Thomas Beltran

Assessment of the King-Devick® (KD) test for screening acute mTBI/concussion in warfighters

OBJECTIVES The Department of Defense reported that 344,030 cases of traumatic brain injury (TBI) were clinically confirmed from 2000 to 2015, with mild TBI (mTBI) accounting for 82.3% of all cases. Unfortunately, warfighters with TBI are often identified only when moderate or severe head injuries have occurred, leaving more subtle mTBI cases undiagnosed. This study aims to identify and validate an eye-movement visual test for screening acute mTBI. METHODS Two-hundred active duty military personnel were recruited to perform the King-Devick® (KD) test. Subjects were equally divided into two groups: those with diagnosed acute mTBI (≤72h) and age-matched controls. The KD test was administered twice for test-retest reliability, and the outcome measure was total cumulative time to complete each test. RESULTS The mTBI group had approximately 36% mean slower performance time with significant differences between the groups (p<0.001) in both tests. There were significant differences between the two KD test administrations in each group, however, a strong correlation was observed between each test administration. CONCLUSIONS Significant differences in KD test performance were seen between the acute mTBI and control groups. The results suggest the KD test can be utilized for screening acute mTBI. A validated and rapidly administered mTBI screening test with results that are easily interpreted by providers is essential in making return-to-duty decisions in the injured warfighter.

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.

Prevalence of Human Papillomavirus in Self-Collected Cervicovaginal Swabs in Young Women in the United States Between 2003 and 2012.

OBJECTIVE: To evaluate whether there was a change in prevalence of human papillomavirus (HPV) in the United States correlated with the introduction of HPV vaccines in both vaccinated and unvaccinated women. METHODS: We performed a retrospective review of prevalence data for women aged 18–29 years living in the United States using the National Health and Nutrition Examination Surveys, which is an ongoing series of cross-sectional surveys. Participants provided responses to standardized questions and self-collected cervicovaginal swabs in which a Linear Array HPV Assay was used to determine HPV prevalence. A total of 783 women from the prevaccine era (2003–2004) and 1,526 from the postvaccine era (2007–2012) were analyzed. RESULTS: Among women aged 18–29 years, the prevalence of vaccine-type HPV declined among women receiving one or more doses of vaccine (P=.003): 10.1% (95% confidence interval [CI] 7.1–13.8%) in the prevaccine era to 4.2% (95% CI 3.3–10.9%) in the postvaccine era. There was no change in prevalence of nonvaccine-type HPV among women receiving one or more doses of vaccine (P>.05). There was also no change in prevalence of vaccine-type HPV among unvaccinated women from the prevaccine era 10.1% (95% CI 7.1–13.8%) to 8.8% (95% CI 5.6–12.9%) in the postvaccine era (P=.4). Vaccine coverage increased to 31.5% of eligible women aged 18–29 years as of 2011–2012. CONCLUSION: Six years after introduction of HPV vaccination in the United States, there has been a decrease in the prevalence of vaccine-type HPV among women correlated with receiving one or more vaccine doses with no change in nonvaccine-type HPV. Furthermore, there has been no change in prevalence of vaccine-type HPV among unvaccinated women.

Prevalence of Toxocara species infection in the U.S.: Results from the National Health and Nutrition Examination Survey, 2011-2014

Toxocariasis is one of the most common neglected infections of poverty in the U.S. with a reported National Health and Nutrition Examination Survey (NHANES) III (1988–1994) seroprevalence of 13.9% based on enzyme immunoassay testing. We reviewed NHANES data from 2011–2014 to assess current levels. Sera collected from NHANES 2011–2014 participants six years and older were tested for exposure using rTc-CTL-1 antigen, a more sensitive and specific recombinant antigen for IgG antibodies for Toxocara spp. These results were subdivided into children (age 6–17) and adults (age ≥ 18) and then compared between various sociodemographic characteristics. Given prior associations of Toxocara exposure with atopic disease and lead exposure, we also reviewed laboratory values including complete blood counts and blood and urine lead levels. Data from 13,509 individuals with Toxocara antibody results were examined including 3337 children (15.2%) and 10172 adults (84.8%). Overall seroprevalence was 5.1%. In adults increased antibody positivity occurred with non-White ethnicity, male gender, less than college-level education and lower income. Among children, increased antibody positivity was solely related to a lack of health insurance. Additionally, seropositivity was associated with increased blood lead and eosinophil levels in adults and both blood and urine lead levels in children. Relative to NHANES III (1988–1994), current data suggest an overall decrease in Toxocara spp. seroprevalence from 13.9% to 5.1%, however this may be artificially lowered due to difference in testing methods used. Persistent disparities appear to be associated with at-risk populations such as minority ethnicity and low socioeconomic status.

The feasibility of employing a home healthcare model for education and treatment of opioid overdose using a naloxone auto-injector in a private practice pain medicine clinic

Abstract Objectives: The purpose of this study was to determine if employing a home healthcare model for education and treatment of opioid overdose using the Evzio (Naloxone) auto-injector in a private practice pain clinic. Methods: A prospective survey was used to determine the feasibility of integrating a naloxone auto-injector within the patient’s home with a home care training model. Twenty moderate or high-risk patients were enrolled from the chronic pain clinic. Patients who were moderate or high risk completed an evaluation survey. The naloxone auto-injector was dispensed to all patients meeting criteria. The treating provider after prescribing the naloxone auto-injector then consulted home health per standard clinical practice. All patients had home health consulted to perform overdose identification and rescue training. A Cochran’s Q test was conducted to examine differences in patient knowledge pre- and post-training. The post training test was done 2–4 weeks later. Results: Forty subjects enrolled after meeting inclusion/exclusion criteria. Twenty withdrew because their insurance declined coverage for the naloxone auto-injector. Those completing home health showed a statistically significant difference in their ability to correctly identify the steps needed to effectively respond to an overdose (p = .03). Discussion: Preliminary evidence would suggest training on overdose symptom recognition and proper use of prescription naloxone for treatment in the home setting by home health staff would prove more beneficial than the clinic setting, but feasibility was hindered by unaffordable costs related to insurance coverage limitations.

HPV Vaccination Does Not Provide Herd Immunity for Unvaccinated Women or Cross-Protection for Nonvaccine HPV Types [12].

INTRODUCTION: To determine if the human papillomavirus (HPV) vaccination offers cross-protection against nonvaccine HPV types and whether introduction of the vaccination has offered herd immunity to unvaccinated women. METHODS: We collected and analyzed HPV prevalence data for females aged 18–29 from the prevaccine era (2007–2008) and postvaccine era (2009–2012) using the National Health and Nutrition Examination Surveys (NHANES); 1628 female respondents aged 18–29, representing 21,135,134 females in the United States non-institutionalized civilian population, provided vaginal swabs across three consecutive NHANES survey cycles. RESULTS: Among females aged 18–29, the prevalence of high risk HPV among women who received at least one dose of the HPV vaccine decreased from 67% (95% confidence interval [CI] 50.7–81.4) in 2007–2008 to 41.5% (95% CI, 30.5–53.1) in 2011–2012; among the women vaccinated for HPV in the postvaccine era, the prevalence of HPV-16 and -18 was 6.4% versus 93.6% for all other high risk HPV types. There was no difference in prevalence in high risk HPV for women who did not receive the vaccine; 49.5% (95% CI, 42.5–56.6) in 2007–2008 versus 50.8% (95% CI, 43.0–58.7) in 2011–2012. CONCLUSION/IMPLICATIONS: The prevalence of high risk HPV significantly decreased among females aged 18–29 years who received the HPV vaccine, but there appeared to be no cross-protection against nonvaccine HPV types. These findings may offer support for usage of the investigational 9-valent HPV vaccine. There also was no evidence to suggest protection against HPV infection for unvaccinated women.

Validation of Visual Objective Biomarkers for Acute Concussion

Objective Despite an increase in the awareness and diagnosis of mild traumatic brain injury (mTBI), there remains a paucity of data examining the comparative efficacy of available assessments. This study aims to validate visual functions as potential biomarkers for mTBI. Methods This case-control correlational design utilizes military personnel diagnosed with acute (≤72 h post-injury) mTBI (n = 100) and age-matched controls (n = 100) to examine the relative effectiveness of the pupillary light reflex (PLR), near point of convergence (NPC) break, King-Devick (KD) test time, and Convergence Insufficiency Symptom Survey (CISS) score to discriminate between participants with mTBI. Results Three of the eight PLR parameters (i.e., average constriction velocity (ACV), average dilation velocity (ADV), and 75% re-dilation time; all p < 0.001) were affected in mTBI participants. Similarly, NPC break, KD test time, and CISS scores showed a statistically significant difference between groups (all p < 0.001). Area under the curve showed that ADV (0.82) and NPC (0.74) have the higher predictive values of all objective parameters. Conclusions ADV, ACV, and NPC break are objective visual functions markedly affected in the acute mTBI group compared with controls; therefore, we proposed that they could be used as biomarkers for acute mTBI.

Acupuncture for the Treatment of Chronic Pain in the Military Population: Factors Associated With Treatment Outcomes

Objectives: Acupuncture is characterized as an alternative or complementary medicine with a low complication rate and minimal side effects. There is a lack of robust evidence that shows acupuncture is an effective treatment for chronic pain. The purpose of this study was to determine which (if any) characteristics can predict successful response to acupuncture in chronic pain patients treated at military treatment facilities. Methods: Data from 222 patients who received treatment for a chronic pain condition were collected from 2 medical centers. The patients underwent at least 4 acupuncture treatments and had an average pain score of 4 or higher on a 0- to 10-point numerical rating scale or visual analog scale in the week before treatment initiation. A successful outcome was defined to be a 2-point or greater reduction on the numerical rating scale or visual analog scale 12 weeks postinitial treatment. Results: The overall treatment success rate was 42.3%. Multivariate logistic regression found a higher baseline pain rating and the use of stimulation needles to be associated with a positive outcome (odds ratio [OR]=1.26; 95% confidence interval [CI], 1.03-1.55; P=0.02 and OR=2.73; 95% CI, 1.39-5.32; P=0.03, respectively). Only the presence of one or more psychological comorbidities was found to be associated with treatment failure (OR=0.67; 95% CI, 0.49-0.92; P=0.01). Discussion: The use of electrical stimulation and higher baseline pain score were associated with a positive treatment outcome, while the presence of a psychological comorbidity diminished the likelihood of treatment success. Practitioners should consider using electrical stimulation more frequently, and addressing psychopathology before or concurrent to treatment, when initiating acupuncture.

Determinants of Patient Satisfaction in a Private Practice Pain Management Clinic

Patient satisfaction is used to measure physician performance in hospital and governmental practice settings. There is limited understanding about factors affecting satisfaction in a chronic pain management setting for patients prescribed chronic opioids.

Regenerative Endodontic Procedures among Endodontists: A Web-based Survey

Introduction: The protocols that endodontists implement for regenerative endodontic procedures (REPs) are unknown. The aim of this study was to examine current REP protocols among practicing endodontists in the United States. Methods: A Web‐based survey was sent to 4060 active members of the American Association of Endodontists (AAE). A total of 850 participants completed the survey, representing a 20.9% response rate. Results: Responses indicated 60% reported having performed REPs; most performed 1 to 3 per year. The most commonly selected source (60.8%) for the clinical protocol was the “AAE Clinical Considerations for a Regenerative Procedure.” Time constraints were the most common reason why 92.4% of respondents did not report their REP cases to the AAE.org database; additionally, 15.5% were unaware of it. Almost half (49.8%) of the participants reported they would attempt an REP on a patient of any age. The most commonly used irrigants were >3% sodium hypochlorite at the first appointment and EDTA at the scaffold formation appointment. As the intracanal medicament, 52.2% used calcium hydroxide, whereas 23.5% used triple antibiotic paste. At the scaffold formation appointment, 77.1% used a local anesthetic without a vasoconstrictor, and 94.3% used a blood clot as the scaffold. Mineral trioxide aggregate was the coronal barrier most often selected. Considering factors most likely to encourage the use of REPs in the future, 79.8% reported the availability of good candidates followed by 40.1% who desired better evidence. Conclusions: Based on the results of this survey, REP protocols appear to be heterogeneous and do not strictly conform to the “AAE Clinical Considerations for a Regenerative Procedure.”