Wrist Injury in Deployed U.S. Marine-How to Maintain the Mission.

Wrist pain commonly affects military members and while most instances are benign, some require urgent orthopedic attention to prevent permanent loss of function. A 27-year-old male Marine while deployed presented with wrist pain after a seemingly benign fall during recreation. Radiographs were initially read as unremarkable and treated as a sprain. Though when reviewed by the Shock Trauma Platoon physicians, a perilunate dislocation was noted. After unsuccessful closed attempts to reduce injury, the Marine was sent to orthopedic surgery and underwent open reduction internal fixation and required a subsequent closed reduction and percutaneous pinning. Perilunate dislocations are uncommon but are among the most severe types of wrist injuries. This case is a reminder that proper evaluation of all injuries is critical. Proper evaluation of wrist injuries includes an attentive physical exam and careful examination of the radiographs; paying close attention to Gilula arcs and collinearity of the radius, lunate, and capitate. Prompt recognition and referral to specialty care for definitive treatment are important to maximize functional outcomes.

Orbital Cellulitis in a Psoriatic Patient Treated With Adalimumab.

INTRODUCTION: Psoriatic patients on tumor necrosis factor alpha inhibitors (TNFi) may be at increased risk for upper respiratory tract infections, including chronic rhino-sinusitis (CRS). Rarely, CRS can progress to orbital cellulitis (OC), an emergent ophthalmic complication wherein respiratory flora from paranasal sinus disease intrude the retro-orbital space. MATERIALS AND METHODS: Single case report. RESULTS: We report the first case, to our knowledge, of an invasive sinusitis that rapidly evolved into OC in a patient receiving adalimumab treatment for plaque psoriasis and psoriatic arthritis. After TNFi withdrawal and appropriate medical and surgical intervention, the patient fully recovered. However, on resumption of TNFi therapy, symptoms of recalcitrant CRS returned. CONCLUSION: More investigation is needed to explore how TNFi might predispose to chronic, refractory rhino-sinusitis and subsequent progression to OC. Military physicians and other medical providers should be aware of this proposed new disease entity and the potential for rapidly evolving and invasive infections in immunocompromised patients. Screening and monitoring for chronic infectious disease, such as CRS before initiating and during TNFi therapy is warranted.

Primary Care of Men Who Have Sex With Men in the U.S. Military in the Post-Don't Ask, Don't Tell Era: A Review of Recent Progress, Health Needs, and Challenges.

BACKGROUND: With repeal of "Don't Ask, Don't Tell" (DADT) in 2011 and the Supreme Court decision regarding Section 3 of the Defense of Marriage Act (DOMA) in 2013, military providers are now able to openly address unique health needs of lesbian, gay, and bisexual (LGB) service members and their same-sex spouse beneficiaries. These federal laws created health care barriers, either real or perceived, between providers and patients and often limited medical research involving LGB patients in the Military Health System (MHS). Men who have sex with men (MSM), the largest proportion of LGB service members, represent a segment of the population with the highest risks for disparities in primary care with regard to sexual health and mental health disorders. We provide a review of available research about this military population, in addition to a review of specific health care needs of the MSM patient in order to aid the primary care provider with screening, testing, and counseling. METHODS: A structured literature search was conducted to identify recent literature pertaining to health needs of U.S. military MSM service members. In addition, a review of applicable clinical guidelines, Department of Defense policies, and expert opinion was used to identify areas of particular relevance. FINDINGS: There is little published to characterize the MSM population and their health needs as beneficiaries of the MHS. Only recently have directed assessments of the active-duty MSM patient population been pursued in the post-DADT, DOMA era. Unique needs of the MSM patient identified center around both sexual and mental health, disparities that are paralleled within the nonmilitary MSM population. Population-specific epidemiology driving risk for sexually transmitted illnesses, substance abuse, and mental health disorders are identified and used to inform preventive medicine recommendations for the MSM patient. In addition, resources on MSM health for the health provider are included. DISCUSSION/IMPACT/RECOMMENDATION: The MHS at large now openly serves the MSM population and is making progress toward addressing their unique health needs. Despite ongoing challenges to address remaining disparities, MSM patients, beneficiaries, and primary providers are now more able to have frank, open discussions about specific health needs of this minority segment of the U.S. military without fear of reprisal.

Pott's disease? AIDS-associated Mycobacterium heckeshornense spinal osteomyelitis and diskitis.

Acid-fast bacillus (AFB) spinal osteomyelitis in a patient with AIDS is often presumed to be caused by reactivated Mycobacterium tuberculosis. However, other AFB pathogens can mimic M. tuberculosis and, to ensure appropriate and adequate therapy, should be considered by clinicians. We present a case of aggressive spinal osteomyelitis caused by Mycobacterium heckeshornense in an AIDS patient; a review of the literature is also included.

Prevalence and factors associated with asymptomatic gonococcal and chlamydial infection among US Navy and Marine Corps men infected with the HIV: a cohort study.

OBJECTIVES: Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) can facilitate transmission of HIV. Men who have sex with men (MSM) may harbour infections at genital and extragenital sites. Data regarding extragenital GC and CT infections in military populations are lacking. We examined the prevalence and factors associated with asymptomatic GC and CT infection among this category of HIV-infected military personnel. DESIGN: Cross-sectional cohort study (pilot). SETTING: Infectious diseases clinic at a single military treatment facility in San Diego, CA. PARTICIPANTS: Ninety-nine HIV-positive men were evaluated-79% men who had sex with men, mean age 31 years, 36% black and 33% married. INCLUSION CRITERIA: male, HIV-infected, Department of Defense beneficiary. EXCLUSION CRITERIA: any symptom related to the urethra, pharynx or rectum. PRIMARY OUTCOME MEASURES: GC and CT screening results. RESULTS: Twenty-four per cent were infected with either GC or CT. Rectal swabs were positive in 18% for CT and 3% for GC; pharynx swabs were positive in 8% for GC and 2% for CT. Only one infection was detected in the urine (GC). Anal sex (p=0.04), male partner (OR 7.02, p=0.04) and sex at least once weekly (OR 3.28, p=0.04) were associated with infection. Associated demographics included age <35 years (OR 6.27, p=0.02), non-Caucasian ethnicity (p=0.03), <3 years since HIV diagnosis (OR 2.75, p=0.04) and previous sexually transmitted infection (STI) (OR 5.10, p=0.001). CONCLUSIONS: We found a high prevalence of extragenital GC/CT infection among HIV-infected military men. Only one infection was detected in the urine, signalling the need for aggressive three-site screening of MSM. Clinicians should be aware of the high prevalence in order to enhance health through comprehensive STI screening practices.

The Role of Sexually Transmitted Infections in HIV-1 Progression: A Comprehensive Review of the Literature.

Due to shared routes of infection, HIV-infected persons are frequently coinfected with other sexually transmitted infections (STIs). Studies have demonstrated the bidirectional relationships between HIV and several STIs, including herpes simplex virus-2 (HSV-2), hepatitis B and C viruses, human papilloma virus, syphilis, gonorrhea, chlamydia, and trichomonas. HIV-1 may affect the clinical presentation, treatment outcome, and progression of STIs, such as syphilis, HSV-2, and hepatitis B and C viruses. Likewise, the presence of an STI may increase both genital and plasma HIV-1 RNA levels, enhancing the transmissibility of HIV-1, with important public health implications. Regarding the effect of STIs on HIV-1 progression, the most studied interrelationship has been with HIV-1/HSV-2 coinfection, with recent studies showing that antiherpetic medications slow the time to CD4 <200 cells/µL and antiretroviral therapy among coinfected patients. The impact of other chronic STIs (hepatitis B and C) on HIV-1 progression requires further study, but some studies have shown increased mortality rates. Treatable, nonchronic STIs (i.e., syphilis, gonorrhea, chlamydia, and trichomonas) typically have no or transient impacts on plasma HIV RNA levels that resolve with antimicrobial therapy; no long-term effects on outcomes have been shown. Future studies are advocated to continue investigating the complex interplay between HIV-1 and other STIs.

Gerbode defect with Staphylococcus lugdunensis native tricuspid valve infective endocarditis.

Coagulase-negative staphylococci are generally not considered to be very virulent; they are an uncommon cause of native valve endocarditis. Staphylococcus lugdunensis is an important exception and causes more severe infections, clinically mimicking S. aureus. We present a case of direct Gerbode defect associated with S. lugdunensis native valve infective endocarditis (IE) requiring cardiac surgery.

Fetal intervention: providing reasonable access to quality care.

Interest in fetal intervention has become widespread in recent years. Laser therapy for the treatment of severe twin-twin transfusion alone has been the subject of more than 100 peer-reviewed articles in the past 3 years. Significant issues have arisen that affect the availability of these new therapies in the United States. Formal training fellowships have yet to be established. Questions as to the ultimate number of treatment centers that are required to provide reasonable access should be addressed. The establishment of research networks to evaluate new fetal therapies through randomized clinical trials would appear paramount to the advancement of the field.

Pseudomonas putida war wound infection in a US Marine: a case report and review of the literature.

US service members are returning from the war in Iraq and Afghanistan with wound infections due to uncommon bacteria. Pseudomonas putida, a member of the fluorescent group of pseudomonads, primarily causes infection in immunosuppressed hosts and patients with invasive medical devices. P. putida has been implicated in outbreaks often traced to a contaminated fluid and is a rare cause of clinical infection. However, it should be considered a pathogen when isolated from pure culture. The objective of this article is to present a case report of a P. putida war wound infection, review previous P. putida infections, and provide a concise review of the epidemiology, risk factors, and management of infections due to this organism.

Paclitaxel chemotherapy in a pregnant patient with bilateral breast cancer.

In this article, we report on a case of a pregnant patient with synchronous bilateral breast cancer treated with weekly paclitaxel. She presented after right mastectomy and anthracycline-based chemotherapy at an outside facility. Staging studies at our hospital before taxane administration demonstrated a 19-20-week gravid uterus and tumor in the remaining left breast. Weekly paclitaxel was given preoperatively during pregnancy. A normal male infant was delivered. Upon completion of chemotherapy, the patient underwent mastectomy and axillary lymph node dissection followed by comprehensive radiation therapy to the chest wall.

Longitudinal measurement of peak systolic velocity in the fetal middle cerebral artery for monitoring pregnancies complicated by red cell alloimmunisation: a prospective multicentre trial with intention-to-treat.

OBJECTIVE: To evaluate the utilisation measurements of peak systolic velocities in the middle cerebral artery combined with B-mode ultrasound imaging to predict anaemia in an unselected population of pregnancies complicated by alloimmune antibodies known to cause immunological hydrops. DESIGN: Prospective study on an intention-to-treat basis. SETTING: Multicentre study in five large tertiary referral centres. POPULATION: One hundred twenty-five fetuses with maternal alloantibodies known to cause immunological hydrops. METHODS: If peak systolic velocity and B-mode scan were reassuring the pregnancy was monitored at 7-14 days interval. If either method showed signs of anaemia, an umbilical fetal blood sampling was performed. When the gestational age was greater than 35 weeks, labour was induced. MAIN OUTCOME MEASURE: Moderate to severe anaemia at delivery. RESULTS: Overall sensitivity to detect moderate to severe anaemia below 35 weeks (haemoglobin level below 0.65 multiples of median) was 88%. Specificity was 87%; positive predictive value was 53% and negative predictive value was 98%. The diagnosis of severe anaemia was missed in one fetus; however, the final outcome was good. The method was not useful after 35 weeks. CONCLUSIONS: Middle cerebral artery peak systolic velocity is a highly sensitive non-invasive means for determining the degree of anaemia present in red blood cell alloimmunised pregnancies. The widespread use of the Doppler method will minimise fetal complications associated with amniocentesis and fetal blood sampling. Non-invasive measurement of middle cerebral artery peak systolic velocities is more convenient and acceptable to alloimmunised pregnancies and may significantly lower health care costs. A Doppler interval of seven days is recommended.