Survey of alcohol use in the U.S. Army.

The objective of this study was to collect data that would provide information about the frequency, attitudes, and consequences of alcohol use in the U.S. Army. A questionnaire was used to assess the frequency of alcohol consumption, attitudes related to the use of alcohol, and adverse consequences experienced with alcohol use. The survey was conducted at Walter Reed Army Medical Center in Washington, D.C. Survey participants included both military employees working at Walter Reed Army Medical Center and military patients. No attempt was made to identify the medical status of the participants. The investigators distributed 1,200 questionnaires. Following distribution, the investigators received 1,010 completed questionnaires, resulting in an 84% return rate. Thirty-four percent of the survey participants (n = 335) were deployed to an area of combat operations. There was a significant difference in binge drinking between military personnel assigned to an area of combat operations and those not assigned to an area of combat operations (p = 0.023). Multiple regression results showed that age, marital status, and deployment status were correlated with four or more drinks at one time (p < 0.001). In other words, binge drinking is more likely to occur among military personnel who are younger, experiencing marital problems, and recently returned from an area of combat operations. Significant differences between the two groups also emerged in terms of other specific consequences associated with consumption. Deployment to an area of combat operations seems to influence consumption patterns, alcohol related attitudes, and behaviors. This could be a consequence of wartime experiences. This study should help guide the clinical screening of alcohol use disorders, which may complicate emotional recovery from traumatic experiences if undetected.

The effect of vein repair on the risk of venous thromboembolic events: a review of more than 100 traumatic military venous injuries.

BACKGROUND: The management of venous trauma remains controversial. Critics of venous repair have cited an increased incidence of associated venous thromboembolic events with this management. We analyzed the current treatment of wartime venous injuries in United States military personnel in an effort to answer this question. METHODS: From December 1, 2001, to October 31, 2005, all United States casualties with named venous injuries were evaluated. A retrospective review of a clinical database was performed on demographics, mechanism of injury, associated injuries, treatment, outcomes, and venous thromboembolic events. Data were analyzed using the Fisher exact test, analysis of variance, and logarithmic transformation. RESULTS: During this 5-year period, 82 patients sustained 103 named venous injuries due to combat operations. All patients were male, with an average age of 27.9 years (range, 20.3-58.3 years). Blast injuries accounted for 54 venous injuries (65.9%), gunshot wounds for 25 (30.5%), and motor vehicle accidents for 3 (3.6%). The venous injury was isolated in 28 patients (34.1%), and 16 (19.5%) had multiple venous injuries. The venous injury in two patients was associated with acute phlegmasia, with fractures in 33 (40.2%), and 22 (28.1%) sustained neurologic deficits. Venous injuries were treated by ligation in 65 patients (63.1%) and by open surgical repair in 38 (36.9%). Postoperative extremity edema occurred in all patients irrespective of method of management. Thrombosis after venous repair occurred in six of the 38 cases (15.8%). Pulmonary emboli developed in three patients, one after open repair and two after ligation (P > .99). CONCLUSION: In the largest review of military venous trauma in more than three decades, we found no difference in the incidence of venous thromboembolic complications between venous injuries managed by open repair vs ligation. Blast injuries of the extremities have caused most of the venous injuries. Ligation is the most common modality of treatment in combat zones. Long-term morbidity associated with venous injuries and their management will be assessed in future follow-up studies.

The intravenous ketamine test predicts subsequent response to an oral dextromethorphan treatment regimen in fibromyalgia patients.

UNLABELLED: Fibromyalgia (FM) is a challenging pain syndrome for which no reliable pharmacologic treatment exists. Recent clinical studies suggest that N-methyl-D-aspartate receptors might play a role in the pathogenesis of this disorder. To determine whether an intravenous (IV) ketamine test predicts the response to a therapeutic trial with an oral N-methyl-D-aspartate receptor antagonist, we performed a low-dose (0.1 mg/kg) IV ketamine infusion on 34 consecutive patients with FM, which was subsequently followed by an oral dextromethorphan (DX) treatment regimen. As per previous guidelines, the cutoff value for a positive response to the IV ketamine test was designated to be 67% pain relief, and a positive response to DX treatment was 50% pain reduction at 4- to 6-week follow-up visits. The degree of correlation between pain relief with ketamine and DX was highly significant (Pearson correlation coefficient, 0.66; P < .001). Ten patients responded positively to both ketamine and DX, 19 responded to neither drug, 3 had a positive response to ketamine but not DX, and 2 obtained good pain relief with DX but not ketamine. The sensitivity of the IV ketamine test was 83%, the specificity was 86%, the positive predictive value was 77%, and the negative predictive value was 91%. An association was also found between the development of side effects to the two treatments. PERSPECTIVE: The response to an IV ketamine infusion was found to predict the subsequent response to an oral dextromethorphan treatment regimen in fibromyalgia patients, with an observed agreement of 83%. Considering the refractory nature of fibromyalgia to conventional pain treatments, the IV ketamine test might enhance patient care by saving time and reducing unnecessary treatment trials.

What imaging studies are necessary for abdominal aortic endograft sizing? A prospective blinded study using conventional computed tomography, aortography, and three-dimensional computed tomography.

OBJECTIVE: Preoperative imaging modalities for endovascular abdominal aortic aneurysm repair (EVAR) include conventional computed tomography (CT), aortography with a marking catheter, and three-dimensional computed tomography (3D CT). Although each technique has advantages, to date no study has compared in a prospective manner the reproducibility of measurements and impact on graft selection of all three modalities. The objective of this study was to determine the most useful imaging studies in planning EVAR. METHODS: Twenty patients being considered for EVAR were enrolled prospectively to undergo a conventional CT scan and aortography. The CT scans were then reconstructed into 3D images using Preview Treatment Planning Software (Medical Media Systems, West Lebanon, NH). Four measurements of diameter and six of length were made from each modality in determining the proper graft for EVAR. RESULTS: Measurements from all three modalities were reproducible with intraobserver correlation coefficients of 0.79 to 1.0 for aortography, 0.87 to 1.0 for CT, and 0.96 to 1.0 for 3D CT. Measurements between observers were also similar from each modality; interobserver correlations were 0.70 to 0.97 for aortography, 0.76 to 0.97 for CT, and 0.73 to 0.99 for 3D CT. Significant differences ( P < .01) in diameter measurements were noted at D2 with aortography compared with 3D CT, whereas differences in length measurements were found between CT and 3D CT at L4 (nonaneurysmal right iliac) ( P < .01). The correlation between CT and 3D CT for most length measurements was acceptable (0.63 to 1.0). Aortography for diameters correlated poorly (0.35 to 0.67) with 3D CT. When the endograft selected by aortography/CT or 3D CT alone was compared with the actual endograft used, there was agreement in 11 of 11 patients when adjusted for +/- one size in diameter or length. CONCLUSION: Reproducible and comparable measures of diameter and length can be obtained by each of three imaging modalities available for endograft sizing. As a single imaging modality, 3D CT appears to have the best correlation for both diameters and lengths; however, the difference is not sufficient enough to alter endograft selection. Three-dimensional CT may be reserved for challenging aortic anatomy where small differences in measurements would affect patient or graft selection for EVAR.

The causes of false-positive medial branch (facet joint) blocks in soldiers and retirees.

OBJECTIVE: The purpose of this study was to determine the factors associated with false-positive medial branch blocks (MBB), the nerve blocks used to diagnose facet arthropathy, in soldiers and retirees. METHODS: The study subjects were 78 patients with chronic low back pain who underwent diagnostic MBB to determine whether or not the facet joints were pain generators. Radiofrequency denervation of these nerves was performed in all patients with positive responses. Patients who failed to obtain pain relief after the blocks (negative blocks) and those who obtained temporary pain relief after MBB but failed radiofrequency denervation (false-positive blocks) then proceeded to undergo discography. Based on patients' responses to diagnostic blocks, discography results, the presence of radicular pain, and previous back surgery, the data were analyzed to determine whether any of these variables correlated with false-positive MBB. RESULTS: The presence of discogenic or radicular pain was not associated with a higher false-positive response rate to MBB. Conversely, the absence of discogenic pain was associated with a higher percentage of false-positive blocks. There was also a trend for patients with previous back surgery to have a higher false-positive rate than those who had not undergone previous surgery. CONCLUSIONS: Although a high incidence of epidural and foraminal spread occurs during the performance of MBB, this is unlikely to be a significant cause of false-positive blocks.