A Diagnosis You Cannot Afford to MIS-C: Multisystem Inflammatory Syndrome in Children Within the Active Duty Population.

Multisystem inflammatory syndrome in children (MIS-C), which is associated with coronavirus disease 2019 (COVID-19) and occurs in the immediately post-infectious period, has never-before been reported within the active duty population. It typically affects children, aged 5-13 years, but has been shown to affect those up to 20 years old. We present an 18-year-old active duty male that arrived at a military treatment facility emergency department with headache, neck pain, and shock without evidence of meningoencephalitis on cerebrospinal fluid analysis and with a negative COVID-19 test. He developed significant abdominal pain and cardiomyopathy. Chest computed tomography showed evidence of ground glass infiltrates, and repeat testing was positive for the COVID-19 virus. Multisystem inflammatory syndrome in children (MIS-C) was diagnosed and treated with a rapid improvement in the patient's condition. It is a rare but potentially fatal condition that has been shown to affect patients up to the age of 20, encompassing a large part of the junior enlisted population. Multisystem inflammatory syndrome in children (MIS-C) can lead to death, yet mimic other diseases leading to delay of care. Thus, it should be considered when faced with the appropriate constellation of symptoms.

Combating the Current Pandemic and Preparing for the Next: Lessons Learned From the COVID-19 Pandemic From the Perspective of Deployed Special Operations Forces.

The coronavirus 2019 (COVID-19) pandemic continues to be a threat to global health, including the health of deployed armed forces. Servicemembers had to adjust to the "new normal" while maintaining the interests of the nation's security as well as that of our host nation partners. This commentary examines how Special Operations Forces operating within four different regions worldwide leveraged the challenges presented by the onset of this pandemic in maintaining stability, sustaining a ready force, and operating forward deployed. Deployed forces face constant difficulties with logistical support, varied medical resources access and a medical system predominantly focused on trauma care. At the onset of the COVID-19 pandemic there was little guidance specific to these circumstances which required an improvised adaptation of the recommendations set by national and Department of Defense medical authorities. Plans were constantly revised to match the ever changing medical and operational environment. Strategies such as the "Bubble Philosophy" and tiered force protection measures helped our units to maintain a rigorous training cycle. New methods of communication and training with our host nation partners such as the use of Unmanned Aerial Systems (UAS) platforms to survey host nation training became standard. Through these measures all of our forces were able to maintain operational capacity, protect the force, and maintain rapport with the host nations. We hope these experiences will provide a rough framework for future forces faced with a similar struggle. We also want to stress that challenges vary depending on the area of operations and the pathogen responsible for the pandemic. Any feedback and collaboration that may come from this work is appreciated and encouraged.

Anthropogenic Disasters.

Anthropogenic disasters may be defined as any disaster caused by human action or inaction. Natural disasters occur without human interference. Injuries caused by terrorists and related criminal activities may be broadly grouped into 3 categories: blunt, blast, and penetrating trauma. Most terrorist and criminal activities that create a mass-casualty situation are performed using the weapons most readily available, such as firearms or explosives. A consistent pattern, comparing terrorism with interpersonal violence, is the greater severity of impact on the victim.

The effects of increased hay-to-grain ratio on behavior, metabolic health measures, and fecal bacterial communities in four Masai giraffe (Giraffa camelopardalis tippelskirchi) at Cleveland Metroparks Zoo.

We evaluated whether increasing the hay-to-grain ratio offered to Masai giraffe (Giraffa camelopardalis tippelskirchi) at Cleveland Metroparks Zoo would reduce oral stereotypies and alter feeding behaviors, maintain or increase serum calcium-to-phosphorus ratio, decrease serum insulin-to-glucose ratio and salivary insulin, and alter fecal bacterial community structure. Giraffe transitioned to a ∼90:10 hay-to-grain ratio in even increments over 8 weeks. A ration balancer was added during the seventh week of transition to ensure proper mineral and nutrient balance. We collected (1) behavioral data collected approximately daily using instantaneous focal sampling; (2) serum collections every other week for insulin-to-glucose and calcium-to-phosphorus ratio analysis and saliva weekly for insulin analysis; and (3) weekly fecal sample collections to examine changes in bacterial community structure during the 8 weeks preceding and following the diet change. After the diet change, giraffe spent significantly more time feeding and less time performing tongue and mouth stereotypies, people-directed and alert behaviors. Salivary and serum insulin and serum insulin-to-glucose ratio decreased, and fecal bacterial community structure changed significantly. However, serum calcium-to-phosphorus ratio remained >1:1 throughout the study. While further studies are needed to elucidate the nature and implications of the change in fecal bacterial community structure and metabolic hormones, the results of this study show promise for incremental improvements in health and welfare from feeding a higher proportion of forage in the diet.

Nearly two decades using the check-type to prevent ABO incompatible transfusions: one institution's experience.

To detect miscollected (wrong blood in tube [WBIT]) samples, our institution requires a second independently drawn sample (check-type [CT]) on previously untyped, non-group O patients who are likely to require transfusion. During the 17-year period addressed by this report, 94 WBIT errors were detected: 57% by comparison with a historic blood type, 7% by the CT, and 35% by other means. The CT averted 5 potential ABO-incompatible transfusions. Our corrected WBIT error rate is 1 in 3,713 for verified samples tested between 2000 and 2003, the period for which actual number of CTs performed was available. The estimated rate of WBIT for the 17-year period is 1 in 2,262 samples. ABO-incompatible transfusions due to WBIT-type errors are avoided by comparison of current blood type results with a historic type, and the CT is an effective way to create a historic type.

Bacterial endocarditis and functional mitral stenosis: a report of two cases and brief literature review.

Mitral valve endocarditis typically results in mitral regurgitation. However, endocarditis leading to functional mitral stenosis is uncommon and, when present, fungal organisms are typically implicated. Thus, obstructive-type bacterial endocarditis due to large vegetations blocking the mitral valve orifice is a rare occurrence, with approximately 20 reported cases in the literature. We report on two patients with bacterial endocarditis and severe functional mitral stenosis requiring emergent surgery. Additionally, this is the first report of vancomycin-resistant enterococcus causing endocarditis and functional mitral stenosis. The discussion emphasizes the hemodynamic instability of these patients and need for early surgical intervention.