Dietary Ingredients as an Alternative Approach for Mitigating Chronic Musculoskeletal Pain: Evidence-Based Recommendations for Practice and Research in the Military.

OBJECTIVE: Approximately 55-76% of Service members use dietary supplements for various reasons, including pain and related outcomes. This work evaluates current research on dietary ingredients for chronic musculoskeletal pain to inform decisions for practice and self-care, specifically for Special Operations Forces personnel. METHODS: A steering committee convened to develop research questions and factors required for decision-making. Key databases were searched through August 2016. Eligible systematic reviews and randomized controlled trials were assessed for methodological quality. Meta-analysis was applied where feasible. GRADE was used to determine confidence in the effect estimates. The committee made evidence-informed judgments and recommendations for practice and self-care use. RESULTS: Nineteen eligible dietary ingredients were assessed for quality, efficacy, and safety. Avocado soybean unsaponifiables, capsaicin, curcuma, ginger (as a food source), glucosamine, melatonin, polyunsaturated fatty acids, and vitamin D were conditionally recommended as their benefits outweighed risks, but there was still some uncertainty about the trade-offs. No recommendations were made for boswellia, ginger (as a dietary supplement), rose hip, or s-adenosyl-L-methionine. Recommendations were made against the use of collagen, creatine, devil's claw, l-carnitine, methylsulfonylmethane, pycnogenol, willow bark extract, and vitamin E. Research priorities were developed to address gaps precluding stronger recommendations. CONCLUSIONS: Currently the scientific evidence is insufficiently robust to establish definitive clinical practice guidelines, but processes could be established to track the impact of these ingredients. Until then, providers have the evidence needed to make informed decisions about the safe use of these dietary ingredients, and future research can address existing gaps.

Case Series: Bilateral Rhegmatogenous Retinal Detachments in Atopic Dermatitis.

SIGNIFICANCE: Bilateral occurrence of rhegmatogenous retinal detachment is a potentially blinding condition seen most commonly in patients with atopic dermatitis. Poor control of the skin condition may lead to simultaneous or sequential retinal detachment and even development of complications such as proliferative vitreoretinopathy. PURPOSE: The purpose of this study was to highlight the importance of the dermatologist's role in aggressive treatment of atopic dermatitis to prevent this potentially blinding condition. CASE REPORTS: A retrospective review of three patients with poorly controlled atopic dermatitis at the Singapore National Eye Centre with bilateral rhegmatogenous retinal detachment was conducted. Two patients presented with sequential rhegmatogenous retinal detachments, and one patient had simultaneous bilateral retinal detachments. At presentation, all three were experiencing atopic dermatitis flares and were either on low-dose oral or topical steroids only. Post-retinal detachment surgery, all eyes except one achieved good visual acuity. The patients were referred to a dermatologist and treated with therapeutic doses of systemic steroids and immunomodulators for their dermatitis flare. CONCLUSIONS: This case series draws attention to the importance of the eye care provider's comanagement of such patients with atopic dermatitis. Aggressive control of facial atopic dermatitis with consideration of immunomodulators or short-term systemic steroids during flares to control facial eczema and eye rubbing may reduce this potentially blinding ocular complication.

Is Hyperbaric Oxygen Therapy Effective for Traumatic Brain Injury? A Rapid Evidence Assessment of the Literature and Recommendations for the Field.

OBJECTIVE: This systematic review examines the efficacy of hyperbaric oxygen (HBO2) for traumatic brain injury (TBI) to make evidence-based recommendations for its application and future research. METHODS: A comprehensive search was conducted to identify studies through 2014. Methodological quality was assessed and synthesis and interpretation of relevant data was performed. RESULTS: Twelve randomized trials were included. All mild TBI studies demonstrated minimal bias and no statistically significant differences between HBO2 and sham arms. Statistically significant improvement occurred over time within both groups. Moderate-to-severe TBI studies were of mixed quality, with majority of results favoring HBO2 compared with "standard care." The placebo analysis conducted was limited by lack of details. CONCLUSIONS: For mild TBI, results indicate HBO2 is no better than sham treatment. Improvements within both HBO2 and sham groups cannot be ignored. For acute treatment of moderate-to-severe TBI, although methodology appears flawed across some studies, because of the complexity of brain injury, HBO2 may be beneficial as a relatively safe adjunctive therapy if feasible. Further research should be considered to resolve the controversy surrounding this field, but only if methodological flaws are avoided and bias minimized.

An analysis of the various chronic pain conditions captured in a systematic review of active self-care complementary and integrative medicine therapies for the management of chronic pain symptoms.

OBJECTIVES: Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures that are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM therapies (ACT-CIM) allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management. METHODS: A systematic review was conducted, using Samueli Institute's rapid evidence assessment of the literature (REAL©) methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities. RESULTS: Following key database searches, 146 randomized controlled trials, covering 33 different pain conditions, were included in the review. CONCLUSIONS: This article categorized studies by pain condition, describing the diagnostic criteria used and modalities that seem most effective for each condition. Complexities associated with investigating chronic pain populations are also discussed. The entire scope of the review, categorized by modality rather than pain condition, is detailed throughout the current Pain Medicine supplement.

Title-plus-abstract versus title-only first-level screening approach: a case study using a systematic review of dietary patterns and sarcopenia risk to compare screening performance.

BACKGROUND: Conducting a systematic review is a time- and resource-intensive multi-step process. Enhancing efficiency without sacrificing accuracy and rigor during the screening phase of a systematic review is of interest among the scientific community. METHODS: This case study compares the screening performance of a title-only (Ti/O) screening approach to the more conventional title-plus-abstract (Ti + Ab) screening approach. Both Ti/O and Ti + Ab screening approaches were performed simultaneously during first-level screening of a systematic review investigating the relationship between dietary patterns and risk factors and incidence of sarcopenia. The qualitative and quantitative performance of each screening approach was compared against the final results of studies included in the systematic review, published elsewhere, which used the standard Ti + Ab approach. A statistical analysis was conducted, and contingency tables were used to compare each screening approach in terms of false inclusions and false exclusions and subsequent sensitivity, specificity, accuracy, and positive predictive power. RESULTS: Thirty-eight citations were included in the final analysis, published elsewhere. The current case study found that the Ti/O first-level screening approach correctly identified 22 citations and falsely excluded 16 citations, most often due to titles lacking a clear indicator of study design or outcomes relevant to the systematic review eligibility criteria. The Ti + Ab approach correctly identified 36 citations and falsely excluded 2 citations due to limited population and intervention descriptions in the abstract. Our analysis revealed that the performance of the Ti + Ab first-level screening was statistically different compared to the average performance of both approaches (Chi-squared: 5.21, p value 0.0225) while the Ti/O approach was not (chi-squared: 2.92, p value 0.0874). The predictive power of the first-level screening was 14.3% and 25.5% for the Ti/O and Ti + Ab approaches, respectively. In terms of sensitivity, 57.9% of studies were correctly identified at the first-level screening stage using the Ti/O approach versus 94.7% by the Ti + Ab approach. CONCLUSIONS: In the current case study comparing two screening approaches, the Ti + Ab screening approach captured more relevant studies compared to the Ti/O approach by including a higher number of accurately eligible citations. Ti/O screening may increase the likelihood of missing evidence leading to evidence selection bias. SYSTEMATIC REVIEW REGISTRATION: PROSPERO Protocol Number: CRD42020172655.

Dietary Patterns and the Risk of Sarcopenia: A Systematic Review and Meta-Analysis.

The purpose of this systematic review is to examine the relationship between dietary patterns and sarcopenia using a protocol developed for use by the 2020 Dietary Guidelines Advisory Committee, and to conduct a meta-analysis to summarize the evidence. Multiple electronic databases were searched for studies investigating sarcopenia risk factors or risk of sarcopenia and dietary patterns. Eligible studies were 1) peer-reviewed controlled trials or observational trials, 2) involving adult or older-adult human subjects who were healthy and/or at risk for chronic disease, 3) comparing the effect of consumption or adherence to dietary patterns (measured as an index/score, factor or cluster analysis; reduced rank regression; or a macronutrient distribution), and 4) reported on measures of skeletal muscle mass, muscle strength, muscle performance, and/or risk of sarcopenia. Thirty-eight publications met all inclusion criteria for qualitative synthesis. Thirteen observational studies met inclusion criteria for meta-analysis. Higher adherence to a healthy dietary pattern was associated with a decreased risk of gait speed reduction (OR = 0.58; 95% CI: 0.18, 0.97). The association between healthy dietary pattern adherence and other intermediate markers or risk of sarcopenia was not statistically significant. The majority of individual studies were judged as "serious" risk of bias and analysis of the collective evidence base was suggestive of publication bias. Studies suggest a significant association between healthy dietary patterns and maintenance of gait speed with age, an intermediate marker of sarcopenia risk, but the evidence base is limited by serious risk of bias, within and between studies. Further research is needed to understand the association between healthy dietary patterns and risk of sarcopenia.

Bridging Connectivity Issues in Digital Access and Literacy: Reflections on Empowering Vulnerable Older Adults in Singapore.

This article describes a ground-up initiative for a volunteer-run digital literacy program in Singapore targeting vulnerable older adults, focusing on the barriers faced in running this program and training these beneficiaries. It further offers possible solutions to overcome these hurdles, providing insight for individuals or organizations seeking to start similar ground-up initiatives.

A Scoping Review of Interactions between Omega-3 Long-Chain Polyunsaturated Fatty Acids and Genetic Variation in Relation to Cancer Risk.

This scoping review examines the interaction of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) and genetic variants of various types of cancers. A comprehensive search was performed to identify controlled and observational studies conducted through August 2017. Eighteen unique studies were included: breast cancer (n = 2), gastric cancer (n = 1), exocrine pancreatic cancer (n = 1), chronic lymphocytic leukemia (n = 1), prostate cancer (n = 7) and colorectal cancer (n = 6). An additional 13 studies that focused on fish intake or at-risk populations were summarized to increase readers' understanding of the topic based on this review, DHA and EPA interact with certain genetic variants to decrease breast, colorectal and prostate cancer risk, although data was limited and identified polymorphisms were heterogeneous. The evidence to date demonstrates that omega-3 long-chain polyunsaturated fatty acids (n-3 LC-PUFA) may decrease cancer risk by affecting genetic variants of inflammatory pathways, oxidative stress and tumor apoptosis. Collectively, data supports the notion that once a genetic variant is identified, the benefits of a targeted, personalized therapeutic regimen that includes DHA and/or EPA should be considered.

Inadequate calcium and vitamin D intake and osteoporosis risk in older Americans living in poverty with food insecurities.

Poverty may be a barrier to acquiring adequate nutrient levels for the prevention of osteoporosis. Age and nutritional intake are major factors that contribute to osteoporosis prevalence. This study examined the relationship between markers of poverty with calcium / vitamin D intake and osteoporosis. A cross-sectional analysis of the United States population was performed using National Health and Nutrition Examination Survey (NHANES) data from 2007-2010 and 2013-2014 for older US adults (n = 3,901 participants, 50 years old and older). Odds of inadequate calcium / vitamin D intake and dietary supplement use and risk of probable osteoporosis were calculated in order to determine the relative difference and possible associations between household income, the Family Monthly Poverty Level Index, food security, and participation in the Supplemental Nutrition Assistance Program (SNAP). A sub-analysis of ethnic disparities and biological sex was also performed. In general, women age 50 and older consistently have inadequate calcium intake, regardless of economic level including poverty. While inadequate calcium intake has a larger prevalence among women, markers of poverty increased the risk of inadequate calcium intake in all men and risk of osteoporosis among some subgroups, with the exception of SNAP program participation. Over one fourth of Non-Hispanic black men in the US are below the poverty line. Approximately half of this population has inadequate calcium (58.9%) and vitamin D (46.7%) intake. Typically, osteoporosis risk is relatively low for Non-Hispanic Black males, however considering poverty status, risk is significantly increased (Relative Risk Ratio [RR]: 2.057 ± 0.012) for those with low income suggesting that calcium and vitamin D supplementation may be of benefit for this population.

Methodological approach to moving nutritional science evidence into practice.

The Metabolically Optimized Brain study explored nutritional science believed to be ready to place into practice to help improve US service members' cognitive performance and, thereby, optimize mission-readiness. A transparent, step-wise, research approach was used for informing evidence-based decisions among and for various, diverse stakeholders. A steering committee and subject-matter experts convened to devise the protocol and independent systematic reviews were performed to determine the quality of the evidence for nutritional science in 4 areas relevant to military populations: (1) caffeinated foods and beverages; (2) omega-3 polyunsaturated fatty acids; (3) plant-based foods and beverages or their phytochemical constituents; and (4) whole dietary patterns. A research expert panel was asked to then recommend future research directions and solutions likely to benefit warfighters. An implementation expert panel further considered how to apply sound nutritional science in a cost-effective manner. This article summarizes the methodological processes, high-level results, global research recommendations, and priorities for implementation. Specific results of the individual dietary interventions, as well as recommendations for moving this field of research and practice forward, are detailed throughout the current supplement.

Phytochemicals to optimize cognitive function for military mission-readiness: a systematic review and recommendations for the field.

Context: Optimizing cognitive performance and preventing cognitive impairments that result from exposure to high-stress situations are important to ensure mission-readiness for military personnel. Objective: This systematic review assesses the quality of the evidence for plant-based foods and beverages, or their phytochemical constituents, across various outcomes related to cognitive function in healthy adult populations to develop research recommendations for the military. Data Sources: PubMed, CINAHL, Embase, PsycInfo, and the Cochrane Library were searched. Study Selection: Peer-reviewed randomized controlled trials published in the English language were eligible. Data Extraction: Twenty-five trials were included and assessed for methodological quality, and descriptive data were extracted. Data Synthesis: The acceptable (n = 16) to high-quality (n = 4) studies produced either no statistically significant effect or mixed results for enhancing cognitive function. Conclusions: The evidence suggested that healthy populations do not experience significant changes in cognitive performance when consuming soy- and non-soy-sourced isoflavones or cocoa. Heterogeneity among other interventions precluded reaching formal conclusions surrounding the evidence. Research recommendations are offered, including conducting more studies on the effect of plant-based interventions on populations reflective of military populations when exposed to military-like situations.

Caffeine to optimize cognitive function for military mission-readiness: a systematic review and recommendations for the field.

Context: In 2001 the Institute of Medicine (IOM) released a report on the use of caffeine during sustained military operations in which recommendations for research and practice were made. Objective: This systematic review serves as an update on the current quality of the evidence and addresses gaps in the current literature surrounding the effects of caffeinated foods and beverages on cognitive functioning in healthy adult populations exposed to military-like moderators. Data Sources: PubMed, CINAHL, Embase, PsycInfo, and the Cochrane Library were searched. Study Selection: Peer-reviewed randomized controlled trials published in the English language since 1998 were eligible. Data Extraction: Twenty-five trials were included and assessed for methodological quality, and descriptive data were extracted according to each military-like moderator identified. Data Synthesis: Moderators included sleep deprivation (n = 17), physical or mental exertion (n = 4), sleep deprivation combined with a sustained military operation (n = 3), and physical exertion combined with low ambient temperature (n = 1). Conclusions: The effects of caffeine supplementation on cognitive functioning in sleep-deprived subjects included improvements in attention and vigilance, complex reaction time, and problem solving and reasoning in the trials reviewed. These findings are consistent with the conclusions reached in the 2001 IOM report. This review contributes to the field by addressing gaps outlined in the IOM report.

Omega-3 polyunsaturated fatty acids to optimize cognitive function for military mission-readiness: a systematic review and recommendations for the field.

Context: There has been interest in identifying whether nutrients might help optimize cognitive performance, especially for the military tasked with ensuring mission-readiness. Objective: This systematic review assesses the quality of the evidence for n-3 polyunsaturated fatty acids (PUFAs) across various outcomes related to cognitive function in healthy adult populations in order to develop research recommendations concerning n-3 PUFAs for mission-readiness. Data Sources: PubMed, CINAHL, Embase, PsycInfo, and the Cochrane Library were searched. Study Selection: Peer-reviewed randomized controlled trials published in the English language were eligible. Data Extraction: Thirteen included trials were assessed for methodological quality, and descriptive data were extracted. Data Synthesis: Of the acceptable-quality (n = 8) and high-quality (n = 1) studies, 2 produced no statistically significant results, 5 produced mixed results, and 2 did not report between-group results. Conclusions: Results indicate that ingestion of n-3 PUFAs does not significantly alter cognitive performance in cognitively healthy persons. Studies exposing subjects to adverse circumstances that would be most relevant for drawing conclusions specifically for the military population are lacking. Several research recommendations are offered to enhance understanding of the role of fatty acids on cognitive functioning.

Whole dietary patterns to optimize cognitive function for military mission-readiness: a systematic review and recommendations for the field.

Context: Optimizing cognitive performance, particularly during times of high stress, is a prerequisite to mission-readiness among military personnel. It has been of interest to determine whether such performance could be enhanced through diet. Objective: This systematic review assesses the quality of the evidence for whole dietary patterns across various outcomes related to cognitive function in healthy adult populations to develop research recommendations for the military. Data Sources: PubMed, CINAHL, Embase, PsycInfo, and the Cochrane Library were searched. Study Selection: Peer-reviewed randomized controlled trials published in the English language were eligible. Data Extraction: Fifteen included trials were assessed for methodological quality, and descriptive data were extracted. Data Synthesis: Of the 6 acceptable-quality studies, 1 demonstrated statistically nonsignificant results, whereas the other 5 showed conflicting results across the cognitive outcomes assessed. Conclusions: Due to the heterogeneity across the included studies, no recommendations could be reached concerning whether certain whole dietary patterns have an effect on cognitive outcomes in healthy populations. Specific recommendations for future research are offered.

The influence of peri-incisional triamcinolone acetonide injection on wound edge apposition.

Local administration of corticosteroids has been demonstrated to have both beneficial and detrimental effects on wound healing. The advantages of limiting localized edema must be weighed against corticosteroids' disadvantageous inhibition of the normal growth factor profile production that is essential for would healing. A single-center prospective, randomized, controlled, single-blind study of 57 patients undergoing hair restoration surgery (HRS) by one of three different surgeons revealed: 1) no dehiscence along the donor wound; 2) no statistically significant difference (p < 0.05) in wound edge apposition noted between patients receiving or not receiving intralesional corticosteroids at any of the four measured scalp regions and 3) a non-statistically significant trend emerged suggesting the benefit of corticosteroid at the temples (points of decreased donor closing tension) versus its potential hindrance along the mastoids (points of increased tension). These results suggest that peri-incisional triamcinolone acetonide (PITMC) does not have a statistically significant effect on donor wound edge apposition within 8-10 days of HRS. A subtle, though not statistically significant, trend emerged demonstrating the benefit of PITMC with respect to early phase donor wound edge apposition in areas of least donor closing tension and the hindrance of PITMC in regions of increased tension.

Drug hypersensitivity syndrome with significant gastrointestinal involvement.

Drug hypersensitivity syndrome (DHS) is an idiosyncratic systemic reaction to a drug. The clinical presentation of this syndrome comprises a diverse spectrum, ranging from mild to fulminating organ failure. Nonspecific gastrointestinal symptoms are common in DHS, but severe morbidities and mortalities attributed to gut disease in DHS are rarely described. We present a case of DHS with significant gastrointestinal symptoms of prolonged profuse watery diarrhoea and persistent hypokalaemia requiring judicious intravenous water and electrolyte replacement. The symptoms resolved only after the introduction of intravenous hydrocortisone. It is important to consider intravenous corticosteroids if the gastrointestinal system is involved, as accelerated gut motility and mucosal damage would affect absorption of oral medications. Supportive treatment with the monitoring of fluid and electrolytes status and judicious replacement remains fundamental in the management of DHS patients with gut involvement.

Cutaneous melioidosis.

Melioidosis is an infection caused by the gram-negative bacterium Burkholderia pseudomallei. This disease is endemic in Southeast Asia and North Australia with sporadic occurrence in temperate countries, mostly imported from travellers. Any organ can be involved in melioidosis whereby Burkholderia pseudomallei causes an acute inflammatory reaction with rapid development of small abcesses which tend to coalesce to form larger abscesses. Cutaneous manifestations vary greatly. We report a man with systemic melioidosis who presented with cutaneous lesions.

Surgical reconstruction for posterolateral rotatory instability of the elbow.

We reviewed the results of 10 patients (10 elbows) who underwent surgical reconstruction for clinically symptomatic posterolateral rotatory instability of the elbow. The symptoms resulted from previous dislocation or a hyperextension or varus stress injury of the elbow. Two elbows had underlying preexisting varus deformity. Surgical reconstruction was performed with a tendon graft in 6 elbows and reattachment of the lateral ulnar collateral ligament to the humerus in 4. Postoperatively, no patient had residual instability or a positive pivot shift test in the elbow. Results were graded as excellent or good in 8 and fair in 2. All patients with excellent results had surgical reconstruction with a tendon graft. Subjective assessment revealed that all 10 patients were satisfied with the outcome of the surgery. Accurate recognition of posterolateral rotatory instability of the elbow is important for appropriate management. Surgical ligament reconstruction or repair is the most favorable treatment option for restoration of normal elbow function. The choice of reconstruction with a tendon graft appeared to produce better results than the reattachment of the injured ligament by itself in achieving an excellent outcome.

A community-based epidemiological study of acne vulgaris in Hong Kong adolescents.

Using a questionnaire survey, the prevalence and severity of acne were assessed in a randomized sample of 522 persons (aged 15-25 years) out of 5,522 telephone interviews in Hong Kong. The prevalence of self-reported acne was 91.3%. At the time of interview, 52.2% had acne. More acne scars and pigmentation were present (52.6%) than in a Western population; 26.6% were disturbed psychologically by acne and 82.9% by its physical appearance. Only 2.4% had sought the advice of a doctor for managing acne, while 41.5% had tried some form of medical treatment. Topical treatment comprised 94.7% of medications used for acne. The results show that acne and its complications are common problems. The treatment of acne scars and pigmentation is difficult and complicated by Asian skin phototypes. The findings suggest the need for refined educational programmes to ensure that adolescents know what effective treatments are available so that complications can be reduced.