Objective Response of Saliva Biomarkers After High-Stress and Mass Casualty Scenarios: A Pilot Study.

INTRODUCTION: Surgeons and military personnel are subjected to high-stress scenarios, which leads to greater rates of burnout. There is room to optimize performance and longevity in these careers by better understanding the body's stress response and applying it to stress management training. This study aims to understand the physiological response in those engaged in trauma scenarios by examining 6 hormones and 42 cytokines during the Intensive Surgical and Trauma Skills Course held at Strategic Operations Inc in San Diego, CA. METHODS: Thirty-seven military medical students participated in full immersion, hyper-realistic, and experiential mass casualty high-stress scenarios. Participants were exposed to both operating and emergency room scenarios. Saliva samples were taken after stress inoculation (postinoculation) and again 1 hr after each scenario (recovery). Saliva samples were analyzed using plex assays from Eve Technologies. Data were grouped and analyzed by location and timing using mixed effect nonlinear models. Distributions were compared by location and were analyzed with respect to biomarker levels over the 4-day training period. RESULTS: For emergency room scenarios, there was a decrease in the following cytokines from postinoculation to recovery: epidermal growth factor (EGF), granulocyte colony stimulating factor (G-CSF), epidermal growth factor, granulocyte colony stimulating factor, interleukin 1alpha (IL-1α), interleukin 1beta (IL-1 ß), IL-1RA, IL-4, IL-8, IL-10, IL-18, monocyte chemotactic protein (MCP) 1, macrophage colony stimulating factor (M-CSF), macrophage derived chemokine (MDC), CXC motif ligand 9 (MIG/CXCL9), regulated upon activation, normal T cell expressed and secreted (RANTES), and vascular endothelial growth factor (P < 0.05, t > 3.0). For operating room scenarios, there was a decrease in the following cytokines: EGF, G-CSF, IL-1α, IL-1 ß, IL-1RA, IL-6, IL-8, IL-10, IL-18, M-CSF, MDC, MIG/CXCL9, RANTES, and tumor necrosis factor alpha. In operating room scenarios, an increase in the hormone levels of progesterone and triodothyronine were observed. The cytokines observed in both groups included EGF, IL-1α, RANTES, MDC, EGF, G-CSF, IL-1RA, IL-18, MIG/CXCL9, IL-8, IL-1ß, M-CSF, and IL-10. These significant biomarkers were also graphed and visualized as variable throughout the week. CONCLUSIONS: These preliminary data narrow a wide array of stress biomarkers to a smaller, significant group. Surgeons and military personnel are subjected to extraordinary levels of stress with narrow margins for error. To optimize performance and outcomes, it is pertinent to understand the physiological stress response. Future investigation and pairing of cytokine measurements with neuropsychological and performance-based testing will target opportunities to direct training and identify profiles of individuals well suited for stressful environments.

A distinct immune cytokine profile is associated with morning cortisol and repeated stress.

OBJECTIVE: The objective of this study was to investigate possible immune cytokine trends throughout a week-long surgical simulation mass-casualty training session in order to determine the effects of stress inoculation on the immune system. METHODS: Thirty-seven military medical students participated in a hyper-realistic surgical simulation training event conducted at Strategic Operations site in San Diego, California. Salivary samples were collected every morning of the stress training exercise for 4 consecutive days. Cortisol, along with a panel of 42 immune cytokines, was measured using multiplex enzyme-linked immunosorbent assays from Eve Technologies. The determined concentrations were averaged and plotted on a scatter plot, and then points were fit to a second-order polynomial trendline of best fit to measure. RESULTS: The cytokines epidermal growth factor, growth-related oncogene-α, interleukin (IL)-1α, and platelet-derived growth factor-AA followed a noted pattern of cortisol decrease throughout the week. In addition, cytokines IL-27, granulocyte colony stimulating factor, IL-10, and IL-13 demonstrated a late peak, followed by a return to baseline at the conclusion of training. Finally, the cytokine monocyte chemoattractant protein-1 displayed a decline throughout the week followed by an increase on the last day of stress training. CONCLUSIONS: Altogether, these results help to identify important biomarkers that may help to improve long-term stress adaptation and prevent post-traumatic stress disorder following exposure to repeated stress.

Exploring the relationship of supernumerary recurrent renal calculi formation and tick-borne infections: a case report.

A 51-year-old male with a history of Cacchi-Ricci disease and long-standing infection with various species of Borrelia, Babesia, and Bartonella presented with recurrent symptoms of right-sided flank pain. Numerous renal calculi were identified on imaging. The etiology of the calculi had not been previously elucidated. Symptoms intermittently date back to 2002 when uric acid stones were identified. Subsequent calculi analysis revealed calcium oxalate stones. Despite the commonality of nephrolithiasis in patients with Cacchi-Ricci disease, the extreme number of calculi and recurrent presentation of symptoms persisted despite a plethora of medical evaluations, dietary changes, and hereditary testing. This case raises questions of etiology including possible immune deficiency and whether his uncommon microbial history contributes to recurrent stone formation.

Start-of-day oculomotor screening demonstrates the effects of fatigue and rest during a total immersion training program.

BACKGROUND: Investigating changes in sleep and fatigue metrics during intensive surgical and trauma skills training, this study explored the dynamic association between oculomotor metrics and fatigue. Specifically, alterations in these relations over extended stress exposure, the influence of time of day, and the impact of fatigue exposure on sleep metrics were examined. METHODS: Thirty-nine military medical students participated in 6 days of immersion, hyper-realistic, and high-stress experiential casualty training. Participants completed surveys assessing the state of sleepiness with oculomotor tests performed each morning and evening, analyzing eye movement and pupillary change to characterize fatigue. Participants wore Fitbit TM devices to measure overall time asleep and time in each sleep stage during the training. RESULTS: Fitbit data showed increased average minutes in rapid eye movement, deep sleep, and less time in light sleep from day 1 to day 4. The microsaccade peak velocity-to-displacement ratio exhibited a morning decrease but not in afternoon sessions, indicating repeated but temporary effects of accumulated fatigue. There were no findings regarding pupil reactivity to illumination changes. CONCLUSION: This study describes characteristics of fatigue measured by rapid and individually calibrated oculomotor tests. It demonstrates oculomotor relationships to fatigue in start-of-day testing, providing a direction for timing for optimal fatigue testing. These data suggest that improved sleep could signal resilience to fatigue during afternoon testing. Further investigation with more participants and longer duration is warranted. A deeper understanding of the interrelationships between training, sleep, and fatigue could improve surgical and military fitness.

Cytokine fluctuation during acute stress is correlated to life trauma.

BACKGROUND: Multiple studies have demonstrated that human neurobiology and behavior are inextricably linked to the activity of our immune systems. Trauma is associated with a multitude of immune system changes; reflecting this, posttraumatic stress disorder (PTSD) is often comorbid with immune-related conditions such as autoimmune disorders. To further investigate this phenomenon, we tested our hypothesis that cytokine fluctuations during and after an acute stress response correlates with experienced life trauma. METHODS: Using a prospective observational approach, this cohort study measured biomarker profiles in firefighter participants (n = 63), with 9 participants having prior PTSD diagnoses and 54 without prior PTSD diagnoses. In addition, life trauma scores were determined from all participants using the Life Events Checklist 5 (LEC-5) survey. Baseline salivary biomarker concentrations were determined, along with levels immediately before, immediately after, and 1 hour following a standardized stressful training event. Biomarkers measured using these salivary samples included 42 cytokines and 6 steroid and thyroid hormones. The concentrations of these markers were then correlated, using Pearson correlation coefficients, with the participants' LEC-5 scores. t Tests were also performed to compare cytokine values between the populations with and without prior PTSD diagnosis. RESULTS: Included in the cytokine panel were interleukin (IL)-8, IL-10, IL-1B, GCSF, IL1-Ra, Groα, IFNa2, PDGFAA, and VEGF, all of which demonstrated positive correlation at various time points in individuals with increased severity of LEC-5 scores (and thus increased experienced life trauma). Concentrations of Groα, PDGFAA, IL1-Ra, IL-1a, Mip1a, IL-1a, IL-6, Mip1b, TNFα, and TGFα were also found to be significantly altered at various time points in participants with prior PTSD diagnoses, demonstrating some overlap with the LEC-5 Pearson correlations. CONCLUSION: The results support our hypothesis and demonstrate that LEC-5 scores are indeed significantly correlated to cytokine concentrations and fluctuations surrounding a stress test. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level IV.

Website Usability Analysis of U.S. Military Residency Programs.

INTRODUCTION: The Military Match is the residency matching system for medical students attending the Uniformed Services University of Health Sciences, and the students were funded by the Health Professions Scholarship Program through the U.S. Army, Air Force, and Navy. To evaluate and compare military residency programs, students use residency program websites. Often, the residency program's website serves as a key source, or the only point of reference, when considering residency options, especially during times when face-to-face interactions are limited.This report aims to provide a systematic evaluation of military residency programs and their websites. MATERIALS AND METHODS: Utilizing a previously published website usability scoring system, military residency programs were categorized to objectively and quantitatively analyze their websites. Usability was divided into four categories for quantifiable analysis: accessibility, marketing, content quality, and technology. The methodology for this analysis was replicated from published reports that have examined healthcare website usability. Each website was analyzed and scored in four categories: accessibility, content quality, marketing, and technology. A "General Usability" score was calculated for each website using a composite of the key factors within the four categories. An overall score was generated utilizing the weighted percentage across all four categories. To address deficiencies of the original methodology, a secondary analysis was performed on the listed websites utilizing an automated methodology for website usability. RESULTS: A comprehensive list of 125 Accreditation Council for Graduate Medical Education U.S. Military residency program websites was compiled. Of these, 96 programs and 106 websites were evaluated. The primary analysis employing usability methodology identified technology as the highest ranked category with a score of 0.749 (SD ± 0.039) (SE 0.005) (P < .05). Marketing and content quality were the lowest scoring categories with mean scores of 0.414 (SD ± 0.054) (SE 0.006) and 0.428 (SD ± 0.229) (SE 0.027), respectively (P < .05). There was no significant difference in overall usability rankings or scores among the 96 residency program websites across the three branches (P < .05).Secondary analysis with the new usability methodology demonstrated military residency websites to exhibit more external backlinking compared to internal backlinking (P < 0.05) and no social media backlinking to any of the 106 analyzed websites. When comparing the three services, the Army had significantly lower external backlinking ranking 43.4 (P < .05) and overall backlinking ranking 56.4 (P < 0.05) when compared to the Navy (mean 48.8 and 71.7, and 43.4). There were no other differences in backlinking rankings across the three branches. CONCLUSIONS: Residency websites have become a primary way to communicate information to applicants. By assessing the overall usability of the various military residency websites, we determined the effectiveness of these websites to relay information to prospective students interested in applying for military residency. We predict that by improving website accessibility, residency programs increase their effectiveness at communicating information to potential applicants and increase interest in military residency programs.

Prospective Validation of the National Field Triage Guidelines for Identifying Seriously Injured Persons.

BACKGROUND: The national field trauma triage guidelines have been widely implemented in US trauma systems, but never prospectively validated. We sought to prospectively validate the guidelines, as applied by out-of-hospital providers, for identifying high-risk trauma patients. STUDY DESIGN: This was an out-of-hospital prospective cohort study from January 1, 2011 through December 31, 2011 with 44 Emergency Medical Services agencies in 7 counties in 2 states. We enrolled injured patients transported to 28 acute care hospitals, including 7 major trauma centers (Level I and II trauma hospitals) and 21 nontrauma hospitals. The primary exposure term was Emergency Medical Services' use of one or more field triage criteria in the national field triage guidelines. Outcomes included Injured Severity Score ≥16 (primary) and critical resource use within 24 hours of emergency department arrival (secondary). RESULTS: We enrolled 53,487 injured children and adults transported by Emergency Medical Services to an acute care hospital, 17,633 of which were sampled for the primary analysis; 13.9% met field triage guidelines, 3.1% had Injury Severity Score ≥16, and 1.7% required early critical resources. The sensitivity and specificity of the field triage guidelines were 66.2% (95% CI, 60.2-71.7%) and 87.8% (95% CI, 87.7-88.0%) for Injury Severity Score ≥16 and 80.1% (95% CI, 65.8-89.4%) and 87.3% (95% CI 87.1-87.4%) for early critical resource use. Triage guideline sensitivity decreased with age, from 87.4% in children to 51.8% in older adults. CONCLUSIONS: The national field triage guidelines are relatively insensitive for identifying seriously injured patients and patients requiring early critical interventions, particularly among older adults.

Emergency department referral for organ donation: more organ donors and more organs per donor.

BACKGROUND: This study sought to determine whether early referral from the emergency department (ED) would increase the number of organ donors and the number of organs transplanted per donor (OTPD). METHODS: This is a retrospective cohort analysis of all patients referred to a single organ procurement organization for a period of 60 months. RESULTS: Patients referred for organ donation evaluation from the ED were more likely to become organ donors than patients referred from the intensive care unit (19.3% vs 5.2%, P < .001). ED referrals had a greater number of OTPD than those referred from the intensive care unit (mean 3.79 vs 3.16, P = .024), even after adjusting for the higher proportion of ED referrals who were trauma patients (P = .001). CONCLUSIONS: Referral for organ donation from the ED is associated with an increased likelihood of organ recovery and with an increased number of OTPD.

A multisite assessment of the American College of Surgeons Committee on Trauma field triage decision scheme for identifying seriously injured children and adults.

BACKGROUND: The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort. STUDY DESIGN: This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ≥ 16. RESULTS: There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings. CONCLUSIONS: The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.

Revolutionary advances in enhancing patient comfort on patients transported on a backboard.

BACKGROUND: Patients with suspected spinal cord injuries are immobilized to a backboard during ambulance and helicopter air transport. It has been well documented that patients who are immobilized to a backboard experience discomfort and eventually become susceptible to pressure ulcer formation. Because the patient lying on a backboard is subjected to high skin interface pressures, it is imperative to improve patient comfort and prevent pressure ulcer formation. OBJECTIVE: Realizing the dangers of the potentially preventable pressure ulcers, our team of scientists, surgeons, and trauma nurses performed a comprehensive study of the Back Raft system that was designed to reduce patient discomfort and skin interface pressure. METHODS: Pressure under the occipital, scapula, and sacral regions of the back was measured using the Tactilus pressure analyzer of 10 healthy volunteers immobilized on a backboard and a backboard with a Back Raft air mattress system. Discomfort levels of each volunteer were measured using a Visual Analog Scale. RESULTS: Data from this study indicated that the Back Raft significantly reduces discomfort as well as tissue interface pressure in the occipital, scapula, and sacral regions of the back. CONCLUSIONS: The implementation of an air mattress system analogous to the Back Raft would facilitate the prevention of pressure ulcer formation during prehospital care and transportation. In 2008, The Centers for Medicare and Medicaid Services enacted a policy in which the Centers for Medicare and Medicaid Services can refuse payment for hospital-acquired conditions. Pressure ulcers were among the hospital-acquired conditions within the final rule.

Advances in the treatment of peanut allergy: a case report.

BACKGROUND: Peanut allergies affect 1.5% of children. The majority of reactions to peanuts are mild, but peanut allergy is also the most common cause of fatal anaphylactic reactions to food. CASE REPORT: The purpose of this case report was to describe a 1-year old boy who developed difficulty breathing after eating a peanut food product. The boy was taken immediately by his mother to an Emergency Department, exhibiting severe respiratory distress. After speaking to the child's mother, the emergency physician (EP) realized that the wheezing was due to a peanut food allergy. The child's respiratory symptoms responded within 10 min to bronchodilatator inhalation. The EP gave the mother educational information regarding the management of asthma and the proper use of metered dose inhalers with spacer devices. The EP referred the child to a clinical allergist who specializes in the management of food allergies. The diagnosis was made by skin prick testing as well as in vitro measurement of peanut-specific immunoglobulin E. CONCLUSION: The allergist explained that the mainstay of management of peanut allergy is avoidance of the allergenic food. Patient education involved teaching the mother to avoid high-risk situations such as dinner with family members who are not informed about the child's allergy to peanuts, encouraging the child to wear a Medic Alert Bracelet, and teaching the family and child to recognize early symptoms of allergic reactions and to manage an anaphylactic reaction, including the use of self-injectable epinephrine, as well as activating emergency services.

Residual urinary volume and urinary tract infection, a life threatening illness: a case report.

Multiple Sclerosis (MS) is an inflammatory disease that demyelinates the central nervous system causing progressive disability. The urodynamics of MS patients is an important consideration because these patients are susceptible to acute urinary bladder retention associated with a high fever. Treatment should include irrigation using a Foley catheter and an irrigation syringe to remove residual urine and sediment from the neurogenic bladder, intravenous fluid resuscitation, bacteriological analysis of the residual urine, and admission to an Intensive Care Unit for further evaluation by a urologist. After discharge, suprapubic cystostomy should be a consideration for patients who have chronic urinary tract infections associated with acute urinary bladder retention, as well as limited mobility to perform self catheterization, or limited personal care assistants trained to perform a urethral clean intermittent catheterization.

Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort.

STUDY OBJECTIVE: The first hour after the onset of out-of-hospital traumatic injury is referred to as the "golden hour," yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality. METHODS: This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged > or =15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders. RESULTS: There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings. CONCLUSION: In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

Modern concepts of the diagnosis and treatment of psoriasis.

Psoriasis is a papulosquamous skin disease that is recognized as one of the most common immune-mediated disorders. At least nine chromosomal psoriasis susceptibility loci have been identified. It is important to emphasize that management of psoriasis begins with identification of the extent of the cutaneous disease. There are three clinical forms of psoriasis, to include psoriasis vulgaris, pustular psoriasis, and erythrodermic psoriasis. Treatments currently available are topical agents used predominantly for mild disease and for recalcitrant lesions in more severe disease, phototherapy for moderate disease, and systemic agents, including photochemotherapy, oral agents, and newer injectable biological agents, which have revolutionized the management of severe psoriasis.

Citizen's Petition to Food and Drug Administration to ban cornstarch powder on medical gloves: Maltese cross birefringence.

BACKGROUND: During the last 25 years, scientific experimental and clinical studies have documented the dangers of cornstarch powder on examination and surgical gloves because the cornstarch promotes wound infection, causes serious peritoneal adhesions and granulomatous peritonitis, and is a well-documented vector of the latex allergy epidemic in the world. Realizing the dangers of cornstarch on examination and surgical gloves, Germany's regulations of personal protective equipment banned the use of surgical glove powder cornstarch in 1997. In 2000, the Purchasing and Supply agency for the United Kingdom ceased to purchase any gloves lubricated with cornstarch. DISCUSSION: Realizing the dangers of cornstarch-powdered gloves, many hospitals and clinics in the United States have banned the use of cornstarch-powdered examination and surgical gloves. Hospitals that have banned cornstarch in their examination and surgical gloves have noted a marked reduction in the latex allergy epidemic in their facilities. Realizing the dangers of cornstarch-powdered examination and surgical gloves, Dr Sheila A. Murphey, branch chief, Infection Control Devices Branch, Division of Anesthesiology, General Hospital, Infection Control, and Dental Devices Office of Device Evaluation, Center for Devices and Radiological Health of the Food and Drug Administration (FDA), recommended that a Citizen's Petition be filed to the FDA to ban cornstarch on surgical and examination gloves. CONCLUSION: The 12 authors of this report have attached the enclosed petition to the FDA to ban the use of cornstarch on all synthetic and latex examination and surgical gloves used in the United States.

Update on the National Vaccine Injury Compensation Program.

The National Childhood Vaccine Injury Act of 1986, as amended, established the Vaccine Injury Compensation Program (VICP). The VICP went into effect on October 1, 1988 and is a Federal "no-fault" system designed to compensate individuals, or families of individuals, who have been injured by covered vaccines. From 1988 until July 2006, a total of 2531 non-autism/thimerosal and 5030 autism/thimerosal claims were made to the VICP. The compensation paid for the non-autism/thimerosal claims from 1988 until 2006 was $902,519,103.37 for 2542 awards. There was no compensation for any of the autism/thimerosal claims. On the basis of the deaths and extensive suffering to patients and families from the adverse reactions to vaccines, all physicians must provide detailed information in the Vaccine Information Statement to the patient or the parent or legal guardian of the child about the potential dangers of vaccines as well as the VICP.