Beyond Trauma: High-Volume Critical Care Medicine in a Military Medical Center-Based Military-Civilian Partnership.

INTRODUCTION: Critical Care Internal Medicine (CCIM) is vital to the U.S. Military as evidenced by the role CCIM played in the COVID-19 pandemic response and wartime operations. Although the proficiency needs of military surgeons have been well studied, this has not been the case for CCIM. The objective of this study was to compare the patient volume and acuity of military CCIM physicians working solely at Military Treatment Facilities (MTFs) with those at MTFs also working part-time in a military-civilian partnership (MCP) at the University Medical Center of Southern Nevada (UMC). MATERIALS AND METHODS: We analyzed FY2019 critical care coding data from the Military Health System and UMC comparing the number of critical care encounters, the number of high-acuity critical care encounters, and the Abilities/Activity component of the Knowledge, Skills, and Abilities/Clinical Activity (KSA) score. This analysis was restricted to critical care encounters defined by Current Procedural Terminology codes for critical care (99291 and 99292). A critical care encounter was considered high acuity if the patient had ICD-10 codes for shock, respiratory failure, or cardiac arrest or had at least three codes for critical care in the same episode. RESULTS: The five AF CCIM physicians in the MCP group performed 2,019 critical care encounters in 206 days, with 63.1% (1,273) being defined as high acuity. The total number of MTF critical care encounters was 16,855 across all providers and services, with 28.9% (4,864) of encounters defined as high acuity. When limited to CCIM encounters, MTFs had 6,785 critical care encounters, with 32.0% being high acuity (2,171). Thus, the five AF CCIM physicians, while working 206 days at the UMC, equated to 12.0% (2,019/16,855) of the total critical care MTF encounters, 27.2% (1,273/4,684) of the total high-acuity MTF critical care encounters, and 29.8% (2,019/6,785) of the MTF CCIM encounters, with 58.6% (1,273/2,171) of the MTF CCIM high-acuity encounters.The USAF CCIM physicians in the MCP group performed 454,395 KSAs in 206 days, with a KSA density per day of 2,206. In the MTF group, CCIM providers generated 2,344,791 total KSAs over 10,287 days, with a KSA density per day of 227.9. Thus, the five CCIM physicians at the UMC accounted for 19.38% of the MTF CCIM KSAs, with a KSA density over 10 times higher (2,206 vs. 227.9). CONCLUSIONS: The volume and acuity of critical care at MTFs may be insufficient to maintain CCIM proficiency under the current system. Military-civilian partnerships are invaluable in maintaining clinical proficiency for military CCIM physicians and can be done on a part-time basis while maintaining beneficiary care at an MTF. Future CCIM expeditionary success is contingent on CCIM physicians and team members having the required CCIM exposure to grow and maintain clinical proficiency.Limitations of this study include the absence of off-duty employment (moonlighting) data and difficulty filtering military data down to just CCIM physicians, which likely caused the MTF CCIM data to be overestimated.

Postoperative infection and bone sarcoma survival: systematic review of the role of infection in bone sarcoma prognosis.

Background: Osteosarcoma (OS) and chondrosarcoma (CS) are primary bone malignancies whose prognoses have stagnated despite advancements in surgical management, chemotherapy, radiation therapy, and immunotherapy. The role of the immune system in generating anti-cancer physiologic responses is critical to prognosis. Prior studies have explored if immune system activation via infection enhances survival in bone sarcomas without a clear consensus. Methods: This study sought to (I) retrospectively examine the effect of postoperative infection on survival in OS and CS and (II) systematically review the effect of postoperative infection on survival in primary bone malignancies. We performed a retrospective case-control study of 192 patients treated between 1/2000-12/2015 at a single academic sarcoma referral center. Patients with OS or CS undergoing operative resection were included. Eligible patients were grouped by presence of metastasis, and survival was compared between patients with or without postoperative infection. Furthermore, we performed a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines investigating the effect of infection on primary bone malignancy survival. Risk of bias assessment was performed utilizing the ROBINS-I (Risk of Bias in Non-randomized Studies-of Interventions) assessment tool. All presented studies included author information, study population, and overall or disease-free survival results. Results: One hundred and four patients were included, with 85 without infection (26 metastatic, 59 non-metastatic) and 19 with infection (10 metastatic, 9 non-metastatic). Five-year survival was greatest in patients without metastasis with a postoperative infection (100%), followed by patients without metastasis who were infection-free (80%). Five-year survival was comparatively lower in patients with metastasis who were infection-free (35%) and lowest in patients with metastasis with a postoperative infection (20%). No significant differences were present (P=0.17) on log-rank analysis. Our systematic review collected six studies exploring the impact of infection on primary bone malignancy survival, with two studies reporting significant findings of infection improving survival. Limitations of this review included risk of bias due to confounding, inconsistency comparing outcomes, and differences in patient populations. Conclusions: This retrospective study and systematic review suggests postoperative infection may play a role in modulating immune response to malignancy. Understanding the synergy between anti-pathogen and anti-cancer responses warrants further investigation as an alternative method of targeted cancer treatment.

Magnetic Resonance Imaging-Measured Cross-Sectional Area of the Median Nerve.

Purpose: The size of the median nerve may serve as a useful parameter to predict carpal tunnel syndrome (CTS) in a subset of patients. The purpose of this study was to evaluate magnetic resonance imaging-based measurements of median nerve cross-sectional area (CSA) to examine trends between patient subgroups and CSA that may assist in predicting the individuals who are most likely to develop CTS symptoms. Methods: A retrospective chart review of 1,273 wrist magnetic resonance images was performed, and the images were analyzed to evaluate the median nerve CSA at the level of the pisiform and the hook of hamate. The age, sex, height, weight, and body mass index (BMI) of the patients were collected from their medical records. Results: The median nerve size correlated with patient BMI. Additionally, patients with CTS had larger median nerves at the hook of hamate and pisiform than those without CTS. When subdividing patients on the basis of BMI, obese patients with CTS had larger median nerve CSA at the pisiform than those without CTS. Conclusions: This study demonstrated that increased BMI is associated with increased median nerve CSA at the hook of hamate and pisiform in patients with or without CTS. Additionally, patients with CTS had larger median nerve CSA than those without CTS. Measurements at these locations may help predict individuals who are likely to experience median nerve impingement. Type of study/level of evidence: Prognostic III.

The Mandated Publication of Individual Hospital Charge Description Masters Does Not Permit the Estimation of Complex Procedure Charges.

BACKGROUND: As healthcare spending continues to rise, price transparency is crucial for patients to calculate a reasonable cost estimate for tests and procedures. Legislative efforts have been successful at mandating increased hospital price transparency, including publishing charge description masters (CDMs), but their usefulness in permitting patients to assess the cost for complex procedures is unclear. We sought to determine CDM and diagnosis-related group (DRG) prevalence and evaluate whether these are effective tools for patients to preemptively ascertain the costs for simple and complex tests and procedures. METHODS: Cross-sectional analysis of publicly available 2019 CDMs and DRGs from 122 hospitals in the United States, including the top-20 as ranked by the US News & World Report Honor Roll and two top-ranked hospitals per state. We first determined the availability of CDMs and DRGs and then determined the ability to estimate the hospital charge for a three-view knee radiograph and a primary total knee arthroplasty (TKA) using CDM and DRG data. RESULTS: One hundred fifteen of 122 (94.3%) hospitals published a CDM, and 78 (63.9%) published a DRG. Top-ranked hospitals published DRGs more frequently than those outside of the Honor Roll designation (P = 0.04). The estimated charge for a three-view knee radiograph could be calculated from 113/115 (98.3%) CDMs. The estimated total charge for a primary TKA could not be obtained from any of the available CDMs. By comparison, the estimated charge for a primary TKA could be obtained from 76/78 (97.4%) of the available DRGs. DISCUSSION: CDMs are available as currently mandated for most hospitals and generally can be used to identify the charges for simple procedures, but they are ineffective tools for patients to estimate the charges associated with a multifaceted healthcare procedure, such as TKA. Although DRGs are less frequently available, they are a more effective resource for patients to estimate charges.

Prognostic factors and survival of patients undergoing surgical intervention for breast cancer bone metastases.

INTRODUCTION: Bone is the most common distant site of breast cancer metastasis. Skeletal lesions can cause significant morbidity due to pain, pathologic fracture, and electrolyte abnormalities. Current treatment for patients with bone metastases (BoM) from breast cancer is highly personalized and often involves a multidisciplinary approach with chemotherapy, hormone therapy, bone-targeted antiresorptive agents, radiation therapy, and surgery. We have retrospectively collected clinical data from a series of patients with bone metastases to evaluate the clinical characteristics, prognostic factors, and survival patterns of patients with breast cancer BoM receiving standard multimodal therapy. METHODS: A consecutive series of 167 patients with breast cancer BoM treated at a single institution between August 2013 and March 2020 were identified. Clinical information was obtained from the medical record and survival analyses were performed to evaluate patient outcomes and identify prognostic factors. RESULTS: Thirty-seven patients (22%) presented with de novo BoM - bone metastases at the time of breast cancer diagnosis - and were 2.6 times more likely to die within the study period than those with asynchronous BoM (HR = 2.62, p = <0.0001). Patients who received bone-targeted medical therapy were 61% less likely to die after BoM diagnosis than those who did not (HR = 0.39, p = 0.001). Operative stabilization of BoM was more frequently employed in patients with lytic (p = 0.02) or mixed (p = 0.02) tumors than it was for those with blastic lesions. Patients treated with surgery had a lower overall bone metastasis survival than those treated without (p < 0.03). DISCUSSION: These findings reflect the current patterns in metastatic breast cancer treatment and associated outcomes. In a series of 167 consecutive patients, we demonstrate the natural history of breast cancer with BoM being treated with modern multimodal therapy. Understanding these treatment patterns and prognostic factors enhances the provider's ability to counsel patients and direct appropriate treatments.

Decades of cough: delayed recognition of atypical cystic fibrosis in an adult patient.

We present a case of a 30-year-old male diagnosed with atypical cystic fibrosis. This report demonstrates the heterogeneity of the presentation of this common genetic disease.

Pneumothoraces Post Mechanical Cardiopulmonary Resuscitation: A Case Series.

The incidence of pneumothoraces with automated cardiopulmonary resuscitation (CPR) is unknown. Herein, we present 4 cases of pneumothoraces occurring in the setting of automated mechanical CPR (AM-CPR) in a 2-month period since incorporating mechanical devices into our resuscitation program. Two of the cases were in-hospital cardiac arrests, whereas the other 2 were out-of-hospital cardiac arrests. The Life-Stat 1008 device was utilized for AM-CPR in all cases. All cases demonstrated confirmed pneumothoraces on post-resuscitation imaging. Several factors may have contributed to the observed pneumothoraces. Two of the cases presented with obstructive lung disease, whereas the other 2 had underlying malignancy. Suboptimal positioning and failure to secure the included shoulder straps could have led to migration of the piston over the ribs. Further study is needed to determine the incidence of complications for all FDA-approved AM-CPR devices compared with manual chest compressions.

Airway hyperreactivity in asymptomatic military personnel.

OBJECTIVES: Asthma is frequently diagnosed in military personnel despite strict guidelines that disqualify persons with active disease or a recent history of asthma. It is generally considered incompatible with military service, because of the regular physical training, outdoor training exercises, and deployments to remote locations. The objective of this study was to determine the prevalence of airway hyperreactivity in asymptomatic military personnel, as an estimate of subclinical reactive airway disease. METHODS: A prospective study of healthy, asymptomatic, military personnel with no previous history of asthma and <1 year on active duty status was conducted. After completion of a screening questionnaire, personnel underwent baseline spirometry with a portable spirometer. Personnel with obstructive indices (based on published guidelines) and matched control subjects participated in an exercise test (1.5-mile run), with pre- and postexercise spirometry. RESULTS: A total of 222 asymptomatic military personnel completed baseline spirometry, and 31 (14%) were found have airway obstruction. A normal matched control group of 31 military personnel and 26 personnel with obstruction performed exercise spirometry. Twenty-three percent of the participants with obstruction demonstrated increased airway hyper-reactivity after exercise, based on a reduction in forced expiratory volume at 1 second, compared with 19% of control subjects. CONCLUSIONS: Asymptomatic airway obstruction has a prevalence of 14% in young military personnel. A significant percentage of individuals also have evidence of worsening obstruction during exercise. These data suggest that screening spirometry may identify early reactive airway disease in asymptomatic individuals and should be considered as a method to identify persons predisposed to developing symptomatic asthma.