The last days: The medical response of United States and allied military teams during the Afghanistan Exodus.

OBJECTIVES: The objective of this study is to describe the United States and allied military medical response during the withdrawal from Afghanistan. BACKGROUND: The military withdrawal from Afghanistan concluded with severe hostilities resulting in numerous civilian and military casualties. The clinical care provided by coalition forces capitalized on decades of lessons learned and enabled unprecedented accomplishments. METHODS: In this retrospective, observational analysis, casualty numbers, and operative information was collected and reported from military medical assets in Kabul, Afghanistan. The continuum of medical care and the trauma system, from the point of injury back to the United States was captured and described. RESULTS: Prior to a large suicide bombing resulting in a mass casualty event, the international medical teams managed distinct 45 trauma incidents involving nearly 200 combat and non-combat civilian and military patients over the preceding 3 months. Military medical personnel treated 63 casualties from the Kabul airport suicide attack and performed 15 trauma operations. US air transport teams evacuated 37 patients within 15 hours of the attack. CONCLUSION: Lessons learned from the last 20 years of combat casualty care were successfully implemented during the culmination of the Afghanistan conflict. Ultimately, the effort, teamwork, and system adaptability exemplify not only the attitudes and character of service members who provide modern combat casualty care but also the paramount importance of the battlefield learning health care system. A continued posture to maintain military surgical preparedness in unique environments remain crucial as the US military prepares for the future.Retrospective observational analysis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Marijuana's Influence on Pain Scores, Initial Weight Loss, and Other Bariatric Surgical Outcomes.

INTRODUCTION: Pain management can be challenging following bariatric surgery, and patients with obesity tend to increase opioid use after undergoing surgery. This report quantifies marijuana (MJ) use and its relationship to pain and other surgery-related outcomes in a population from a state that has legalized MJ. METHODS: Data were collected for consecutive patients undergoing weight reduction surgeries between May 1, 2014 and July 31, 2015. Demographics, preoperative comorbidities, medications, and perioperative opioid use were analyzed. The primary outcome evaluated was inpatient opioid pain medication use quantified using natural log morphine equivalents. Secondary outcomes included percentage of total body weight loss after three months, postoperative complications, and changes in medical comorbidities. RESULTS: A total of 434 patients, among whom 36 (8.3%) reported MJ use, comprised the study population. Perioperative opioid requirements were significantly higher in the MJ-user group (natural log morphine equivalents of 3.92 vs 3.52, p = 0.0015) despite lower subjective pain scores (3.70 vs 4.24, p = 0.07). MJ use did not affect percentage of 90-day total body weight loss, development of postoperative complications, or improvement in medical comorbidities. CONCLUSION: Perioperative opioid use was significantly higher in the MJ-user group despite lower subjective pain scores. The difference in opioid requirements suggests an interaction between MJ use and opioid tolerance or pain threshold. The percentage of total body weight loss, improvement in medical comorbidity, and incidence of postoperative complications at 90-day follow-up were not affected by MJ use in this cohort analysis.

Amniotic Fluid Embolism: Using the Medical Staff Process to Facilitate Streamlined Care.

Amniotic fluid embolism (AFE) is a catastrophic consequence of labor and delivery that often results in maternal and neonatal death. These poor outcomes are related largely to the rarity of the event in a population overwhelmingly biased by overall good health. Despite the presence of national AFE registries, there are no published algorithmic approaches to its management, to our knowledge. The purpose of this article is to share a care pathway developed by a multidisciplinary group at a community teaching hospital. Post hoc analysis of a complicated case of AFE resulted in development of this pathway, which addresses many of the major consequences of AFE. We offer this algorithm as a template for use by any institution willing to implement a clinical pathway to treat AFE. It is accompanied by the remarkable case outcome that prompted its development.

Taxonomic and Geographic Bias in Conservation Biology Research: A Systematic Review of Wildfowl Demography Studies.

Demographic data are important to wildlife managers to gauge population health, to allow populations to be utilised sustainably, and to inform conservation efforts. We analysed published demographic data on the world's wildfowl to examine taxonomic and geographic biases in study, and to identify gaps in knowledge. Wildfowl (order: Anseriformes) are a comparatively well studied bird group which includes 169 species of duck, goose and swan. In all, 1,586 wildfowl research papers published between 1911 and 2010 were found using Web of Knowledge (WoK) and Google Scholar. Over half of the research output involved just 15 species from seven genera. Research output was strongly biased towards 'high income' countries, common wildfowl species, and measures of productivity, rather than survival and movement patterns. There were significantly fewer demographic data for the world's 31 threatened wildfowl species than for non-threatened species. Since 1994, the volume of demographic work on threatened species has increased more than for non-threatened species, but still makes up only 2.7% of total research output. As an aid to research prioritisation, a metric was created to reflect demographic knowledge gaps for each species related to research output for the species, its threat status, and availability of potentially useful surrogate data from congeneric species. According to the metric, the 25 highest priority species include thirteen threatened taxa and nine species each from Asia and South America, and six from Africa.

Effects of muscarinic receptor antagonists on acetylcholine-induced contractions of jejunal smooth muscle in horses.

This study investigated the effects of a muscarinic type 1 (M(1)), 2 (M(2)), and 3 (M(3)) antagonists (4-DAMP, pirenzepine, and methoctramine, respectively) on acetylcholine (Ach)-induced contractions of longitudinal jejunal muscle strips of horses. Strips were irrigated with Krebs-Henseleit solution gassed with 95% O(2) and 5% CO(2), and the developed tension in response to Ach was recorded before and after incubation with increasing concentrations of 4-DAMP (10(-8)-10(-6) M), pirenzepine (10(-6)-10(-4) M), and methoctramine (10(-5)-10(-3) M). When competitive antagonism was characterized, the affinity constant (pA(2)) was calculated by Schild plots. A parallel rightward shift in the concentration-response curves was observed after 4-DAMP and pirenzepine. Methoctramine presented a dual effect on the concentration-response curves: lower concentrations induced a parallel rightward shift without altering the maximum intensity of contraction (E(max)), while the highest concentration increased slope of the concentration-response curve and increased E(max). The pA(2) for 4-DAMP and pirenzepine was 9.18 and 7.13, respectively. Acetylcholine-induced contractions of longitudinal jejunal smooth muscle are mediated mainly via M(3) receptors. The complex role of M(2) receptors in jejunal smooth muscle contractions was evident because methoctramine potentiated the contractile response to higher doses of Ach.

Fibular segment bone bridging in trans-tibial amputation.

The purpose of this paper is to present an alternative method of achieving a synostosis between tibia and fibula in trans-tibial amputations by means of a fibular segment in place of tibial osteoperiosteal flaps as described by Ertl, in 1949. From May 1997 through to February 2003, 15 patients were submitted to the proposed procedure. As a result, all patients produced a solid synostosis between tibia and fibula and were rehabilitated with the use of prostheses. The capacity of these patients for distal weight-bearing on the stump was remarkable when compared to patients submitted to the conventional trans-tibial amputation technique.

Humanization of a mouse monoclonal antibody that blocks the epidermal growth factor receptor: recovery of antagonistic activity.

BACKGROUND: Antibody humanization by transplanting the complementarity determining regions (CDRs) of a murine antibody to a human framework aims to reduce the response of the human immune system against a foreign molecule. Frequently, however, some murine amino acids from the framework have to be retained to recover binding affinity. OBJECTIVES: To redesign R3, a mouse monoclonal antibody (mAb) that binds the human epidermal growth factor (EGF)-receptor and inhibits the binding of EGF, to be a human IgG1. STUDY DESIGN: The light and heavy chains of REI and Eu, respectively, were selected as human immunoglobulin (Ig) frameworks for CDR-grafting based on their high homology with the corresponding sequences of murine R3. Molecular modeling was used to analyze the possible effects of mutating murine residues that underlie the CDRs. RESULTS: CDR-grafting dramatically reduced the binding capability of the antibody. Molecular modeling suggested that two amino acids (Thr 76 and Thr 93), among five immunoglobulin heavy chain variable region (VH) residues underlying the CDRs, were critical for antigen binding. The five residues were mutated back to the original murine amino acids in different combinations contained in six variants of humanized antibodies. In agreement with molecular modeling analysis. The variant in which three murine residues were retained (Ser 75, Thr 76 and Thr 93) exhibited a similar capacity to inhibit the binding of 125I-labeled EGF to its receptor as compared with the original antibody. This humanized antibody was at least 2-fold less immunogenic in African Green monkeys than the chimeric antibody. CONCLUSIONS: Only very few mutations in the frameworks may be necessary to recover the binding capability of a humanized antibody. Molecular modeling can serve as a powerful tool to identify residues critical for binding.

Minimizing the risk of brain herniation during treatment of diabetic ketoacidemia: a retrospective and prospective study.

We studied retrospectively, 219 episodes of diabetic ketoacidemia in 119 patients aged 13 months to 30 years, to determine the trend of the concentration of sodium in serum as glucose declined during treatment of uncomplicated episodes and of episodes with complications attributable to brain swelling. Of 20 complication, 13 were minor (headache only) and 7 major (death or near death). The concentration of sodium in serum failed to rise as that of glucose declined in 82 (54%) of 164 uncomplicated episodes and in 18 (95%) of 20 complicated episodes (p less than 0.01). Hence complications were more likely to occur among patients with a failure of the concentration of sodium to rise as glucose declined. Fifty-eight episodes of diabetic ketoacidemia in 40 patients aged 1 1/2 to 20 years were then studied prospectively on a 48-hour treatment plan to provide the volume of deficit evenly, with half the deficit of sodium in the first 42 hours. Sodium concentration in serum rose in 55 (95%) of 58 episodes as that of glucose declined. No patient had a major complication. We conclude that failure of the sodium concentration measured in serum to rise as glucose concentration declines is a marker for excessive administration of free water. An expanded repair period, with repair fluid containing an average of 125 mmol/L Na+ early in therapy, will usually protect against a downward trend in the concentration of sodium in serum and therefore against a rapid decline in effective serum osmolality. This regimen may be protective against near-death episodes and brain herniation during treatment.

Un enfoque educativo internacional de las enfermedades venereas / An international educative approach of the venereal diseases

Resumen Se inició un programa educativo en cooperación con el Departamento de Salud de Texas (Texas Department of Health) y con oficiales de salud mexicanos, en respuesta a un incremento de la gonorrea entre los adolescentes. Estudiantes debidamente entrenados del Departamento de Salud de la Universidad de Texas en El Paso (Department ofHealth al the UniversityofTexas al El Paso) presentan programas en español e inglés a estudiantes. centros de la comunidad y grupos juveniles tanto en Ciudad Juárez como en El Paso. Estudiantes de pre-médica en Ciudad Juárez están trabajando conjuntamente con los estudiantes de Estados Unidos con el fin de familiarizarse con el programa y poder transmitir sus conocimientos a otras panes de México después de graduarse. El programa consiste en una presentación oral y una película, seguidas de preguntas y respuestas. Se distribuyen folletos que resumen los síntomas de las enfermedades, el tratamiento, y dónde puede conseguirse dicho tratamiento. Este programa ha funcionado desde hace cinco años en los Estados Unidos y dos en México. El propósito del programa es instruirla lajuventud acerca de enfermedades que se transmiten sexual mente, y alentar a los jóvenes a que visiten, sin costo, clínicas para someterse a un tratamiento. Los resultados de esta operación han sido alentadores. Ochenta por ciento de todos los pacientes tratados en El Paso, Texas, y aproximadamente cincuenta por ciento de aquellos tratados en Mexico, indican que visitaron una clínica después de asistir a una presentación. Esto demuestra que cuando se da la información apropiada la gente toma las medidas necesarias que con tribu y en a su salud. Datos de evaluación estarán disponibles aproximadamente dentro de 18 meses