Frostbite: a treatment guideline for prehospital treatment in a military environment.

Frostbite remains a severe medical condition that causes long-lasting sequelae and can threaten military operations. Information on prehospital treatment of frostbite is scarce and existing guidelines are aimed at the general population.This paper provides a guideline on prehospital emergency care of frostbite in the (Netherlands) Armed Forces. The insights gained from studies reporting on frostbite treatment in the prehospital setting were combined with the expert opinions of the authors and applied to the military context. The resulting guideline consists of two stages: (prolonged) field care and care at a Medical Treatment Facility. The cornerstones are rewarming in warm water and evacuation to a medical facility. Additional aspects of prehospital treatment are rehydration, proper analgesia, non-steroidal anti-inflammatory drugs and wound care.We suggest further collaboration among North Atlantic Treaty Organization partners and other affiliated nations, focusing on the full spectrum of military injury management including state-of-the-art aftercare, long-lasting sequelae and return to duty after frostbite.

Frostbite: a systematic review on freezing cold injuries in a military environment.

BACKGROUND: Military practice or deployment in extreme conditions includes risks, dangers and rare disorders. One of the challenges is frostbite; however, current literature does not provide an overview of this condition in a military context. This review aims to map the incidence, risk factors and outcome of frostbite in military casualties in the armed forces. METHODS: A systematic literature search on frostbite (freezing cold injuries) in military settings from 1995 to the present was performed. A critical appraisal of the included articles was conducted. Data on incidence, risk factors, treatment and outcome were extracted. RESULTS: Fourteen studies were included in our systematic review. Most studies of frostbite in a military setting were published nearly half a century ago. Frostbite incidence has declined from 7% to around 1% in armed forces in arctic regions but could be as high as 20% in small-scale arctic manoeuvres. Overall and military-specific risk factors for contracting frostbite were identified. CONCLUSION: During inevitable arctic manoeuvres, frostbite is a frequently diagnosed injury in service members. Postfreezing symptoms often persist after severe frostbite injury, which decreases employability within the service. Over time, military practice has changed considerably, and modern protective materials have been introduced; therefore, re-evaluation and future study in the military field are appropriate, preferably with other North Atlantic Treaty Organization partners.

Differential linguistic features of verbal fluency in behavioral variant frontotemporal dementia and primary progressive aphasia.

Frontotemporal dementia (FTD) is an early-onset neurodegenerative disorder with a heterogeneous clinical presentation. Verbal fluency is regularly used as a sensitive measure of language ability, semantic memory, and executive functioning, but qualitative changes in verbal fluency in FTD are currently overlooked. This retrospective study examined qualitative, linguistic features of verbal fluency in 137 patients with behavioral variant (bv)FTD (n = 50), or primary progressive aphasia (PPA) [25 non-fluent variant (nfvPPA), 27 semantic variant (svPPA), and 34 logopenic variant (lvPPA)] and 25 control participants. Between-group differences in clustering, switching, lexical frequency (LF), age of acquisition (AoA), neighborhood density (ND), and word length (WL) were examined in the category and letter fluency with analysis of variance adjusted for age, sex, and the total number of words. Associations with other cognitive functions were explored with linear regression analysis. The results showed that the verbal fluency performance of patients with svPPA could be distinguished from controls and other patient groups by fewer and smaller clusters, more switches, higher LF, and lower AoA (all p < 0.05). Patients with lvPPA specifically produced words with higher ND than the other patient groups (p < 0.05). Patients with bvFTD produced longer words than the PPA groups (p < 0.05). Clustering, switching, LF, AoA, and ND-but not WL-were differentially predicted by measures of language, memory, and executive functioning (range standardized regression coefficient 0.25-0.41). In addition to the total number of words, qualitative linguistic features differ between subtypes of FTD. These features provide additional information on lexical processing and semantic memory that may aid the differential diagnosis of FTD.

Impaired Knowledge of Social Norms in Dementia and Psychiatric Disorders: Validation of the Social Norms Questionnaire-Dutch Version (SNQ-NL).

The Social Norms Questionnaire-Dutch version (SNQ-NL) measures the ability to understand and identify social boundaries. We examined the psychometric characteristics of the SNQ-NL and its ability to differentiate between patients with behavioral variant frontotemporal dementia (bvFTD; n = 23), Alzheimer's dementia (AD; n = 26), chronic psychiatric disorders (n = 27), and control participants (n = 92). Between-group differences in the Total score, Break errors, and Overadhere errors were examined and associations with demographic variables and other cognitive functions were explored. Results showed that the SNQ-NL Total Score and Break errors differed between patients with AD and bvFTD, but not between patients with bvFTD and psychiatric disorders. Modest correlations with age, sex, and education were observed. The SNQ-NL Total score and Break errors correlated significantly with emotion recognition and verbal fluency but not with processing speed or mental flexibility. In conclusion, the SNQ-NL has sufficient construct validity and can be used to investigate knowledge of social norms in clinical populations.

It's all about timing, early treatment with hyperbaric oxygen therapy and corticosteroids is essential in acute acoustic trauma.

BACKGROUND: Acute acoustic trauma (AAT) is an acute hearing impairment caused by intense noise-impact. The current management strategy for AAT with substantial hearing loss in the Dutch military is the combination therapy with corticosteroids and hyperbaric oxygen therapy (HBOT). In a previous study, early initiation of the combination therapy was associated with better outcomes. Therefore, we performed a new analysis to assess the difference in hearing outcome between patients in whom combination therapy was started within two days, versus after more than two days. METHODS: A retrospective analysis was performed on military patients diagnosed with AAT with substantial hearing loss who presented between February 2018 and March 2020. Absolute and relative hearing improvement between first and last audiograms were calculated for all affected frequencies (defined as loss of ≥20 dB on initial audiogram). We also determined the amount of patients who recovered to the level of Dutch military requirement, and performed speech discrimination tests. RESULTS: In this analysis, 30 male patients (49 ears) with AAT were included. The median age was 24.5 years (IQR 23-29). The median time to initiation of therapy with corticosteroids and HBOT were one and two days, respectively. HBOT was started within two days in 31 ears, and after more than two days in 18 ears. The mean absolute and relative hearing gains were 18.8 dB (SD 14.6) and 46.8% (SD 31.3) on all affected frequencies. The 100% discrimination/speech perception level improved from 64.0 dB to 51.7 dB (gain 12.3 dB ± 14.1). There was significantly more improvement in absolute and relative hearing improvement when HBOT was started in ≤2 days, compared to >2 days. CONCLUSION: Our analysis shows results in favor of early initiation (≤2 days) of the combination treatment of HBOT and corticosteroids in patients with AAT.

Differences in Discriminability and Response Bias on Rey Auditory Verbal Learning Test Delayed Recognition in Behavioral Variant Frontotemporal Dementia and Alzheimer's Disease.

OBJECTIVE: Episodic memory is impaired in Alzheimer's disease (AD) dementia but thought to be relatively spared in behavioral variant frontotemporal dementia (bvFTD). This view is challenged by evidence of memory impairment in bvFTD. This study investigated differences in recognition memory performance between bvFTD and AD. METHOD: We performed a retrospective analysis on the recognition trial of the Rey Auditory Verbal Learning Test in patients with bvFTD (n = 85), AD (n = 55), and control participants (n = 59). Age- and education-adjusted between-group analysis was performed on the total score and indices of discriminative ability and response bias. Correlations between recognition and measures of memory, language, executive functioning, and construction were examined. RESULTS: Patients with AD had a significantly lower total recognition score than patients with bvFTD (control 28.8 ± 1.5; bvFTD 24.8 ± 4.5; AD 23.4 ± 3.6, p < .01). Both bvFTD and AD had worse discriminative ability than controls (A' control 0.96 ± 0.03; bvFTD 0.87 ± 0.03; AD 0.84 ± 0.10, p < .01), but there was no difference in response bias (B" control 0.9 ± 0.2; bvFTD 1.6 ± 1.47; AD 1.4± 1.4, p < .01). AD had worse discriminability than bvFTD (p < .05). Discriminability was associated with memory for both patient groups (median correlation coefficient r = .34) and additionally associated with language (r = .31), but not executive functioning (r = -.03) in bvFTD. Response bias was unrelated to other cognitive functions (r = -.02). CONCLUSIONS: Discriminability, but not response bias, differentiated patients with bvFTD from AD. The presence of an impaired discrimination index suggests a "pure" (recognition) memory deficit in bvFTD.

Correction to: Cognitive profiles discriminate between genetic variants of behavioral frontotemporal dementia.

The original version of this article unfortunately contained a mistake.

Cognitive profiles discriminate between genetic variants of behavioral frontotemporal dementia.

INTRODUCTION: Trials to test disease-modifying treatments for frontotemporal dementia are eagerly awaited and sensitive instruments to assess potential treatment effects are increasingly urgent, yet lacking thus far. We aimed to identify gene-specific instruments assessing clinical onset and disease progression by comparing cognitive functioning between bvFTD patients across genetic mutations. METHODS: We examined differences in 7 cognitive domains between bvFTD patients with GRN (n = 20), MAPT (n = 29) or C9orf72 (n = 31) mutations, and non-carriers (n = 24), and described longitudinal (M = 22.6 months, SD = 16.6) data in a subsample (n = 27). RESULTS: Patients showed overall cognitive impairment, except memory recall, working memory and visuoconstruction. GRN patients performed lower on executive function (mean difference - 2.1; 95%CI - 4.1 to - 0.5) compared to MAPT and lower on attention compared to MAPT (mean difference - 2.5; 95%CI - 4.7 to - 0.3) and C9orf72 (mean difference - 2.4; 95%CI - 4.5 to - 0.3). Only MAPT patients were impaired on delayed recall (mean difference - 1.4; 95%CI - 2.1 to - 0.7). GRN patients declined rapidly on attention and memory, MAPT declined in confrontation naming, whereas C9orf72 patients were globally impaired but remained relatively stable over time on all cognitive domains. DISCUSSION: This study shows gene-specific cognitive profiles in bvFTD, which underlines the value of neuropsychological tests as outcome measures in upcoming trials for genetic bvFTD.

Neuropathological and genetic characteristics of a post-mortem series of cases with dementia with Lewy bodies clinically suspected of Creutzfeldt-Jakob's disease.

INTRODUCTION: The disease course of dementia with Lewy bodies (DLB) can be rapidly progressive, clinically resembling Creutzfeldt-Jakob's disease (CJD). To better understand factors contributing to this rapidly progressive disease course, we describe load and distribution of neuropathology, and the presence of possible disease-associated genetic defects in a post-mortem series of DLB cases clinically suspected of CJD. METHODS: We included pathologically confirmed DLB cases with a disease duration of 3.5 years or less from the Dutch Surveillance Center for Prion Diseases, collected between 1998 and 2014. Lewy body disease (LBD) and Alzheimer's disease (AD)-related pathology were staged and semi-quantitatively scored in selected brain regions. Whole exome sequencing analysis of known disease-associated genes, copy number analysis, APOE ε genotyping and C9orf72 repeat expansion analysis were performed to identify defects in genes with a well-established involvement in Parkinson's disease or AD. RESULTS: Diffuse LBD was present in nine cases, transitional LBD in six cases and brainstem-predominant LBD in one case. Neocortical alpha-synuclein load was significantly higher in cases with intermediate-to-high than in cases with low-to-none AD-related pathology (p = 0.007). We found two GBA variants (p.D140H and p.E326K) in one patient and two heterozygous rare variants of unknown significance in SORL1 in two patients. CONCLUSION: A high load of neocortical alpha-synuclein pathology was present in most, but not all DLB cases. Additional burden from presence of concomitant pathologies, synergistic effects and specific genetic defects in the known disease-associated genes may have contributed to the rapid disease progression.

Differential insular cortex subregional vulnerability to α-synuclein pathology in Parkinson's disease and dementia with Lewy bodies.

AIM: The insular cortex consists of a heterogenous cytoarchitecture and diverse connections and is thought to integrate autonomic, cognitive, emotional and interoceptive functions to guide behaviour. In Parkinson's disease (PD) and dementia with Lewy bodies (DLB), it reveals α-synuclein pathology in advanced stages. The aim of this study is to assess the insular cortex cellular and subregional vulnerability to α-synuclein pathology in well-characterized PD and DLB subjects. METHODS: We analysed postmortem insular tissue from 24 donors with incidental Lewy body disease, PD, PD with dementia (PDD), DLB and age-matched controls. The load and distribution of α-synuclein pathology and tyrosine hydroxylase (TH) cells were studied throughout the insular subregions. The selective involvement of von Economo neurons (VENs) in the anterior insula and astroglia was assessed in all groups. RESULTS: A decreasing gradient of α-synuclein pathology load from the anterior periallocortical agranular towards the intermediate dysgranular and posterior isocortical granular insular subregions was found. Few VENs revealed α-synuclein inclusions while astroglial synucleinopathy was a predominant feature in PDD and DLB. TH neurons were predominant in the agranular and dysgranular subregions but did not reveal α-synuclein inclusions or significant reduction in density in patient groups. CONCLUSIONS: Our study highlights the vulnerability of the anterior agranular insula to α-synuclein pathology in PD, PDD and DLB. Whereas VENs and astrocytes were affected in advanced disease stages, insular TH neurons were spared. Owing to the anterior insula's affective, cognitive and autonomic functions, its greater vulnerability to pathology indicates a potential contribution to nonmotor deficits in PD and DLB.

Functional connectivity and microstructural white matter changes in phenocopy frontotemporal dementia.

OBJECTIVES: Phenocopy frontotemporal dementia (phFTD) is a rare and poorly understood clinical syndrome. PhFTD shows core behavioural variant FTD (bvFTD) symptoms without associated cognitive deficits and brain abnormalities on conventional MRI and without progression. In contrast to phFTD, functional connectivity and white matter (WM) microstructural abnormalities have been observed in bvFTD. We hypothesise that phFTD belongs to the same disease spectrum as bvFTD and investigated whether functional connectivity and microstructural WM changes similar to bvFTD are present in phFTD. METHODS: Seven phFTD patients without progression or alternative psychiatric diagnosis, 12 bvFTD patients and 17 controls underwent resting state functional MRI (rs-fMRI) and diffusion tensor imaging (DTI). Default mode network (DMN) connectivity and WM measures were compared between groups. RESULTS: PhFTD showed subtly increased DMN connectivity and subtle microstructural changes in frontal WM tracts. BvFTD showed abnormalities in similar regions as phFTD, but had lower increased DMN connectivity and more extensive microstructural WM changes. CONCLUSIONS: Our findings can be interpreted as neuropathological changes in phFTD and are in support of the hypothesis that phFTD and bvFTD may belong to the same disease spectrum. Advanced MRI techniques, objectively identifying brain abnormalities, would therefore be potentially suited to improve the diagnosis of phFTD. KEY POINTS: • PhFTD shows brain abnormalities that are similar to bvFTD. • PhFTD shows increased functional connectivity in the parietal default mode network. • PhFTD shows microstructural white matter abnormalities in the frontal lobe. • We hypothesise phFTD and bvFTD may belong to the same disease spectrum.

Retinal vascular caliber and risk of dementia: the Rotterdam study.

BACKGROUND: Retinal vessels provide a unique opportunity to study both systemic and cerebrovascular disease. Smaller retinal arteriolar calibers are strongly related to hypertension, whereas larger retinal venular calibers are more related to inflammation, cerebral hypoperfusion, and cerebrovascular disease. Whether retinal vessel calibers are related to dementia remains unclear. METHODS: We investigated whether retinal arteriolar and venular calibers are associated with risk of dementia, and its subtypes Alzheimer disease (AD) and vascular dementia, in the prospective population-based Rotterdam Study. Digitized retinal images were available in 5,553 participants aged 55 years or over and dementia-free at baseline (1990-1993). Participants were re-examined in 1993-1994, 1997-1999, and 2002-2004 and were continuously monitored for development of dementia. RESULTS: During a mean follow-up of 11.6 years, 655 participants developed dementia. AD was diagnosed in 519 and vascular dementia in 73 participants. Larger venular calibers were associated with an increased risk of dementia, in particular vascular dementia (age- and sex-adjusted hazard ratio per SD increase: 1.31; 95% confidence interval 1.06-1.64), but not AD. The association remained significant after adjustment for stroke and cardiovascular risk factors. Smaller arteriolar calibers were also associated with an increased risk of vascular dementia, yet only when adjusted for venular calibers. CONCLUSIONS: Retinal venular widening is associated with an increased risk of vascular dementia. Our findings are in line with previous observations in stroke and cerebral small-vessel disease and suggest that the association between larger retinal venular calibers and dementia may reflect cerebral hypoperfusion and subsequent ischemia.

Coma in thrombotic thrombocytopenic purpura.

Thrombotic thrombocytopenic purpura (TTP) is characterised by a thrombotic, haemolytic microangiopathy leading to microvascular occlusion, haemolysis and ischaemic dysfunction of various organs including the brain. TTP may present with a variety of neurological symptoms, including headache, focal deficits, seizures and coma. The authors describe a 55-year-old man presenting with abdominal pain and rapidly progressive deterioration into coma without focal neurological deficits or seizures. A concomitant, transient, rapid increase in blood pressure raised the suspicion of a hypertensive crisis. Yet, our patient did not improve after vigorous treatment with antihypertensives. Brain imaging excluded a hypertensive leucoencephalopathy. Despite the absence of a disintegrin and metalloproteinase with a thrombospondin type 1 motif member 13 (ADAMTS13) deficiency, the diagnosis idiopathic TTP was made after excluding secondary causes of TTP. Upon treatment with plasma exchange, corticosteroids and vincristin our patient gradually improved. On discharge to a rehabilitation centre he was awake and alert, had minor cognitive deficits and a mild proximal tetraparesis consistent with a critical illness poly(neuro)myopathy.

Retinal vessel diameters and risk of stroke: the Rotterdam Study.

BACKGROUND: Retinal vessels may provide information on cerebral vascular pathology, because they share many features with cerebral vessels. A smaller ratio of the retinal arteriolar-to-venular diameters reportedly predicts the risk of stroke. It is unclear if this is due to arteriolar narrowing or venular dilation. OBJECTIVE: To investigate whether smaller arteriolar or larger venular diameters are related to the risk of stroke and cerebral infarction. METHODS: This study was based on the prospective population-based Rotterdam Study and included 5,540 participants of 55 years or over, who had gradable fundus transparencies and were free of stroke at baseline (1990 to 1993). For each participant, retinal arteriolar and venular diameters were measured on digitized images of one eye. Follow-up for first-ever stroke was complete until January 1, 2002. RESULTS: After a mean follow-up of 8.5 years, 411 participants had a stroke, of whom 259 had cerebral infarction. Larger venular diameters were associated with an increased risk of stroke (hazard ratio [HR] adjusted for age and sex per SD increase: 1.12 [95% CI: 1.02 to 1.24]) and cerebral infarction (HR: 1.15 [95% CI: 1.02 to 1.29]). Smaller arteriolar diameters were neither related to the risk of stroke (HR per SD decrease: 1.02 [95% CI: 0.93 to 1.13]) nor to the risk of cerebral infarction (HR: 1.02 [95% CI: 0.90 to 1.15]). After additional adjustment for other cardiovascular risk factors, the results did not change. CONCLUSIONS: Larger retinal venular diameters are associated with an increased risk of stroke and cerebral infarction. The role of venules in cerebrovascular disease warrants further exploration.

Improving service delivery: provider perspectives on building community-based systems of care.

This article examines the views of service providers toward different public policy efforts to improve service delivery to elders requiring multiple services from an array of organizations. The authors examine the relationship between provider assessments of the adequacy of their community-based systems of care and community resource levels, coordination strategies, and client characteristics. Findings, based on responses from managers of programs serving older adults (n = 250) to a mailed survey, were that two-thirds (69.4%) evaluated their service delivery systems as adequate or better. A regression model used to explain system adequacy indicated that 22% of the variance was accounted for by community resource level, information and service availability, attention to specific need clients, and percentage of minority clients served by the respondents' programs. Findings suggest that community resource level appears to be an important factor in respondents' evaluation of system adequacy. While respondents indicated that improved coordination could enhance their efforts to deliver services, this strategy was not one they favored in improving their community-based system of care. Instead, they preferred strategies which expanded or improved the services that were available.

Mammography use in older women with regular physicians: what are the predictors?

Results of a longitudinal study of 1,050 women 65 years of age and older under the care of faculty internists demonstrate that individual and sociodemographic factors predict mammography use. The majority of the sample (79%) had received a mammogram within the past two years. Multiple logistic regression analyses of findings from a telephone survey showed that mammographic screening was significantly higher among women who had recently received a Pap smear, whose annual household incomes exceeded $30,000, and whose personal health care habits were preventively oriented; they used more preventive services such as routine dental care and engaged in more preventive behaviors such as seat-belt use and routine exercise. Mammography use was significantly higher among those 75 or younger. These findings suggest that enhancing patient preventive orientations should be part of interventions designed to increase screening. Medical Subject Headings (MeSH): appropriateness review, preventive health services, utilization, aged, Medicare.

Screening for depression among a well elderly population.

This article describes a geriatric wellness program in which social work practitioners played a major role. The focus of this article is twofold: to examine the use of a telephone screening test for depression among a well elderly population and to compare the results of that screening with the clinical judgment of social workers. Overall findings indicated that a telephone screening instrument incorporating the Rand Mental Health Inventory and the Center for Epidemiological Studies Depression Scale was an efficient tool for assessing a population with a higher rate of major depression. Furthermore, the social workers identified many previously undetected cases of major depression, and a majority of people referred for treatment completed those referrals.

Health promotion and disease prevention for older adults: opportunity for change or preaching to the converted?

Health promotion and disease prevention for the elderly offer the potential for improving the quality of life for the growing population of older adults, while reducing the economic burden on the health system. Whether this potential can be realized depends, in part, on whether those older adults whose health behaviors put them at risk actually use preventive services when offered the opportunity. In 1988 the Health Care Financing Administration began a series of health promotion demonstrations to address health issues related to older adults. This article reports on program participation at one of the five demonstration sites. Over 1,900 community-dwelling Medicare beneficiaries who receive their health care through fee-for-service providers were enrolled in the demonstration. These enrollees were randomly assigned to control and experimental groups, with the latter offered health screening and promotion services. Nine hundred-seventy-three of the experimental subjects and 938 of the control subjects completed a lengthy telephone interview, which determined each person's use of preventive services and practices. Although all 973 experimental subjects were invited by letter and follow-up telephone calls to attend these free-of-charge, Medicare-provided sessions, not everyone attended. We analyzed 17 health behaviors of those who attended the first session and those who did not. Those engaging in these preventive behaviors were neither more nor less likely to attend the screening services. Thus, we found neither "favorable" nor "unfavorable" selection bias in the use of these preventive services.

The relationship between dental utilization and preventive participation among a well-elderly sample.

Previous studies have shown that dental utilization by older people is lower than for the general population. This study hypothesizes that an elder's tendency toward participating in preventive health activities may be an important factor in explaining the likelihood of accessing the dentist. Subjects included 1,911 older individuals who enrolled in the UCLA Medicare Screening and Health Promotion Trial. All were interviewed about their utilization of preventive health services and participation in preventive behaviors. A recent dental visit was positively associated with all sociodemographic variables examined except age and sex. It was also related to health status questions and utilization of the preventive health services and health behaviors studied. Logistic regression analysis showed that both summary preventive health behavior and preventive service utilization variables were important factors in explaining a recent dental visit (model chi-square = 221.4, P = .001) along with income, not having a removable prosthesis, and perceiving the need for dental care. This study showed that dental utilization is related to older people's participation in other preventive activities. When in contact with older people, health care professionals should consider current oral and general preventive health status and encourage appropriate referral for preventive activities.