San Antonio, TX, United States
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Neuroimaging approaches that are currently used in hospitals have little role in the diagnosis of mild TBI. In fact, patients with this condition often have normal routine brain scans. However, advanced types of magnetic resonance imaging (MRI) are showing increasing promise in demonstrating changes that are known to occur in mild TBI. These advanced imaging approaches include diffusion tensor imaging (DTI), functional connectivity, perfusion weighted imaging, and volumetric imaging. Despite their promise, these advanced approaches are currently primarily confined to research use. The numerical nature of the information these advanced imaging approaches yield is difficult to translate from the study of groups of individuals to a single patient without a reference. To bridge the divide between the current research applications of these advanced imaging approaches and their use in clinical care, researchers must first use the technology to characterize the normal range of variation across the population. Known cases of TBI could then be compared with this reference to establish diagnostic differences that may be used to establish a diagnosis and help to guide patient management. To achieve this goal, Cohen Veterans Bioscience and the American College of Radiology Head Injury Institute are embarking on a program to perform standardized advanced neuroimaging scans on 3,000 adult volunteers. The initial iteration of this work will be conducted at four sites: Lackland Air Force Base, the San Antonio Military Medical Center, Baylor College of Medicine, and the University of Virginia Health System. The resulting imaging data, along with demographic information and the results of neurocognitive assessments, will form the basis for a library documenting population variation in brain structure and function as measured by these advanced imaging methods. Standards developed by the project for performing imaging and assessing volunteers will also be released to the research community, so that future efforts may employ this resource in the study of individuals with traumatic brain injury. "Injuries to the brain can be so subtle and so easily missed, not only because they may not be seen on an MRI, but because clinicians can only rely on patient-reported symptoms. Patients may feel fine yet have a potentially life-altering condition," says Magali Haas, MD, PhD, CEO & President of Cohen Veterans Bioscience. "With this new reference library we can create a diagnostic standard by which all individuals who suffer from a TBI can be assessed and receive immediate treatment." "Medical imaging as a whole is in the process of undergoing a critical evolution which will see advanced analytical tools increasingly employed in hospitals to aid with patient diagnosis and management," says James R. Stone, MD, PhD, scientific principal investigator for the effort and  Vice Chair of Research for the UVA Department of Radiology and Medical Imaging. "The TBI imaging reference library will provide key information necessary to capitalize on these increasingly available analytical approaches to allow for imaging to help support decisions in the management of patients with mild TBI." "We are committed to maximizing the learning opportunity from every single patient. This approach is a giant step forward where medicine and imaging are concerned", Alexander Norbash MD, MS, FACR, ACR Head Injury Institute Chair. "Cohen Veterans Bioscience has made this possible, and it is a transformative opportunity." About the American College of Radiology (ACR) Head Injury Institute The ACR Head Injury Institute was formed to help advance the diagnosis, understanding and treatment of head injuries. One of the greatest needs in the advancement of head injury medicine is the identification and development of biomarkers — such as microscopic structural differences in the brain — that can help identify the nature and severity of a head injury. The Head Injury Institute brings a broad and deep range of capabilities and relationships to this challenge. About Cohen Veterans Bioscience Cohen Veterans Bioscience is the only 501(c)(3) non-profit research organization with a singular focus on PTSD and TBI research. We are dedicated to fast-tracking the development of diagnostic tests and personalized medicines for the millions of veterans and civilians who suffer the devastating effects of trauma on the brain. More information is available at To view the original version on PR Newswire, visit:

Kwok R.M.,U.S. National Institutes of Health | Torres D.M.,U.S. National Institutes of Health | Harrison S.A.,San Antonio Military Medical Center
Hepatology | Year: 2013

Vitamin D is a secosteroid with known effects on calcium homeostasis that has recently been shown to have other significant functions regarding immune modulation, cell differentiation and proliferation, and the inflammatory response. As our understanding of the many functions of vitamin D has grown, the presence of vitamin D deficiency (VDD) has become more evident in Western populations. Concomitantly, nonalcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease. NAFLD and VDD are often found together, and while this is not unexpected, given their similar associations with obesity and sedentary lifestyle, a growing body of evidence points to a closely linked and potentially causative relationship between VDD and NAFLD. The epidemiologic association between VDD and NAFLD as well as the role of VDD in the pathogenesis of NAFLD and the available evidence on the clinical utility of vitamin D replacement in NAFLD populations are discussed. (Hepatology 2013;53:1166-1174). © 2013 by the American Association for the Study of Liver Diseases.

Torres D.M.,U.S. National Institutes of Health | Harrison S.A.,San Antonio Military Medical Center
Seminars in Liver Disease | Year: 2012

Nonalcoholic fatty liver disease (NAFLD) is easily the most common cause of chronic liver disease in the United States (U.S.) as the hepatic manifestation of the metabolic syndrome. Although only 5 to 20% of patients with NAFLD are generally considered to meet criteria for nonalcoholic steatohepatitis (NASH), with its inherent risk for progression to cirrhosis, this still represents an alarmingly large number of individuals. The exponentially growing rates of hepatocellular carcinoma (HCC) in the U.S. may be partially attributable to increased numbers of NASH cirrhotics, although recent evidence has suggested that NAFLD may directly promote hepatic carcinogenesis independent of cirrhosis. This review focuses on HCC in noncirrhotic NASH with an emphasis on clinical presentation, pathogenesis, and implications for screening. © 2012 by Thieme Medical Publishers, Inc.

Rivera J.C.,San Antonio Military Medical Center
The Journal of the American Academy of Orthopaedic Surgeons | Year: 2012

The Army Physical Evaluation Board results for wounded warriors from a previously described cohort were reviewed to identify permanently disabling conditions and whether the conditions were preexisting or caused by battlefield injury. Arthritis was the most common unfitting condition in this cohort, with 94.4% of cases attributed to combat injury and only 5.6% attributed to preexisting conditions or documented in the health records prior to battle injury. The most common causes of injury that resulted in arthritis were intra-articular fractures secondary to explosions, traumatic arthrotomies resulting from fragment projectiles, and gunshot wounds. Arthritis was recognized as a disabling condition an average of 19 ± 10 months after injury. Research is needed to enhance prevention and management of joint injuries in order to minimize the disabling effects of joint degeneration in this young patient population.

Bedigrew K.M.,San Antonio Military Medical Center
Clinical orthopaedics and related research | Year: 2014

Patients with severe lower extremity trauma have significant disability 2 years after injury that worsens by 7 years. Up to 15% seek late amputation. Recently, an energy-storing orthosis demonstrated improved function compared with standard orthoses; however, the effect when integrated with rehabilitation over time is unknown. (1) Does an 8-week integrated orthotic and rehabilitation initiative improve physical performance, pain, and outcomes in patients with lower extremity functional deficits or pain? (2) Is the magnitude of recovery different if enrolled more than 2 years after their injury versus earlier? (3) Does participation decrease the number considering late amputation? We prospectively evaluated 84 service members (53 less than and 31 > 2 years after injury) who enrolled in the initiative. Fifty-eight sustained fractures, 53 sustained nerve injuries with weakness, and six had arthritis (there was some overlap in the patients with fractures and nerve injuries, which resulted in a total of > 84). They completed 4 weeks of physical therapy without the orthosis followed by 4 weeks with it. Testing was conducted at Weeks 0, 4, and 8. Validated physical performance tests and patient-reported outcome surveys were used as well as questions pertaining to whether patients were considering an amputation. By 8 weeks, patients improved in all physical performance measures and all relevant patient-reported outcomes. Patients less than and greater than 2 years after injury improved similarly. Forty-one of 50 patients initially considering amputation favored limb salvage at the end of 8 weeks. We found this integrated orthotic and rehabilitation initiative improved physical performance, pain, and patient-reported outcomes in patients with severe, traumatic lower extremity deficits and that these improvements were sustained for > 2 years after injury. Efforts are underway to determine whether the Return to Run clinical pathway with the Intrepid Dynamic Exoskeletal Orthosis (IDEO) can be successfully implemented at additional military centers in patients > 2 years from injury while sustaining similar improvements in patient outcomes. The ability to translate this integrated orthotic and rehabilitation program into the civilian setting is unknown and warrants further investigation.

Ficke J.R.,San Antonio Military Medical Center
The Journal of the American Academy of Orthopaedic Surgeons | Year: 2012

Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.

Schmitz M.R.,San Antonio Military Medical Center
The Journal of bone and joint surgery. American volume | Year: 2013

Symptomatic femoroacetabular impingement is a known prearthritic condition. Impingement morphology is poorly defined in the adolescent population. The purpose of this study was to document the prevalence of radiographic impingement morphology in adolescents with no symptomatic hip problems. Ninety anteroposterior images of the hip in forty-five consecutive adolescents with scoliosis met the inclusion criteria. Sex distribution was equal. The second cohort (ninety hips) was an age-matched group with no scoliosis. None had symptomatic hip problems. Images were analyzed for coxa profunda, protrusio acetabuli, Tönnis angle, anteroposterior alpha angle, center-edge angle, acetabular crossover, ischial spine sign, and neck-shaft angle. Of the 180 hips, 92.8% demonstrated at least one parameter suggesting impingement morphology, whereas 52.2% showed at least two signs. Evidence of coxa profunda was seen in 81.7% of the hips, while a negative Tönnis angle was seen in 31.1% and a center-edge angle indicative of acetabular overcoverage was seen in 15%. An acetabular crossover sign was detected in 27.2% of the hips, while an abnormal anteroposterior alpha angle was found in 5.6% of the hips in male patients and 6.7% of the hips in female patients. Statistical analysis revealed that abnormal alpha angles (p = 0.029), crossover signs (p = 0.029), and ischial spine signs (p = 0.026) were more common in the cohort without scoliosis, and coxa profunda was more common in females (p = 0.034). There was a high prevalence of radiographic impingement morphology beyond the spectrum of normal in this double-cohort study of adolescents. Femoroacetabular impingement remains a dynamic problem, and we caution against relying only on the use of hard-set static radiographic parameters when evaluating femoroacetabular impingement. This study raises the important question of what morphologic characteristics should be defined as abnormal, when at least one finding of impingement morphology is noted in such a large segment of the population. On the basis of the normative data obtained, reference values for radiographic parameters of femoroacetabular impingement morphology should be redefined. Normal values for a Tönnis angle were between -8° and 14°, the upper limit of the center-edge angle was 44°, and the normal values for femoral neck-shaft angle were between 121° and 144°. Surgical indications should be tailored to physical examination findings and not radiographic findings alone.

Barrera J.E.,San Antonio Military Medical Center
Laryngoscope | Year: 2014

Objectives/Hypothesis Determine the feasibility and accuracy of using virtual surgical planning (VSP) to direct the surgical and polysomnography (PSG) outcomes of patients with obstructive sleep apnea (OSA). Study Design Prospective case series. Methods Skeletal and soft tissue dimensions were measured from computed tomography (CT) to include posterior airway space (PAS) diameters at the occlusal (PAS-O) and mandibular (PAS-M) plane, position of the maxilla, and tooth-to-lip distance. All patients underwent an in-lab attended PSG whereby apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and lowest oxyhemoglobin saturation percent (LSAT) were measured preoperatively and at least 9 months postoperatively. Results Four patients with OSA demonstrated a mean AHI and RDI of 60.1 and 69.5 events per hour, respectively. The mean preoperative LSAT was 76%. Mean CT-based measures for PAS-O and PAS-M were 3.08 mm and 9.03 mm, respectively. VSP was used to direct the amount of advancement and impaction in maxillomandibular advancement (MMA) surgery. The mean PAS-O and PAS-M postoperative measures significantly increased to 8.15 and 14 mm (P<.004), whereas the mean tooth-to-lip relationship stayed the same, 3.17 to 3.18, P=.98. The AHI and RDI significantly improved to 2.83 and 4.5 events per hour, respectively, P=.03, whereas the LSAT improved from 76% to 87%. Conclusions VSP for MMA in OSA patients is feasible and safe while offering improvements in the predictability of airway change and tooth-to-lip measures. © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

Davis J.M.,San Antonio Military Medical Center
The Journal of the American Academy of Orthopaedic Surgeons | Year: 2012

Pelvic fractures were sustained by ≥26% of service members who died during Operation Enduring Freedom and Operation Iraqi Freedom in 2008. To determine factors associated with patient mortality following combat-related pelvic fracture (CRPF), the Joint Theater Trauma Registry database was searched to identify service members who survived CRPF sustained in the year 2008 (group 1), and the Armed Forces Medical Examiner System was searched to identify nonsurvivors of such trauma in the same year (group 2). Stable pelvic ring injuries were associated with a lower mortality rate than were unstable injuries when controlling for large-vessel and anatomic brain injuries (43% and 85%, respectively; P < 0.05). Associated injuries that were significant predictors of mortality included large-vessel, anatomic brain, cardiopulmonary, and solid organ abdominal (P < 0.05). Compared with a similar cohort of nonsurvivors, persons who survive CRPF have less severe pelvic fractures and associated injuries. In addition, pelvic fractures secondary to direct combat (ie, blast-related blunt injury, penetrating injury) were significantly more lethal than were those caused by mechanisms analogous to civilian trauma.

Patzkowski J.C.,San Antonio Military Medical Center
The Journal of the American Academy of Orthopaedic Surgeons | Year: 2012

Posttraumatic osteoarthritis affects approximately 5.6 million Americans annually. Those affected are typically younger and more active than persons with primary osteoarthritis. Arthrodesis is the typical management option for persons with end-stage ankle and subtalar posttraumatic arthritis. Arthroplasty is typically reserved for elderly persons. The functional limitations resulting from any of these strategies make treatment of this young population challenging. Combat wounds frequently lead to severe lower extremity injuries. We present a series of patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint after combat trauma. They were treated at our institution with an integrated orthotic and rehabilitation initiative called the Return To Run clinical pathway. This clinical pathway may serve as an alternative or adjunct to arthrodesis and arthroplasty for young patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint.

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