bluuebunny/crossref_metadata_2025 huggingface dataset:
Fair allocation of cryopreserved donor oocytes: towards an accountable process
Authors: Kool E M , van der Graaf R , Bos A M E , Fauser B C J M , Bredenoord A L
Published: December 2020

A growing number of people desire ART with cryopreserved donor oocytes. The allocation of these oocytes to couples and mothers to be is a 2-fold process. The first step is to select a pool of recipients. The second step is to decide who should be treated first. Prioritizing recipients is critical in settings where demand outstrips supply. So far, the issue of how to fairly allocate cryopreserved donor oocytes has been poorly addressed. Our ethical analysis aims to support clinics involved in allocation decisions by formulating criteria for recipient selection irrespective of supply (Part I) and recipient prioritization in case supply is limited (Part II). Relevant criteria for recipient selection are: a need for treatment to experience parenthood; a reasonable chance for successful treatment; the ability to safely undergo an oocyte donation pregnancy; and the ability to establish a stable and loving relationship with the child. Recipients eligible for priority include those who: have limited time left for treatment; have not yet experienced parenthood; did not undergo previous treatment with cryopreserved donor oocytes; and contributed to the supply of donor oocytes by bringing a donor to the bank. While selection criteria function as a threshold principle, we argue that the different prioritization criteria should be carefully balanced. Since specifying and balancing the allocation criteria undoubtedly raises a moral dispute, a fair and legitimate allocation process is warranted (Part III). We argue that allocation decisions should be made by a multidisciplinary committee, staffed by relevant experts with a variety of perspectives. Furthermore, the committees’ reasoning behind decisions should be transparent and accessible to those affected: clinicians, donors, recipients and children born from treatment. Insight into the reasons that underpin allocation decisions allows these stakeholders to understand, review and challenge decisions, which is also known as accountability for reasonableness.
Efficacy of Ustekinumab for Active Perianal Fistulizing Crohn Disease: A Double-Center Cohort Study
Authors: Attauabi Mohamed , Burisch Johan , Seidelin Jakob Benedict
Published: December 2020

This double-center cohort study found a high short-term and long-term efficacy of ustekinumab for perianal fistulizing Crohn disease that was also well tolerated.
Histologic Remission Is Associated With Lower Risk of Treatment Failure in Patients With Crohn Disease in Endoscopic Remission
Authors: Yoon Hyuk , Jangi Sushrut , Dulai Parambir S , Boland Brigid S , Jairath Vipul , Feagan Brian G , Sandborn William J , Singh Siddharth
Published: December 2020

Background

Although achieving histologic remission in ulcerative colitis is established, the incremental benefit of achieving histologic remission in patients with Crohn disease (CD) treated to a target of endoscopic remission is unclear. We evaluated the risk of treatment failure in patients with CD in clinical and endoscopic remission by histologic activity status.

Methods

In a single-center retrospective cohort study, we identified adults with active CD who achieved clinical and endoscopic remission through treatment optimization. We evaluated the risk of treatment failure (composite of clinical flare requiring treatment modification, hospitalization, and/or surgery) in patients who achieved histologic remission vs persistent histologic activity through Cox proportional hazard analysis.

Results

Of 470 patients with active CD, 260 (55%) achieved clinical and endoscopic remission with treatment optimization; 215 patients with histology were included (median age, 33 years; 46% males). Overall, 132 patients (61%) achieved histologic remission. No baseline demographic, disease, or treatment factor was associated with achieving histologic remission. Over a 2-year follow-up, patients with CD in clinical and endoscopic remission who achieved histologic remission experienced a 43% lower risk of treatment failure (1-year cumulative risk: 12.9% vs 18.2%; adjusted hazard ratio, 0.57 [95% confidence interval, 0.35-0.94]) as compared with persistent histologic activity.

Conclusions

Approximately 61% of patients with active CD who achieved clinical and endoscopic remission with treatment optimization simultaneously achieved histologic remission, which was associated with a lower risk of treatment failure. Whether histologic remission should be a treatment target in CD requires evaluation in randomized trials.
Assessment of Body Composition From CT Images at the Level of the Third Lumbar Vertebra in Inflammatory Bowel Disease
Authors: Bamba Shigeki , Inatomi Osamu , Takahashi Kenichiro , Morita Yasuhiro , Imai Takayuki , Ohno Masashi , Kurihara Mika , Takebayashi Katsushi , Kojima Masatsugu , Iida Hiroya , Tani Masaji , Sasaki Masaya
Published: December 2020

Background

Although there are several reports of associations between body composition parameters and outcomes in patients with inflammatory bowel disease (IBD), it is not clear which muscle tissue parameters and/or adipose tissue parameters most strongly affect outcomes. Therefore, this study sought to determine the associations of such parameters determined at the level of the third lumbar vertebra (L3) on computed tomography (CT) images with outcomes in IBD patients.

Methods

Subjects were IBD patients who were admitted to our hospital and underwent abdominal CT. The following parameters were assessed: skeletal muscle index, psoas muscle index, visceral adipose tissue/height index, visceral to subcutaneous adipose tissue area ratio, and intramuscular adipose tissue content. In this study, short- and long-term outcomes were defined as prolonged length of stay (≥30 days) and intestinal resection during the overall period of observation, respectively.

Results

In total, 187 patients were enrolled, 99 with Crohn’s disease and 88 with ulcerative colitis. For all IBD patients, multivariate logistic regression analysis revealed that low albumin level and low psoas muscle index on admission were associated with prolonged length of stay. Multivariate Cox regression analysis revealed that male sex, Crohn’s disease (not ulcerative colitis), low psoas muscle index, and high visceral to subcutaneous adipose tissue area ratio were associated with intestinal resection.

Conclusions

This study revealed that muscle volume is associated with the short-term outcome of prolonged length of stay, whereas muscle volume and visceral adipose tissue volume (relative to subcutaneous adipose tissue volume) are associated with the long-term outcome of intestinal resection.
Generating 3D texture models of vessel pipes using 2D texture transferred by object recognition☆
Authors: Kim Min-Ji , Lee Kyung-Ho , Han Young-Soo , Lee Jaejoon , Nam Byungwook
Published: December 2020

Research and development of smart vessels has progressed significantly in recent years, and ships have become high-value technology-intensive resources. These ships entail high production costs and long-life cycles. Thus, modernized technical design, professional training, and aggressive maintenance are important factors in the efficient management of ships. With the continuing digital revolution, the industrial shipbuilding applicability of augmented reality (AR) and virtual reality (VR) technologies as well as related 3D system modeling and processes has increased. However, resolving the differences between AR/VR and real-world models remains burdensome. This problem is particularly evident when mapping various texture characteristics to virtual objects. To mitigate the burden and improve the performance of such technologies, it is necessary to directly define various texture characteristics or to express them using expensive equipment. The use of deep-learning-based CycleGAN, however, has gained attention as a method of learning and automatically mapping real-object textures. Thus, we seek to use CycleGAN to improve the immersive capacities of AR/VR models and to reduce production costs for shipbuilding. However, when applying CycleGAN’s textures to pipe structures, the performance is insufficient for direct application to industrial piping networks. Therefore, this study investigates an improved CycleGAN algorithm that can be specifically applied to the shipbuilding industry by combining a modified object-recognition algorithm with a double normalization method. Thus, we demonstrate that basic knowledge on the production of AR industrial pipe models can be applied to virtual models through machine learning to deliver low-cost and high-quality textures. Our results provide an on-ramp for future CycleGAN studies related to the shipbuilding industry.
Inheritance and Fitness ofPlutella xylostella(Lepidoptera: Plutellidae) Resistance to Chlorfenapyr
Authors: Lima Neto Jaconias Escócio , da Solidade Ribeiro Lílian Maria , de Siqueira Herbert Álvaro Abreu
Published: December 2020

The diamondback moth, Plutella xylostella (L.) (Lepidoptera: Plutellidae), is a key pest of Brassicaceae worldwide. Populations have globally evolved resistance to various insecticides including chlorfenapyr, which was observed at high frequency in Brazil. We report the genetic characterization and fitness costs associated with chlorfenapyr resistance in a field-derived strain. The resistant strain (BZR-RR) and a susceptible strain (REC-SS) were used in both concentration–response bioassays and demography-based approach. Inheritance pattern of chlorfenapyr resistance was determined by conducting reciprocal crosses between susceptible and resistant strains, and by backcrossing. Next, life table analysis for the susceptible, heterozygotes, and resistant strains was performed to assess eventual fitness costs associated with chlorfenapyr resistance. Resistance of P. xylostella (BZR-RR) strain to chlorfenapyr was very high (RR50 = 421.58-fold) and also autosomal (no differences between reciprocal crosses), monofactorial and incompletely dominant (F1 pool DD = 0.26 ± 0.14). Dominance (h) was concentration dependent with 16 mg/l allowing at least 95% survival of the resistant heterozygotes. Recessive fitness cost was observed to be associated with resistance to chlorfenapyr. The relative fitness of heterozygotes (RS) and resistant homozygotes (BZR-RR) in comparison to the susceptible strain (REC-SS) was 0.91 and 0.23, respectively. Significant differences were found for many fitness components in the resistant homozygotes. Altogether, results suggest a rational use of chlorfenapyr in areas where susceptible populations still prevail, in parallel with the use of diagnostic concentrations (e. g., 20 mg chlorfenapyr/l), and rotation with different mode of actions, for which fitness costs of resistance are nonrecessive in P. xylostella.
Methods for Testing Repellents Against Bed Bugs (Hemiptera: Cimicidae)
Authors: Krüger Anne , Schmolz Erik , Vander Pan Arlette
Published: December 2020

Bed bug repellents should not only prevent humans from being bitten but impede an infestation of personal belongings. Only a few test proposals for evaluating the efficacy of repellents against bed bugs have been published so far. In the present study, two test systems were assessed for efficacy testing with five potential bed bug repellents (cinnamon oil, icaridin, N,N-diethyl-3-methylbenzamide (DEET), permethrin, and margosa extract). The first test setup was a harborage choice test system that consisted of a crystallizing dish with a treated and an untreated harborage. Sixty minutes and 24 h after treatment, DEET, icaridin, and cinnamon oil showed the highest repellency with a median proportion of at least 99% repelled bed bugs. The second test system was a barrier test. Bed bugs were attracted by CO2 and heat to cross filter papers treated with the potential repellents. The repellency of substances was significantly lower in comparison to the harborage choice test, except for DEET. The latter showed the highest repellency (97%) against bed bugs 24 h after application compared to controls. Results show that bed bugs are less sensitive to repellents when searching for a bloodmeal than when searching for a shelter.
Colonoscopic evaluation of diarrhea/colitis occurring as an immune-related adverse event
Authors: Yamauchi Yohei , Arai Makoto , Akizue Naoki , Ohta Yuki , Okimoto Kenichiro , Matsumura Tomoaki , Fan Meng Meng , Imai Chiaki , Tawada Akinobu , Kato Jun , Kato Naoya , Takiguchi Yuichi
Published: December 2020

Objective

Diarrhea is often observed as an immune-related adverse event. In this study, we conducted a retrospective review of the severity of diarrhea, its treatment and the endoscopic findings in patients developing diarrhea as an immune-related adverse event.

Methods

From August 2015 to June 2019, a total of 369 patients received treatment with immune checkpoint inhibitors at our hospital. For this study, development of grade 2 or more diarrhea in these patients was defined as an immune-related adverse event. We analyzed the histopathological severity of the bowel lesions according to the Nancy histological index for ulcerative colitis.

Results

Of the 369 patients, 27 (7.3%) developed diarrhea as an immune-related adverse event. Of these 27 patients, 18 received steroid treatment. Colonoscopy was performed in 17 patients and culture of the feces in 18. The tests revealed evidence of bacterial colitis (Aeromonas hydrophila) in two patients. The Nancy histological index was 4, 3, 2, 1 and 0 in two, three, two, two and seven patients, respectively. No findings on colonoscopy were observed in 7 of the 17 patients (41%) who underwent colonoscopy, and most of these patients recovered without steroid treatment. Patients with lower values of the Nancy histological index tended to show better responses to steroid treatment.

Conclusions

To avoid unnecessary steroid administration, colonoscopic evaluation is essential in patients receiving treatment with immune checkpoint inhibitors who present with diarrhea as an immune-related adverse event. In addition, the endoscopic findings could be useful to predict the response to steroid treatment.
Spray Safe, Play Safe: Story-Based Films Increase Homeowner Confidence About Backyard Tick Management
Authors: Hornbostel Victoria L , Krell Rayda K , Reid Jennifer J , Schappach Brittany L , Volpe Scott , Connally Neeta P
Published: December 2020

Lyme disease incidence is increasing in the United States despite myriad efforts to educate individuals about effective prevention practices to reduce exposure to nymphal Ixodes scapularis Say (Acari: Ixodidae) (blacklegged tick), the primary vector of the pathogen causing Lyme disease. Furthermore, Lyme prevention educational needs currently exceed the ability of public health professionals to deliver the information in person. Past work has shown there is especially high confusion regarding the use of acaricides for tick management by homeowners. Story-based education is known to engage individuals and change behaviors. To increase the reach and engagement regarding Lyme disease prevention practices, especially residential acaricide use, we created short, story-based educational films (Spray Safe, Play Safe) and evaluated their educational benefit with a survey pre- and post-viewing. We determined that after viewing the films, a significantly higher percentage of respondents reported increased confidence in identifying the riskiest areas in their yards for ticks, using personal protective measures to prevent tick bites, using tick-safe landscaping, and using tick control products. This study also suggests that using short, engaging films that can be posted to popular websites and social media outlets could be employed more frequently for successful and engaging Lyme disease education, as creative and up-to-date educational methods are needed.
Morphological Characterization of the Antennal Sensilla of the Afrotropical Sand Fly,Phlebotomus duboscqi(Diptera: Psychodidae)
Authors: Bahia Ana Cristina , Barletta Ana Beatriz F , Pinto Luciana Conceição , Orfanó Alessandra S , Nacif-Pimenta Rafael , Volfova Vera , Volf Petr , Secundino Nágila Francinete Costa , de Freitas Fernandes Fernando , Pimenta Paulo Filemon P
Published: December 2020

We investigated by scanning electron microscopy the morphology, distribution, and abundance of antennal sensilla of females Phlebotomus duboscqi sand fly, an important vector of zoonotic cutaneous leishmaniasis at Afrotropical region. Thirteen well-differentiated sensilla were identified, among six types of cuticular sensilla. The probable function of these sensillary types is discussed in relation to their external structure and distribution. Five sensillary types were classified as olfactory sensilla, as they have specific morphological characters of sensilla with this function. Number and distribution of sensilla significantly differed between antennal segments. The results of the present work, besides corroborating in the expansion of the morphological and ultrastructural knowledge of P. duboscqi, can foment future electrophysiological studies for the development of volatile semiochemicals, to be used as attractants in traps for monitoring and selective vector control of this sand fly.
Synthetic Pyrethroid, Natural Product, and Entomopathogenic Fungal Acaricide Product Formulations for Sustained Early Season Suppression of Host-SeekingIxodes scapularis(Acari: Ixodidae) andAmblyomma americanumNymphs
Authors: Schulze Terry L , Jordan Robert A
Published: December 2020

We compared the ability of product formulations representing a synthetic pyrethroid acaricide (Talstar P Professional Insecticide), a natural product-based acaricide (Essentria IC3), and an entomopathogenic fungal acaricide (Met52 EC Bioinsecticide) to suppress Ixodes scapularis Say and Amblyomma americanum (L.) nymphs when applied following USEPA approved manufacturers’ label recommendations for tick control using hand-pumped knapsack sprayers before the beginning of their seasonal activity period in the spring. We applied Met52 EC Bioinsecticide (11% Metarhizium anisopliae Strain F52) to five 100 m2 plots (10.6 ml AI/plot) in mid-April 2020. Two weeks later at the end of April 2020, we treated an additional five 100 m2 plots each with either Talstar P Professional Insecticide (7.9% bifenthrin @ 2.5 ml AI/plot) or Essentria IC3 (10% rosemary oil, 5% geraniol, and 2% peppermint oil @ 86.6 ml AI/plot). Weekly sampling of all plots through the end of June 2020 showed that both Met52 EC Bioinsecticide and Essentria IC3 failed to maintain a 90% suppression threshold for I. scapularis, compared to control plots, and required two additional applications over the course of the trial. In contrast, Talstar P Professional Insecticide suppressed 100% of I. scapularis nymphs and ≥96 and 100% of A. americanum nymphs and adults, respectively. Such pre-season applications of synthetic pyrethroids significantly reduce the early season acarological risk for exposure to host-seeking ticks as well as the frequency of acaricide applications.
Effect of Larval Food Availability on Adult Aedes Aegypti (Diptera: Culicidae) Fitness and Susceptibility to Zika Infection
Authors: Rocha-Santos Carlucio , Dutra Ana Cristina Vieira Paes Leme , Fróes Santos Rogério , Cupolillo Catharina D’Oliveira Loures Schwartz , de Melo Rodovalho Cynara , Bellinato Diogo Fernandes , dos Santos Dias Luciana , Jablonka Willy , Lima José Bento Pereira , Silva Neto Mário Alberto Cardoso , Atella Georgia Correa
Published: December 2020

Aedes (Stegomyia) aegypti (Linnaeus, 1762) is a mosquito species of significant medical importance. The use of this vector in research studies usually requires a large number of mosquitoes as well as rearing and maintenance in a laboratory-controlled environment. However, laboratory conditions may be different from field environments, presenting stressful challenges such as low food concentration, especially during larval stages, which may, in turn, impair vector biology. Therefore, we tested herein if larval food availability (0.004, 0.009, 0.020, and 0.070% diets) would affect overall adult insect fitness. We observed slower development in mosquitoes fed a 0.004% diet 15 d post-eclosion (DPE) and shorter mean time in mosquitoes fed a 0.020% diet (7 DPE). Larval diet and adult mosquito weight were positively correlated, and heavier females fed higher larval diets exhibited greater blood feeding capacity and oviposition. In addition, larval diet concentrations led to median adult lifespan variations (male/female in days—0.004%: 30 ± 1.41, 45 ± 1.3; 0.009%: 31.5 ± 1.33, 41 ± 1.43; 0.020%: 26 ± 1.18, 41 ± 1.45; 0.070%: 29 ± 1.07, 44 ± 1.34), reduced tolerance to deltamethrin (1 mg/m2) and changes in detoxification enzyme activities. Moreover, in the larval 0.070% diet, females presented higher Zika susceptibility (plaque-forming unit [PFU]: 1.218 × 106) compared with other diets (0.004%: 1.31 × 105; 0.009%: 2.0 × 105; 0.020%: 1.25 × 105 PFU). Altogether, our study demonstrates that larval diet restriction results not only in larval developmental arrest but also in adult fitness impairment, which must be considered in future assessments.
Developmental Models of the Forensically Important Carrion Beetle,Thanatophilus sinuatus(Coleoptera: Silphidae)
Authors: Montoya-Molina Santiago , Jakubec Pavel , Qubaiová Jarin , Novák Martin , Šuláková Hana , Růžička Jan
Published: December 2020

Carrion beetles of genus Thanatophilus (Leach, 1815) are an important group of necrophagous insects, with great potential for forensic entomology in temperate zones of Africa, America, Asia, and Europe. Developmental models for majority of Thanatophilus species remain unknown. In this study, we will provide new thermal summation models for all the developmental stages of Thanatophilus sinuatus (Fabricius, 1775), one of the most abundant and widespread species of the genus. The beetles were bred at seven different constant temperatures, and developmental time was measured for each developmental stage (egg, three larval instars, postfeeding stage, and pupa). Temperature–sex influence was tested, and thermal summation constants were calculated to be used for postmortem interval estimation during criminal investigations.
Pre-existing Microfilarial Infections of American Robins (Passeriformes: Turdidae) and Common Grackles (Passeriformes: Icteridae) Have Limited Impact on Enhancing Dissemination of West Nile Virus in Culex pipiens Mosquitoes (Diptera: Culicidae)
Authors: Vaughan Jefferson A , Hinson Juanita , Andrews Elizabeth S , Turell Michael J
Published: December 2020

Microfilariae (MF) are the immature stages of filarial nematode parasites and inhabit the blood and dermis of all classes of vertebrates, except fish. Concurrent ingestion of MF and arboviruses by mosquitoes can enhance mosquito transmission of virus compared to when virus is ingested alone. Shortly after being ingested, MF penetrate the mosquito’s midgut and may introduce virus into the mosquito’s hemocoel, creating a disseminated viral infection much sooner than normal. This phenomenon is known as microfilarial enhancement. Both American Robins and Common Grackles harbor MF—that is, Eufilaria sp. and Chandlerella quiscali von Linstow (Spirurida: Onchocercidae), respectively. We compared infection and dissemination rates in Culex pipiens L. mosquitoes that fed on birds with and without MF infections that had been infected with West Nile virus (WNV). At moderate viremias, about 107 plaque-forming units (pfu)/ml of blood, there were no differences in infection or dissemination rates among mosquitoes that ingested viremic blood from a bird with or without microfilaremia. At high viremias, >108.5 pfu/ml, mosquitoes feeding on a microfilaremic Grackle with concurrent viremia had significantly higher infection and dissemination rates than mosquitoes fed on viremic Grackles without microfilaremia. Microfilarial enhancement depends on the specific virus, MF, and mosquito species examined. How virus is introduced into the hemocoel by MF differs between the avian/WNV systems described here (i.e., leakage) and various arboviruses with MF of the human filarid, Brugia malayi (Brug) (Spirurida: Onchocercidae) (i.e., cotransport). Additional studies are needed to determine if other avian species and their MF are involved in the microfilarial enhancement of WNV in nature.
Strategic National Urban Forest Inventory for the United States
Authors: Edgar Christopher B , Nowak David J , Majewsky Mark A , Lister Tonya W , Westfall James A , Sonti Nancy F
Published: December 2020

In response to the strategic plan required by the Agricultural Act of 2014, the USDA Forest Service Forest Inventory and Analysis (FIA) program is initiating a strategic inventory of the nation’s urban forests. The inventory is designed to provide timely and credible data on urban forests, thereby meeting an expanding need for information on trees located in communities where more than 80% of people live. The program monitors the status and trends of trees in urban settings (i.e., urban forests), enabling assessment of their composition and structure, ecosystem services and values, health, and risk from pests and disease. At full implementation with funding, resources, and partnerships in place, the program as designed would provide annual updates of urban forest conditions on approximately 68 million acres of land and for 100 of the most populous cities in the United States. The traditional forestland inventory of FIA continues and is complemented by the new urban inventory providing the means for a more complete assessment of the tree and forest resources across the United States.
Sources of Stress and Psychological Health Outcomes for Remotely Piloted Aircraft Operators: A Comparison Across Career Fields and Major Commands
Authors: Bryant-Lees Kinsey B , Prince Lillian , Goodman Tanya , Chappelle Wayne , Thompson Billy
Published: December 2020

Introduction

U.S. Air Force remotely piloted aircraft (RPA) operators perform a variety of around-the-clock global intelligence, surveillance, and reconnaissance (ISR) missions that are considered critical to operational effectiveness. The growing need for ISR operations has led to significant increases in operational tempo and workload, resulting in elevated operational stress, burnout, and psychological distress. These negative outcomes are linked to conditions such as long hours, low manning, lack of sleep, and communication issues. Through regular assessments and the implementation of additional resources (i.e., embedded health care providers), Air Force leadership is working to alleviate the stressors and maintain psychological well-being. Thus, the purpose of this study is to compare the levels of stress, and prevalence of burnout and psychological distress across RPA career fields within two major commands.

Materials and Methods

Assessments were completed by 571 RPA operators from 2 major commands: Air Force Special Operations Command (n = 158) and Air Combat Command (n = 413). RPA career fields included pilots (n = 331), sensor operators (n = 137), and intelligence operators (n = 103).

Results

Results revealed that high stress levels from an array of sources continue to result in increased risk of burnout and psychological distress for RPA operators. Several significant differences in sources of high stress across career fields and major commands are identified and discussed.

Conclusions

Overall, the results of this study highlight specific problem areas unique to certain subsets of the RPA community in need of targeted intervention and clarify several avenues for future research.
The Damage Control Resuscitation and Surgical Team: The New French Paradigm for Management of Combat Casualties
Authors: Luft Antoine , Pasquier Pierre , Soucanye de Landevoisin Emmanuel , Morel-Stum Nelly , Baillon Arthur , Louis Serge , Menini William , Sagalle Yannick , Gintte Julie , Bouquet Antoine , Avaro Jean-Philippe
Published: December 2020

Introduction

The aim of this work was to introduce the new French forward resuscitation and surgical unit. It’s also to discuss the choices and waivers granted to fit the tactical context of modern conflicts and the current epidemiology of combat casualties.

Materials and Methods

A multidisciplinary task force of 11 people proceeded to the conception and the creation of a new military resuscitation and surgical unit. The preliminary work included a scoping review of the combat casualties’ epidemiology in modern conflicts and an analysis of the recent French medical–surgical treatment facilities lessons learned. In April 2019, a technical–operational evaluation was conducted to confirm all the technical, ergonomic, and organizational choices made during the design phase.

Results

The multidisciplinary task force resulted in the creation of the Damage Control Resuscitation and Surgical Team (DCRST). The DCRST focused on the resuscitation strategy, including transfusion of blood products, and the life-saving surgical procedures to be performed as close as possible to the point of injury. It was designed for the resuscitation of two patients: the life-saving surgery of two patients and the very short-term intensive care (<12 hours) of four patients at the same time. The DCRST provided sufficient autonomy to provide take care of four T1 and four T2 or T3 casualties per day for 48 hours. It was armed with 23 soldiers. The technical equipment represented 5,300 kg and 27 m3. All the technical medical equipment could be stored in two 20-foot containers.

Conclusion

The DCRST represents a new paradigm in medical support of French military operations. It offers the advantage of two combat casualties’ surgical management at the same time, as close as possible to the combat zone. It responds to a 2-fold epidemiological and logistical challenge.
Molecular Monitoring of Enteropathogens in Sewage During NATO Exercise Trident Juncture 2018: Potential Tool in Early Outbreak Warning?
Authors: Ørmen Øyvind , Madslien Elisabeth Henie
Published: December 2020

Introduction

Outbreaks of gastrointestinal disease among military service personnel can have severe impact on operational effectivity and force readiness. Thus, early outbreak detection is critical to minimize spread. This pilot study aimed to explore field-based molecular screening of sewage as a supplemental tool in early outbreak warning before disease is diagnosed in personnel seeking medical care.

Materials and Methods

Sewage from permanent (n = 3) and temporary (n = 3) military camps, hosting national and international military personnel, were sampled during the NATO Exercise TRJE18 taking place in southern Norway during fall 2018. Samples were screened for 22 gastrointestinal pathogens using multiplex PCR.

Results

Markers of multiple enteropathogens were detected in samples from all locations with some variations in diversity. Yersinia enterocolitica, pathogenic Escherichia coli, adenovirus, and Giardia were detected in sewage from all six camps during the exercise. Agent diversity seemed to increase with population size, regardless of nationality. Only a minor outbreak (n = 6) of norovirus was reported in one of the permanent camps. From the same camp, genetic markers of norovirus were detected in sewage 2 days before outbreak notification. No other outbreaks of gastrointestinal disease were reported during the exercise, indicating that markers of several enteropathogens can be normally found in sewage from healthy soldier populations. Thus, discriminating between true outbreaks and nonrelevant “background levels” would be of critical importance for correct decision-making in operational contexts.

Conclusions

Molecular screening of sewage allows rapid detection of multiple gastrointestinal pathogens in biological waste from military camps. However, background levels of pathogens challenges interpretation of qualitative analyses in outbreak situations. As such, quantitative measures, as well as high-resolution sequence-based methods, which allows strain identification and broader target spectrum, should be further explored in future studies.
Optimizing Fetal Aneuploidy Screening in an Austere Military Clinical Environment: A Prenatal Cost Comparison
Authors: Burrus Ashton D , Shaw-Williams Michelle M , Thagard Andrew S
Published: December 2020

Introduction

Austere clinical settings, including remote military installations, face unique challenges in screening pregnant women for aneuploidy. The objective of this study was to compare the direct and indirect prenatal costs of traditional 2-part serum-based screening to cell-free DNA (cfDNA) for detection of trisomies 18 and 21 for a military treatment facility with limited in-house perinatal resources.

Materials and Methods

We identified Naval Hospital Guantanamo Bay as a surrogate for an austere clinical environment. A prenatal cost of care analysis incorporating direct and indirect expenses was performed to compare the 2 aneuploidy screening strategies for a theoretical cohort of 100 patients for detection of trisomies 18 and 21. The baseline aneuploidy uptake rate was determined using a historical cohort. Test performance characteristics were obtained from the contracting laboratory. Aneuploidy rates and costs were calculated using previously published data.

Results

Assuming a baseline screen uptake rate of 87%, initial screening using the traditional approach would directly cost $8,285.01 versus $44,140.32 with cfDNA. Considering indirect costs such as travel, consultative services, evaluation and follow-up testing of an abnormal screen result, and lost productivity, the cost difference narrows to $14,458.25 over a 5- to 6-year period. Cost equivalence is achieved when cfDNA is priced at $341.17 per test.

Conclusion

Cell-free DNA as an initial screening strategy offers enhanced detection rates for trisomies 18 and 21 but remains more costly than traditional screening when incorporating direct and indirect expenses. In a low volume setting with limited resources, the added cost may be justified given the implications of unrecognized aneuploidy.
Usability Assessment of the Rehabilitation Lower-limb Orthopedic Assistive Device by Service Members and Veterans With Lower Limb Loss
Authors: Symsack Allison , Gaunaurd Ignacio , Thaper Akshay , Springer Barbara , Bennett Christopher , Clemens Sheila , Lucarevic Jennifer , Kristal Anat , Sumner Matthew , Isaacson Brad , Pasquina Paul , Gailey Robert
Published: December 2020

Introduction

Telehealth is an increasingly common approach to improve healthcare delivery, especially within the Veterans Health Administration and Department of Defense (DoD). Telehealth has diminished many challenges to direct access for clinical follow-up; however, the use of mobile telehealth for specialty rehabilitative care is emerging and is referred to as telerehabilitation. As early adopters of telehealth, the Veterans Affairs and DoD have supported collaborated efforts for programs designed to increase the access and quality of rehabilitative care while improving the functional ability of our service members (SMs) and veterans with lower limb amputation (LLA). The DoD and Veterans Health Administration collaborated on a Mobile Device Outcomes-based Rehabilitation Program (MDORP) to help injured SMs and veterans with LLA. The MDORP project utilized a mobile health system called the Rehabilitative Lower Limb Orthopedic Accommodating Device (ReLOAD) to assess walking quality. The ReLOAD system includes real-time auditory biofeedback to notify the user of their most prominent gait deviation and then recommends exercises that address specific balance and strength impairments. The purpose of this study was to describe the responses to a postintervention survey evaluating the feasibility and usability of ReLOAD completed by SMs and veterans with LLA who used the system for 5 months.

Materials and Methods

A link to an anonymous usability survey was emailed to all participants who completed MDORP. The survey was modeled after the System Usability Scale, with agreeableness to items rated on a 5-point Likert-style questionnaire in addition to open feedback. Data visualization of Likert-style questionnaires was conducted using ggplot2 and reshape2 statistical packages and was analyzed using R. We obtained institutional review board approval through both Miami Veterans Affairs Healthcare System and Walter Reed National Military Medical Center.

Results

The majority of participants reported that they would use the system again for home rehabilitation (65%) and that auditory biofeedback helped them walk better (59%). Participants also suggested that future work should include a greater variety of exercise options and the use of smart phones for the ReLOAD application in addition to the iPad tablet.

Conclusions

The participants provided positive and constructive feedback that will enhance the value and usability of telerehabilitation interventions like the ReLOAD system for future users.
An Analysis of Conflicts Across Role 1 Guidelines
Authors: Johnson Sarah A , Lauby Ryann S , Fisher Andrew D , Naylor Jason F , April Michael D , Long Brit , Schauer Steven G
Published: December 2020

Introduction

Role 1 care is vital to patient survival and includes many echelons of care from point-of-injury first aid to medical attention at battalion aid stations. Many guidelines are written for Role 1 care providers to optimize care for different scenarios. Differences in the guidelines lead to confusion and discrepancies between the types of treatment medical care providers provide. Although the guidelines were written for different areas of care, uniformity between the guidelines is needed and will lead to a reduced mortality rate.

Materials and Methods

It was determined that the Tactical Combat Casualty Care Guidelines, Prolonged Field Care Guidelines, Joint Trauma System Clinical Practice Guidelines, and Standard Medical Operating Guidelines from medical evacuation were the military medical guidelines most relevant to Role 1 care. These Guidelines were compared side by side to determine the differences between them.

Results

Although the guidelines were largely similar, many major differences were found between them. Our online tables contain large inconsistences between guidelines including direct contradictions in conversion of junctional tourniquets and the administration of tranexamic acid.

Conclusions

Role 1 care is vital to patient survival, including care from point of injury to battalion aid stations, but the guidelines available to instruct this care and the guidance on which personnel should provide this care are conflicting. This lack of clarity and consistency may adversely impact treatment outcomes. The reduction or elimination of conflicting information across the various guidelines, augmentation of guidance for pediatric care, more specific guidance for unique levels of care, and clearer delineation of the Role 1 phases of care (as well as which guidelines are most appropriate to each) should be considered as urgent priorities within the military medical community.
Curricular Change and Resiliency in the Era of Coronavirus (COVID-19): The Uniformed Services University of the Health Sciences (USU) Experience
Authors: Pock Arnyce R , Williams Pamela M , Maranich Ashley M , Landoll Ryan R , Witkop Catherine T , Reamy Brian V , Durning Steven J
Published: December 2020

Introduction

The Coronavirus (COVID-19) pandemic has presented a myriad of organizational and institutional challenges. The Uniformed Services University of the Health Sciences, like many other front line hospitals and clinics, encountered a myriad of challenges in fostering and sustaining the education of students enrolled at the nation’s only military medical school. Critical to the function of any academic medical institution, but particularly one devoted to the training of future physicians for the Military Health System, was the ability to rapidly adapt, modify, and create new means of keeping medical students engaged in their core curricula and progressing toward full and timely attainment of established educational goals and objectives.

Methods

This article highlights some of the particular challenges faced by faculty and students during the first 6 months of the COVID-19 pandemic and describes how they were managed and/or mitigated.

Results

Six key “lessons learned” were identified and summarized in this manuscript. These lessons may be applicable to other academic institutions both within and outside of the Military Health System.

Conclusions

Recognizing and embracing these key tenets of academic change management can accelerate the generation of a cohesive, organizational response to the next pandemic or public health crisis.
Firearm Suicide Among Veterans of the U.S. Military: A Systematic Review
Authors: Theis Jason , Hoops Katherine , Booty Marisa , Nestadt Paul , Crifasi Cassandra
Published: December 2020

Introduction

In the United States, firearm suicide represents a major cause of preventable, premature death among veterans. The purpose of this systematic review was to characterize the body of literature on veteran firearm suicide and identify areas for future research, which may facilitate the development of firearm suicide interventions in Veterans Health Administration (VHA) and non–Veterans Health Administration clinical settings.

Materials and Methods

All randomized controlled trials, quasi-experimental, naturalistic, observational, and case study designs published between January 1, 1990 and February 21, 2019 were included in our review. Following title and abstract review, 65 papers were included in our full-text review and 37 studies were included in our analysis. We based our approach on a modification of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies were grouped into broad, nonmutually exclusive categories: (1) heterogeneity of datasets and veteran status determination for inclusion, (2) service histories, (3) firearm ownership, storage, behaviors, and risk perceptions, (4) patient and clinician attitudes toward firearm restriction interventions, (5) firearm suicide risk factors by study population, and (6) assessments of clinical firearm interventions.

Results

This body of literature consists predominately of cross-sectional studies with mixed definitions and validation of veteran status, which revealed high concordance of increased risk of firearm suicide compared with nonveterans. Veterans have higher rates of firearm ownership than the general population, primarily citing personal protection as the reason for gun ownership. Veterans often exhibit risky firearm usage and storage behaviors but tend to favor measures that limit access to firearms by at-risk individuals. Despite this, there remains persistent hesitation among clinicians to screen and counsel veterans on firearm safety.

Conclusions

This systematic review highlights an urgent need to produce higher quality evidence and new data with standard definitions that are critical to inform clinical practice and enhance public health measures to reduce firearm suicide among veterans.
Multisystem Inflammatory Syndrome in Children during the COVID-19 Pandemic: A Case Report on Managing the Hyperinflammation
Authors: Cirks Blake T , Geracht Jennifer C , Jones Olcay Y , May Joseph W , Mikita Cecilia P , Rajnik Michael , Helfrich Alison M
Published: December 2020

The novel human coronavirus of 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has quickly swept throughout the entire world. As the ongoing pandemic has spread, recent studies have described children presenting with a multisystem inflammatory disorder sharing the features of Kawasaki disease (KD) and toxic shock syndrome, now named Multisystem Inflammatory Syndrome in Children (MIS-C). These cases report a similar phenotype of prolonged fever, multisystem involvement, and biomarkers demonstrating marked hyperinflammation that occurs temporally in association with local community spread of SARS-CoV-2. Herein, we describe the presentation, clinical characteristics, and management of an 11-year-old boy with prolonged fever, strikingly elevated inflammatory markers, and profound, early coronary artery aneurysm consistent with a hyperinflammatory, multisystem disease temporally associated with coronavirus disease 2019. We highlight our multidisciplinary team’s management with intravenous immunoglobulin, methylprednisolone, and an interleukin-1 receptor antagonist, anakinra, as a strategy to manage this multisystem, hyperinflammatory disease process.
Influence of Self-managed Rehabilitation on Work Efficiency in Active Duty Military With a Knee Injury
Authors: Talbot Laura A , Brede Emily , Metter E Jeffrey
Published: December 2020

Introduction

Knee injuries associated with intense physical training are one of the most frequent injuries associated with medical encounters for military members. The purpose of this study was to evaluate four approaches to physiotherapy rehabilitation and their effects on work efficiency in active duty military with a knee injury. The four groups included neuromuscular electrical stimulation (NMES), walking with a weighted vest (WALK), combined NMES/Walk, and standard physiotherapy rehabilitation. All groups received standard physiotherapy rehabilitation.

We have previously reported that quadriceps muscle strength improved over 18 weeks in the study for the three interventions relative to standard rehabilitation alone. This report presents results from an examination of work efficiency as evaluated during a step test while measuring oxygen utilization.

Methods

A randomized controlled trial was conducted, with repeated outcome measures of work efficiency assessed at baseline, 3, 6, 12, and 18 weeks. The sample consisted of 67 active duty service members between the ages of 18 and 50 years with a knee injury. Participants were randomized to one of the four approaches to physiotherapy rehabilitation: (1) NMES was applied to the quadriceps muscle four times per week, for 30 minutes (15 minutes to each leg), consisting of 15 quadriceps muscle contractions per leg; (2) graduated strength walking using a weighted vest (WALK) was for 30 minutes, 3 to 4 days a week; (3) combined NMES with strength walking received both the NMES therapy and the weighted vest walking; and (4) standard physiotherapy consisted of progressive exercise with the number and type of sessions not controlled by the study. All four groups received the standard physiotherapy for a knee injury. The primary outcome was work efficiency, as measured by oxygen utilization during a 2-minute self-paced step test over 18 weeks. The primary analysis used repeated measures, linear mixed-effects models with a random effect for subject.

Results

Both the number of steps performed and gross work efficiency improved during the study for all three intervention groups. For gross work efficiency, standard rehabilitation improved 12%, WALK showed a 19% improvement, NMES increased by 24%, and the NMES/Walk group improved by 40%.

Conclusions

All groups showed improved submaximal exercise efficiency based on oxygen utilization, with the intervention groups showing a greater improvement in work efficiency as compared to standard rehabilitation. Knee injuries can be problematic for active duty members because of reduced mobility leading to deconditioning and associated declines in work efficiency. Rehabilitative programs, including those described in this study, may minimize loss of work efficiency and fitness and promote a quicker recovery.