Lumbar Laminectomy Precedes Positional Headache and MRI-Confirmed Pseudomeningocele With Duro-Cutaneous Fistula.

Pseudomeningoceles (PMs) are collections of cerebrospinal fluid (CSF) occurring as a direct result of a dural rent. This article presents a well-documented case of a 68-year-old male presenting to the emergency department with postoperative lumbar PM with a duro-cutaneous fistula. It was initially recognized on palpation of the patient's postoperative incision site and later diagnosed with magnetic resonance imaging (MRI). Incidental durotomies (IDs) leading to PMs are a rare complication of laminectomies and other spinal surgeries. A thorough physical exam, diagnostic imaging, and lumbar drainage to survey the integrity of the dura mater are important aspects of postoperative care.

Case Report of Torsion of Cryptorchid Testis Causing Abdominal Pain.

INTRODUCTION: A myriad of pathologies can cause abdominal pain. Genitourinary causes including testicular torsion must be considered. CASE REPORT: In this report, we present a 17-year-old male evaluated in the emergency department for lower abdominal pain. After physical exam, computed tomography, and ultrasound were completed, torsion of undescended testicle within the inguinal canal was diagnosed. Surgical exploration revealed a twisted, ischemic testis, and subsequent orchiectomy was performed. CONCLUSION: This case highlights the importance of a thorough genitourinary exam in patients with lower abdominal pain.

Study of Active Duty Military Personnel for Environmental Deployment Exposures: Pre- and Post-Deployment Spirometry (STAMPEDE II).

BACKGROUND: There is significant concern about the respiratory health of deployed military service members given the reported airborne hazards in southwest Asia, which range from geologic dusts, burn pit emissions, chemical exposures, and increased rates of smoking. There has been no previous comparison of pre- and post-deployment lung function in these individuals. METHODS: Military personnel who deployed to southwest Asia in support of ongoing military operations were recruited from the Soldier Readiness Processing Center at Fort Hood, Texas, from 2011 to 2014. The participants were asked to complete a brief survey on their respiratory health and perform both spirometry and impulse oscillometry studies at baseline with repeated survey and testing after deployment. RESULTS: Of the 1,693 deployed personnel who completed baseline examinations, 843 (50%) completed post-deployment testing. Post-deployment values demonstrated no statistical or clinical change in spirometry, with an increase in mean ± SD FEV1 (% predicted) from 95.2 ± 12.6 to 96.1 ± 12.4 (P = .14), increase in mean ± SD FVC (% predicted) from 95.9 ± 11.8 to 96.4 ± 11.9 (P = .32), and increase in mean ± SD FEV1/FVC from 81.5 ± 5.9 to 81.8 ± 6.1 (P = .29). Impulse oscillometry values showed statistical improvement with reduction in resistance (at 5 Hz and 20 Hz) and reactance (at 5 Hz). The presence of pre-deployment obstruction, self-reported asthma, smoking history, or increased body mass index also did not change spirometry values after deployment. DISCUSSION: To our knowledge, this was the first prospective evaluation of deploying military by using spirometry as an indicator for the possible development of pulmonary disease related to environmental exposures. Pre-deployment testing with spirometry and impulse oscillometry was unable to detect any significant change. In those with abnormal spirometry pre-deployment or asthma history, there was also not identifiable change that indicated worsening lung function. CONCLUSIONS: Utilization of spirometry for the deploying military population had little benefit and did not identify individuals with lung disease after deployment. Routine use was not warranted before or after deployment in the absence of pulmonary symptoms.

Screening Spirometry in Military Personnel Correlates Poorly with Exercise Tolerance and Asthma History.

BACKGROUND: Spirometry is an easy-to-perform test for evaluating pulmonary symptoms but has several limitations to include adequate test performance for valid results. Spirometry is not recommended to screen a general population for evidence of pulmonary disease unless symptoms are present or longitudinal screening is done for potential occupational exposures. METHODS: A single-spirometry examination was performed on 900 active duty Army soldiers, ages 18-35 yr, without documented respiratory disease. Abnormal studies were identified (obstructive, restrictive, mixed, and flow volume loop abnormalities) and compared with reported respiratory symptoms, smoking history, prior diagnosis of asthma, and failure of the Army physical fitness test 2-mile run using generalized linear modeling techniques. RESULTS: The cohort population had spirometry values comparable with published NHANES III reference values. Ninety-eight subjects (10.9%) were identified with abnormal spirometry included 33 obstructive, 44 restrictive, 3 mixed, and 18 isolated flow volume loop abnormalities. Historical features (smoking, exertional dyspnea, cough, asthma, or APFT failure) had no effect on the probability of an abnormal spirometry result (p = 0.56). Although APFT failure probability is strongly affected by exertional dyspnea (p = 0.00) and current smoking (p = 0.01), abnormal spirometry results did not have a statistically significant effect (p = 0.38). DISCUSSION: For potential screening of military personnel with spirometry to detect pulmonary disease, study findings identified a significant percentage with non-specific abnormalities requiring further evaluation. Spirometry may be indicated in those individuals with a history of asthma or active dyspnea symptoms. Spirometry as a screening tool is poorly (and often incorrectly) predictive for respiratory symptoms or decreased exercise tolerance in a military cohort. CONCLUSION: Spirometry should not be used to screen the military force for the presence of respiratory disorders. In those individuals with a history of asthma, in-depth testing should be performed to fully evaluate any non-specific findings identified during spirometry.

Pulmonary Function and Respiratory Health of Military Personnel Before Southwest Asia Deployment.

BACKGROUND: Significant concern exists regarding the respiratory health of military personnel deployed to Southwest Asia, given their exposures to numerous environmental hazards. Although the deployed military force is generally assumed to be fit, the pre-deployment respiratory health of these individuals is largely unknown. METHODS: Soldiers deploying to Southwest Asia were recruited from the pre-deployment processing center at Fort Hood, Texas. Participants completed a general and respiratory health questionnaire and performed baseline spirometry. RESULTS: One thousand six hundred ninety-three pre-deployment evaluations were completed. The average age of the participants was 32.2 y, and 83.1% were male. More than one third of surveyed solders had a smoking history, 73% were overweight or obese, and 6.2% reported a history of asthma. Abnormal spirometry was found in 22.3% of participants. Soldiers with abnormal spirometry reported more asthma (10.1% vs 5.1%, P < .001), failed physical fitness tests (9.0% vs 4.6%, P = .02), and respiratory symptoms (32.8% vs 24.3%, P = .001). DISCUSSION: This is the first prospective pre-deployment evaluation of military personnel that delineates factors potentially associated with the development of pulmonary symptoms and/or disease. This study suggests that deploying soldiers are older, heavier, frequently smoke, and may have undiagnosed pre-deployment lung disease. Abnormal spirometry is common but may not represent underlying disease. Self-reported asthma, wheezing, and slower 2-mile run times were predictive of abnormal spirometry. CONCLUSIONS: Pre-deployment evaluation of military personnel identified numerous soldiers with active pulmonary symptoms and abnormal spirometry. When combined with questions regarding asthma history, wheezing and exercise intolerance, spirometry may identify individuals at risk for deployment-related respiratory complaints.

Deployment-related Respiratory Issues.

Military deployment to Southwest Asia since 2003 in support of Operations Enduring Freedom/Iraqi Freedom/New Dawn has presented unique challenges from a pulmonary perspective. Various airborne hazards in the deployed environment include suspended geologic dusts, burn pit smoke, vehicle exhaust emissions, industrial air pollution, and isolated exposure incidents. These exposures may give rise to both acute respiratory symptoms and in some instances development of chronic lung disease. While increased respiratory symptoms during deployment are well documented, there is limited data on whether inhalation of airborne particulate matter is causally related to an increase in either common or unique pulmonary diseases. While disease processes such as acute eosinophilic pneumonia and exacerbation of preexisting asthma have been adequately documented, there is significant controversy surrounding the potential effects of deployment exposures and development of rare pulmonary disorders such as constrictive bronchiolitis. The role of smoking and related disorders has yet to be defined. This article presents the current evidence for deployment-related respiratory symptoms and ongoing Department of Defense studies. Further, it also provides general recommendations for evaluating pulmonary health in the deployed military population.

Management of Asthma in the Military.

This article examines the evaluation and management of asthma based on current guidelines, advances in therapy, and the challenges of managing asthma in today's military.

Langerhans cell histiocytosis presenting as uncontrolled asthma.

Langerhans cell histiocytosis (LCH) is an uncommon disorder affecting primarily young adult smokers. It is characterized by abnormal proliferation of Langerhans cells, specialized monocyte-macrophage lineage antigen-presenting cells. LCH can affect the lungs in isolation or as part of a systemic disease. Most commonly, the disease presents in the third or fourth decade without gender predominance. Symptoms typically include dyspnea and cough. Commonly, physical examination is unremarkable but cor pulmonale may be observed in advanced disease. The chest radiograph is typically abnormal with nodular or interstitial infiltrates and cystic changes. High-resolution computed tomography of the chest with these findings in the middle and upper lobes of an adult smoker is virtually diagnostic of LCH. Pulmonary function assessment is variable. Asthma has rarely been reported in association with this disorder. There are only three reported cases of the diagnosis of concomitant asthma which have been made in association with the diagnosis of LCH. We present a case in which our patient presented with signs and symptoms of asthma to include confirmatory findings of airway hyperresponsiveness. The diagnosis of LCH was established after the patient failed to respond to conventional treatment for asthma, and further evaluation was completed.