Alexander Niven

Prevalence and Impact of Short Sleep Duration in Redeployed OIF Soldiers

STUDY OBJECTIVES Short sleep duration (SSD) is common among deployed soldiers. The prevalence of SSD during redeployment, however, is unknown. DESIGN Cross-sectional study of a brigade combat team (n = 3152 US Army soldiers) surveyed 90-180 days after completing a 6-15 month deployment to Iraq as part of Operation Iraqi Freedom (OIF). Survey items targeted sleep habits and comorbid medical conditions. Multivariate logistic regression analyses were performed to calculate adjusted odds ratios of medical comorbidities associated with SSD. SETTING US Army Infantry Post. SUBJECTS All soldiers from a redeploying brigade combat team participated in a health assessment between 90 and 180 days upon return to Ft. Lewis from Iraq. INTERVENTIONS None. MEASUREMENTS AND RESULTS A total of 2738 (86.9%) soldiers answered questions regarding self-perceived sleep and were included in the analysis. Mean sleep duration was 5.8 ± 1.2 hours. Nineteen hundred fifty-nine (72%) slept ≤ 6 h, but only 16% reported a daytime nap or felt their job performance was affected due to lack of sleep. Short sleep was more common among soldiers who reported combat exposure. After controlling for combat exposure, short sleep duration (SSD) was associated with symptoms of depression, posttraumatic stress disorder, panic syndrome, and with high-risk health behaviors such as abuse of tobacco and alcohol products, and suicide attempts. CONCLUSIONS SSD is common among redeployed soldiers. Soldiers who experienced combat are at increased risk for persistent SSD and comorbidities associated with SSD. Efforts to reestablish good sleep habits and aggressive evaluation of soldiers with persistent SSD following deployment may aid in the prevention and management of associated medical conditions.

The Prevalence and Impact of Respiratory Symptoms in Asthmatics and Nonasthmatics during Deployment

OBJECTIVE The purpose of this study was to compare the prevalence, severity, and impact of respiratory symptoms in asthmatics and nonasthmatics during Operation Enduring Freedom and Operation Iraqi Freedom. METHODS A survey was given to 1,250 active duty soldiers and Department of Defense contractors returning from Operation Enduring Freedom/Operation Iraqi Freedom. Subjects were asked about demographics, smoking habits, respiratory symptoms, and impact on job performance before and during deployment. Patients with a history of asthma were asked method of diagnosis, current symptoms, and asthma therapy. RESULTS A total of 1,193 subjects returned the completed questionnaire (95% response rate). Mean age of respondents was 38 +/- 11 years, 83% (n = 977) were male, and 31% (n = 375) were past or present smokers. Sixty-one subjects (5%) reported a previous diagnosis of asthma. Both asthmatics and nonasthmatics had increased respiratory symptoms of wheezing, cough, sputum production, chest pain/tightness, and allergy symptoms during deployment compared to predeployment (p < 0.05 for all). When compared to nonasthmatics, asthmatic subjects reported more wheezing, sputum production, and chest pain/tightness during deployment (p < 0.0001, 0.05, 0.05 respectively), had more difficulty with military duties (p < 0.05), and were more likely to seek medical attention and receive duty restrictions (p < 0.0001). Twenty-six percent (n = 16) of asthmatics reported poor baseline symptom control, and this group had significantly increased symptoms, functional limitations, and health care utilization when compared to asthmatics who were symptom-controlled at baseline. CONCLUSIONS Respiratory symptoms were common among both asthmatics and nonasthmatics during deployment. Differences in symptoms and health care utilization in this group of asthmatics were primarily due to subjects with poor baseline control.

Congenital Pulmonary Airway Malformation: A Case Report and Review of the Literature

Congenital parenchymal lung malformations have an estimated incidence at 1:25,000–1:35,000 births. We present a case of this rare congenital abnormality in a 38 year-old male, review the current literature with discussion of proposed causes, malignant potential, and management strategies. A 38-year-old white male presented with a 4-day history of chronic stable hemoptysis. Social history was notable for a 50-pack-year active smoking history and remote heavy alcohol consumption. Physical examination was normal. Chest radiograph revealed an ill defined right lower lobe infiltrate. Chest computed tomography demonstrated an irregular, thin-walled, cystic lesion with adjacent nodularity and calcifications. The patient received a right lower lobectomy. Pathologic specimen demonstrated a 10-cm, mostly thin-walled cyst with features suggestive of a congenital cyst adenomatoid malformation and areas of adenocarcinoma (mixed subtype with acinar and bronchioloalveolar patterns). Congenital cyst adenomatoid malformations have recently been renamed as congenital pulmonary airway malformations and are the most common type of congenital parenchymal lung malformations. Individuals typically present with recurrent pulmonary infections, pneumothorax, or hemoptysis. The development is controversial but believed to be a result of arrested development of the fetal bronchial tree during the sixth and seventh week of fetal development. Defects in thyroid transcription factor 1 have also been proposed. With the increasing use and image resolution of ultrasound in modern obstetric practice, congenital pulmonary airway malformations rarely go undetected into adulthood. Management remains controversial; however, most authors agree with early surgical excision.

Tacrolimus-associated thrombotic microangiopathy in a lung transplant recipient.

A 25-year-old woman with a history of bilateral lung transplant secondary to cystic fibrosis presented with non-specific abdominal complaints and was found to have acute kidney injury, thrombocytopaenia and laboratory findings consistent with a microangiopathic haemolytic anaemia. Her thrombotic microangiopathy (TMA) was attributed to tacrolimus, which was discontinued and replaced with cyclosporine with resolution of her TMA and no subsequent complications. This is the fifth reported case of TMA associated with tacrolimus use in a lung transplant patient, and the third to be successfully managed with cyclosporine substitution. Clinicians must be aware of this uncommon, but likely under-reported complication of tacrolimus therapy in lung transplant recipients. Cyclosporine replacement may be used as a successful therapy to treat tacrolimus-associated TMA without increasing the risk of acute rejection that may be associated with other treatment strategies.

Critical Care Management of Major Disasters: A Practical Guide to Disaster Preparation in the Intensive Care Unit

Recent events and regulatory mandates have underlined the importance of medical planning and preparedness for catastrophic events. The purpose of this review is to provide a brief summary of current commonly identified threats, an overview of mass critical care management, and a discussion of resource allocation to provide the intensive care unit (ICU) director with a practical guide to help prepare and coordinate the activities of the multidisciplinary critical care team in the event of a disaster.

Spontaneous mediastinal haematoma: a rare complication of warfarin therapy

A 64-year-old woman presented with shortness of breath, right-sided pleuritic chest pain and dry cough. She was systemically anticoagulated with warfarin for a pulmonary embolism diagnosed 3 months previously, with an international normalised ratio (INR) of 3.0 on presentation. Chest radiograph demonstrated a new right paratracheal abnormality, and CT scan showed a large mediastinal mass not present 3 weeks earlier. MRI demonstrated an ovoid mass with a fluid/fluid level with high T2 and dark T1 signal consistent with a mediastinal haematoma. The patients anticoagulation was emergently reversed and a temporary inferior vena cava filter was placed. The haematoma slowly resolved on serial follow-up with no additional intervention. Spontaneous mediastinal haematoma is a rare but life-threatening diagnosis that frequently presents with chest pain, dry cough and dysphagia. It is frequently associated with therapeutic anticoagulation and may potentially be caused by sudden, atraumatic rise in intrathoracic pressure (ie, cough or emesis).

Ventilator Management: A Practical Approach to Respiratory Failure in Combat Casualties

The survival of combat casualties from the point of injury to definitive medical care has significantly improved over the last decade. Survival is >95% for casualties who survive their initial injury and are evacuated to definitive care. This improvement can be credited to several factors, including advances in body armor, an improved skill set of prehospital personnel, the presence of forward surgical teams, the availability of surgical and critical care assets in austere environments, and deployment of an increased number of soldiers skilled in basic and advance trauma life support. Early and effective management of battlefield casualties can be successful when the basic principles of prehospital, trauma, and critical care are maintained throughout the entire medical evacuation process. A critical care-trained physician may not be available to treat casualties; thus, all deploying physicians should be familiar with principles of respiratory failure and ventilator management.

Postoperative Intensive Care Unit Management After Ruptured Abdominal Aortic Aneurysm

Management of the patient with a ruptured abdominal aortic aneurysm (rAAA) is arguably the most challenging emergency in vascular surgery and requires rapid and complex decision-making starting from the time of arrival and continuing throughout the ICU stay. Immediate initiation of care based on modern and evidence-based critical care principles is often the deciding factor between a live postoperative patient and a death in the ER or OR. Intensive care unit (ICU) management after surgical repair of the rAAA is a complex undertaking and requires close coordination and cooperation between multiple providers and services, but most importantly the intensivist and the vascular surgeon. The initial ICU period is usually focused on continuing the resuscitation started in the OR and optimizing the patient’s physiology based on the degree of insult, the current status, and function of critical organ systems, with consideration of the multiple preexisting comorbid conditions that typically are present in this patient population. This chapter focuses on the optimal ICU resuscitation and stabilization strategies, timely recognition and treatment of the most common complications, and a system-based strategy for delivery of high-quality, evidence-based, and experience-proven ICU care. Finally, this should all occur within an overarching framework of salvaging not just a survivor but a functional patient who can return to a meaningful level of activity, cognition, and quality of life.

Hemoptysis in young adults.

Vol XIV N.o 4 Julho/Agosto 2008 Comentário A hemoptise continua a ser uma queixa frequente que obriga a uma intervenção urgente. As causas mais frequentes são a bronquite, a neoplasia do pulmão, primária ou secundária, doenças autoimunes, enfarte pulmonar e de etiologia cardíaca. Neste trabalho, os autores foram determinar a importância da broncoscopia na abordagem inicial de doentes jovens adultos com Resumo A hemoptise é uma queixa médica frequente que pode requerer broncoscopia para o seu diagnóstico e tratamento. Não está completamente esclarecido quais são os doentes que beneficiam da broncoscopia como abordagem precoce. Está estabelecido que os jovens adultos com hemoptises são doentes de baixo risco, quando comparados com velhos; contudo, não há muitos trabalhos sobre o interesse da broncoscopia na abordagem deste grupo etário. Os autores resolveram avaliar, retrospectivamente, todos os doentes submetidos a broncoscopia por hemoptises, caracterizando a apresentação clínica e a avaliação diagnóstica dos jovens adultos (18 aos 40 anos), incluindo a utilidade diagnóstica da broncoscopia. Satisfizeram os critérios de inclusão 18 doentes. Na broncoscopia realizada nos doentes com hemoptises que apresentavam radiografia do tórax e T AC do tórax normal não foram identificadas quaisquer alterações endobrônquicas. Os autores, perante estes resultados preconizam que os doentes jovens adultos com hemoptises, com radiografias do tórax e TAC do tórax normais, não necessitam da avaliação broncoscópica inicial, devendo ser seguidos em follow-up clínico apertado. Hemoptises em jovens adultos

Hemoptises em jovens adultos

Resumo A hemoptise e uma queixa medica frequente que pode requerer broncoscopia para o seu diagnostico e tratamento. Nao esta completamente esclarecido quais sao os doentes que beneficiam da broncoscopia como abordagem precoce. Esta estabelecido que os jovens adultos com hemoptises sao doentes de baixo risco, quando comparados com velhos; contudo, nao ha muitos trabalhos sobre o interesse da broncoscopia na abordagem deste grupo etario. Os autores resolveram avaliar, retrospectivamente, todos os doentes submetidos a broncoscopia por hemoptises, caracterizando a apresentacao clinica e a avaliacao diagnostica dos jovens adultos (18 aos 40 anos), incluindo a utilidade diagnostica da broncoscopia. Satisfizeram os criterios de inclusao 18 doentes. Na broncoscopia realizada nos doentes com hemoptises que apresentavam radiografia do torax e T AC do torax normal nao foram identificadas quaisquer alteracoes endobronquicas. Os autores, perante estes resultados preconizam que os doentes jovens adultos com hemoptises, com radiografias do torax e TAC do torax normais, nao necessitam da avaliacao broncoscopica inicial, devendo ser seguidos em follow-up clinico apertado.