Landstuhl Regional Medical Center, Germany
Landstuhl Regional Medical Center, Germany

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Waibel K.H.,Landstuhl Regional Medical Center
Vaccine | Year: 2015

Immunoglobulin (Ig) E antibodies to galactose-α-1,3-galactose (α-Gal) are associated with delayed anaphylaxis to mammalian food products and gelatin-based foods (Commins et al., J Allergy Clin Immunol 2009;123:426; Caponetto et al., J Allergy Clin Immunol Pract 2013;1:302). We describe a patient with α-Gal allergy who successfully tolerated the live zoster vaccine and we review anaphylactic reactions reported to this vaccine. Our patient, who tolerated a vaccine containing the highest gelatin content, is reassuring but continued safety assessment of gelatin-containing vaccines for this patient cohort is recommended as there are multiple factors for this patient cohort that influence the reaction risk. © 2015 .


Kurihara C.,Anesthesia Service | Plunkett A.,Anesthesia Service | Nguyen C.,Landstuhl Regional Medical Center | Strassels S.A.,University of Texas at Austin
The Lancet | Year: 2010

Background: Anticipation of the types of injuries that occur in modern warfare is essential to plan operations and maintain a healthy military. We aimed to identify the diagnoses that result in most medical evacuations, and ascertain which demographic and clinical variables were associated with return to duty. Methods: Demographic and clinical data were prospectively obtained for US military personnel who had been medically evacuated from Operation Iraqi Freedom or Operation Enduring Freedom (January, 2004-December, 2007). Diagnoses were categorised post hoc according to the International Classification of Diseases codes that were recorded at the time of transfer. The primary outcome measure was return to duty within 2 weeks. Findings: 34 006 personnel were medically evacuated, of whom 89% were men, 91% were enlisted, 82% were in the army, and 86% sustained an injury in Iraq. The most common reasons for medical evacuation were: musculoskeletal and connective tissue disorders (n=8104 service members, 24%), combat injuries (n=4713, 14%), neurological disorders (n=3502, 10%), psychiatric diagnoses (n=3108, 9%), and spinal pain (n=2445, 7%). The factors most strongly associated with return to duty were being a senior officer (adjusted OR 2·01, 95% CI 1·71-2·35, p<0·0001), having a non-battle-related injury or disease (3·18, 2·77-3·67, p<0·0001), and presenting with chest or abdominal pain (2·48, 1·61-3·81, p<0·0001), a gastrointestinal disorder (non-surgical 2·32, 1·51-3·56, p=0·0001; surgical 2·62, 1·69-4·06, p<0·0001), or a genitourinary disorder (2·19, 1·43-3·36, p=0·0003). Covariates associated with a decreased probability of return to duty were serving in the navy or coast guard (0·59, 0·45-0·78, p=0·0002), or marines (0·86, 0·77-0·96, p=0·0083); and presenting with a combat injury (0·27, 0·17-0·44, p<0·0001), a psychiatric disorder (0·28, 0·18-0·43, p<0·0001), musculoskeletal or connective tissue disorder (0·46, 0·30-0·71, p=0·0004), spinal pain (0·41, 0·26-0·63, p=0·0001), or other wound (0·54, 0·34-0·84, p=0·0069). Interpretation: Implementation of preventive measures for service members who are at highest risk of evacuation, forward-deployed treatment, and therapeutic interventions could reduce the effect of non-battle-related injuries and disease on military readiness. Funding: John P Murtha Neuroscience and Pain Institute, and US Army Regional Anesthesia and Pain Management Initiative. © 2010 Elsevier Ltd. All rights reserved.


Zonies D.,Landstuhl Regional Medical Center | Eastridge B.,Surgical Theater
Journal of Trauma and Acute Care Surgery | Year: 2012

Background: As a performance improvement measure to optimize patient outcome, theater-wide clinical practice guidelines (CPGs) have been developed to standardize the management of many injury patterns seen during combat operations. Battle-related splenic injury presents differently from civilian practice, and a combat-related CPG was developed. The epidemiology and validation of the spleen injury CPG were analyzed. Methods: The Joint Theater Trauma Registry was queried for splenic injury from 2001 to 2010. Theater of operation (Afghanistan and Iraq), injury year, mechanism, patients' baseline characteristics, and severity were recorded. Patient charts were reviewed for management decisions and outcomes. Results: The 10-year experience identified 393 patients who sustained splenic injury (rate of 16.1 per 1000 injuries). Most victims were men (97.5%), blunt, and severely injured (70.7%; mean Injury Severity Score, 32.5, respectively), with a mean age of 25.4 years. The prominent mechanism was explosion (62.2%), followed by vehicle crash (25.9%). The most prevalent injury was grade II (56.2%), followed by III (21.1%), IV (11.7%), and V (9.7%). More than half of patients underwent splenectomy (52.7%), most of which occurred in theater (95.1%). All nonoperative failures were treated within 4 days of injury at the role IV facility in Landstuhl. Patients who underwent splenectomy received more blood products, crystalloid, and demonstrated a longer length of stay than those treated nonoperatively. High-grade injuries treated nonoperatively were successfully managed. The overall cohort mortality was 9%, and no death was directly related to delayed diagnosis or treatment. Conclusion: Splenic injury has been successfully managed during combat operations through the use of a well-established CPG. The overall mortality remains low, with few delayed nonoperative failures. Refinements in this validated CPG may now address controversies in higher grade injuries. Level of Evidence: Prognostic/epidemiologic study, level III. © 2012 Lippincott Williams & Wilkins.


Jones A.,Landstuhl Regional Medical Center | Jones A.,U.S. Army | Ingram M.V.,U.S. Army
Clinical Neuropsychologist | Year: 2011

Using a relatively new statistical paradigm, Optimal Data Analysis (ODA; Yarnold & Soltysik, 2005), this research demonstrated that newly developed scales for the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and MMPI-2 Restructured Form (MMPI-2-RF) specifically designed to assess over-reporting of cognitive and/or somatic symptoms were more effective than the MMPI-2 F-family of scales in predicting effort status on tests of cognitive functioning in a sample of 288 military members. ODA demonstrated that when all scales were performing at their theoretical maximum possible level of classification accuracy, the Henry Heilbronner Index (HHI), Response Bias Scale (RBS), Fake Bad Scale (FBS), and the Symptom Validity Scale (FBS-r) outperformed the F-family of scales on a variety of ODA indexes of classification accuracy, including an omnibus measure (effect strength total, EST) of the descriptive and prognostic utility of ODA models developed for each scale. Based on the guidelines suggested by Yarnold and Soltysik for evaluating effect strengths for ODA models, the newly developed scales had effects sizes that were moderate in size (37.66 to 45.68), whereas the F-family scales had effects strengths that ranged from weak to moderate (15.42 to 32.80). In addition, traditional analysis demonstrated that HHI, RBS, FBS, and FBS-R had large effect sizes (0.98 to 1.16) based on Cohen's (1988) suggested categorization of effect size when comparing mean scores for adequate versus inadequate effort groups, whereas F-family of scales had small to medium effect sizes (0.25 to 0.76). The MMPI-2-RF Infrequent Somatic Responses Scale (F S) tended to perform in a fashion similar to F, the best performing F-family scale. © 2011 Psychology Press.


Mac Donald C.L.,University of Washington | Johnson A.M.,University of Washington | Cooper D.,University of Washington | Nelson E.C.,University of Washington | And 9 more authors.
New England Journal of Medicine | Year: 2011

BACKGROUND: Blast-related traumatic brain injuries have been common in the Iraq and Afghanistan wars, but fundamental questions about the nature of these injuries remain unanswered. METHODS: We tested the hypothesis that blast-related traumatic brain injury causes traumatic axonal injury, using diffusion tensor imaging (DTI), an advanced form of magnetic resonance imaging that is sensitive to axonal injury. The subjects were 63 U.S. military personnel who had a clinical diagnosis of mild, uncomplicated traumatic brain injury. They were evacuated from the field to the Landstuhl Regional Medical Center in Landstuhl, Germany, where they underwent DTI scanning within 90 days after the injury. All the subjects had primary blast exposure plus another, blast-related mechanism of injury (e.g., being struck by a blunt object or injured in a fall or motor vehicle crash). Controls consisted of 21 military personnel who had blast exposure and other injuries but no clinical diagnosis of traumatic brain injury. RESULTS: Abnormalities revealed on DTI were consistent with traumatic axonal injury in many of the subjects with traumatic brain injury. None had detectible intracranial injury on computed tomography. As compared with DTI scans in controls, the scans in the subjects with traumatic brain injury showed marked abnormalities in the middle cerebellar peduncles (P<0.001), in cingulum bundles (P = 0.002), and in the right orbitofrontal white matter (P = 0.007). In 18 of the 63 subjects with traumatic brain injury, a significantly greater number of abnormalities were found on DTI than would be expected by chance (P<0.001). Follow-up DTI scans in 47 subjects with traumatic brain injury 6 to 12 months after enrollment showed persistent abnormalities that were consistent with evolving injuries. CONCLUSIONS: DTI findings in U.S. military personnel support the hypothesis that blast-related mild traumatic brain injury can involve axonal injury. However, the contribution of primary blast exposure as compared with that of other types of injury could not be determined directly, since none of the subjects with traumatic brain injury had isolated primary blast injury. Furthermore, many of these subjects did not have abnormalities on DTI. Thus, traumatic brain injury remains a clinical diagnosis. (Funded by the Congressionally Directed Medical Research Program and the National Institutes of Health; ClinicalTrials.gov number, NCT00785304.). Copyright © 2011 Massachusetts Medical Society. All rights reserved.


Owens B.D.,United States Military Academy | Campbell S.E.,Landstuhl Regional Medical Center | Cameron K.L.,United States Military Academy
American Journal of Sports Medicine | Year: 2014

Background: While anterior glenohumeral instability has been shown to be common in young athletes, the risk factors for injuryare poorly understood.Purpose/Hypothesis: To determine the modifiable and nonmodifiable risk factors for anterior shoulder instability in a high-riskcohort. The hypothesis was that specific baseline factors would be associated with the subsequent risk of injury.Study Design: Cohort study (prognosis); Level of evidence, 2. an Methods: We conducted a prospective cohort study in which 714 young athletes were followed from June 2006 through May2010. Baseline assessments included a subjective history of instability, physical examination by a sports medicine fellowshiptrained orthopaedic surgeon, range of motion, strength with a handheld dynamometer, and bilateral noncontrast shoulder magneticresonance imaging (MRI). A musculoskeletal radiologist measured glenoid version, glenoid height, glenoid width, glenoidindex (height-to-width ratio), glenoid depth, rotator interval (RI) height, RI width, RI area, RI index, and the coracohumeral interval.Subjects were followed to document all acute anterior shoulder instability events during the 4-year follow-up period. The time toanterior shoulder instability event during the follow-up period was the primary outcome of interest. Univariate and multivariableCox proportional hazards regression models were used to analyze the data.Results: Complete data were available for 714 subjects. During the 4-year surveillance period, there were 39 anterior instabilityevents documented at a mean of 285 days. While we controlled for covariates, significant risk factors of physical examinationwere as follows: apprehension sign (hazard ratio [HR], 2.96; 95% CI, 1.48-5.90; P = .002) and relocation sign (HR, 4.83; 95%CI, 1.75-13.33; P = .002). Baseline range of motion and strength measures were not associated with subsequent injury. Significantanatomic risk factors on MRI measurement were glenoid index (HR, 8.12; 95% CI, 1.07-61.72; P = .043) and the coracohumeralinterval (HR, 1.20; 95% CI, 1.08-1.34; P = .001).Conclusion: This prospective cohort study revealed significant risk factors for shoulder instability in this high-risk population.Physical examination findings of apprehension and relocation were significant while controlling for history of injury. The anatomicvariables of significance were not surprising-tall and thin glenoids were at higher risk compared with short and wide glenoids,and the risk of instability increased by 20% for every 1-mm increase in coracohumeral distance. ©2013 The Author(s).


Waibel K.H.,Landstuhl Regional Medical Center
Annals of Allergy, Asthma and Immunology | Year: 2016

Background: Telehealth continues to advance as a health care modality; however, reported experience for synchronous TeleAllergy is limited. Objective: To determine the percentage of new and follow-up visits conducted via TeleAllergy in a hospital-based clinic. Methods: A retrospective study evaluating the first 2 years of a synchronous patient-to-allergist TeleAllergy platform. Results: A total of 112 synchronous TeleAllergy encounters were conducted from January 2014 through December 2015; 66 (59%) of these were new consultations. The mean (SD) age was 26.9 (15.3) years, and 54% of the participants were female. Food allergy (30%), allergic rhinitis (20%), and urticaria (16%) represented the top 3 consultation reasons. Sixteen of 66 patients (24.2%) and 3 of 46 patients (6.5%) attending new and follow-up TeleAllergy visits, respectively, were recommended for an in-person appointment (P = .02). No difference was found between new and follow-up TeleAllergy visits regarding subsequent telephone communication (41% vs 26%, P = .11) or prescriptions ordered (50% vs 33%, P = .08). New TeleAllergy visits were more likely to have more than 1 laboratory test ordered (45% vs 17%, P = .002). On the basis of patient location, the 112 TeleAllergy visits resulted in an estimated savings of 200 workdays or schooldays, US$58,000 in travel-related costs, and 80,000 kilometers not driven. Conclusion: Both new and follow-up visits to the allergist/immunologist were well received by patients and demonstrated significant indirect cost savings, with less than one fourth of the patients recommended for an in-person visit. This appears to be the first systematic assessment of TeleAllergy for new and follow-up patient encounters in a clinic-based allergy/immunology practice. © 2016.


Martin D.,Landstuhl Regional Medical Center
Southern Medical Journal | Year: 2011

This review evaluates the current understanding of the benefits and risks of physical activity and exercise on the gastrointestinal system. A significant portion of endurance athletes are affected by gastrointestinal symptoms, but most symptoms are transient and do not have long-term consequences. Conversely, physical activity may have a protective effect on the gastrointestinal system. There is convincing evidence that physical activity reduces the risk of colon cancer. The evidence is less convincing for gastric and pancreatic cancers, gastroesophageal reflux disease, peptic ulcer disease, nonalcoholic fatty liver disease, cholelithiasis, diverticular disease, irritable bowel syndrome, and constipation. Physical activity may reduce the risk of gastrointestinal bleeding and inflammatory bowel disease, although this has not been proven unequivocally. This article provides a critical review of the evidence-based literature concerning exercise and physical activity effects on the gastrointestinal system and provides physicians with a better understanding of the evidence behind exercise prescriptions for patients with gastrointestinal disorders. Well-designed prospective randomized trials evaluating the risks and benefits of exercise and physical activity on gastrointestinal disorders are recommended for future research. Copyright © 2011 by The Southern Medical Association.


Traumatic brain injury contributes significantly to military combat morbidity and mortality. No longer maintaining comprehensive medical care facilities throughout the world, the US military developed a worldwide trauma care system making the patient the moving part of the system. Life-saving interventions are performed early, and essential care is delivered at forward locations. Patients then proceed successively through increasingly capable levels of care culminating with arrival in the US. Proper patient selection and thorough mission preparation are crucial to the safe and successful intercontinental aeromedical evacuation of critical brain-injured patients during Operations Iraqi Freedom and Enduring Freedom.


Allan P.F.,Landstuhl Regional Medical Center
Respiratory Care | Year: 2010

INTRODUCTION: High-frequency percussive ventilation (HFPV) is an increasingly used mode of mechanical ventilation, for which there is no proven real-time means of measuring delivered tidal volume (VT). OBJECTIVE: To validate a pneumotachograph for HFPV and then exploit flowsensor data to describe the behavior of both low-frequency and high-frequency breaths. METHODS: Sensor performance was gauged during changes in high-frequency (4-12 Hz) and lowfrequency rate and ratio, mean airway pressure, oxygen concentration, heated or heated-humidified gas flow, and endotracheal tube diameter. Glass bottle (adiabatic VT) and test lung (adiabatically derived low-frequency VT) based adiabatic conditions provided both an initial source for analogsignal calibration and an accepted standard comparator to flow-sensor measurement of highfrequency and low-frequency (flow-sensor-derived) VT), respectively. RESULTS: Pneumotachography proved accurate and precise over an array of tested settings and conditions when analyzing both high-frequency (difference between mean ± SD high-frequency VT and adiabatic VT was -0.2 ± 1.8%, 95% confidence interval -0.5 to 0.9%) and low-frequency breaths (mean ± SD difference between flow-sensor-derived low-frequency VT and adiabatically derived low-frequency VT was 0.6 ± 2.4%, 95% confidence interval 0.1-1.1%). High-frequency VT and frequency exhibited an exponential relationship. During HFPV, flow-sensor-derived low-frequency VT had a mean ± SD of 1,337 ± 700 mL, 95% confidence interval 1,175-1,499 mL. CONCLUSIONS: Readily available pneumotachography provided accurate measurements of low-frequency and high-frequency VT during HFPV. In the setting of acute lung injury, typical HFPV settings may deliver injurious VT.

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