Buccal transposition flap for closure of maxillary lip defects in 5 dogs.

OBJECTIVE: To describe the technique and outcomes of the closure of maxillary lip defects using a buccal transposition flap and to identify potential routes of vascular supply to the flap. ANIMALS: Five dogs treated clinically and 1 cadaveric dog head. STUDY DESIGN: Short case series and cadaveric study. METHODS: A left maxillary labial defect and a buccal transposition flap were created on a cadaver head. Iodinated contrast was injected into the left common carotid artery and computed tomography was performed to assess the vascular supply. Medical records were reviewed for all dogs that underwent tumor excision with maxillary lip resection, reconstructed with a buccal transposition flap. RESULTS: The buccal transposition flap was perfused by branches of the angularis oris artery and superior labial artery. Five dogs were included in this study. All flaps survived. Three dogs developed postoperative complications, including oronasal fistula (n = 2) and partial flap dehiscence (n = 1). The cosmetic and functional outcomes were considered satisfactory in all cases. CONCLUSION: Buccal transposition flaps for the closure of large maxillary lip defects provided adequate functional and cosmetic outcomes. The buccal transposition flap had vascular contributions from the angularis oris artery and the superior labial artery.

Impact of a Standardized Patient Hand-off Tool on Communication between Emergency Medical Services Personnel and Emergency Department Staff.

INTRODUCTION: Handoff communication between Emergency Medical Services (EMS) and Emergency Department (ED) staff is critical to ensure quality patient care. In January 2016, the Southwest Texas Regional Advisory Council (STRAC) implemented MIST (Mechanism, Injuries, vital Signs, Treatments), a standardized EMS to ED handoff tool. The En route Care Research Center conducted a Pre-MIST implementation survey of ED staff in December 2015 and a Post-MIST follow-up survey in July 2017 to determine the impact of the MIST handoff tool on the perceived quality of transmission of pertinent patient information and in the overall handoff experience. METHODS: We administered a nine-item Likert scale questionnaire to Brooke Army Military Medical Center (BAMC) ED providers and nurses before and after implementation of MIST. The questionnaire captured perceived competence and satisfaction with handoff communication (Cronbach's alpha 0.73). We analyzed responses for the total sample and by occupation (providers and nurses), and we calculated odds ratios to determine items that may be most predictive of a positive handoff experience from the perspective of the ED staff. We performed chi-square tests and reported data as percentages. RESULTS: Total respondents Pre- and Post-MIST were 128 (62%) nurses and 80 (38%) providers (MDs, DOs, and PAs). Following the implementation of MIST, more respondents reported that they were "informed of prehospital treatments" (p < 0.001), that "Red/Blue Trauma Alert Criteria were conveyed" (p < 0.001), and that the "time to give the report was sufficient to convey pertinent information" (p < 0.001). Nurses more frequently reported that "Red/Blue Trauma Alert Criteria were conveyed" post-MIST (p < 0.01). Providers more frequently reported that "Assessment findings were conveyed" (p < 0.05), that they 'interrupted the report for clarification" (p < 0.04), that "time to give the report was sufficient to convey pertinent information" (p < 0.001) and that they "felt positive about the overall handoff experience" (p < 0.03) Post-MIST. Overall satisfaction with the handoff was associated with frequently being informed of prehospital treatments (OR 5.5; 2.1-14.4) and frequently receiving a copy of the prehospital record (OR 2.9; 1.1-7.2). CONCLUSIONS: These data demonstrate that providers and nurses reported an improvement in the handoff experience Post-MIST. This study supports the use of a standardized handoff tool at this critical step in patient care.

Impact of a Standardized EMS Handoff Tool on Inpatient Medical Record Documentation at a Level I Trauma Center.

BACKGROUND: The emergency department (ED) poses challenges to effective handoff from emergency medical services (EMS) personnel to ED staff. Despite the importance of a complete and accurate patient handoff report between EMS and trauma staff, communication is often interrupted, incomplete, or otherwise ineffective. The Mechanism of injury/Medical Complaint, Injuries or Inspections head to toe, vital Signs, and Treatments (MIST) report initiative was implemented to standardize the handoff process. The objective of this study was to evaluate whether documentation of prehospital care in the inpatient medical record improved after MIST implementation. METHODS: Research staff abstracted data from the EMS and inpatient medical records of trauma patients transported by EMS and treated at a Level I trauma center from January 2015 through June 2017. Data included patient demographics, mechanism and location of injury, vital signs, treatments, and period of data collection (pre-MIST and post-MIST). We summarized the MIST elements in EMS and inpatient medical records and assessed the presence or absence of data elements in the inpatient record from the EMS record and the agreement between the two sets of records over time to determine if implementation of MIST improved documentation. RESULTS: We analyzed data from 533 trauma patients transported by EMS and treated in a Level I trauma center (pre-MIST: n = 281; post-MIST: n = 252). For mechanism of injury, agreement between the two records was ≥96% before and after MIST implementation. Cardiac arrest and location of injury were under-reported in the inpatient record before MIST; post-MIST, there were no significant discrepancies, indicating an improvement in reporting. Reporting of prehospital hypotension improved from 76.5% pre-MIST to 83.3% post-MIST. After MIST implementation, agreement between the EMS and inpatient records increased for the reporting of fluid administration (45.6% to 62.7%) and decreased for reporting of pain medications (72.2% to 61.9%). CONCLUSIONS: The use of the standardized MIST tool for EMS to hospital patient handoff was associated with a mixed value on inpatient documentation of prehospital events. After MIST implementation, agreement was higher for mechanism and location of injury and lower for vital signs and treatments. Further research can advance the prehospital to treatment facility handoff process.

Staged mandibular lip flap for closure of a large palatal defect after maxillectomy in a dog.

OBJECTIVE: To report closure of an oronasal defect secondary to maxillectomy with a staged mandibular lip flap. STUDY DESIGN: Case report ANIMALS: One 9-year-old female spayed golden retriever. METHODS: A combined dorsolateral and intraoral approach was used to perform a central maxillectomy to excise a 2.4- × 2- × 2.7-cm oral osteosarcoma with 1-cm margins. A buccal mucosal flap was used to close the palatal defect but the site subsequently dehisced. A staged mandibular lip flap was performed to close the defect. An incision was made on the mandible at the intersection of the buccal mucosa and gingiva from the mandibular canine to the level of the commissure. A second incision was made 3 cm ventral to the lip margin. The flap pedicle was based at the commissure. The flap was rotated to cover the palatal defect from rostral to the canine tooth to the fourth premolar. A second procedure was performed 4 weeks after flap placement to desquamate the haired skin and transect the flap pedicle. RESULTS: Partial dehiscence at the caudal aspect of the flap occurred after the first revision. The defect was closed after pedicle transection on day 41, with acceptable cosmesis. The dog was eating canned food with no evidence of discomfort 159 days after the maxillectomy. Recurrence was noted on day 270 postoperatively. CONCLUSION: Closure of a large palatal defect with a staged mandibular lip flap led to good cosmesis and function.

Prehospital Life-Saving Interventions Performed on Pediatric Patients in a Combat Zone: A Multicenter Prospective Study.

OBJECTIVES: We aimed to describe and evaluate prehospital life-saving interventions performed in a pediatric population in the Afghanistan theater of operations. DESIGN: Our study was a post hoc, subanalysis of a larger multicenter, prospective, observational study. SETTING: We evaluated casualties enrolled upon admission to one of the nine military medical facilities in Afghanistan between January 2009 and March 2014. PATIENTS: Adult and pediatric (<17 yr old) patients. MEASUREMENTS: We conducted initial descriptive analyses followed by comparative tests. For comparative analysis, we stratified the study population (adult vs pediatric), and subsequently, we compared injury descriptions and the interventions performed. Following tests for normality, we used the t test or Wilcoxon rank-sum test (nonparametric) for continuous variables and chi-square or Fisher exact for categorical variables. We reported percentages and 95% CIs. MAIN RESULTS: We enrolled 2,106 patients, of which 5.6% (n = 118) were pediatric. Eighty-two percent of the pediatric patients were male, and 435 had blast related injuries. A total of 295 prehospital life-saving interventions were performed on 118 pediatric patients, for an average of 2.5 life-saving interventions per patient. Vascular access (IV 96%, intraosseous 91%) and hypothermia prevention-related interventions (69%) were the most common. Incorrectly performed life-saving interventions in pediatric patients were rare (98% of life-saving interventions performed correctly) and n equals to 24 life-saving interventions over the 6-year period were missed. The most common incorrectly performed and missed life-saving interventions were related to vascular access. When compared with adult life-saving interventions received in the prehospital environment, pediatric patients were more likely to receive intraosseous access (p < 0.0001), whereas adult patients were more likely to have a tourniquet placed (p = 0.0019), receive wound packing with a hemostatic agent (p = 0.0091), and receive chest interventions (p = 0.0003). CONCLUSIONS: In our study, the most common intervention was vascular access followed by hypothermia prevention and hemorrhage control. The occurrence of missed or incorrectly performed life-saving interventions were rare.

Treatment of idiopathic chylothorax in dogs and cats: A systematic review.

OBJECTIVE: To evaluate the evidence published on the treatment of idiopathic chylothorax (IC) in small animals. STUDY DESIGN: Systematic literature review. SAMPLE POPULATION: Dogs and cats with IC. METHODS: A literature search was performed in three bibliographic databases in July 2018 for publications on IC in dogs and cats. Articles meeting criteria for inclusion were evaluated for treatment, survival, outcome data, and level of evidence (LoE) with a modified Oxford Level of Evidence (mOLE) and GRADE (Grading of Recommendations, Assessment, Development and Evaluations) system. RESULTS: Eleven of 313 identified articles met the inclusion criteria. Only one study was identified in dogs as having higher LoE by using the mOLE system, whereas no study was identified as such in either species with the GRADE system. Surgery was the primary treatment in all dogs and in 93% (68/73) of cats. Medical therapy was the primary treatment in 7% (5/73) of cats. The most common surgical treatment combined thoracic duct ligation (TDL) and subtotal pericardiectomy (SP; 40%; 34/84) in dogs and TDL in cats (51% [37/73]). CONCLUSION: The body of literature for IC treatment in small animals was limited to one higher LoE study in dogs and none in cats. No strong conclusion could be drawn regarding the effectiveness of any one surgical method in dogs or cats, and no evidence was found to support medical therapy as a primary treatment. CLINICAL SIGNIFICANCE: The best available evidence regarding the treatment of IC is published in dogs and provides some support for surgical treatment with either TDL + cisterna chyli ablation or TDL + SP. Additional evidence is required to confirm this finding.

Complex Polypharmacy in Patients With Schizophrenia-Spectrum Disorders Before a Psychiatric Hospitalization: Prescribing Patterns and Associated Clinical Features.

BACKGROUND: Current evidence-based guidelines provide unclear support for many common polypharmacy practices in schizophrenia. Excessive or complex polypharmacy (≥4 psychotropics) has been studied in patients with bipolar disorder, but not in schizophrenia to date. METHODS: We conducted a digital medical record data extraction of 829 patients consecutively admitted to a psychiatric hospital and diagnosed as having schizophrenia-spectrum disorders. RESULTS: In those prescribed psychiatric medication preadmission, 28.1% (n = 169) met the criteria for complex polypharmacy. Complex polypharmacy patients were older, female, white, and disabled, and had more comorbidities compared with those without complex polypharmacy. In multivariable analysis, complex polypharmacy was specifically associated with being white and disabled, and having a comorbid anxiety disorder, tobacco use disorder, metabolic condition, and neurological condition compared with noncomplex polypharmacy patients. CONCLUSIONS: Although there is little evidence to support complex polypharmacy in schizophrenia, rates were relatively high in patients requiring hospitalization, especially when they are also diagnosed as having comorbid psychiatric and medical conditions. Future research is needed to study the risk-benefit profile for these patients, especially considering their higher medical burden and related health risks.

Comorbid Cannabis and Tobacco Use Disorders in Hospitalized Patients with Psychotic-Spectrum Disorders.

OBJECTIVE: Individuals with psychotic-spectrum disorders use tobacco and cannabis at higher rates than the general population and individuals with other psychiatric disorders, which may contribute to increased rates of medical problems and mortality. The present study examined whether individuals with psychosis and comorbid tobacco and/or cannabis use disorders exhibit differing clinical characteristics in terms of their sociodemographic, mental health, substance use, physical health, and medication use patterns. Elucidation of these profiles, and determining their relative severity, has important implications for treatment, including offering more targeted interventions based on type of comorbidity pattern. METHODS: We examined the electronic medical records of 829 patients with psychotic-spectrum disorders admitted to a psychiatric hospital and categorized them as having: (1) cannabis use disorder (CUD); (2) tobacco use disorder (TUD); (3) comorbid cannabis and tobacco use disorders (CUD + TUD); or (4) neither disorder (no CUD/TUD). Multinomial logistic regression was used to compare the aforementioned groups on multiple variables controlling for age and sex. RESULTS: Alcohol and stimulant use disorder diagnoses were each related to higher odds of having a CUD and CUD + TUD, relative to no CUD/TUD. Stimulant and polysubstance use disorder diagnoses were each related to higher odds of having a TUD compared to no CUD/TUD. Greater number of prescribed psychotropic medications was related to higher odds of a TUD compared to no CUD/TUD. CONCLUSIONS: Although several differences between groups were accounted for by age of cannabis versus tobacco users, findings point to the importance of considering comorbid alcohol and substance use disorders among those with psychosis and CUD/TUD, as these comorbidities have important implications for screening and treatment selection during and following acute hospitalization.

Arterial anomalies of the celiac trunk and median arcuate ligament compression in dogs and cats assessed by computed tomography angiography.

OBJECTIVE: To identify abnormalities of the celiac artery (CA) and major branches in dogs and cats by computed tomography angiography (CTA). STUDY DESIGN: Multi-institutional retrospective case series. ANIMALS: Two hundred fifty-four dogs and 13 cats. METHODS: Abdominal CTA images from 2009 to 2017 were reviewed. Logistic regression models were used to evaluate the relationship between CA abnormalities and sex, age, size of dog, concurrent venous anomaly, or presence of gastrointestinal signs. RESULTS: Abnormalities in the CA were observed in 32 animals (11.9%) including 9 with abnormal branching (3.4%) and 23 with CA compression (8.6%). A celiacomesenteric trunk was observed in 8 (2.9%; 6 dogs, 2 cats). The splenic artery originated from the cranial mesenteric artery in 1 dog; the hepatic arterial branches originated from the left gastric artery in another. Four out of 32 animals (12.5%) with an arterial anomaly had another vascular abnormality. Large breed dogs were more likely to have an arterial anomaly (OR 4.3, 95% CI: 1.18-15.5, P = .02) and 12 times more likely to have CA compression (OR 12.0, 95% CI: 1.4-97.7, P = .02) compared to small breed dogs. Dogs with CA compression were more likely to present for gastrointestinal signs (OR 3.6, 95% CI: 1.2-10.3, P = .01). CONCLUSION: Anomalies of the celiac trunk are apparent on CTA and may impact surgical or image-guided intervention. Compression at the origin of the CA was apparent on imaging, similar to the median arcuate ligament syndrome in people, although the significance of this finding in dogs is unknown.

Attenuated Positive Psychotic Symptoms in Relation to Cigarette Smoking in a Nonclinical Population.

INTRODUCTION: This study explored the association between cigarette smoking and attenuated positive psychotic symptoms in a young adult nonclinical sample. METHODS: Undergraduates (N = 930), aged 18-35 years (26.3% male), completed a battery of self-report measures assessing subthreshold psychotic symptoms, cigarette smoking behavior/dependence, and drug use. RESULTS: Individuals endorsing a greater number of attenuated positive psychotic symptoms were more likely to be smokers. Exploratory analyses indicated that the odds of being a smoker were two times greater for those at potential higher risk for psychosis compared with individuals at lower risk. Results were consistent after adjusting for sex and other drug use. CONCLUSIONS: In line with findings from psychotic populations, results suggest that attenuated positive psychotic symptoms, particularly those endorsed as distressing in a nonclinical, undergraduate population, are related to cigarette smoking. IMPLICATIONS: Even in nonclinical, undergraduate populations, subthreshold psychotic symptoms are related to cigarette smoking, and cigarette smokers are twice as likely to be considered at potentially higher risk for psychosis compared with noncigarette smokers. In summary, there may be a threshold whereby psychotic symptoms confer increased risk for nicotine consumption, with endorsement of a greater number of distressing subthreshold psychotic symptoms increasing the likelihood of cigarette use.

Diagnosis and neurocognitive profiles in first-episode non-affective psychosis patients.

This study explored whether there are distinguishable neurocognitive profiles in diagnostic subgroups of first-episode non-affective psychosis (FEP) patients. Four hundred and eighty-seven individuals with diagnoses of non-affective psychosis disorders were evaluated 6 months after first contact with psychiatric services. Individuals with schizophrenia (n = 257), schizophreniform (n = 141), brief psychotic disorder (n = 54), and psychosis not otherwise specified (n = 35) were compared on baseline neuropsychological variables using analyses of variance and covariance with potential clinical, premorbid, and sociodemographic confounders. The brief psychotic disorder subgroup was the least impaired on global cognitive function, in particular when compared to the schizophrenia subgroup, and specifically on executive function, processing speed, and motor dexterity domains. However, with the exception of the processing speed domain, profile differences could be explained by sex, age, psychotic and negative symptoms, years of education, and premorbid IQ. These results suggest processing speed as a diagnostic marker for brief psychotic disorder in FEP patients. Further, there are quantitative and qualitative differences across the schizophrenia spectrum disorders subgroups, indicating different profiles with varying degrees of deficit.

Outcome after placement of an artificial urethral sphincter in 27 dogs.

OBJECTIVE: To evaluate the safety and efficacy of an adjustable artificial urethral sphincter (AUS) in a population of dogs with acquired or congenital urinary incontinence. STUDY DESIGN: Case series. ANIMALS: Dogs (n = 27) with naturally occurring urinary incontinence. METHODS: Medical records (January 2009-July 2011) of dogs that had AUS implantation for treatment of urinary incontinence were reviewed and owners were interviewed by telephone to assess outcome. Continence was scored using a previously established analogue scale, with 1 representing constant leakage and 10 representing complete continence. RESULTS: Twenty-four female and 3 male dogs had AUS implantation. Causes of incontinence included urethral sphincter mechanism incompetence (n = 18), continued incontinence after ectopic ureter repair (6), and pelvic bladder (3). Medical therapy was unsuccessful in 25 dogs before AUS implantation. Surgery was performed without major complications in 25 dogs; 2 developed partial urethral obstruction after 5 and 9 months. Median (interquartile range) follow-up for the other 25 dogs was 12.5 (6-19) months. Continence scores were significantly improved (P < .0001) between the preoperative period (2 [1-4]) and last follow-up (9 [8-10]). Overall, 22 owners described themselves as very satisfied, 2 as satisfied, and 3 as unsatisfied. CONCLUSIONS: AUS implantation was successful in restoring continence in male and female dogs with both congenital and acquired urinary incontinence. Dogs that develop partial urethral obstruction may require AUS removal.

Management of Combat Casualties during Aeromedical Evacuation from a Role 2 to a Role 3 Medical Facility.

INTRODUCTION: Emergent clinical care and patient movements through the military evacuation system improves survival. Patient management differs when transporting from the point-of-injury (POI) to the first medical treatment facility (MTF) versus transporting from the Role 2 to the Role 3 MTF secondary to care rendered within the MTF, including surgery and advanced resuscitation. The objective of this study was to describe care provided to patients during theater inter-facility transports and compare with pre-hospital transports (POI to first MTF). MATERIALS AND METHODS: We performed a retrospective chart review of patients with the Role 2 to the Role 3 transports in Afghanistan and Iraq from 2007 to 2016. Data collected included procedures and events at the MTF and during transport. We compared the intra-theater transport data (Role 2 to Role 3) to data from a previous study evaluating pre-hospiital transports (POI to first MTF). RESULTS: We reviewed the records of 869 Role 2 to Role 3 transport patients. Role 2 to Role 3 transports were longer in duration compared to POI transports (39 minutes vs. 23 minutes) and were more likely to be staffed by advanced personnel (nurses, physician assistants, and physicians) (57% vs. 3%). The sample primarily consisted of military-aged males (mean age 27 years) who suffered from explosive or blunt force injuries. Procedures performed during each phase of care reflected the capabilities of the teams and locations. Pain and cardiac events were more common in POI evacuations compared to the Role 2 to Role 3 transports, but documentation of respiratory events, hemodynamic events, neurologic events, and equipment failure was more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1-5%]). CONCLUSIONS: Inter-facility transports (Role 2 to Role 3) are longer in duration, transport more complex patients, and are staffed by more advanced level provider types compared to transports from POI.

Injuries and Interventions on Transported Military Working Dogs Within the US Central Command.

BACKGROUND: Limited veterinary care is available in the far forward environment, leading to human medical personnel being responsible, in part, for treatment of military working dogs (MWD). Though guidelines for MWD care exist, there is little research on the care and treatment of MWDs by human medical personnel. There is a lot of research on the care and treatment of MWDs. METHODS: This is a secondary analysis of a dataset from the Transportation Command (TRANSCOM) Regulating Command & Control and Evacuation System (TRAC2ES) database within the US Central Command (CENTCOM) from 2008 to 2018. Within this dataset specific to regulated transport from locations within CENTCOM, we abstracted all entries involving MWDs and analyzed causes of injury, type of injury, and interventions performed on traumatically and non-traumatically injured MWDs. RESULTS: Within our dataset, there were 84 MWD cases for analysis. Of those, 36 (43%) were transported for traumatic injuries, and the remaining 48 (57%) were transported for other medical ailments. The most common cause of trauma was gunshot wound (31%), followed by explosion (22%). The majority of trauma MWDs had injuries to the extremities (67%), and hemorrhage requiring intervention occurred in 25%. The most common interventions performed on traumas were analgesia (67%), antibiotics (31%), IV fluids (28%), and surgery (31%). The most common indications that occurred in MWDs treated for nontraumatic medical indications were gastrointestinal diseases (33%), followed by nontraumatic orthopedic injuries (21%). CONCLUSIONS: Of the MWDs in our dataset, most were transported for nontraumatic medical events. The most frequent intervention performed was medication administration for both traumatic and medical ailments. Our dataset adds to the limited body of MWD data from theater.

Characterization of Long-range Aeromedical Transport and Its Relationship to the Development of Traumatic Extremity Compartment Syndrome: A 7-year, Retrospective Study.

BACKGROUND: Military aeromedical transport evacuates critically injured patients are for definitive care, including patients with or at risk for developing traumatic compartment syndrome of the extremities (tCSoE). Compartment pressure changes of the extremities have not been determined to be associated with factors inherent to aeromedical transport in animal models, but the influence of aeromedical evacuation (AE) transport on the timing of tCSoE development has not been studied in humans. Using a registry-based methodology, this study sought to characterize the temporal features of lower extremity compartment syndrome relative to the timing of transcontinental AE. With this approach, this study aims to inform practice in guidelines relating to the timing and possible effects of long-distance AE and the development of lower extremity compartment syndrome. Using patient care records, we sought to characterize the temporal features of tCSoE diagnosis relative to long-range aeromedical transport. In doing so, we aim to inform practice in guidelines relating to the timing and risks of long-range AE and postulate whether there is an ideal time to transport patients who are at risk for or with tCSoE. METHODS: We performed a retrospective record review of patients with a diagnosis of tCSoE who were evacuated out of theater from January 2007 to May 2014 via aeromedical transport. Data abstractors collected flight information, laboratory values, vital signs, procedures, in-flight assessments, and outcomes. We used the duration of time from injury to arrival at Landstuhl Regional Medical Center (LRMC) to represent time to transport. We compared groups based on time of tCSoE (inclusive of upper and lower extremity) diagnosis relative to injury day and time of transport (preflight versus postflight). We used descriptive statistics and multivariable regression models to determine the associations between time to transport, time to tCSoE diagnosis, and outcomes. RESULTS: Within our study window, 238 patients had documentation of tCSoE. We found that 47% of patients with tCSoE were diagnosed preflight and 53% were diagnosed postflight. Over 90% in both groups developed tCSoE within 48 hours of injury; the time to diagnosis was similar for casualties diagnosed pre- and postflight (P = .65). There was no association between time to arrival at LRMC and day of tCSoE diagnosis (risk ratio, 1.06; 95% CI, 0.96-1.16). CONCLUSION: The timing of tCSoE diagnosis is not associated with the timing of transport; therefore, AE likely does not influence the development of tCSoE.

The Role of Medical Comorbidity in the Rapid Psychiatric Readmission of Patients With Schizophrenia-spectrum Disorders.

OBJECTIVE: Inpatient admissions are common for individuals with schizophrenia-spectrum disorders, and difficulty transitioning from the hospital to the community results in these individuals being at high risk for hospital readmissions. Thus, psychotic disorders account for high rates of rapid readmission within 30 days of discharge. Increasing evidence highlights the role of comorbid medical conditions, such as circulatory and metabolic problems, in contributing to early readmission rates for these patients. This study examined the specific role of circulatory and metabolic problems in predicting psychiatric rehospitalizations while accounting for other medical conditions, psychiatric comorbidities, and preadmission medications. METHODS: The electronic medical records of 752 patients admitted to a psychiatric hospital were examined, with patients classified as having readmission within 30 days of their index hospitalization (n=79) or no readmission within 30 days (n=673). The 2 groups were compared on multiple variables in univariate and multivariate analyses. RESULTS: Male sex [odds ratio (OR)=2.02, P=0.019)], disability status (OR=1.96, P=0.027), and presence of a circulatory (but not a metabolic) condition (OR=3.43, P=0.003) were associated with significantly increased odds of being rehospitalized within 30 days, even when accounting for additional predictors, including age, substance use disorder, race, and other medical conditions. CONCLUSIONS: These findings highlight the importance of considering circulatory, in addition to metabolic disorders, during inpatient stays. This comorbidity pattern may signify a subset of individuals with schizophrenia-spectrum disorders requiring more comprehensive discharge planning and support after an inpatient hospitalization to prevent rapid rehospitalization.

An Analysis of US Africa and Indo-Pacific Commands Military Working Dog Medical Transportation, 2008-2018.

Military working dogs (MWD) deploy with diverse tasks. Given significant utilization in Central Command (CENTCOM) for combat operations, the majority of MWD medical literature centers on combat trauma from this theater. Other commands, to include Indo-Pacific Command (INDOPACOM) and Africa Command (AFRICOM) utilize MWDs for low-intensity operations. To date, there is no analysis of medical evacuations of MWDs from the INDOPACOM and AFRICOM theaters. We seek to analyze MWD medical evacuations from these theaters utilizing the Transportation Command (TRANSCOM) Regulating and Command and Control Evacuation System (TRAC2ES). METHODS: We performed a retrospective review of all TRAC2ES medical records for MWD medical evacuations from the INDOPACOM and AFRICOM theaters conducted between January 2008 and December 2018. We abstracted free text data entry in TRAC2ES for diagnostic and therapeutic interventions performed prior to movement requests. RESULTS: MWD evacuations constituted 0.2% (n=10) of 4,217 documented medical evacuations from INDOPACOM and 0.3% (n=3) of 962 individually documented medical evacuations from AFRICOM. Most were routine precedence (n=8). All MWDs were evacuated for disease and non-battle injury including bone (n=4) and dental (n=2) fractures. Some had more than one provisional diagnosis and/or poly trauma. Analgesia was the most common intervention prior to evacuation (n=4). CONCLUSIONS: MWDs accounted for a small proportion of TRAC2ES evacuations in AFRICOM and INDOPACOM theaters from 2008-2018, most due to non-battle traumatic injuries. Future studies should consider more focused MWD medical evaluations in these theaters to develop a broader understanding of medical treatment trends.

Prehospital Use of Ketamine in the Combat Setting: A Sub-Analysis of Patients With Head Injuries Evaluated in the Prospective Life Saving Intervention Study.

OBJECTIVES: Ketamine is used as an analgesic for combat injuries. Ketamine may worsen brain injury, but new studies suggest neuroprotection. Our objective was to report the outcomes of combat casualties with traumatic brain injury (TBI) who received prehospital ketamine. METHODS: This was a post hoc, sub-analysis of a larger prospective, multicenter study (the Life Saving Intervention study [LSI]) evaluating prehospital interventions performed in Afghanistan. A DoD Trauma Registry query provided disposition at discharge and outcomes to be linked with the LSI data. RESULTS: For this study, we enrolled casualties that were suspected to have TBI (n = 160). Most were 26-year-old males (98%) with explosion-related injuries (66%), a median injury severity score of 12, and 5% mortality. Fifty-seven percent (n = 91) received an analgesic, 29% (n = 46) ketamine, 28% (n = 45) other analgesic (OA), and 43% (n = 69) no analgesic (NA). The ketamine group had more pelvic injuries (P = 0.0302) and tourniquets (P = 0.0041) compared to OA. In comparison to NA, the ketamine group was more severely injured and more likely to require LSI procedures, yet, had similar vital signs at admission and disposition at discharge. CONCLUSIONS: We found that combat casualties with suspected TBI that received prehospital ketamine had similar outcomes to those that received OAs or NAs despite injury differences.

Development and Evaluation of An Abbreviated Extracorporeal Membrane Oxygenation (ECMO) Course for Nonsurgical Physicians and Nurses.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a modification of cardiopulmonary bypass that allows prolonged support of patients with severe respiratory or cardiac failure. ECMO indications arse rapidly evolving and there is growing interest in its use for cardiac arrest and cardiogenic shock. However, ECMO training programs are limited. Training of emergency medicine and critical care clinicians could expand the use of this lifesaving intervention. Our objective was to develop and evaluate an abbreviated ECMO course that can be taught to emergency and critical care physicians and nurses. METHODS: We developed a training model using Yorkshire swine (Sus scrofa), a procedure instruction checklist, a confidence assessment, and a knowledge assessment. Participants were assigned to teams of one emergency medicine or critical care physician and one nurse and completed an abbreviated 8-hour ECMO course. An ECMO specialist trained participants on preparation of the ECMO circuit and oversaw vascular access and ECMO initiation. We used the instruction checklist to evaluate performance. Participants completed confidence and knowledge assessments before and after the course. RESULTS: Seventeen teams (34 clinicians) completed the abbreviated ECMO course. None had previously completed an ECMO certification course. Immediately following the course, all teams successfully primed and prepared the ECMO circuit. Fifteen teams (88%, 95% confidence interval [CI] = 64% to 99%) successfully initiated ECMO. Participants improved their knowledge (difference 21.2, 95% CI = 16.5 to 25.8) and confidence (difference 40.3, 95% CI = 35.6 to 45.0) scores after completing the course. CONCLUSIONS: We developed an accelerated 1-day ECMO course. Clinicians' confidence and knowledge assessments improved and 88% of teams could successfully initiate venoarterial ECMO after the course.

Patients With Traumatic Brain Injury Transported by Critical Care Air Transport Teams: The Influence of Altitude and Oxygenation during Transport.

INTRODUCTION: Traumatic brain injuries (TBIs) are life-threatening, and air transport of patients with TBI requires additional considerations. To mitigate the risks of complications associated with altitude, some patients fly with a cabin altitude restriction (CAR) to limit the altitude at which an aircraft's cabin is maintained. The goal of this study was to examine the effects of CARs on patients with TBI transported out of theater via Critical Care Air Transport Teams. MATERIALS AND METHODS: We conducted a retrospective chart review of patients with moderate-to-severe TBI evacuated out of combat theater to Landstuhl Regional Medical Center via Critical Care Air Transport Teams. We collected demographics, flight and injury information, procedures, oxygenation, and outcomes (discharge disposition and hospital/ICU/ventilator days). We categorized patients as having a CAR if they had a documented CAR or maximum cabin altitude of 5,000 feet or lower in their Critical Care Air Transport Teams record. We calculated descriptive statistics and constructed regression models to evaluate the association between CAR and clinical outcomes. RESULTS: We reviewed the charts of 435 patients, 31% of which had a documented CAR. Nineteen percent of the sample had a PaO2 lower than 80 mm Hg, and 3% of patients experienced a SpO2 lower than 93% while in flight. When comparing preflight and in-flight events, we found that the percentage of patients who had a SpO2 of 93% or lower increased for the No CAR group, whereas the CAR group did not experience a significant change. However, flying without a CAR was not associated with discharge disposition, mortality, or hospital/ICU/ventilator days. Further, having a CAR was not associated with these outcomes after adjusting for additional flights, injury severity, injury type, or preflight head surgery. CONCLUSIONS: Patients with TBI who flew with a CAR did not differ in clinical outcomes from those without a CAR.