Extracorporeal Organ Support for Burn-Injured Patients.

As mortality relating to severe acute burn injury improves, patients are surviving longer into the critical care phase, which is commonly complicated by multisystem organ failure. Extracorporeal organ support (ECOS) represents a set of potential therapeutic technologies for managing patients with organ-specific complications. This article provides a comprehensive review of the existing literature, focusing on the use of continuous kidney replacement therapy, extracorporeal membrane oxygenation, extracorporeal carbon dioxide removal, and extracorporeal blood purification.

Characterizing the Asthma Phenotype of Military Personnel.

Introduction: Asthma is the most common diagnosis in military personnel who endorse chronic dyspnea. Service members have unique occupational risk factors, and there is concern that airborne exposures in the deployed environment as well as other occupational exposures may contribute to the development of asthma or exacerbate pre-existing disease. Asthma phenotyping with clinical biomarkers such as serum immunoglobulin E (IgE) levels and eosinophil (EOS) counts is useful in defining treatment strategies for the management of asthma.

Bronchoalveolar Lavage Fluid Cytology of Deployed Military Personnel With Chronic Respiratory Symptoms From the STAMPEDE III Study.

Introduction: Deployed military personnel may be at risk for developing acute and chronic lung disease. Prior studies of this patient population have revealed that unexplained exertional dyspnea is the most common diagnosis despite an extensive evaluation. There is a concern that an occult disorder may be affecting this population.

Enterococcus faecium Empyema Following Extracorporeal Membrane Oxygenation for COVID-19 Acute Respiratory Distress Syndrome.

A 33-year-old male with severe COVID-19 required prolonged veno-venous extracorporeal membrane oxygenation (ECMO) support. Following decannulation, he developed an empyema. Tube thoracostomy and broad-spectrum antibiotics were initiated, followed by an unsuccessful attempt at pleural irrigation with saline, given the patient had an increased risk of bleeding due to the concomitant requirement for systemic anticoagulation.

Single-Center Experience With the Seraph-100® Microbind® Affinity Blood Filter in Patients With SARS-CoV-2 Infection and Septic Shock at a Military Treatment Facility.

Introduction: Coronavirus disease 2019 (COVID-19) infection is characterized by a dysregulated inflammatory response, which may result in severe hemodynamic instability and septic shock. The Seraph-100® Microbind® Affinity Blood Filter is a commercially available extracorporeal pathogen absorbent device with the ability to bind pathogens and cytokines present within the blood. Our study aimed to evaluate the efficacy of the Seraph-100® for patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and septic shock.

Financial and Clinical Impact of Virtual Care During the COVID-19 Pandemic: Difference-in-Differences Analysis.

Background: Virtual care (VC) and remote patient monitoring programs were deployed widely during the COVID-19 pandemic. Deployments were heterogeneous and evolved as the pandemic progressed, complicating subsequent attempts to quantify their impact. The unique arrangement of the US Military Health System (MHS) enabled direct comparison between facilities that did and did not implement a standardized VC program.

Standardization of Pulmonary Embolism Evaluation and Management Through Implementation of a Pulmonary Embolism Response Team: A Single-Center Experience at Brooke Army Medical Center.

Introduction: Pulmonary embolism (PE) is associated with significant rates of morbidity and mortality. Management of PE is complex, and adverse patient events are not uncommon. Brooke Army Medical Center (BAMC) is among several select institutions that have implemented multidisciplinary pulmonary embolism response teams (PERTs) to improve PE outcomes.

Argatroban for Anticoagulation in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation in Coronavirus Disease 2019.

Unlabelled: A significant proportion of patients with coronavirus disease 2019 requiring venovenous extracorporeal membrane oxygenation at our institution demonstrated heparin resistance, which in combination with a heparin shortage resulted in the transition to argatroban with or without aspirin as an alternative anticoagulation strategy. The optimal anticoagulation strategy for coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation is unknown, and therefore, we sought to evaluate the efficacy and safety of argatroban with or without aspirin as an alternative anticoagulation strategy in this patient population.

Design: Retrospective cohort.

Simulation-Based Medical Education Improves Procedural Confidence in Core Invasive Procedures for Military Internal Medicine Residents.

Introduction The American Board of Internal Medicine (ABIM) requires that trainees receive procedural training for certification; however, Internal Medicine (IM) residents perform a variable number of procedures throughout residency training. This results in differences in confidence levels as well as procedural competence. For active-duty military trainees, this is especially problematic, as these procedural skills are often required during deployment soon after residency graduation.

Reporting the Presence of Coronary Artery Calcium in the Final Impression of Non-gated CT Chest Scans Increases the Appropriate Utilization of Statins.

Background Coronary artery calcium (CAC) scoring based on gated non-contrast cardiac computed tomography (CT) is a validated risk marker of major adverse cardiovascular events (MACE). Reporting of CAC on non-gated CT chest (NGCT) scans and the impact on medical therapy is not well studied. Methods A retrospective cohort of 5,043 NGCT scans was reviewed for the presence of CAC.

Secondary Spontaneous Pneumothorax Mimicking Lung Herniation.

Patients with chronic obstructive pulmonary disease (COPD) are at an increased risk for numerous pulmonary complications, including secondary spontaneous pneumothorax (SSP) and lung herniation. We describe the case of a 66-year-old female patient with severe COPD and previous lingula-sparing left upper lobectomy from adenocarcinoma who presented to the emergency department with a painful anterior chest wall mass that varied in size with respiration. This finding, in a patient with a prior history of an invasive thoracic procedure, is suggestive of lung herniation.

Mediastinal Actinomycosis After Esophagogastroduodenoscopy.

Actinomycosis is an uncommon bacterial infection that presents as an indolent, progressive disease that can affect multiple organ systems. We describe the case of a 66-year-old female with end-stage renal disease who presented to the emergency department after developing acute dyspnea and chest pain two weeks after undergoing a diagnostic esophagogastroduodenoscopy (EGD). A CT scan was obtained that revealed a large mediastinal mass, which was initially concerning for a potential malignancy.

Statin-Induced Immune-Mediated Necrotizing Myopathy: An Increasingly Recognized Inflammatory Myopathy.

Statin-induced immune-mediated necrotizing myopathy, also known as anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) myopathy, is an inflammatory myopathy that is triggered by statin exposure and persists after statin discontinuation. It is a rare side effect of statins, distinct from the more commonly recognized statin-induced myalgia, that is challenging to diagnose and treat. We describe a case of anti-HMGCR myopathy in a 59-year-old male with a prior history of statin intolerance presenting with markedly elevated creatinine kinase, myoglobinuria, and one month of progressive proximal muscle weakness after restarting atorvastatin 10 months prior to admission.

Reducing the Inappropriate Use of Proton Pump Inhibitors in an Internal Medicine Residency Clinic.

Introduction Proton pump inhibitors (PPI) are commonly prescribed in the primary care setting. While generally considered to be safe, there is growing evidence suggesting that PPI misuse is associated with a variety of significant adverse outcomes and unnecessary cost. The goal of this quality improvement project was to identify patients with non-guideline recommended PPI prescriptions in our internal medicine residency clinics and implement a process to de-prescribe or reduce the dose of PPIs across this patient population.

Adoption of coronary artery disease - Reporting and Data System (CAD-RADS™) and observed impact on medical therapy and systolic blood pressure control.

Background: CAD-RADS was developed to standardize communication of per-patient maximal stenosis on coronary CT angiography (CCTA) and provide treatment recommendations and may impact primary prevention care and resource utilization. The authors sought to evaluate CAD-RADS adoption on preventive medical therapy and risk factor control amongst a mixed provider population.

Methods: Statins, aspirin (ASA), systolic blood pressure and, when available, lipid panel changes were abstracted for 1796 total patients undergoing CCTA in the 12 months before (non-standard reporting, NSR, cohort) and after adoption of the CAD-RADS reporting template.

Incidence and Implication of Coronary Artery Calcium on Non-gated Chest Computed Tomography Scans: A Large Observational Cohort.

Introduction  Coronary artery calcification (CAC) scoring is typically performed utilizing non-contrast, electrocardiogram- (ECG) gated CT and offers an estimation of cardiovascular (CV) prognosis and risk stratification beyond previously established cardiac risk factors. Coronary calcification can also be assessed during non-gated chest CT, which is significant given the recent recommendations for lung cancer screening by low-dose CT. Methods We retrospectively reviewed 4,953 non-contrast chest CT scans in a single, closed referral tertiary military treatment facility over an 18-month period.

Adoption of the Coronary Artery Disease-reporting and Data System: Reduced Downstream Testing and Cardiology Referral Rates in Patients with Non-obstructive Coronary Artery Disease.

Introduction The coronary artery disease-reporting and data system (CAD-RADS) was developed to standardize communication of per-patient maximal stenosis and provide treatment recommendations that may affect downstream testing. Methods Downstream testing, cardiology referral, and cost were abstracted for 1,796 consecutive patients undergoing coronary CT angiography (CCTA) before and after the adoption of the CAD-RADS reporting template at a single-center closed referral hospital system. Cost analysis was based on direct invasive and non-invasive testing utilizing the Center for Medicare & Medicaid Services (CMS) outpatient prospective payment system (OPPS) final rule for 2018.

An Uncommon Presentation of Erythrodermic Psoriasis in a Patient Without a History of Psoriasis.

Erythrodermic psoriasis is a rare and potentially fatal skin condition. We present the case of a 68-year-old woman, with no prior dermatologic history, who was treated with steroid injection for an insect bite one month prior to presentation and subsequently developed a diffuse erythematous rash. She presented to a military medical center in shock, with weeping, coalesced plaques covering the majority of her skin.

Hemoglobin San Diego: An Uncommon Cause of Hereditary Erythrocytosis Discovered Incidentally in a Military Trainee.

High-affinity hemoglobinopathies are a rare clinical entity that commonly presents as an isolated erythrocytosis in asymptomatic individuals. We report such a case involving an 18-year-old active duty military trainee who presented to the hematology clinic after an isolated erythrocytosis was incidentally discovered during a flight physical. The patient was asymptomatic but did report a family history of erythrocytosis in his mother and maternal grandmother which intermittently required venesection.