Dismounted Blast Injuries in Patients Treated at a Role 3 Military Hospital in Afghanistan: Patterns of Injury and Mortality.

BACKGROUND: The purposes of this study are to define the pattern of injuries sustained by dismounted troops exposed to improvised explosive devices blasts treated at a Role 3 combat support hospital and to assess injury patterns and mortality associated with the mechanism. Our hypothesis was that mortality is associated with pelvic fracture, massive transfusion, high Injury Severity Score (ISS), multiple limb amputations, and transfer from a Role 2 facility. STUDY DESIGN: Retrospective study of 457 patients. Analysis performed on trauma registry data and systematic review of radiographs. RESULTS: 99.9% were men with a median age of 23 years and median ISS 10. 141 patients (30.9%) required massive blood transfusion. Limb amputations were frequently observed injuries, 109 of 172 amputees (63.4%) had a double amputation. 34 subjects (7.4%) had pelvic fractures; majority of pelvic fractures (88%) were unstable (Tile B or C). Risk factors associated with the overall mortality rate of 1.8% were an ISS greater than 15 (odds ratio: 11.5; 95% confidence interval: 1.38, 533; p = 0.009), need for massive transfusion (p < 0.0001), and the presence of a pelvic fracture (odds ratio: 7.63; 95% confidence interval: 1.13, 41.3; p = 0.018). CONCLUSIONS: Dismounted improvised explosive devices blast injuries result in devastating multiple limb amputations and unstable pelvic fractures, which are associated with mortality after initial trauma resuscitation at a Role 3 hospital.

Task-shifting of antiretroviral delivery from health care workers to persons living with HIV/AIDS: clinical outcomes of a community-based program in Kenya.

OBJECTIVES: To assess whether community-based care delivered by people living with HIV/AIDS (PLWAs) could replace clinic-based HIV care. DESIGN: Prospective cluster randomized controlled clinical trial. SETTING: Villages surrounding 1 rural clinic in western Kenya. SUBJECTS: HIV-infected adults clinically stable on antiretroviral therapy (ART). INTERVENTION: The intervention group received monthly Personal Digital Assistant supported home assessments by PLWAs with clinic appointments every 3 months. The control group received standard of care monthly clinic visits. MAIN OUTCOMES MEASURED: Viral load, CD4 count, Karnofsky score, stability of ART regimen, opportunistic infections, pregnancies, and number of clinic visits. RESULTS: After 1 year, there were no significant intervention-control differences with regard to detectable viral load, mean CD4 count, decline in Karnofsky score, change in ART regimen, new opportunistic infection, or pregnancy rate. Intervention patients made half as many clinic visits as did controls (P < 0.001). CONCLUSIONS: Community-based care by PLWAs resulted in similar clinical outcomes as usual care but with half the number of clinic visits. This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs, expediting ART rollout and increasing access to treatment while expanding the capacity of health care institutions in resource-constrained environments.

A retrospective study of memantine in children and adolescents with pervasive developmental disorders.

RATIONALE: There are no drugs that have been shown to effectively treat the core social impairment of autism. OBJECTIVES: The purpose of this study was to examine the effectiveness and tolerability of memantine for social impairment in children and adolescents with pervasive developmental disorders (PDDs). MATERIALS AND METHODS: Medical records of 18 patients with PDDs consecutively treated with open-label memantine were retrospectively reviewed. The data reviewed included prospectively obtained assessments of severity (S) and improvement (I) using the Clinical Global Impressions Scale (CGI). Pretrial and follow-up parent ratings were also available on six patients using the Aberrant Behavior Checklist (ABC). RESULTS: Eighteen patients (15 male, 3 female; mean age=11.4 years, range 6-19 years) received memantine (mean dosage=10.1 mg/day, range 2.5-20 mg/day) over a mean duration of 19.3 weeks (range 1.5-56 weeks). Eleven of 18 (61%) patients were judged responders to memantine based on a rating of "much improved" or "very much improved" on the CGI-I. Significant improvement was also seen on the CGI-S. Improvement was primarily seen clinically in social withdrawal and inattention. Adverse effects occurred in 7 of 18 (39%) patients and led to drug discontinuation in 4 of 18 (22%) patients. Thirteen of 18 (72%) patients received stable doses of concomitant medications during the memantine trial. CONCLUSIONS: In this open-label retrospective study, memantine was effective in a number of patients with PDDs. Controlled studies are warranted to further assess the efficacy and safety of memantine in PDDs.