The effect of geographic origin and destination on congenital heart disease outcomes: a retrospective cohort study.

BACKGROUND: Congenital heart disease (CHD) is a common and significant birth defect, frequently requiring surgical intervention. For beneficiaries of the Department of Defense, a new diagnosis of CHD may occur while living at rural duty stations. Choice of tertiary care center becomes a function of geography, referring provider recommendations, and patient preference. METHODS: Using billing data from the Military Health System over a 5-year period, outcomes for beneficiaries age < 10 years undergoing CHD surgery were compared by patient origin (rural versus urban residence) and the distance to treatment (patient's home and the treating tertiary care center). These beneficiaries include children of active duty, activated reserves, and federally activated National Guard service members. Analysis of the outcomes were adjusted for procedure complexity risk. Treatment centers were further stratified by annual case volume and whether they publicly reported results in the society of thoracic surgery (STS) outcomes database. RESULTS: While increasing distance was associated with the cost of admission, there was no associated risk of inpatient mortality, one year mortality, or increased length of stay. Likewise, rural origination was not significantly associated with target outcomes. Patients traveled farther for STS-reporting centers (STS-pr), particularly high-volume centers. Such high-volume centers (> 50 high complexity cases annually) demonstrated decreased one year mortality, but increased cost and length of stay. CONCLUSIONS: Together, these findings contribute to the national conversation of rural community medicine versus regionalized subspecialty care; separation of patients between rural areas and more urban locations for initial CHD surgical care does not increase their mortality risk. In fact, traveling to high volume centers may have an associated mortality benefit.

Isolated cardiac cysticercosis in an adolescent.

Cardiac cysticercosis is a rare and typically asymptomatic infection. We report a case of a young man from Cameroon with a left ventricular cyst discovered during a screening echocardiogram. Computed tomography and plain films did not reveal additional cysts. Serology was negative. The patient had the cyst surgically removed for suspected echinococcosis. Sectioning demonstrated a cysticercus. The literature on cardiac cysticercosis is reviewed.

Military-civic action: lessons learned from a brigade-level aid project in the 2003 war with Iraq.

The primary mission of the military physician assigned to a combat-arms unit is to sustain the unit's fighting strength through prevention, primary medical care, and trauma resuscitation. Technical and organizational details of civic action assistance are not emphasized routinely during training. Real-world deployment, however, presents challenges approachable only with flexibility and improvisation. Historically, combatant commanders have recognized the health of civilians in their operational area as a target through which local acceptance of United States (US) intervention may be achieved. The medium-unit (battalion and brigade) physician may be charged with providing care to the host-nation populace. Because the mission's emphasis is one of public relations and not sustainable development, lasting medical benefits are not attained. This article addresses the challenge of on-the-spot military civic assistance. The experience of the 173d Airborne Brigade (Bde) Medical Section is used to color concepts with real events. The unit attempted to reach beyond the immediate directive in order to create a program of lasting results.

Autoimmune pancreatitis - diagnosis, management and longterm follow-up.

BACKGROUND & AIMS: Autoimmune pancreatitis (AIP) is a fibroinflammatory condition affecting the pancreas and could present as a multisystem disorder. Diagnosis and management can pose a diagnostic challenge in certain groups of patients. We report our experience of managing this condition in a tertiary pancreaticobiliary centre in the North East of England. METHODS: Patients were identified from a prospectively maintained database of patients diagnosed with AIP between 2005 and 2013. Diagnosis of definite/probable AIP was based on the revised HISORt criteria. When indicated, patients were treated with steroids and relapses were treated with azathioprine. All patients have been followed up to date. RESULTS: Twenty-two patients were diagnosed with AIP during this period. All patients had pancreatic protocol CT performed while some patients had either MR or EUS as part of the work up. Fourteen out of 22 (64%) had an elevated IgG4 level (mean: 10.9 g/L; range 3.4 - 31 g/L). Four (18%) patients underwent surgery. Extrapancreatic involvement was seen in 15 (68%) patients, with biliary involvement being the commonest. Nineteen (86%) were treated with steroids and five (23%) required further immunosuppression for treatment of relapses. The mean follow up period was 36.94 months (range 7 - 94). CONCLUSION: Autoimmune pancreatitis is being increasingly recognized in the British population. Extrapancreatic involvement, particularly extrahepatic biliary involvement seems to be a frequent feature. Diagnosis should be based on accepted criteria as this significantly reduces the chances of overlooking malignancy. Awareness of this relatively rare condition and a multi-disciplinary team approach will help us to diagnose and treat this condition more effectively thereby reducing unnecessary interventions.

Hypoplastic left heart syndrome in US military family members: trends in intervention, survival, and prevalence.

INTRODUCTION: Hypoplastic left heart syndrome was uniformly fatal until the 1980s but now has survival approaching 70% to age 5 due to treatment advances. The current study was undertaken to examine trends in the intervention rate, survival, and prevalence of hypoplastic left heart syndrome among US military family members. We hypothesized that increased rates of intervention and survival would produce a demonstrable increase in prevalence in this population. METHODS: This was a retrospective review of administrative data. Central databases contain records from Army hospital admissions since 1972, all military hospital admissions since 1989, outpatient visits since 2000, and civilian bills to the military system since 2000. Patients with an instance of the relevant diagnosis (code 746.7) were included and all of their data records reviewed. Patients with incompatible diagnoses or survival were excluded. RESULTS: There were 366 patients identified, 63 born in the 1980s, 155 in the 1990 s, and 148 after 2000. The rate of intervention increased from 54% in the 1990 s to 97% in the 2000s (P < .001). Five-year survival increased markedly between the 1980s and the 1990 s. For patients born since 2000 and undergoing intervention, survival was 66% to 21 months (95% confidence interval 56-75%). Prevalence at birth in military hospitals was 1.4 per 10,000 with no significant trend over time. Prevalence among inpatients other than at birth increased from 0.4 to 15 per 10,000 between 1989 and 2005 (r(2) = 0.92, P < .001). CONCLUSIONS: The rates of intervention and survival of patients with hypoplastic left heart syndrome have increased dramatically over the past 15 years. This has resulted in a demonstrable increase in prevalence among the beneficiary population. Future study focused on this cohort could detail their healthcare needs and demonstrate the effect of hypoplastic left heart syndrome on the family and its growing impact on the military healthcare system.