Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update.

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2019.

Remote Patient Monitoring in Diabetes: How to Acquire, Manage, and Use All of the Data.

The ability of patients and health care providers to use various forms of technology for general health has significantly increased in the past several years with the expansion of telehealth, digital applications, personal digital devices, smartphones, and other internet-connected platforms and devices. For individuals with diabetes, this also includes connected blood glucose meters, continuous glucose monitoring devices, and insulin delivery systems. In this article, the authors outline several steps to facilitate the acquisition, management, and meaningful use of digital diabetes data that can enable successful implementation of both diabetes technology and telehealth services in primary care clinics.

Smoking is associated with a higher risk of unplanned medical visits among adult patients with diabetes, using retrospective electronic medical record data from 2014 to 2016.

BACKGROUND: Smoking exacerbates the complications of diabetes, but little is known about whether patients with diabetes who smoke have more unplanned medical visits than those who do not smoke. This study examines the association between smoking status and unplanned medical visits among patients with diabetes. METHODS: Data were drawn from electronic medical records (EMR's) from a large healthcare provider in the Northern Plains region of the US, from adult (≥18 years old) patients with type 1 or type 2 diabetes who received care at least once during 2014-16 (N = 62,149). The association between smoking status (current, former, or never smoker) and having ≥1 unplanned visit (comprised of emergency department visits, hospitalizations, hospital observations, and urgent care) was examined after adjusting for age, race/ethnicity, and body mass index (BMI). The top ten most common diagnoses for unplanned visits were examined by smoking status. RESULTS: Both current and former smoking were associated with an approximately 1.2-fold increase in the odds of having at least one unplanned medical visit in the 3-year period (OR = 1.22, 95% CI = 1.16-129; OR = 1.23, 95% CI = 1.19-1.28, respectively), relative to never-smokers. Most common diagnoses for all patients were pain-related. However, diagnoses related to musculoskeletal system and connective tissue disorders were more common among smokers. Smoking is associated with a higher rate of unplanned medical visits among patients with diabetes in this regional healthcare system. CONCLUSIONS: Results from this study reveal higher rates of unplanned visits among smokers and former smokers, as well as increased frequencies of unplanned medical visits among current smokers.

Implementation of Diabetes Technologies in Primary Care: Challenges and Rewards.

This article focuses on the challenges to and rewards of using technology in diabetes care. The authors provide everyday, practical information regarding the integration of technology, including insulin pumps, continuous glucose monitoring devices, and other diabetes consumer technologies, into busy primary care practices. Cases are presented to highlight these tips.

Cardiovascular Disease and Risk Management: Review of the American Diabetes Association Standards of Medical Care in Diabetes 2018.

Description: The American Diabetes Association (ADA) annually updates its Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. Methods: For the 2018 standards, the ADA Professional Practice Committee searched MEDLINE through November 2017 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C depending on the quality of evidence or E for expert consensus or clinical experience. The standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. Recommendations: This synopsis focuses on guidance relating to cardiovascular disease and risk management in nonpregnant adults with diabetes. Recommendations address diagnosis and treatment of cardiovascular risk factors (hypertension and dyslipidemia), aspirin use, screening for and treatment of coronary heart disease, and lifestyle interventions.

Using a Six-Domain Framework to Include Biopsychosocial Information in the Standard Medical History.

PROBLEM: The traditional approach to physicians' history taking is designed to facilitate diagnosis and treatment of biomedical conditions. However, in the 21st century, health is critically influenced by the interaction of biomedical conditions and nonbiomedical factors such as patient's ability to manage chronic disease and the social determinants of health. Interventions to expand routine history taking to include nonbiomedical factors have not been widely adopted, possibly due to the difficultly of incorporating long checklists into routine care and the inability to achieve consensus on the relevant behavioral or social determinants of health content applicable to all patients. INTERVENTION: In 2015-2016, we introduced medical students to a 6-domain (biomedical and psychiatric conditions, behavioral health, living environment/resources, social support, and functional status) approach to history taking and instructed them to elicit information from each domain alongside the traditional approach. Students were required to obtain information from each domain in one admitting history or one daily progress note, discuss their findings with the attending physician, and involve members of the medical team in addressing concerns and barriers in the care of that patient. Students' history notes were reviewed for completeness and compared to those from a student control group. Students also completed a 10-question evaluation of the model. CONTEXT: The intervention was conducted during a 1-month rotation on a hospitalist general medicine service from May 2015 through August 2016. OUTCOME: Patient history and daily progress notes were collected from 38 fourth-year intervention students and compared to 24 control students on the same service from the previous year. Compared to control students, intervention students provided more patient information (p ≤ .001) in all nonbiomedical domains except behavioral health. Intervention students reported that the 6-domain model helped them identify clinical information that could be addressed with existing resources and prompted involvement of social workers, pharmacists, and nurses in care planning. They also indicated the framework added clinically valuable information and enhanced team-based care. LESSONS LEARNED: A domain-based framework can be used by medical students to identify clinically relevant behavioral conditions and social determinants of health tailored to individual patients while avoiding long standardized checklists. Arguably, routine collection of behavioral and social determinants of health is a necessary first step in enhancing physicians' awareness and skills in working with health care teams to address nonbiomedical determinants of patients' health.

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2019 Update.

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2014.

Interprofessional education and practice guide: interprofessional team writing to promote dissemination of interprofessional education scholarship and products.

Collaborations to develop, implement, evaluate, replicate, and write about interprofessional education (IPE) activities within and across institutions are wonderful opportunities to experience teamwork, team communication, ethics and values, and the roles and responsibilities of interprofessional team writing. Just as effective communication in interprofessional team-based care is essential for providing safe, high-quality health care, similar communication strategies are necessary to produce high-quality scholarship of IPE curricula and activities. Relationship and communication issues that affect health care teams' abilities to work together effectively (e.g., hierarchy, exclusion, assumptions, non-responsiveness, biases, stereotypes and poor hand-offs of information) can also occur in interprofessional team writing. Between 1970 and 2010, interprofessional practice research publications increased by 2293%. Although there has been tremendous growth in the IPE literature, especially of articles that require collaborative writing, there have not been any papers addressing the challenges of interprofessional team writing. As more teams collaborate to develop IPE, there is a need to establish principles and strategies for effective interprofessional team writing. In this education and practice guide, a cross-institutional team of faculty, staff, and graduate students who have collaborated on externally funded IPE grants, conferences, products, and workshops will share lessons learned for successfully collaborating in interprofessional team writing.

Initiating therapy in patients newly diagnosed with type 2 diabetes: Combination therapy vs a stepwise approach.

There is clear evidence that achieving glycaemic targets reduces the risk of developing complications as a result of type 2 diabetes (T2D). Many patients, however, continue to have suboptimal glycaemic control because of issues that include unclear advice on how to achieve these targets as well as clinical inertia. The two management approaches recommended for patients newly diagnosed with T2D are stepwise and combination therapy, each of which has advantages and disadvantages. Stepwise therapy may result in good patient adherence and allow greater individualization of therapy, and minimization of side effects and cost, and so may be appropriate for patients who are closer to goal. Stepwise therapy, however, may also lead to frequent delays in achieving glycaemic goals and longer exposure to hyperglycaemia. Combination therapy, which is now emerging as an important therapy option, has a number of potential advantages over stepwise therapy, including reduction in clinical inertia and earlier and more frequent achievement of glycated haemoglobin goals by targeting multiple pathogenic mechanisms simultaneously, which may more effectively delay disease progression. Compared with stepwise therapy, the disadvantages of combination therapy include reduced patient adherence resulting from complex, multi-drug regimens, difficulty determining the cause of poor efficacy and/or side effects, patient refusal to accept disease, and higher cost. Fixed-dose and fixed-ratio combinations are novel therapeutic approaches which may help address several issues of treatment complexity and patient burden associated with combination therapy comprising individual drugs. The choice of which drugs to administer and the decision to use stepwise vs combination therapy, however, should always be made on an individualized basis.

A high-resolution photoelectron imaging and theoretical study of CP- and C2P.

The discovery of interstellar anions has been a milestone in astrochemistry. In the search for new interstellar anions, CP- and C2P- are viable candidates since their corresponding neutrals have already been detected astronomically. However, scarce data exist for these negatively charged species. Here we report the electron affinities of CP and C2P along with the vibrational frequencies of their anions using high-resolution photoelectron imaging. These results along with previous spectroscopic data of the neutral species are used further to benchmark very accurate quartic force field quantum chemical methods that are applied to CP, CP-, C2P, and two electronic states of C2P-. The predicted electron affinities, vibrational frequencies, and rotational constants are in excellent agreement with the experimental data. The electron affinities of CP (2.8508 ± 0.0007 eV) and C2P (2.6328 ± 0.0006 eV) are measured accurately and found to be quite high, suggesting that the CP- and C2P- anions are thermodynamically stable and possibly observable. The current study suggests that the combination of high-resolution photoelectron imaging and quantum chemistry can be used to determine accurate molecular constants for exotic radical species of astronomical interest.

Periodontal Disease and Diabetes: Perceptions, Communication, and Referral Between Rural Primary Care Physicians and Dentists.

BACKGROUND AND OBJECTIVE: Connections between oral health and systemic disease, specifically diabetes, are well described in the literature. Screening strategies for diabetes in dental settings and dental screenings in diabetes care settings exist. The purpose of this study was to evaluate the communication and referral patterns between dentists and physicians in a rural state with respect to recognition of dental disease and diabetes. METHODS: Surveys were sent to the members of the North Dakota Academy of Family Physicians, the North Dakota Medical Association, and the North Dakota Dental Association. RESULTS: Overall, 85 responses were collected, with 100% of responding physicians and dentists answering "yes" to a perceived link between oral and systemic health. Physician respondents tended to make a referral for dental evaluation in patients with prediabetes or diabetes more often than dentists referred patients with periodontal disease to physicians. CONCLUSION: Awareness of the link between dental disease and diabetes and of the need for referral is higher among physicians than among dentists. Opportunity exists to improve awareness and increase referrals.

A comparative outcomes analysis evaluating clinical effectiveness in two different human placental membrane products for wound management.

Advances in tissue preservation have led to the commercialization of human placental membranes for the purposes of wound management with each product being characterized by different compositions and properties. The a priori specification of the research question in this investigator-initiated study focused on the clinical outcomes in two nonrandomized, however statistically equal and homogenous patient cohorts receiving either a viable intact cryopreserved human placental membrane (vCPM) or a dehydrated human amnion/chorion membrane (dHACM), for the management of wounds at a single center. A total of 79 patients with 101 wounds were analyzed: 40 patients with 46 wounds received vCPM and 39 patients with 55 wounds received dHACM. The proportion of wounds achieving complete wound closure was 63.0% (29/46) for vCPM and 18.2% (10/55) for dHACM (p < 0.0001) for all treated wounds combined. This is the first comparative effectiveness study to report on the clinical outcomes associated with the use of different placental wound care products once broadly implemented in the clinical setting.

Bond dissociation energies of TiSi, ZrSi, HfSi, VSi, NbSi, and TaSi.

Predissociation thresholds have been observed in the resonant two-photon ionization spectra of TiSi, ZrSi, HfSi, VSi, NbSi, and TaSi. It is argued that because of the high density of electronic states at the ground separated atom limit in these molecules, the predissociation threshold in each case corresponds to the thermochemical bond dissociation energy. The resulting bond dissociation energies are D0(TiSi) = 2.201(3) eV, D0(ZrSi) = 2.950(3) eV, D0(HfSi) = 2.871(3) eV, D0(VSi) = 2.234(3) eV, D0(NbSi) = 3.080(3) eV, and D0(TaSi) = 2.999(3) eV. The enthalpies of formation were also calculated as Δf,0KH°(TiSi(g)) = 705(19) kJ mol-1, Δf,0KH°(ZrSi(g)) = 770(12) kJ mol-1, Δf,0KH°(HfSi(g)) = 787(10) kJ mol-1, Δf,0KH°(VSi(g)) = 743(11) kJ mol-1, Δf,0KH°(NbSi(g)) = 879(11) kJ mol-1, and Δf,0KH°(TaSi(g)) = 938(8) kJ mol-1. Using thermochemical cycles, ionization energies of IE(TiSi) = 6.49(17) eV and IE(VSi) = 6.61(15) eV and bond dissociation energies of the ZrSi- and NbSi- anions, D0(Zr-Si-) ≤ 3.149(15) eV, D0(Zr--Si) ≤ 4.108(20) eV, D0(Nb-Si-) ≤ 3.525(31) eV, and D0(Nb--Si) ≤ 4.017(39) eV, have also been obtained. Calculations on the possible low-lying electronic states of each species are also reported.

CARDIOVASCULAR OUTCOME TRIALS OF THE INCRETIN-BASED THERAPIES: WHAT DO WE KNOW SO FAR?

OBJECTIVE: Diabetes is a well-established pro-inflammatory state with an increased risk for cardiovascular (CV) diseases. In recent years, the number of different classes of agents for the treatment of type 2 diabetes has increased substantially, and while glycemic control is the major focus of these medications, CV safety has become of interest. Two incretin-based therapies are currently available: glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) and dipeptidyl peptidase-4 (DPP-4) inhibitors. METHODS: The literature was reviewed for information regarding the incretin-based therapies and their effects on the CV system. RESULTS: Independent of their glucose-lowering action, incretin-based therapies may have incretin-dependent mechanisms that positively affect blood pressure, weight, and other markers of CV disease risk, and, in the case of DPP-4 inhibition, nonincretin-dependent actions such as improving endothelial function. Several CV outcomes trials (CVOTs) with incretin-based therapies have recently completed with no excess CV risk observed, and positive effects have been reported in at least 1 trial of GLP-1 RAs, with more studies ongoing. Results for the risk for heart failure with DPP-4 inhibitor use are mixed, but no increase has been demonstrated with GLP-1 RAs. CONCLUSION: Future CVOTs will need to be redesigned to help address these questions in the context of the emerging scope of the underlying mechanisms of cardio-metabolic disease in populations with diabetes. ABBREVIATIONS: A1C = hemoglobin A1C ACS = acute coronary syndrome CHD = coronary heart disease CI = confidence interval CV = cardiovascular CVOT = Cardiovascular Outcome Trial DPP-4 = dipeptidyl peptidase 4 FDA = U.S. Food and Drug Administration GIP = glucose-dependent insulinotropic polypeptide GLP-1 = glucagon-like protein 1 GLP-1 RA = glucagon-like protein 1 receptor agonist HF = heart failure HR = hazard ratio LVEF = left ventricular ejection fraction MACE = major adverse cardiovascular events MI = myocardial infarction T2D = type 2 diabetes.

Predissociation measurements of bond dissociation energies: VC, VN, and VS.

The abrupt onset of predissociation in the congested electronic spectra of jet-cooled VC, VN, and VS has been observed using resonant two-photon ionization spectroscopy. It is argued that because of the high density of electronic states in these molecules, the predissociation threshold occurs at the thermochemical threshold for the production of separated atoms in their ground electronic states. As a result, the measured threshold represents the bond dissociation energy. Using this method, bond dissociation energies of D0(V C) = 4.1086(25) eV, D0(V N) = 4.9968(20) eV, and D0(V S) = 4.5353(25) eV are obtained. From these values, enthalpies of formation are derived as Δf,0KH°(V C(g)) = 827.0 ± 8 kJ mol(-1), Δf,0KH°(V N(g)) = 500.9 ± 8 kJ mol(-1), and Δf,0KH°(V S(g)) = 349.3 ± 8 kJ mol(-1). Using a thermochemical cycle and the well-known ionization energies of V, VC, and VN, our results also provide D0(V(+)-C) = 3.7242(25) eV and D0(V(+)-N) = 4.6871(20) eV. These values are compared to previous measurements and to computational results. The precision of these bond dissociation energies makes them good candidates for testing computational chemistry methods, particularly those that employ density functional theory.

Bond dissociation energies of diatomic transition metal selenides: TiSe, ZrSe, HfSe, VSe, NbSe, and TaSe.

Predissociation thresholds have been observed in the resonant two-photon ionization spectra of TiSe, ZrSe, HfSe, VSe, NbSe, and TaSe. It is argued that the sharp onset of predissociation corresponds to the bond dissociation energy in each of these molecules due to their high density of states as the ground separated atom limit is approached. The bond dissociation energies obtained are D0(TiSe) = 3.998(6) eV, D0(ZrSe) = 4.902(3) eV, D0(HfSe) = 5.154(4) eV, D0(VSe) = 3.884(3) eV, D0(NbSe) = 4.834(3) eV, and D0(TaSe) = 4.705(3) eV. Using these dissociation energies, the enthalpies of formation were found to be Δf,0KHo(TiSe(g)) = 320.6 ± 16.8 kJ mol-1, Δf,0KHo(ZrSe(g)) = 371.1 ± 8.5 kJ mol-1, Δf,0KHo(HfSe(g)) = 356.1 ± 6.5 kJ mol-1, Δf,0KHo(VSe(g)) = 372.9 ± 8.1 kJ mol-1, Δf,0KHo(NbSe(g)) = 498.9 ± 8.1 kJ mol-1, and Δf,0KHo(TaSe(g)) = 562.9 ± 1.5 kJ mol-1. Comparisons are made to previous work, when available. Also reported are calculated ground state electronic configurations and terms, dipole moments, vibrational frequencies, bond lengths, and bond dissociation energies for each molecule. A strong correlation of the measured bond dissociation energy with the radial expectation value, ⟨r⟩nd, for the metal atom is found.

Resonant two-photon ionization spectroscopy of jet-cooled OsSi.

The optical spectrum of diatomic OsSi has been investigated for the first time, with transitions observed in the range from 15 212 to 18 634 cm(-1) (657-536 nm). Two electronic band systems have been identified along with a number of unclassified bands. Nine bands have been investigated at rotational resolution, allowing the ground state to be identified as X(3)Σ0(+) (-), arising from the 1σ(2)1π(4)2σ(2)3σ(2)1δ(2) configuration. The ground X(3)Σ0(+) (-) state is characterized by re = 2.1207(27) Å and ΔG1/2″ = 516.315(4) cm(-1) for the most abundant isotopologue, (192)Os(28)Si (38.63%). The A1 excited electronic state, which is thought to be primarily (3)Π1 in character, is characterized by T0 = 15 727.7(7) cm(-1), ωe = 397.0(7) cm(-1), and re = 2.236(16) Å for (192)Os(28)Si. The B1 excited electronic state is characterized by T0 = 18 468.71 cm(-1), ΔG1/2 = 324.1 cm(-1), and re = 2.1987(20) Å for (192)Os(28)Si and is thought to be primarily (1)Π1 in character. These results are placed in context through a comparison to other transition metal carbides and silicides.

Wilderness Medical Society practice guidelines for basic wound management in the austere environment: 2014 update.

In an effort to produce best-practice guidelines for wound management in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for the management of wounds sustained in an austere (dangerous or compromised) environment. Recommendations are made about several parameters related to wound management. These recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks or burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians. This is an updated version of the original guidelines published in Wilderness & Environmental Medicine 2014;25(3):295-310.

Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.

To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the treatment and prevention of lightning injuries. These guidelines include a review of the epidemiology of lightning and recommendations for the prevention of lightning strikes, along with treatment recommendations organized by organ system. Recommendations are graded on the basis of the quality of supporting evidence according to criteria put forth by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for Prevention and Treatment of Lightning Injuries published in Wilderness & Environmental Medicine 2012;23(3):260-269.

Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update.

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the original guidelines published in Wilderness & Environmental Medicine 2011;22(2):156-166.