC can identify patients most likely to benefit from statin treatment. MethodsThe authors identified consecutive subjects without pre-existing ASCVD or malignancy who underwent CAC scoring from 2002 to 2009 at Walter Reed Army Medical Center. The primary outcome was first major adverse cardiovascular event (MACE), a composite of acute myocardial infarction, stroke, and cardiovascular death. The effect of statin therapy on outcomes was analyzed stratified by CAC presence and severity, after adjusting for baseline comorbidities with inverse probability of treatment weights based on propensity scores. ResultsA total of 13,644 patients (mean age 50 years; 71% men) were followed for a median of 9.4 years. Comparing patients with and without statin exposure, statin therapy was associated with reduced risk of MACE in patients with CAC (adjusted subhazard ratio: 0.76; 95% confidence interval: 0.60 to 0.95; p = 0.015), but not in patients without CAC (adjusted subhazard ratio: 1.00; 95% confidence interval: 0.79 to 1.27; p = 0.99). The effect of statin use on MACE was significantly related to the severity of CAC (p < 0.0001 for interaction), with the number needed to treat to prevent 1 initial MACE outcome over 10 years ranging from 100 (CAC 1 to 100) to 12 (CAC >100). ConclusionsIn a largescale cohort without baseline ASCVD, the presence and severity of CAC identified patients most likely to benefit from statins for the primary prevention of cardiovascular diseases.

Intraocular Foreign Body Trauma in Operation Iraqi Freedom and Operation Enduring Freedom: 2001 to 2011

We update the incidence of intraocular foreign bodies (IOFB) in soldiers admitted to Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. This consecutive retrospective case series included 890 eyes of 652 patients. Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any American soldier or Department of Defense civilian with an IOFB injured in Operation Iraqi Freedom/Operation Enduring Freedom. Closed globe injuries with orbital foreign bodies, injury outside of a combat zone, or non-Department of Defense civilian trauma were the exclusion criteria. Primary outcome measures were final visual outcome and the number, size, and location of IOFBs. Secondary outcome measures included surgical procedures, use of eye protection, associated complications, source of injury and Ocular Trauma Score. There were 890 eye injuries in 652 patients evacuated to Walter Reed Army Medical Center between2001 and 2011. IOFBs were found in 166 eyes of 149 patients (18.6%; 95% confidence interval [CI], 16.2%-21.3%). Most patients had a single IOFB (80.7%). An IOFB was positively associated with Ocular Trauma Score grade 1 or 2 (0-65) injuries (odds ratio [OR], 1.58; 95% CI, 1.07-2.38; P= 0.01). There were 130 eyes (78.33%) that had recorded time from initial visual acuity to final visual acuity and it ranged from 8 to 2421 days (mean, 433.24 days). Thirty-eight (25.16%; 95% CI, 18.89%-32.67%) eyes had no change in visual acuity, 98 (64.90%; 95% CI, 57.00%-72.07%) had improved visual acuity, and 15 (9.93%; 95% CI, 6.01%-15.84%) had decreased visual acuity. IOFB was not found to predict final visual acuity of <20/200 in multivariate analysis when other injury features were known (P= 0.1). Pars plana vitrectomy was completed on 124 eyes (74.70%). Removal of IOFB was performed in 118 eyes (71.08%; average of 31.67 days after initial injury) with a delayed procedure occurring after primary closure and antibiotics owing to a lack of surgical capacity in Iraq and Afghanistan. Retinal detachment occurred in 48 eyes (28.92%) and proliferative vitreoretinopathy in 44 eyes (26.5%). IOFBs occur frequently in combat ocular trauma and are significantly associated with moresevereinjuries. However, IOFBs were not found to be a significant risk factor for visual acuity of <20/200.

Talking About Firearms With Patients Necessary, But Examine Your Beliefs First

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessTalking About Firearms With Patients Necessary, But Examine Your Beliefs FirstMark MoranMark MoranSearch for more papers by this authorPublished Online:30 May 2018https://doi.org/10.1176/appi.pn.2018.6a39Abstract“If you simply say to a patient, ‘You need to get rid of your gun,’ you may never see that patient again. … We have a responsibility to care for patients who may not believe what we believe.”How do you talk about gun safety with patients who are gun owners? James Curtis West, M.D., says clinicians need to consider their own views about gun ownership and how those views may affect the relationship with the patient. Seated at the table are (left to right) Janee Mestrovich, D.O., Matthew Goldenberg, M.D., M.Sc., and Sonya Lewis, M.D., M.P.H.David HathcoxIt’s a conversation in which physicians have a responsibility to engage, and it requires more than simply asking “Do you have a gun or not?,” said psychiatrist James Curtis West, M.D., at APA’s 2018 Annual Meeting last month in the symposium “Patients and Personal Firearms: Approaches to the Physician-Patient Conversation to Reduce Risk.”“Firearm ownership is prevalent and increases the risk for death and injury,” West said. “Our obligation is to communicate effective harm-reduction strategies to patients. This is best achieved through culturally competent, evidence-based intervention.” West is an associate professor and vice chair of the Department of Psychiatry at the Uniformed Services University of the Health Sciences and a scientist in the university’s Center for the Study of Traumatic Stress.He was joined at the symposium by Matthew Goldenberg, M.D., M.Sc., section chief of Psychiatric Emergency Services at Yale University; Sonya Lewis, M.D., a private practitioner and instructor at the University of Michigan; and Janee Mestrovich, D.O., a psychiatry resident at Walter Reed Army Medical Center. Goldenberg presented statistics about firearm deaths:Each year in the United States, there are 38,000 firearm-related deaths and 84,000 firearm-related nonfatal injuries.Suicide, the 10th leading cause of death in the United States, accounts for the majority of gun deaths (21,175 in 2013).The majority of suicides (51.5 percent of 41,149) are by firearm.Lewis discussed the principles of safe gun storage. These include storing the gun unloaded, disassembled or with a properly applied locking device, or locked in a gun safe or secure storage container. Ammunition should be locked and stored separately. “The four practices of keeping a gun locked and unloaded and storing ammunition locked and in a separate location are each associated with a protective effect and suggest a feasible strategy to reduce these types of injuries in homes with children and teenagers where guns are stored,” she said. Yet physicians are sometimes reluctant to talk to patients about firearms and how to safely store them, Prominent reasons for not doing so include the following:Lack of timeBelief that the gun ownership is not a problemSense of helplessness (“there’s nothing I can do to help”)Fear that the subject is too controversial and the patient will get angry“I don’t know enough about firearms”“I don’t know how to have the conversation”But West emphasized that it is possible—and necessary—to hold a conversation with patients that enables them to move incrementally to safer gun storage practices drawing on the principles of motivational interviewing. It also requires the clinician to consider his or her own views about gun ownership and how those views may affect the relationship with the patient. “Take a moment to consider your own assumptions about guns and safety,” West said. “Ask the patient about their reasons for keeping firearms and assess their current safety practices. “If you simply say to a patient, ‘You need to get rid of your gun,’ you may never see that patient again,” West said. “We have a responsibility to care for patients who may not believe what we believe. We need to have a culturally competent discussion built on a relationship with the patient and promoting an open dialogue.” ■ ISSUES NewArchived

Profile of Warren J. Leonard

The immune system is the human body’s natural defense against disease. Many molecules and cells take part in the immune response, including cytokines, a critical group of intercellular signaling molecules that influence the development and actions of immune cells. Warren J. Leonard. Image courtesy of Bill Branson (National Institutes of Health, Bethesda, MD). Immunologist Warren J. Leonard, at the National Institutes of Health (NIH) in Bethesda, Maryland, has dedicated much of his career to studying the molecular aspects of the immune system, in particular, cytokines. Leonard’s early work on cloning a component of the human receptor for the cytokine IL-2 was the foundation for his later work dissecting cytokine pathways, and led to the discovery of the genetic factors underlying the immune disorder X-linked severe combined immunodeficiency (XSCID), or “Bubble Boy” disease, as well as other forms of human immunodeficiency. Moreover, it also served as the basis for a range of other fundamental contributions by his laboratory over the years. Leonard’s research has earned him multiple awards and accolades, including election to the US National Academy of Sciences in 2015. Leonard grew up in Bethesda. His father, Fred Leonard, was a physical and polymer chemist, and his mother worked in retail sales. Leonard’s father directed a biomedical research laboratory at the Walter Reed Army Medical Center Forest Glen Annex from 1948 to 1972, and later became the dean of research at George Washington University School of Medicine in Washington, DC. Among his father’s accomplishments were major contributions to prosthetics and to the discovery of α-cyanoacrylate adhesives, the basis of superglue, for which he held the patent for medical and dental applications. For these efforts, President Richard Nixon awarded Leonard’s father the President's Award for Distinguished Federal Civilian Service. As a child, Leonard was inspired by his father and enjoyed visits …