The COVID-19 Army Rapid Assessment Tool (CARAT) for Management of COVID-19 in the Deployed Setting.

The COVID-19 pandemic poses unique challenges within the austere clinical setting, and the time between patient presentation and deterioration is a critical opportunity for intervention. In some cases, this may be a life-saving transfer to a higher level of care. US Central Command (CENTCOM) has provided valuable guidance for COVID-19 management in the operational environment,1 and has proposed the National Early Warning System 2 (NEWS2) scoring tool as a useful adjunct to gauging illness severity. NEWS2, however, does not consider co-morbidities, such as diabetes or chronic cardiac disease, which could worsen the clinical course of SARS-CoV-2 patients. Thus, NEWS2 fails to address such factors during the risk stratification of patients to a higher level of care. To address this concern, June 2020, 3rd Medical Brigade, Operation Spartan Shield (OSS) developed the COVID-19 Army Rapid Assessment Tool (CARAT) with inputs from clinicians and researchers (The Team). The CARAT is a clinical scoring system, modified from the NEWS2, which combines the effects of co-morbid disease with the current physiological condition of a COVID-19 patient. The Team obtained clinical data for 105 patients from the CENTCOM area of responsibility (AOR), who presented to a military treatment facility (MTF) symptomatic for, and testing positive for SARS-CoV-2, during the time period of June to mid-August 2020. Each patient was retrospectively assigned a CARAT score based on his or her initial presentation. Preliminary review of data suggested a CARAT value of 4 or greater was an indicator for risk of further deterioration. Patients were then grouped into two categories: patients who received transfer to a higher level of care, versus "stay-in-place" supportive care. Results showed that 100% of patients with a score ≥4 had been transferred to a higher echelon of care, compared to 2% of patients with scores less than 4. A Fisher's exact test demonstrated a statistically significant difference between these two groups (p is less than 0.001). Interestingly, when compared with the NEWS2 score, the CARAT identified 9 individuals for transfer to a higher level of care, of whom only one patient was identified by the NEWS2, clearly underscoring the significance of CARAT despite small sample size. We therefore recommend that CARAT be further validated in predicting disease severity and need for emergent evacuation in larger patient settings.

History of posttraumatic stress disorder · priapism · Dx?

A 35-year-old African-American man, who was an active duty service member, presented to the Troop Medical Clinic with a 4-hour history of priapism. He had been taking sertraline 100 mg and prazosin 10 mg nightly for 4 months to treat his posttraumatic stress disorder (PTSD) with no reported adverse effects. These doses were titrated 2 months prior to presentation. The patient reported that he took his usual medication doses before bed and awoke at 3 am with a penile erection. At 7 am, he presented to the clinic because of pain from the continued erection.

Phenology of Brown Marmorated Stink Bug in a California Urban Landscape.

The brown marmorated stink bug, Halyomorpha halys (Stål) (Hemiptera: Pentatomidae), is an invasive pest that has been resident in California since 2006. To better understand its seasonal phenology, we used baited traps to estimate nymph and adult population densities in midtown Sacramento, the focal area of the Northern California invasion. Adult H. halys populations were found soon after trapping began in February (2015-2016) or March (2014); the first egg masses for 2014, 2015, and 2016 were found on 5 May, 17 April, and 12 April, respectively, and the first nymphs were found 3 June, 19 May, and 9 May, respectively. There were two generations per year, with one peak in June and another in September. Summer temperatures above 36°C in July and August were associated with reduced catches in traps of both nymphs and adults. This extreme heat may have helped to form two clear nymph peaks and suppressed egg deposition. In 2016, two trap types and four lures were also compared. Trap type influenced season-long nymph captures, with fewer nymphs in double cone traps than pyramid traps. Lure type influenced season-long trap catch, with more nymphs and adults trapped with the Rescue lure than the AgBio Combo lure, Alpha Scents, or Trécé Pherocon Combo lures, although this difference was only associated with the capture of nymphs and we did not compare for longevity or seasonal variation. These data are discussed with respect to H. halys' phenology from the mid-Atlantic region.

Inhibiting Oxidative Phosphorylation In Vivo Restrains Th17 Effector Responses and Ameliorates Murine Colitis.

Integration of signaling and metabolic pathways enables and sustains lymphocyte function. Whereas metabolic changes occurring during T cell activation are well characterized, the metabolic demands of differentiated T lymphocytes are largely unexplored. In this study, we defined the bioenergetics of Th17 effector cells generated in vivo. These cells depend on oxidative phosphorylation (OXPHOS) for energy and cytokine production. Mechanistically, the essential role of OXPHOS in Th17 cells results from their limited capacity to increase glycolysis in response to metabolic stresses. This metabolic program is observed in mouse and human Th17 cells, including those isolated from Crohn disease patients, and it is linked to disease, as inhibiting OXPHOS reduces the severity of murine colitis and psoriasis. These studies highlight the importance of analyzing metabolism in effector lymphocytes within in vivo inflammatory contexts and suggest a therapeutic role for manipulating OXPHOS in Th17-driven diseases.

Cost impact analysis of Enhanced Recovery After Surgery program implementation in Alberta colon cancer patients.

BACKGROUND: The Enhanced Recovery After Surgery (eras) colorectal guideline has been implemented widely across Alberta. Our study examined the clinical and cost impacts of eras on colon cancer patients across the province. METHODS: We first used both summary statistics and multivariate regression methods to compare, before and after guideline implementation, clinical outcomes (length of stay, complications, readmissions) in consecutive elective colorectal patients 18 or more years of age and in colon cancer and non-cancer patients treated at the Peter Lougheed Centre and the Grey Nuns Hospital between February 2013 and December 2014. We then used the differences in clinical outcomes for colon cancer patients, together with the average cost per hospital day, to estimate cost impacts. RESULTS: The analysis considered 790 patients (398 cancer and 392 non-cancer patients). Mean guideline compliance increased to 60% in cancer patients and 57% in non-cancer patients after eras implementation from 37% overall before eras implementation. From pre- to post-eras, mean length of stay declined to 8.4 ± 5 days from 9.5 ± 7 days in cancer patients, and to 6.4 ± 4 days from 8.8 ± 5.5 days in non-cancer patients (p = 0.0012 and p = 0.0041 respectively). Complications declined significantly in the renal, hepatic, pancreatic, and gastrointestinal groups (difference in proportions: 13% in cancer patients; p < 0.05). No significant change in the risk of readmission was observed. The net cost savings attributable to eras implementation ranged from $1,096 to $2,771 per cancer patient and from $3,388 to $7,103 per non-cancer patient. CONCLUSIONS: Implementation of eras not only resulted in clinical outcome improvements, but also had a significant beneficial impact on scarce health system resources. The effect for cancer patients was different from that for non-cancer patients, representing an opportunity for further refinement and study.

Sterol metabolism controls T(H)17 differentiation by generating endogenous RORγ agonists.

Retinoic acid receptor-related orphan receptor γ (RORγt) controls the differentiation of naive CD4(+) T cells into the TH17 lineage, which are critical cells in the pathogenesis of autoimmune diseases. Here we report that during TH17 differentiation, cholesterol biosynthesis and uptake programs are induced, whereas their metabolism and efflux programs are suppressed. These changes result in the accumulation of the cholesterol precursor, desmosterol, which functions as a potent endogenous RORγ agonist. Generation of cholesterol precursors is essential for TH17 differentiation as blocking cholesterol synthesis with chemical inhibitors at steps before the formation of active precursors reduces differentiation. Upon activation, metabolic changes also lead to production of specific sterol-sulfate conjugates that favor activation of RORγ over the TH17-inhibiting sterol receptor LXR. Thus, TH17 differentiation is orchestrated by coordinated sterol synthesis, mobilization and metabolism to selectively activate RORγ.

Evaluation of Dormant-Stage Inoculum Sanitation as a Component of a Fire Blight Management Program for Fresh-Market Bartlett Pear.

From 2010 to 2013, the efficacy of copper-based inoculum sanitation as a component of fire blight management programs was evaluated in commercial pear orchards located in northern California. Forty-one 4-ha sections of orchard were split into two equal-sized plots, with the orchardist applying horticultural oil alone to one plot and horticultural oil plus a fixed copper bactericide to the other plot. These treatments were timed to begin just prior to and finish at the "green tip" phenological stage, which occurs about 5 weeks before full bloom. During bloom, flower samples were collected from the plots and subjected to a loop-mediated isothermal DNA amplification (LAMP) assay for specific detection of Erwinia amylovora. Overall, epiphytic populations of E. amylovora on flowers were detected rarely at midbloom (6% of samples) but commonly at petal fall (44% of samples). In three of four seasons, E. amylovora detection in flower samples at a given bloom stage was significantly suppressed in copper-plus-oil-treated plots compared with oil-only plots. All orchards also received antibiotic treatments during the bloom period and, perhaps as a consequence, the development of fire blight was sporadic and not affected significantly by the copper treatment in any season. The pathogen detection data indicate that copper sanitation may add value to a fire blight management program by delaying the increase of epiphytic populations of E. amylovora in flowers to the late stages of the bloom period, at which time the number of susceptible flowers declines rapidly.

Tuberculosis screening for long-term care: a cost-effectiveness analysis.

SETTING: Long-term care facilities in Canada, a low tuberculosis (TB) incidence country. OBJECTIVE: To compare the impact and cost-effectiveness of three screening strategies for TB on entry to long-term care: no screening, screening for latent tuberculous infection (LTBI) using the tuberculin skin test (TST) or screening for active disease with a chest X-ray. DESIGN: Cost effectiveness analysis. RESULTS: With the LTBI screening strategy, the number needed to screen to prevent one active case was 1410 and the cost per case averted was Canadian $109 913. The number needed to screen to prevent one case using the active screening strategy was 1266, and the cost per case averted was $672 298. CONCLUSIONS: Our findings suggest that TB screening strategies on entry to long-term care are costly, with large numbers needed to screen. Screening with TST was more cost-effective than chest X-ray screening. Higher risk of reactivation of LTBI is associated with improved cost-effectiveness of screening. Short time horizons and test performance characteristics place limitations on screening programmes in this setting. Future considerations include the changing demographics of the institutionalised elderly.

Scapular kinematics and subacromial-impingement syndrome: a meta-analysis.

CONTEXT: The literature does not present a consistent pattern of altered scapular kinematics in patients with shoulder-impingement syndrome (SIS). OBJECTIVES: To perform meta-analyses of published comparative studies to determine the consistent differences in scapular kinematics between subjects with SIS and controls. In addition, the purpose was to analyze factors of the data-collection methods to explain the inconsistencies in reported kinematics. The results of this study will help guide future research and enable our understanding of the relationship between scapular kinematics and SIS. EVIDENCE ACQUISITION: A search identified 65 studies; 9 papers met inclusion criteria. Sample sizes, means, and SDs of 5 scapular-kinematic variables were extracted or obtained from each paper's lead author. Standard difference in the mean between SIS and controls was calculated. Moderator variables were plane of arm elevation, level of arm elevation (ARM) and population (POP). EVIDENCE SYNTHESIS: Overall, the SIS group had less scapular upward rotation (UR) and external rotation (ER) and greater clavicular elevation (ELE) and retraction (RET) but no differences in scapular posterior tilt (PT). In the frontal plane, SIS subjects showed greater PT and ER, and in the scapular plane, less UR and ER and greater ELE and RET. There was also greater ELE and RET in the sagittal plane. There was less UR at the low ARM and greater ELE and RET at the high ARM with SIS. Athletes and overhead workers showed less UR, while athletes showed greater PT and workers showed less PT and ER. The general population with SIS had greater ELE and RET only. CONCLUSIONS: Subjects with SIS demonstrated altered scapular kinematics, and these differences are influenced by the plane, ARM, and POP. Athletes and overhead workers have a different pattern of scapular kinematics than the general population. The scapular plane is most likely to demonstrate altered kinematics. These factors should be considered when designing futures studies to assess the impact of altered kinematics in patients with SIS.

Predicting the result of nerve conduction tests in carpal tunnel syndrome using a questionnaire.

We performed a study to determine whether the results of a questionnaire could be used to predict the results of nerve conduction tests in patients with suspected carpal tunnel syndrome. Two hundred and eleven consecutive patients underwent electrophysiological testing, and completed the questionnaire designed by Kamath and Stothard. Two questionnaire threshold scores were identified, which classified with high sensitivity and high specificity those patients who had normal, and abnormal nerve conduction tests respectively. Patients who scored greater than 6 on the questionnaire could be classified with 87% specificity as having abnormal tests, and patients scoring below 3 on the questionnaire could be classified with 87% sensitivity as having normal studies. We suggest therefore that patients who score above 6, or below 3 on this questionnaire may not need to be referred for nerve conduction tests, as the result can be predicted with adequate accuracy.

Are hip protectors correctly positioned in use?

There are many designs of hip protectors ranging from small elliptical shaped hard shell designs to large circular soft pads. They are held in position usually by being contained in a close fitting pocket on a garment that patients wear all the time they are at risk of sustaining a fracture of the hip if they fall onto the area of the greater trochanter (GT). It is important for the function of the hip protector that the pad element is positioned over the GT when the subject falls onto a surface such as the floor so as to provide the maximal protection by reducing the large forces transmitted to the femoral neck that lead to the fracture of the bone. In this study, anatomical measurements show where the GT is relevant to the centre of the hip protector, and position and movement studies have shown that generally the hard shell design of the hip protector lies posterior and proximal to the GT both for erect and flexed positions of the hip. The position of the GT relevant to the anterior superior iliac crest was established using ultrasound examinations on control and patients admitted with a fracture of the hip due to a fall. The diagonal surface distance for the three groups of test subjects was approximately 12 cm and a template was developed that could be used to locate the GT. A 'zone' of GT position and movement has been established relative to the anterior superior iliac crest, and designers of garments should ensure that this zone is within the area of protection provided by their hip protector pad design.

Heel bone densitometry: device specific thresholds for the assessment of osteoporosis.

A diagnosis of osteoporosis is facilitated by bone mineral density (BMD) measurement of the lumbar spine and hip using dual energy X-ray absorptiometry (DXA), interpreted in accordance with criteria published by the World Health Organization (WHO). The use of peripheral DXA is growing in primary care and guidance on its use has recently been published by the National Osteoporosis Society (NOS), recommending a triage approach using thresholds specific to each type of peripheral device. However, no data currently exist for the Norland Apollo heel densitometer (Cooper Surgical, Trumbull, USA). 215 women between 50 years and 75 years of age (mean age 64.6 years) referred for hip and spine BMD measurements also had a heel BMD measurement. Device specific upper and lower thresholds were calculated for the Norland Apollo heel densitometer to give a 90% sensitivity and 90% specificity for osteoporosis at the hip or spine. Patients with a heel T-score of above -1.2 are very likely to have normal bone density on axial densitometry, whilst patients with heel T-score of below -2.2 are very likely to have osteoporosis at the hip or spine. Patients whose measurements lie between the thresholds should be referred for axial DXA.

Sustainability of irrigated agriculture in the San Joaquin Valley, California.

The sustainability of irrigated agriculture in many arid and semiarid areas of the world is at risk because of a combination of several interrelated factors, including lack of fresh water, lack of drainage, the presence of high water tables, and salinization of soil and groundwater resources. Nowhere in the United States are these issues more apparent than in the San Joaquin Valley of California. A solid understanding of salinization processes at regional spatial and decadal time scales is required to evaluate the sustainability of irrigated agriculture. A hydro-salinity model was developed to integrate subsurface hydrology with reactive salt transport for a 1,400-km(2) study area in the San Joaquin Valley. The model was used to reconstruct historical changes in salt storage by irrigated agriculture over the past 60 years. We show that patterns in soil and groundwater salinity were caused by spatial variations in soil hydrology, the change from local groundwater to snowmelt water as the main irrigation water supply, and by occasional droughts. Gypsum dissolution was a critical component of the regional salt balance. Although results show that the total salt input and output were about equal for the past 20 years, the model also predicts salinization of the deeper aquifers, thereby questioning the sustainability of irrigated agriculture.

Acute and long-term management of patients with vertebral fractures.

Symptomatic vertebral fractures are associated with significant morbidity, excess mortality and health and social service expenditure. Up to 20% of patients with an incident vertebral fracture experience a further vertebral fracture within one year. It is therefore important that vertebral fractures are detected early, and treatment considered as soon as possible. Only a third of vertebral fractures come to medical attention, where they typically present with acute back pain, but other presentations include loss of height and increasing kyphosis. Spine X-rays should then be performed to confirm the diagnosis and exclude other pathology. Bone density measurements are not essential before starting treatment for osteoporosis in patients with low-trauma vertebral fractures, but may be useful to confirm osteoporosis when there is uncertainty about previous trauma. They may also aid in selecting the most appropriate therapy and monitoring response to treatment. Up to 30% of women and 55% of men with symptomatic vertebral crush fractures have underlying secondary osteoporosis, where treatment may lead to large increases in bone density. These conditions should therefore be sought by medical history, physical examination and appropriate investigations. The management of patients with acute vertebral fractures should include measures to reduce pain and improve mobility, as well as starting treatment for osteoporosis. Treatments have now been shown in randomized controlled trials to improve bone density and reduce the incidence of vertebral and non-vertebral fractures in patients with osteoporosis. Choice of treatment will depend on the underlying causes of bone loss, efficacy in any particular situation, cost, patient preference and the potential non-skeletal advantages and disadvantages.

Subliminal ultraviolet-B irradiation for the prevention of vitamin D deficiency in the elderly: a feasibility study.

AIM: To investigate whether daily subliminal ultraviolet-B irradiation in elderly subjects can maintain a normal vitamin D status. MATERIAL AND METHODS: In an open, uncontrolled study, 10 residents (four men and six women), mean age on entry of 83 years (range 65-97 years), from a residential nursing home in County Durham, England, were exposed daily to an artificial source of ultraviolet-B radiation equivalent to 15 min of summer sunshine. The change in plasma 25-hydroxyvitamin D levels following irradiation was measured. RESULTS: Improvement in the vitamin D status of the elderly residents was achieved with no change in their routine and with no intervention on the part of carers. CONCLUSIONS: On the basis of this small pilot study we conclude that subliminal ultraviolet-B irradiation may be effective in maintaining vitamin D status in elderly people at a lower cost than that of using oral vitamin D supplementation. Further controlled studies are needed before this technique can be recommended to change health policy with regard to the vitamin D status of institutionalised elderly people.