Military medicine
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HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) Syndrome is a rare but serious complication of pregnancy that can lead to disseminated intravascular coagulation, pulmonary edema, respiratory failure, hepatic and renal injury, and death if not recognized and treated promptly. A 36-year-old nulligravid (G0) active duty Marine at 36 weeks and 1 day gestation with dichorionic diamniotic twins presented to triage for routine cervical examination found to have elevated blood pressures and symptomatic thrombocytopenia, with a suspected diagnosis of HELLP. A multidisciplinary decision was made by anesthesiology, obstetrics and gynecology, and pediatrics to deliver the twins to avoid any further complications. ⋯ Ultimately, the decision was made to provide analgesia through a remifentanil PCA (patient-controlled analgesia) for labor and a ketamine bolus for delivery. The mother delivered both twins vaginally in the operating room without perioperative complication. This case demonstrates the safety of alternate forms of anesthesia for delivery when neuraxial anesthesia is contraindicated.
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Alopecia areata (AA) is a disease that manifests as patchy hair loss on the scalp and other parts of the body; severe disease may result in disfigurement, functional impairment, and significant psychological distress. This condition is understood to be caused by autoimmunity to the hair follicle and subsequent arrest of hair growth. New medications, baricitinib and ritlecitinib, belong to the Janus kinase (JAK) inhibitor family and are among the first FDA-approved treatments for severe AA. In this manuscript, we aim to answer the question: What treatment options exist for AA in the military health care system (MHS)? In doing so, we review the pathogenesis, physical and psychosocial impact of AA, conventional treatment of AA, and the efficacy and safety of baricitinib and ritlecitinib. ⋯ Baricitinib and ritlecitinib are effective treatments for widespread, progressive, and refractory AA. Although JAK inhibitors demonstrate improved effectiveness compared to non-immunomodulator treatments, their use in the MHS for this purpose is limited.
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Sexually transmitted infections (STIs) are commonly reported in military populations. Point-of-care tests (POCTs) are commercially available, but their use is variable in the civilian sector. Their use among military providers has not been evaluated. We sought to identify the pattern of use and barriers to using STI POCTs for military obstetrician/gynecologists (OBGYNs). ⋯ Military OBGYNs rely on several STI-related POCTs. Economic factors and interruption to workflow were cited as the most significant barriers to using POCTs for military OBGYNs. Test cost and impact on workflow should be considered in future development and procurement of POCTs for the Military Health System.
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We report a management strategy for disseminated Fusarium solani fungal infection in an adult 35% total body surface area burn patient with brain abscesses and concomitant pulmonic valve endocarditis resulting in the longest survival reported in a burn patient. Early in his hospital course, the patient was diagnosed with a Fusarium burn wound infection with concomitant fungemia and was treated with a prolonged course of intravenous (IV) antifungal monotherapy. Shortly thereafter, he developed focal neurologic deficits and was found to have brain abscesses on MRI. ⋯ However, this patient survived for approximately 1 year after diagnosis with treatment including source control via craniotomy and debridement coupled with prolonged courses of combination antifungal therapy (given the near pan-resistance of his fungal infection). Pharmacogenomic testing was utilized to establish the patient's metabolism of voriconazole and dosing adjusted accordingly to improve the efficacy of the combination therapy. To our knowledge, an adult burn patient surviving this length of time after Fusarium brain abscesses with disseminated infection has not been previously described.
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It has been demonstrated that there was an increase in later-stage prostate cancer (PCa) at diagnosis after the U.S. Preventive Services Task Force recommended against prostate-specific antigen screening for prostate cancer. However, the cancer characteristics at diagnosis within the equal-access Military Health System (MHS) during the period have not been described. In this study, we compared PCa stage at diagnosis and its trends between the military health care system and the general public and further compared the trends in tumor stage by race. ⋯ The MHS consistently diagnosed PCa at an earlier stage than the U.S. general population across all time periods evaluated in this study. Although similar trends were observed for White patients between both populations, the proportion of stages I and II at diagnosis increased from 2012 among Black patients in the MHS, which stands in sharp contrast to trends in the U.S. general population. Although the differences between the two populations may be associated with various factors, differences in accessibility to care and thus the use of prostate-specific antigen testing might play an important role.