20 Armoured Infantry Brigade downgrade study: epidemiology of principal conditions and plugging leaks in the rehabilitation pipeline.

INTRODUCTION: In April 2017, 22% of Army Full-time Trade Trained Strength was downgraded, reducing fully deployable strength to 60 546, against a target of 82 000. In June 2017, Commander 20 Armoured Infantry Brigade (20 AI Bde) initiated a study to look at the principal conditions causing medical downgrading, as a stepping stone to finding ways of reducing injury, enhancing rehabilitation and improving deployability. METHOD: The Defence Medical Information Capability Programme medical records for every downgraded soldier in 20 AI Bde and supporting units were scrutinised to identify their Medical Deployment Standard and the primary condition causing downgrading. RESULTS: A total of 842 downgraded soldiers were identified from a held strength of 3827 personnel. Sixty-five per cent of these downgrades were due to musculoskeletal injury (MSKI). Of this 65%, the majority were due to knee (31%), spine (28%) and foot/ankle (23%). Of the remaining 35%, the majority were due to noise-induced hearing loss (NIHL) (22%), adjustment disorders (19%) and non-freezing cold injury (NFCI) (13%).Several factors that slowed an individual's recovery pathway were identified. They mainly relate to soldiers being lost to follow-up through lack of active case management. CONCLUSIONS: MSKI is responsible for most downgraded personnel at Brigade level. The distribution of principal conditions is similar to previous studies looking at recruits and individual units.The creation of a rehabilitation troop, delivering active case management, can reduce the number of soldiers leaking out of the rehabilitation pipeline.

Use of a novel percutaneous biopsy localization device: initial musculoskeletal experience.

OBJECTIVE: To preliminarily evaluate a new CT-biopsy guidance device, the SeeStar (Radi, Uppsala, Sweden), for use in musculoskeletal applications. DESIGN: The device was evaluated using an imaging phantom and in various simulated clinical biopsy situations. The phantom study was undertaken to optimize the linear metallic artifacts produced by the guidance device. The phantom and guidance device were imaged with CT after altering different imaging parameters, including field of view, filter, focal spot size, kV, mAs, slice thickness and pitch. Clinical biopsy situations were simulated for a superficial biopsy, a deep biopsy and a horizontal biopsy approach. RESULTS: Altering CT parameters had little effect on the subjective appearance of the linear metal artifact, which is used to plan the biopsy approach. Placement of an 18-G needle inside of the biopsy device was subjectively helpful in exaggerating the artifact. Use of this artifact could be helpful in planning biopsy approach for deep lesions or lesions near critical structures. The metal guide on the device adequately supports a standard biopsy needle, making it potentially advantageous for biopsy of superficial lesions and lesions approached from a horizontal orientation. CONCLUSION: Use of this CT-biopsy guidance device is potentially useful for musculoskeletal applications. The linear metal artifact produced by the device can help plan the biopsy approach. The device can also be useful in biopsy situations where the biopsy needle requires external support during imaging.

Assessment of bone biopsy needles for sample size, specimen quality and ease of use.

OBJECTIVE: To assess whether there are significant differences in ease of use and quality of samples among several bone biopsy needles currently available. DESIGN: Eight commonly used, commercially available bone biopsy needles of different gauges were evaluated. Each needle was used to obtain five consecutive samples from a lamb lumbar pedicle. Subjective assessment of ease of needle use, ease of sample removal from the needle and sample quality, before and after fixation, was graded on a 5-point scale. The number of attempts necessary to reach a 1 cm depth was recorded. Each biopsy specimen was measured in the gross state and after fixation. RESULTS: The RADI Bonopty 15 g and Kendall Monoject J-type 11 g needles were rated the easiest to use, while the Parallax Core-Assure 11 g and the Bard Ostycut 16 g were rated the most difficult. Parallax Core-Assure and Kendall Monoject needles had the highest quality specimen in the gross state; Cook Elson/Ackerman 14 g and Bard Ostycut 16 g needles yielded the lowest. The MD Tech without Trap-Lok 11 g needle had the highest quality core after fixation, while the Bard Ostycut 16 g had the lowest. There was a significant difference in pre-fixation sample length between needles (P<0.0001), despite acquiring all cores to a standard 1 cm depth. Core length and width decrease in size by an average of 28% and 42% after fixation. CONCLUSION: Bone biopsy needles vary significantly in performance. Detailed knowledge of the strengths and weaknesses of different needles is important to make an appropriate selection for each individual's practice.

Carcinoma of the stomach with hepatocyte differentiation (hepatoid adenocarcinoma).

A case of hepatoid adenocarcinoma of the stomach is reported, and the literature is reviewed. The stomach is one of the most common sites in which hepatoid adenocarcinomas have been detected. Of the 59 cases reviewed from the literature (including the current case), a 2:1 male predominance was noted, and the serum alpha-fetoprotein level was almost always increased. All patients were adults, and most had evidence of metastases at the time of resection. Prognosis seems less favorable than that associated with the more common intestinal type of adenocarcinoma of the stomach. Hepatoid adenocarcinomas typically show periodic acid-Schiff-positive, diastase-resistant intracytoplasmic globules, which are demonstrated to be positive with antibodies to alpha-fetoprotein. The tumor cells resemble liver cells, and rare cases, including our own, have evidence of bile production. In our case, messenger RNA for albumin, unique to liver cells, was demonstrated by in situ hybridization of the tumor cells.

Glucose response to discontinuation of parenteral nutrition in patients less than 3 years of age.

BACKGROUND: The effects of abrupt discontinuation and tapering of total parenteral nutrition (TPN) on glucose concentration were compared in patients < 3 years of age. METHODS: Serial glucose concentrations were measured over 120 minutes after abrupt discontinuation as compared with tapering (decreasing infusion rate by 50% for 1 hour before discontinuation). Serial insulin concentrations were measured after abrupt discontinuation. RESULTS: There was a significantly greater decrease in glucose concentration from baseline at 30 minutes after abrupt discontinuation as compared with tapering. Fifty-five percent (6/11) of the patients developed hypoglycemia (glucose concentration < 40 mg/dL) after abrupt discontinuation. Age, glucose infusion rate, and serum insulin concentrations were not predictive of the development of hypoglycemia. The tapering regimen did not prevent hypoglycemia, which developed in 20% (2/10). CONCLUSION: The high incidence of hypoglycemia after TPN discontinuation in children < 3 years of age requires monitoring of serum glucose concentration when initiating intermittent TPN until tolerance is documented.

Occurrence of fibroadenomas in postmenopausal women referred for breast biopsy.

OBJECTIVE: To examine the occurrence of breast fibroadenomas in postmenopausal patients referred for breast biopsy. DESIGN: A retrospective review of breast biopsy outcome and of patient demographics, including menstrual and hormonal status. SETTING: The Tucson Breast Center, a large outpatient breast cancer detection clinic affiliated with the University of Arizona Health Sciences Center in Tucson, Arizona. PARTICIPANTS: All women seen at the Tucson Breast Center between 1985 and 1990 who were referred for breast biopsy. RESULTS: A total of 100 fibroadenomas were found in 709 breast biopsies whose results were known. Fifty-two of these were in premenopausal women and 44 in postmenopausal women; the menopausal status of four women was unknown. In postmenopausal women, 11 of the 44 patients reported hormone use. Fibroadenomas constituted 20% (39 of 195) of the benign masses and 12% (39 of 339) of all breast masses in postmenopausal women. Fibroadenomas constituted 10% (44 of 447) of all biopsies in postmenopausal women, including those with breast masses, abnormal calcifications, or other lesions. CONCLUSION: Noncalcified fibroadenomas of the breast are not confined to young women and may constitute a small but noteworthy proportion of lesions coming to breast biopsy in postmenopausal women.

C-reactive protein in acute pulmonary exacerbations of patients with cystic fibrosis.

C-reactive protein (CRP) concentrations were evaluated in 9 cystic fibrosis (CF) patients with acute pulmonary exacerbations and 14 patients with acute exacerbations of asthma without any symptoms of an acute infection. CRP concentrations were serially evaluated over the course of therapy in CF patients and compared with pulmonary function tests (PFTs) and clinical scores. CF patients were treated with aerosolized bronchodilators, intravenous fluids, and chest physiotherapy for 48 hours. Intravenous antibiotic therapy was added after 48 hours. Initial CRP concentrations differed significantly between patients with CF and those with asthma. CRP concentrations were elevated in 7 of 9 CF patients versus 3 of 14 asthma patients (P < 0.02). In CF patients, CRP concentrations did not correlate with PFTs (except on day 0) or clinical scores. Frequently PFTs and clinical scores continued to improve after CRP levels had reached their lowest concentrations. CRP concentrations decreased only after the addition of antibiotic therapy.

Assessment of truncal edema following breast cancer treatment using modified Harpenden skinfold calipers.

After initial treatment for breast cancer, lymphedema often affects the trunk as well as the arm. Evaluation of truncal swelling by the clinical "pinch test" of the posterior axillary fold is unreliable. Our aim was to develop an objective measurement, using modified Harpenden skinfold calipers. Standard Harpenden skinfold calipers exert a pressure of 12.6 g.mm-2, which rapidly squeezes edema fluid out of the skinfold. Springs were substituted to exert a lighter but relatively constant load (3.7 g.mm-2). Repeated skinfold thickness measurements on the same, normal subject then gave a relative standard deviation (r.s.d.) or coefficient of variation of 5%. The posterior axillary folds of 14 patients (age 56 +/- 13 (s.d.) years) with an average 30% arm swelling were measured using the same procedure. Readings were taken at 10 s, and again after 60 s of sustained application to assess the rate of creep, or deformation with time, attributed to displacement of pressurized interstitial fluid. Two patients had clinically observable axillary fold swelling. Eight patients, including the above two, showed axillary fold swelling by caliper measurement, defined as a 10% increase over the contralateral side (2 r.s.d.'s). Creep was greater on the affected side in all 14 patients. Thus, modified calipers can detect axillary fold edema, and thereby provide an objective method for assessing changes in swelling after lymphedema treatment.

Grasp biopsy, suction biopsy, and clinical history in the evaluation of esophagitis in infants 0-6 months of age.

Fifty-three infants 0-6 months of age with abnormal 24-h intraesophageal pH monitoring were evaluated by esophageal suction biopsies and endoscopic grasp biopsies. Histologic esophagitis was present in 30% of the infants. Of the infants with esophagitis, 88% were accurately identified by suction biopsy, and 75% were accurately identified by endoscopic grasp biopsy. Suction biopsy alone was not significantly different from combined grasp and suction biopsy, while differences between grasp biopsy and combined biopsy approached significance (p = 0.051). Twelve clinical symptoms and 21 intraesophageal pH monitoring parameters were evaluated for their ability to predict esophagitis, and none were found to be useful. We conclude that endoscopic esophageal biopsy, while more costly, offers no advantage over suction biopsy for the detection of esophagitis in young infants.

Breast cancer diagnosis in women with subglandular silicone gel-filled augmentation implants.

PURPOSE: To determine whether breast augmentation implants interfere with detection of breast cancer and to characterize the projections that offer an improvement in the detection of disease. MATERIALS AND METHODS: The mammographic examinations, clinical presentation, and pathologic findings were retrospectively reviewed in 18 patients who underwent breast augmentation with silicone gel-filled implants. RESULTS: At diagnosis, 16 patients (89%) had palpable abnormalities. Standard mammographic views were negative in 17 patients (94%). Modified implant compression views (used with implant displacement) showed abnormalities in 12 patients (67%). Sixteen (89%) of the 18 patients had invasive carcinomas, and seven (39%) had positive axillary lymph nodes. CONCLUSION: Standard mammographic views are inadequate for breast cancer screening in patients with silicone gel-filled implants. Although additional modified compression views offer a moderate improvement in breast cancer detection, imaging with tangential mammographic views, sonography of palpable areas, and breast physical examination in conjunction with mammography will offer additional benefit in breast cancer detection.

Skin microvascular architecture and perfusion studied in human postmastectomy oedema by intravital video-capillaroscopy.

Breast cancer treatment often causes chronic arm oedema. Oedema depends on the balance between microvascular filtration and lymph drainage, but little is known about the microvessels in postmastectomy oedema (PMO). We investigated cutaneous capillary density in PMO, since capillary density is one of the factors influencing fluid load on the lymphatic system. Video-capillaroscopy allows the skin microcirculation to be examined in vivo and recorded for later analysis. Patient arm volumes, measured optoelectronically, increased by 30 +/- 13%. The forearm skin of each arm was examined in 7 normal subjects (mean age 22 years) and 15 PMO patients (mean age 61 years). Native capillaroscopy was found to underestimate capillary density. Venous congestion increased the number of capillaries detected by native capillaroscopy by 26-28%. Fluorescein detected 19-27% more capillaries than native capillaroscopy. Using fluorescein, no significant difference in mean capillary density was found between the right (50 mm-2) and left (48 mm-2) arms of normal subjects (p = 0.53). Surprisingly, cutaneous capillary density in the swollen arm (33 mm-2) was not significantly less than in nonswollen arms (35 mm-2) of patients, despite a mean 14% increase in skin area. Capillary density decreased significantly with age. Relative to the volume and area changes, the density results indicated that cutaneous neovascularization had occurred in the swollen arm.

Esophagitis and modified Bernstein tests in infants with apparent life-threatening events.

OBJECTIVE: The current study was undertaken to determine the prevalence of abnormal intraesophageal pH monitoring, esophagitis, and oxygen desaturation after experimental esophageal acidification (modified Bernstein test) in patients with apparent life-threatening events (ALTEs). METHODS: Fifty patients admitted to the hospital with ALTEs were evaluated. Patients underwent 24-hour intraesophageal pH monitoring, esophageal suction biopsies, and modified Bernstein tests to document oxygen desaturation during experimental esophageal acidification. RESULTS: Abnormal pH monitoring was present in 82%, esophagitis in 16%, and oxygen desaturation of at least 5% with experimental esophageal acidification in 22% of the patients. Esophagitis was present in only 3 of 11 patients with oxygen desaturation, which was not different from those patients without oxygen desaturation. Clinical history was not predictive of oxygen desaturation during experimental acidification except that patients with a history of an ALTE while awake were more likely to demonstrate oxygen desaturation with acid. CONCLUSION: We conclude that 1) the prevalence of oxygen desaturation with experimental acidification in infants with ALTEs is significant and warrants further evaluation; 2) esophagitis is not a necessary predisposing condition to esophageal acid sensitivity in infants with ALTEs; and 3) ALTEs while awake are frequently associated with a positive modified Bernstein test.