A survey of outpatient visits in a United States Army forward unit during Operation Desert Shield.

Reports suggest that deployed soldiers during Operations Desert Shield and Desert Storm remained healthy, but primary care data are limited. We reviewed the outpatient visit surveillance data from the 3d Armored Cavalry Regiment to obtain information regarding soldiers' health in the field. Nontraumatic orthopedic problems accounted for the highest incidence of primary health care visits, followed by unintended injuries, gastrointestinal, respiratory, and dermatologic conditions. Visits for heat injuries, sexually transmitted diseases, unexplained fever, and psychiatric problems were low, probably due to preventive measures. These results suggest that increased prevention to decrease orthopedic problems and unintended injuries may substantially reduce outpatient visits during future deployments. Medical surveillance during future deployments can be improved by taking advantage of current advances in technology to facilitate patient data retrieval and provide timely information to first- and second-echelon medical personnel.

Lessons learned from producing health information booklets for deploying U.S. military personnel.

Health information booklets deliver information to large groups quickly and economically. Rapidly deploying soldiers are a group that needs such information. Military personnel responsible for the health of troops should know of the materials produced to meet this need so that they can facilitate booklet distribution. The Walter Reed Army Institute of Research within the U.S. Army Medical Research and Material Command has produced health information booklets in support of deployments to Southwest Asia, Somalia, Rwanda, Haiti, and the former Republics of Yugoslavia. This article describes these booklets' content, use during military operations, distribution, costs, and benefits. A discussion of lessons learned includes steps to develop and evaluate health information and is followed by an explanation of the current situation. We offer suggestions to improve the booklet development process; our experience may be helpful to others developing health information materials for military personnel or civilians.

Antimicrobial treatment of occult bacteremia: a multicenter cooperative study.

This prospective multicenter study was conducted to define more clearly clinical and laboratory criteria that predict a strong probability of occult bacteremia and to evaluate the effect of empiric broad spectrum antimicrobial treatment of these children. Children 3 to 36 months old with fever > or = 40 degrees C (104 degrees F) or, > or = 39.5 degrees C (103 degrees F) with white blood cells (WBC) > or = 15 x 10(9)/liter, and no focus of infection had blood cultures obtained and were randomized to treatment with oral amoxicillin/potassium clavulanate or intramuscular ceftriaxone. Sixty of 519 (11.6%) study patients had positive blood cultures: Streptococcus pneumoniae, 51; Haemophilus influenzae b, 6; Neisseria meningitidis, 2; and Group B Streptococcus, 1. Subgroups of high risk were identified as fever > or = 39.5 degrees C and WBC > or = 15 x 10(9)/liter, 55 of 331 or 16.6% positive with increasing incidence of positive culture with increasing increments of degrees of leukocytosis to WBC > or = 30 x 10(9)/liter where 9 of 21 or 42.9% were positive. Subgroups of significantly lower risk were identified as fever > or = 39.5 degrees C and WBC < 15 x 10(9)/liter, 5 of 182 or 2.7% positive and those with WBC < 10 x 10(9)/liter, 0 of 99 or 0.0% positive. Children with positive cultures who received ceftriaxone were nearly all afebrile after 24 hours whereas a significant number who received amoxicillin/potassium clavulanate remained febrile. In the 459 culture-negative children more amoxicillin/potassium clavulanate-treated children developed diarrhea and had less improvement in clinical scores after 24 hours than ceftriaxone-treated children.(ABSTRACT TRUNCATED AT 250 WORDS)

An approach to development of specific T-lymphocyte lines by use of preprocessed antigens in Plasmodium vinckei vinckei murine malaria.

The development of parasite-specific T-cell lines represents one approach to the potential identification of relevant immunogens in erythrocytic malarial infection. However, the use of parasitized-erythrocyte lysates as antigens inhibits the proliferation of T cells. To circumvent this problem, we preincubated antigen-presenting cells (APCs) from spleens of malaria-naive, BALB/c mice with a Plasmodium vinckei vinckei (hereafter referred to as P. vinckei)-parasitized erythrocyte lysate. APCs were subsequently irradiated and washed prior to being incubated with T lymphocytes from P. vinckei-immune, histocompatible mice. After 8 to 10 cycles of antigenic stimulation and rest, two T-cell lines were analyzed. Both lines were predominantly CD4+. Proliferation assays demonstrated marked lymphocyte blastogenesis to syngeneic but not allogeneic APCs that had preprocessed malarial antigen. Antigen incubated directly with T cells and nonpulsed APCs in vitro did not result in T-cell proliferation. Assays of interleukin-2 (IL-2), IL-4, IL-5, and gamma interferon were compatible with one cell line being predominantly TH1 and the other being TH2. Thus, APCs that have preprocessed malarial antigen and are free of extraneous parasite material induce highly reactive, antigen-specific, major histocompatibility complex-restricted T-cell lines that functionally appear capable of inducing humoral and/or cell-mediated immunity.

Diarrheal disease during Operation Desert Shield.

BACKGROUND: Under combat conditions infectious disease can become a major threat to military forces. During Operation Desert Shield, there were numerous outbreaks of diarrhea among the U.S. forces. To evaluate the causes of and risk factors for diarrheal disease, we collected clinical and epidemiologic data from U.S. troops stationed in northeastern Saudi Arabia. METHODS: Between September and December 1990, stool cultures for enteric pathogens were obtained from 432 military personnel who presented with diarrhea, cramps, vomiting, or hematochezia. In addition, a questionnaire was administered to 2022 soldiers in U.S. military units located in various regions of Saudi Arabia. RESULTS: A bacterial enteric pathogen was identified in 49.5 percent of the troops with gastroenteritis. Enterotoxigenic Escherichia coli and Shigella sonnei were the most common bacterial pathogens. Of 125 E. coli infections, 39 percent were resistant to trimethoprim-sulfamethoxazole, 63 percent to tetracycline, and 48 percent to ampicillin. Of 113 shigella infections, 85 percent were resistant to trimethoprim-sulfamethoxazole, 68 percent to tetracycline, and 21 percent to ampicillin. All bacterial isolates were sensitive to norfloxacin and ciprofloxacin. After an average of two months in Saudi Arabia, 57 percent of the surveyed troops had at least one episode of diarrhea, and 20 percent reported that they were temporarily unable to carry out their duties because of diarrheal symptoms. Vomiting was infrequently reported as a primary symptom, but of 11 military personnel in whom vomiting was a major symptom, 9 (82 percent) had serologic evidence of infection with the Norwalk virus. CONCLUSIONS: Gastroenteritis caused by enterotoxigenic E. coli and shigella resistant to a number of drugs was a major problem that frequently interfered with the duties of U.S. troops during Operation Desert Shield.

Evaluation of the necessity for hospitalization of the febrile infant less than three months of age.

We reviewed records of 443 consecutive infants less than 3 months of age who were hospitalized during a 28-month period for complete evaluation of fever (rectal temperature greater than or equal to 38 degrees C), close observation and consideration of antimicrobial therapy. Infants less than 2 weeks of age were more likely to be treated with parenterally administered antibiotics than older infants (67%, 39%, 29% and 31% in the first and second two weeks of life, second and third months, respectively), and were more likely to have bacteremia and bacterial meningitis (4.8%, 2.1%, 0.5% and 2.3%, respectively), as well as serious bacterial illness (25%, 13%, 7% and 14%, respectively). Five infants (2.5% of those not initially treated) had unexpectedly positive blood (1), urine (3) or stool (1) cultures and were treated with parenteral antibiotics when culture results were known. None was less than 2 weeks of age and all had good outcomes that did not appear to be altered by the delay in diagnosis and treatment. No infant's therapy was modified as a result of clinical deterioration or persistent fever. We conclude that many febrile infants who are hospitalized "for observation" can be managed as outpatients provided that a thorough initial evaluation is performed, that parents can reliably monitor the infant closely at home and that dependable follow-up can be assured.

Tropical splenomegaly syndrome associated with cytomegalovirus infection.

The tropical splenomegaly syndrome (TSS) is characterized by massive splenomegaly with hypersplenism, moderate hepatomegaly, and lymphocytic infiltration of the hepatic sinusoids. In previous reports this syndrome has been shown to be a consequence of a disordered immunologic response of the host to malarial infection. Treatment with antimalarial drugs has resulted in a decrease in malarial antibody titers and a reduction in splenic size. We report a child who had TSS associated with cytomegalovirus infection rather than malaria. Our results suggest that TSS may be precipitated by a variety of infections producing chronic antigenic stimulation and perhaps by autoantigenic stimulation as well.