Practicing internal medicine onboard the USNS COMFORT in the aftermath of the Haitian earthquake.

On 12 January 2010, a 7.0-magnitude earthquake devastated the island nation of Haiti, leading to the world's largest humanitarian effort in over 6 decades. The catastrophe caused massive destruction of homes and buildings and overwhelmed the Haitian health care system. The United States responded immediately with a massive relief effort, sending U.S. military forces and civilian volunteers to Haiti's aid and providing a tertiary care medical center aboard the USNS COMFORT hospital ship. The COMFORT offered sophisticated medical care to a geographically isolated population and helped to transfer resource-intensive patients from other treatment facilities. Working collaboratively with the surgical staff, ancillary services, and nursing staff, internists aboard the COMFORT were integral to supporting the mission of the hospital ship and provided high-level care to the casualties. This article provides the perspective of the U.S. Navy internists who participated in the initial response to the Haitian earthquake disaster onboard the COMFORT.

Prevalence of short partial thromboplastin times in a military treatment facility.

BACKGROUND: It was recently noted that a shortened activated partial thromboplastin time (aPTT) is associated with increased venous thromboembolic events. The prevalence of aPTT shortening remains unknown. METHODS: We conducted a retrospective analysis of aPTT results over a 2-month period. These results were not associated with patient clinical information. RESULTS: We obtained 3,376 aPTT samples, which were analyzed in groups: <25.0, 25.0-35.0, and >35.0 seconds (two standard deviations from our laboratory's normal values). Eighty-six samples had aPTT<25 (8.5%), 2,026 samples between 25.0-35.0 (60.0%), and 1,064 samples>35.0 (31.5%). Using chi-square goodness-of-fit, we found a clinically significant greater-than-expected prevalence of low aPTT levels (p<0.001). CONCLUSIONS: Although elevated aPTT samples could be explained by anticoagulation therapy, the reason for our findings of an increased number of low-aPTT studies remains unexplained. Further studies are required to investigate the clinical correlation of low aPTT levels and the incidence of venous thromboembolic events (VTEs) in our population.

Recognizing asthma mimics and asthma complications.

Asthma is a chronic inflammatory disorder of the airways characterized by airflow obstruction, bronchial hyperreactivity, and underlying inflammation. Two common reasons asthmatics fail standard therapy are incorrect diagnosis and failure to recognize underlying contributing factors. A correct diagnosis of asthma is of great importance to military practitioners since misdiagnosis or uncontrolled asthma affects an individual's operational readiness or determines whether one can receive a medical waiver to enlist in military service. This article presents four cases of patients with dyspnea that have conditions which mimic asthma or complicate asthma management: vocal cord dysfunction misdiagnosed as asthma, respiratory bronchiolitis interstitial lung disease mistaken as asthma, difficult-to-control asthma because of bronchiectasis and allergic bronchopulmonary aspergillosis, and difficult and fatal asthma. Asthma is contrasted to other respiratory disorders, and an outlined approach to asthma diagnosis and management is presented using the Global Initiative for Asthma guidelines.

Removal of COVID-19 Spike Protein, Whole Virus, Exosomes, and Exosomal MicroRNAs by the Hemopurifier® Lectin-Affinity Cartridge in Critically Ill Patients With COVID-19 Infection.

Coronavirus-19 (COVID-19) has rapidly spread throughout the world resulting in a significant amount of morbidity and mortality. Despite advances in therapy, social distancing, masks, and vaccination many places in the world continue to see an increase in the number of cases and deaths. Viremia is commonly present in severely ill patients with COVID-19 infections and is associated with organ dysfunction and poor outcomes. Exosomes released by activated cells have been implicated in the pathogenesis of COVID-19 infection. We report the experience of two cases of critically ill COVID-19 patients treated with the Hemopurifier; a lectin affinity cartridge designed to remove mannosylated viruses and exosomes. Both patients tolerated the Hemopurifier sessions without adverse effects. In the first patient removal of exosomes and exosomal microRNAs was associated with improved coagulopathy, oxygenation, and clinical recovery, while in a second patient removal of COVID-19 by the Hemopurifier cartridge was observed. The Hemopurifier is currently under further investigation in up to 40-patients in a safety and feasibility study in ICU patients with COVID-19 infection.

Predominant cartilaginous hamartoma: an unusual variant of chondromatous hamartoma.

Chondromatous hamartomas are the most common benign lung tumors and the third most common pulmonary nodule. Histologically, they are characteristically composed of hyaline cartilage mixed with fibromyxoid stroma and adipose tissue surrounded by epithelial cells. We report the case of a healthy, 60-year-old woman with an incidentally discovered chondromatous hamartoma that was thorascopically excised. Her pulmonary hamartoma was predominantly cartilaginous, which only occurs in 1% of hamartomas.

Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL.

BACKGROUND: Anticipated circumstances during the next severe influenza pandemic highlight the insufficiency of staff and equipment to meet the needs of all critically ill victims. It is plausible that an entire country could face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. There may even be such resource shortfalls that some patients would not be able to access even the most basic of life-sustaining interventions. Rationing of critical care in this circumstance would be difficult, yet may be unavoidable. Without planning, the provision of care would assuredly be chaotic, inequitable, and unfair. The Task Force for Mass Critical Care Working Group met in Chicago in January 2007 to proactively suggest guidance for allocating scarce critical care resources. TASK FORCE SUGGESTIONS: In order to allocate critical care resources when systems are overwhelmed, the Task Force for Mass Critical Care Working Group suggests the following: (1) an equitable triage process utilizing the Sequential Organ Failure Assessment scoring system; (2) the concept of triage by a senior clinician(s) without direct clinical obligation, and a support system to implement and manage the triage process; (3) legal and ethical constructs underpinning the allocation of scarce resources; and (4) a mechanism for rapid revision of the triage process as further disaster experiences, research, planning, and modeling come to light.

Operation Aftershock: the U.S. military disaster response to the Yogyakarta earthquake May through June 2006.

The U.S. military has recently been involved in many humanitarian assistance and disaster response missions around the world. This newfound role is in response to the U.S. government's desire to use "medical diplomacy" rather than "military might" to shape its relationship with foreign governments. With each of these humanitarian assistance and disaster response missions, the U.S. military has learned how to more rapidly insert desperately needed services and skill sets into disaster-struck communities, how to arrange for in-country services (translation services, transportation, etc.) that cannot be readily brought in, and how to work closely with foreign governments and nongovernmental organizations to determine their needs and expectations without the U.S. military appearing as if it were trying to establish a permanent presence.

Postthrombotic syndrome complicating a case of May-Thurner syndrome despite endovascular therapy: case report and review.

External compression of the left iliac vein is a common finding in the general population. It may predispose patients to the development of deep vein thrombosis (DVT) of the left leg and may also lead to a more complicated course than in other types of DVT. This entity has been well-described by other authors. External compression of the left iliac vein should be suspected in cases of complicated DVT or in cases of DVT with no predisposing factors. We describe a case of May-Thurner syndrome that involved a complicated treatment course, and a review of current options for diagnosis and therapy.

Hypersensitivity pneumonitis following anthrax vaccination.

A case of hypersensitivity pneumonitis (HP) following anthrax vaccination is described. The patient is a 39-year-old, previously healthy man on active duty in the US Marine Corps, in whom a urticaral skin rash and progressive dyspnea on exertion developed following subcutaneous anthrax vaccination. A diagnosis of bronchiolitis obliterans with organizing pneumonia was made from transbronchial lung biopsy samples after evaluation excluded multiple infectious and collagen vascular etiologies. This appears to be the first recorded case of HP following an anthrax vaccination; however, a case report of pulmonary and cutaneous vasculitis following hepatitis B vaccination has been reported in the literature and is reviewed.

Exhaled nitric oxide as a predictor of exercise-induced bronchoconstriction.

INTRODUCTION: Exercise-induced bronchoconstriction (EIB) is present in 40 to 90% of patients with asthma. Exhaled NO (eNO) levels have been correlated with bronchial hyperresponsiveness to methacholine, and have correlated with the degree of decrease in FEV(1) with exercise. The purpose of our study was to examine whether eNO measurements prior to or after exercise could be used as a surrogate marker of exertional bronchoconstriction in a population referred specifically for the evaluation of EIB. METHODS: We studied 50 consecutive subjects without a history of asthma who were referred for the clinical evaluation of EIB. eNO levels were measured prior to exercise challenge and every 5 min for a total of 30 min after exercise. Forced expiratory flows were measured prior to and serially after exercise challenge. RESULTS: Seven subjects had a decrease in FEV(1) of > or = 15% with exercise. The mean eNO level prior to exercise was 41 parts per billion (ppb) [median +/- SD, 23 +/- 42.2 ppb] in the EIB group and 25.6 ppb (median, 19.95 +/- 18.47 ppb) in the group without EIB. A receiver operator characteristic curve yielded a value of 0.636. When using an eNO level of < 12 ppb, the sensitivity, specificity, negative predictive value, and positive predictive value for EIB were 1.0, 0.31, 0.19, and 1.0, respectively; therefore, no one with a baseline eNO of < 12 ppb demonstrated EIB. CONCLUSIONS: No subjects with very low pre-exercise eNO levels (< 12 ppb) demonstrated bronchial hyperresponsiveness to exercise. eNO measurement may obviate the need for bronchoprovocation testing in patients who complain of exertional dyspnea.

Halting a pneumococcal pneumonia outbreak among United States Marine Corps trainees.

BACKGROUND: Streptococcus pneumoniae is the leading cause of bacterial pneumonia in all age groups. Identifying outbreaks of pneumococcal disease and key risk factors may lead to improvements in vaccination and prevention strategies for high-risk groups. A significant outbreak of S. pneumoniae pneumonia that occurred among Marine recruits is reported here. METHODS: An outbreak was investigated using standard microbiologic procedures and epidemiologic evaluation to define the extent of the outbreak, determine the microbiologic causative agent(s), identify risk factors for the development of disease, and institute preventive measures against further cases of pneumonia among recruits. RESULTS: Fifty-two cases of radiographically confirmed pneumonia occurred among 3367 Marine recruits over a 2-week period in November 2000. Twenty-five of these cases occurred in a single company of 481 men, with an attack rate of 5.2%. Twelve of the 25 cases were caused by S. pneumoniae, serotypes 4 and 9v. The outbreak rapidly ended following isolation of cases, prophylaxis with oral azithromycin, and administration of the 23-valent pneumococcal vaccine. CONCLUSIONS: This outbreak of pneumococcal disease occurred in the setting of intense military training and a crowded environment. The use of the pneumococcal vaccine year-round in military trainees and other high-risk populations to reduce pneumococcal disease should be considered.

Vesicants and nerve agents in chemical warfare. Decontamination and treatment strategies for a changed world.

Vesicants and nerve agents have been used in chemical warfare for ages. They remain a threat in today's altered political climate because they are relatively simple to produce, transport, and deploy. Vesicants, such as mustard and lewisite, can affect the skin, eyes, respiratory system, and gastrointestinal system. They leave affected persons at risk for long-term effects. Nerve agents, such as tabun, sarin, soman, and VX, hyperstimulate the muscarinic and nicotinic receptors of the nervous system. Physicians need to familiarize themselves with the clinical findings of such exposures and the decontamination and treatment strategies necessary to minimize injuries and deaths.

Resource-poor settings: infrastructure and capacity building: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

BACKGROUND: Planning for mass critical care (MCC) in resource-poor or constrained settings has been largely ignored, despite their large populations that are prone to suffer disproportionately from natural disasters. Addressing MCC in these settings has the potential to help vast numbers of people and also to inform planning for better-resourced areas. METHODS: The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of disaster (mitigation/preparedness/response/recovery), literature searches were conducted to identify evidence on which to answer the key questions in these areas. Given a lack of data upon which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. RESULTS: The five key questions were then separated as follows: definition, infrastructure and capacity building, resources, response, and reconstitution/recovery of host nation critical care capabilities and research. Addressing these questions led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part 1, Infrastructure/Capacity in this article, and part 2, Response/Recovery/Research in the accompanying article. CONCLUSIONS: Lack of, or presence of, rudimentary ICU resources and limited capacity to enhance services further challenge resource-poor and constrained settings. Hence, capacity building entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is needed to mount a surge response. Moreover, planning should include when to disengage and how the host nation can provide capacity beyond the mass casualty care event.

Resource-poor settings: response, recovery, and research: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

BACKGROUND: Planning for mass critical care in resource-poor and constrained settings has been largely ignored, despite large, densely crowded populations who are prone to suffer disproportionately from natural disasters. As a result, disaster response has been suboptimal and in many instances hampered by lack of planning, education and training, information, and communication. METHODS: The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of the disaster cycle (mitigation/preparedness/response/recovery). Literature searches were conducted to identify evidence to answer the key questions in these areas. Given a lack of data on which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. RESULTS: The five key questions were as follows: definition, capacity building and mitigation, what resources can we bring to bear to assist/surge, response, and reconstitution and recovery of host nation critical care capabilities. Addressing these led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part I, Infrastructure/Capacity in the accompanying article, and part II, Response/Recovery/Research in this article. CONCLUSIONS: A lack of rudimentary ICU resources and capacity to enhance services plagues resource-poor or constrained settings. Capacity building therefore entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is often needed to mount a surge response. Moreover, the disengagement of these responding groups and host country recovery require active planning. Future improvements in all phases require active research activities.

Plasmapheresis in the management of severe hypertriglyceridemia.

Plasmapheresis can benefit a variety of critically ill patients. A woman with diabetic ketoacidosis and severe hypertriglyceridemia was treated with plasmapheresis when conventional treatments did not markedly reduce her triglyceridemia. The patient was admitted to a medical intensive care unit because of diabetic ketoacidosis with severe lipemia. The lipemia-associated interference in laboratory studies made treatment of electrolyte abnormalities extremely difficult. The hypertriglyceridemia was initially treated with insulin, antilipidemic medications, and heparin, but the levels of triglycerides remained elevated, delaying results of needed laboratory studies for hours. After plasmapheresis, the serum level of triglycerides decreased by 77% in less than 24 hours. Severe lipemia interferes with photometric laboratory studies, yielding an underestimation of serum levels of electrolytes. Plasmapheresis is safe, rapid, and effective for emergent management of severe hypertriglyceridemia in critically ill patients. The impact of the procedure on critical care nursing is growing as nurses become involved in the treatment and follow-up care of patients who have plasmapheresis.

Healthcare ethics: the experience after the Haitian earthquake.

On January 12, 2010, a 7.0 Richter earthquake devastated Haiti and its public health infrastructure leading to a worldwide humanitarian effort. The United States sent forces to Haiti's assistance including the USNS Comfort, a tertiary care medical center on board a ship. Besides setting a transparent triage and medical regulating system, the leadership on the Comfort instituted a multidisciplinary Healthcare Ethics Committee to assist in delivering the highest level efficient care to the largest number of victims. Allocation of resources was based on time-honored ethics principles, the concept of mass casualty triage in the setting of resource constraints, and constructs developed by the host nation's Ministry of Health. In offering aid in austere circumstances, healthcare practitioners must not only adhere to the basic healthcare ethics principles but also practice respect for communities, cultures, and traditions, as well as demonstrate respect for the sovereignty of the host nation. The principles outlined herein should serve as guidance for future disaster relief missions. This work is in accordance with BUMEDINST 6010.25, Establishment of Healthcare Ethics Committees.

The obesity paradox.

The term "obesity paradox" refers to the observation that, although obesity is a major risk factor in the development of cardiovascular and peripheral vascular disease, when acute cardiovascular decompensation occurs, for example, in myocardial infarction or congestive heart failure, obese patients may have a survival benefit. In addition, it has been suggested that obese patients tend to fare better after certain surgical procedures, such as coronary artery bypass surgery. Moreover, it appears that obese men with chronic hypertensive heart disease live longer than men of normal weight. Mounting evidence shows that obesity alone may confer a survival benefit independent of age, medical care, or therapy. Perhaps the definition of obesity needs to be revisited, and it is also possible that all fat is not equal.