Cristóbal S. Berry-Cabán

Analysis of mushroom exposures in Texas requiring hospitalization, 2005-2006.

IntroductionTexas has approximately 200 species of wild mushrooms, including toxic and hallucinogenic varieties. Mushroom ingestions in Texas were studied for 2005–2006.MethodsData was obtained via Texas Poison Control Centers and retrospectively reviewed. Case notes were reviewed individually regarding initial reporting, age, signs and symptoms, toxic effect, management, and patient outcomes.ResultsA total of 742 exposures occurred during the study period. All exposures were acute and intentional. Of these exposures, 59 (7.9%) were admitted to the hospital, with 17 (28.8% of admissions) requiring admission to a critical care unit. Four cases required inpatient psychiatric admission. The average age of admitted exposures was 20.5 years, with a male-to-female predominance of 3.3:1. Eleven (22.9%) of the admitted exposures were identified, with Psilocybin being the most common agent (n = 10, 91%). Among the admissions, co-ingestions were identified with the mushroom ingestion in eleven patients (40.7%). The most common symptoms in admitted patients were vomiting (n = 34, 57.6%), nausea (n = 19, 32.2%), altered mental status (n = 17, 28.8%), abdominal pain (n = 13, 22%), and diarrhea (n = 10, 16.9%).ConclusionsAll mushroom exposures examined were acute and intentional. Major toxic reactions were uncommon, and no deaths were reported. Serious poisoning from mushroom ingestion is rare in Texas; however, there is greater need for information dissemination on morbidity.

A Preliminary Examination of the Comparative Efficacy of Intravenous vs Oral Acetaminophen in the Treatment of Perioperative Pain.

Objective The management of postoperative pain is a major health care issue. While the cost of intravenous acetaminophen (IVA) is significantly greater than its oral acetaminophen (OA) counterpart, less is known regarding comparative effectiveness of these routes. The purpose of this study was to determine whether perioperative IVA is equivalent in reducing postoperative pain compared with perioperative OA for laparoscopic cholecystectomy (LapChole). Design Double-blinded, prospective, randomized placebo-controlled trial. Setting Womack Army Medical Center, Fort Bragg, North Carolina. Subjects Adults (age > 18 years) active duty military, veterans, and beneficiaries receiving a laparoscopic cholecystectomy. Methods This study was conducted at Womack Army Medical Center (WAMC), Fort Bragg, North Carolina, between January 2013 and June 2015. Sixty-seven subjects with symptomatic cholelithiasis were randomly assigned to receive two doses (1,000 mg each) of either IVA or OA. A numerical rating scale (NRS) score of pain was obtained preoperatively and every six hours for 24 hours postoperation. The primary objective was to assess whether treatment groups had significantly different 24-hour postoperative sum of pain intensity differences (SPID24) using an analysis of covariance test. Results Sixty subjects completed the study and were included in the analysis. Treatment groups did not differ in SPID24, even when controlling for age, gender, and preoperative pain levels (F(1,55) = 0.39, P = 0.54, partial η2 = 0.007), nor did 24-hour opioid consumption when controlling for age, gender, and operation time (F(1, 46) = 0.47, P = 0.50, partial η2 = 0.01). Furthermore, treatment groups were equally as likely to report average postoperative NRS scores of 4 or higher (β = 0.24, Exp(B) = 1.28, P = 0.68). Conclusions The results show no evidence of differences between IVA or OA in pain or opioid consumption among a sample of patients undergoing LapChole. Due to low sample size, these descriptive findings warrant larger studies, which may have a significant economic impact.

Megaloblastic hematopoiesis in a 20 year old pregnant female.

Summary Background: Nitrous oxide can cause disordered blood cell proliferation and lead to pancytopenia and altered immune function. Case Report: A young pregnant female patient presented after binge nitrous oxide abuse with altered mental status and abnormal vital signs. From her initial assessment she was noted to have pancytopenia and was found to have megaloblastic, hyper-cellular changes in a subsequent bone marrow biopsy. This presentation was determined to be secondary to toxic effects after heavy use of nitrous oxide. Conclusions: Nitrous oxide exposure, including use as an inhalant, over 12 hours can lead to bone marrow abnormalities such as megaloblastic hematopoiesis.

Association of Spouse Deployment on Pregnancy Outcomes in a U.S. Military Population.

OBJECTIVE: To evaluate the association of spousal deployment during the antenatal period on maternal and neonatal outcomes and to estimate whether group prenatal care may be beneficial in reducing adverse outcomes when spouses are deployed. METHODS: Primigravid women who delivered at Womack Army Medical Center, Fort Bragg, North Carolina, were prospectively enrolled and selected for participation on a random basis between January 2013 and January 2014. Women whose spouses were deployed to a combat zone during the entire pregnancy (deployed group) were compared with women whose spouses were not deployed during the pregnancy (nondeployed group). Pregnancy and neonatal outcomes were compared between groups. RESULTS: Three hundred ninety-seven women were enrolled with 183 (46.1%) in the deployed group and 214 (53.9%) in the nondeployed group. Spouse deployment was associated with increased risk of preterm delivery (38 [20.8%] compared with 16 [7.5%], P<.001) and postpartum depression (30 [16.4%] compared with 13 [6.1%], P=.001) when compared with women in the nondeployed group. There were no differences in the incidence of preterm delivery and postpartum depression for women in the deployed group who participated in group prenatal care when compared with women participating in traditional care (preterm delivery 6 [14.6%] compared with 32 [22.5%], P=.38; postpartum depression 4 [9.8%] compared with 26 [18.3%], P=.24). CONCLUSION: Women who have a spouse deployed during their pregnancy are at increased risk for preterm birth and postpartum depression. Larger studies are needed to evaluate whether spouse deployment during pregnancy has other perinatal effects and whether group prenatal care may have a positive effect on adverse perinatal outcomes in this population. LEVEL OF EVIDENCE: II

Self-reported Hypertension on a Caribbean Island

Background Although current guidelines emphasize the importance of hypertension knowledge, little is known about accuracy of this knowledge, factors affecting accuracy and the relationship of self-reported hypertension with cardiovascular disease (CVD). Methods One hundred and forty seven subjects were asked to provide self-reported data on hypertension. Results These were correlated with levels of systolic and diastolic hypertension measures. Demographic characteristics were considered as determinants of awareness and accuracy. Women were more likely than men to be aware of their hypertension levels. However men were more likely to exercise, use salt, smoke and consume alcohol. Women were more likely to be hypertensive, nonsmokers, and moderate drinkers. Higher levels of self-reported hypertension were strongly associated with increased risk of CVD. Women that smoke, have untreated hypertension, or a sedentary lifestyle have a decrease in awareness of their hypertension levels. Conclusions Self-reported hypertension underestimates measured values, but is strongly related to CVD. Lack of awareness of elevated hypertension is associated with increased risk of CVD. Keywords Cardiovascular disease; Hypertension; Risk factors; Self-report; Caribbean

Correlations between Vitamin D Concentrations and Lipid Panels in Active Duty and Veteran Military Personnel

Vitamin D deficiency is common in the United States and has been associated with dyslipidemia along with additional cardiovascular conditions. Dyslipidemia raises the risk for cardiovascular disease and has been linked to symptoms of post-traumatic stress disorder (PTSD) in military personnel. The purpose of this study was to identify significant correlations between serum vitamin D and lipid panel concentrations in active duty and veteran military personnel. This analysis examined 3,053 unique cases of serum vitamin D and lipid panel assessments ordered at Womack Army Medical Center, Fort Bragg, North Carolina, from January 2012 to September 2013. Assessments were drawn within 21 days of one another. Fiftyseven percent of subjects had insufficient vitamin D status, and 36.6% had high total cholesterol according to the Army Medical Department guidelines, using 30 ng/ml for 25-hydroxyvitamin D and 200 mg cholesterol, respectifvely. In regression models, vitamin D was significantly positively correlated with high-density lipoprotein cholesterol in all subjects after controlling for age, gender and military status. Body mass index (BMI) was available for active personnel only, and including BMI values in analysis reduced the significance of vitamin D in the model. Vitamin D concentrations were negatively associated with total cholesterol and low-density lipoprotein in veterans only. Overall, our data suggest that lipoprotein concentrations are complex and may be influenced by vitamin D status in military service members. Therefore, future research should aim to explain the correlation between vitamin D and cholesterol concentrations in service members to determine if improving vitamin D status would also improve cholesterol status.

Telemedicine in US Army soldiers with type 1 diabetes

A retrospective study of a telemedicine clinic for active duty US Army soldiers with type 1 diabetes was conducted. Fifty-one consecutive patients (mean age 33.9 years) were enrolled into the clinic. All soldiers with known or newly diagnosed type 1 diabetes received three weekly office visits for intensive diabetes education. After this, all communication occurred via a messaging system consisting of texting, web-based download, and/or email to a diabetes management team. For urgent matters, 24/7 direct paging or telephone access was provided. Routine adjustments in insulin dosing were accomplished via email. Soldiers were followed for a mean of 17.1 months. Baseline, three-month, and end of study glycated hemoglobin (A1C) values were 9.8, 7.3, and 6.9, respectively. There were no significant differences in end of study A1C levels between patients with known vs. newly diagnosed type 1 diabetes, nor were there any differences between those patients who received insulin via pump therapy vs. multiple daily injections. Telemedicine was safe and effective in lowering A1C levels in US Army soldiers with type 1 diabetes.

Review of Interventions Designed to Address Drinking Among Soldiers

Heavy and abusive alcohol use is a major health problem facing military service members. We reviewed literature on alcohol intervention programs targeting military personnel to assess the methodological quality and effectiveness of the programs. Although the search yielded more than 42,000 citations, only 150 met initial screening criteria. Eighteen studies had sufficient evidence to meet secondary screening and of these only 10 studies were included in the review. These studies employed several types of interventions, but only 1 used a randomized controlled trial. Our findings indicate that there is greater need to assess intervention strategies, and there is a particular need for high-quality studies using randomized controlled trials with standardized assessment tools to improve the generalizability of the findings. We discuss the implications of our findings for future research in this area.

A case of acute carpal tunnel syndrome.

ABSTRACTAcute carpal tunnel syndrome is a rare diagnosis in orthopedic medicine. This article describes a 35-year-old man who presented to the ED with complaints of discomfort and paresthesias in his right wrist after a fall, and was subsequently diagnosed with acute carpal tunnel syndrome. The article reviews the pathophysiology of the syndrome and suggested treatment.

Prevalence of Beers Criteria Medications Among Elderly Patients in a Military Hospital

Objective: This study aims to examine potentially inappropriate medication (PIM) prevalence and factors that affect the use of PIMs in a military treatment facility. Method: Admission and discharge medication lists of 60 patients aged ≥65 years were retrospectively reviewed by a clinical pharmacist and a member of the study team for the presence of PIM using the 2012 Beers Criteria. Patients included were those discharged between December 2012 and September 2013 from the Womack Army Medical Center, Internal Medicine unit. Results: Among the 60 patients evaluated, 44 (73%) were on at least one PIM at admission, whereas the prevalence of PIM at discharge (30 patients) was 50% (p < .001). The top three classes of PIM at admission were antihistamines (11, 15.3%), nonsteroidal anti-inflammatory drugs (10, 13.9%), and benzodiazepines (6, 8.3%). Patients on >10 medications at admission (37, 62%) were 4 times more likely to have a PIM (p < .001). Conclusion: Data showed a high and a previously unknown PIM prevalence among older adults in a U.S. military treatment facility.