David Grant USAF Medical Center

Comparing the intraocular pressure lowering (IOP-L) of microdrops (MD) dispensed with the Nanodropper with conventional drops (CD) in patients on IOP-L monotherapy. Outpatient clinic. Prospective, crossover, examiner-masked, active-controlled, randomized trial conducted at a single center. We enrolled adults with stable primary glaucoma or ocular hypertension on monotherapy with either latanoprost 0.005% or timolol maleate 0.5%. Participants self-administered either CD or MD for 12 weeks, then crossed over to the alternate treatment for an additional 12 weeks. The primary outcome was IOP at 12 weeks compared with baseline at enrollment. Secondary outcomes included running out of drops (premature bottle exhaustion or PBE), adverse effects (AEs), and subjective evaluations of the device's usability. 29 participants completed the study. MD significantly decreased IOP from baseline by 1.6 mm Hg (95% CI 0.88-2.29), compared with a CD (0.13 mm Hg, 95% CI -0.26 to 0.52). Incidence of PBE decreased from 83% with CD to 17% with MD. AEs were reduced from 83% of participants reporting at least 1 AE with CD vs 62% with MD. Most found MD easy to administer and believed it helped prevent eyedrop waste. MD delivered with the Nanodropper adaptor provided additional IOP-L, significantly reduced PBE, and decreased the occurrence and severity of nonsystemic AEs compared with CD in this cohort of stable primary open-angle glaucoma/ocular hypertension participants. MD use among glaucoma participants may enhance tolerability, and improve adherence and long-term IOP control.

PurposeLower extremity spasticity can cause pain and limit function. This study examined the safety and efficacy of hyperselective neurectomy (HSN) of the gastrocnemius-soleus complex (GSC) in addressing spastic equinus deformities in pediatric patients.MethodsPediatric patients that underwent HSN of the GSC by a single surgeon were retrospectively reviewed. Preoperative and postoperative Modified Ashworth Score and passive ankle dorsiflexion (°) were compared using Wilcoxon signed-rank test and Student's paired two-tailed t-test, respectively.ResultsTen lower extremities in seven patients with a mean age of 10 years were reviewed. Mean follow-up was 15 months. All extremities demonstrated improvement in spasticity. All exhibited improved passive ankle dorsiflexion range of motion with the knee in extension (mean change +17°, SD = 8°, p = 0.000). Five patients demonstrated improved passive dorsiflexion with the knee in flexion while two remained unchanged from preoperative assessment (mean change +13°, SD = 9°, p = 0.002). One complication, wound dehiscence, was noted and managed conservatively. No patients reported loss of strength or sensation. Four patients underwent subsequent staged surgery on the ipsilateral extremity for concomitant contractures.ConclusionHSN of the GSC is safe in pediatric patients and effectively reduces spastic equinus deformity and improves ankle passive dorsiflexion in short-term follow-up.

Post-operative Achilles tendinopathy (AT) can cause persistent, debilitating posterior ankle pain. The optimal treatment for recalcitrant AT following surgical repair of Achilles tendon rupture has not been well-established. Conservative management includes early weight-bearing and mobilization with structured physical therapy (PT) and a progressive return to activity. Despite completion of conservative measures, symptoms may persist long after surgical repair. Platelet-rich plasma (PRP) has been shown to effectively treat painful MSK conditions, including AT. There have been no published studies assessing the efficacy or safety of PRP injections to treat post-operative AT after repair of tendon rupture. We present two cases of refractory AT after surgical repair of a ruptured Achilles tendon treated with ultrasound (US) guided PRP injections.

This article presents an overview of a novel process improvement project that aimed to enhance the utilization of prolonged exposure for treating posttraumatic stress disorder in behavioral health clinics within the Military Health System (MHS). The MHS is a geographically dispersed medical system encompassing diverse clinics and poses unique challenges to the adoption of evidence-based practices. To address these challenges, the Targeted Assessment and Context-Tailored Implementation of Change Strategies project was developed. Implemented across eight MHS clinics, this project involved conducting a comprehensive needs assessment to identify barriers, developing customized implementation plans for each site, and providing coaching calls and access to a clinic optimization toolkit for the clinic staff. We describe the development of Targeted Assessment and Context-Tailored Implementation of Change Strategies intervention components, including an implementation rubric that documents barriers to evidence-based practice utilization and proposes specific actions based on the underlying causes of these barriers. Additionally, a needs assessment interview tool and an implementation toolkit were developed to identify clinic-level challenges and support the implementation process, respectively. The needs assessment phase of the project involved conducting interviews with clinic staff and leadership, as well as reviewing clinic appointment data to discern trends and patterns in care. The insights gleaned from these interviews were instrumental in formulating tailored implementation plans for increasing the usage of prolonged exposure. Each plan was collaboratively developed with clinic leadership and subsequently put into practice at the site with the support of weekly coaching calls provided by an implementation science expert. Portions of this research project occurred during the COVID-19 pandemic, and we discuss the impact of the pandemic on the implementation of this study. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Prolonged Casualty Care (PCC) is a military adaptation of Tactical Combat Casualty Care providing up to 72 hours of prehospital care in delayed extrication. However, providing PCC is challenging because of recommended medications outweighing size/weight restrictions during dismounted operations. We sought to narrow down the medication and supply items required for 72 hours of PCC to create a standardized and effective prolonged field care kit (PFAK) with a weight limitation of 20 lbs. Joint Trauma Systems Clinical Practice Guidelines were reviewed to generate a list of potential contents for the PFAK. A two-step Delphi survey that included various PCC subgroups was performed. The Delphi results were subjected to an expert panel (containing military and civilian medical personnel) survey to finalize the choices. Participant responses were analyzed using mean rank scores and finalized using expert consensus to determine the final components of the PFAK. Eleven Joint Trauma Systems Clinical Practice Guidelines relevant to PCC were selected, encompassing 47 potential medications and 5 adjuncts to PCC. The Delphi surveys were distributed to 100 participants (response rates of 57% and 65% for the two rounds, respectively). A total of 18 medications were shortlisted after the second Delphi survey. Finally, following the expert panel survey, 14 medications and 4 equipment were shortlisted for the PCC. The total weight of the PFAK with medications and adjuncts was under 20 lbs. Providing efficient PCC is limited by the size and weight restrictions in military dismounted operations. Using a Delphi survey approach, we have shortlisted the optimal medications and adjuncts that can be used to deliver effective PCC. Prognostic and Epidemiological; Level IV.

The objective was to determine whether oral non-steroidal anti-inflammatory drugs (NSAIDs) affect the efficacy of dextrose prolotherapy (DPT) in patients with knee osteoarthritis, and if the combination of these treatments is safe and well-tolerated. Five patients with symptomatic knee osteoarthritis were included in this prospective case series. Participants underwent a series of three DPT injections at four-week intervals in their symptomatic knee(s) and were immediately prescribed a seven-day course of Ibuprofen after each injection. The main outcome measures included changes in the Knee Injury in Osteoarthritis (KOOS) questionnaire subscales (pain, symptoms, quality of life, sports and recreation function, and activities of daily living) and the Numeric Pain Rating Scale (NPRS). There was a statistically significant improvement in the KOOS subscales of pain (P < 0.0001), Symptoms (P = 0.01), and Quality of Life (P = 0.001) after 12 weeks. The KOOS subscales for Sports and Recreation function (P = 0.06) and Activities of Daily Living (P = 0.10) showed numerical improvement over time that fell short of statistical significance. There was a statistically significant improvement in the NPRS scores compared with baseline NPRS scores after 12 weeks (P < 0.0001). In addition, NPRS scores were significantly lower at one-week follow-up after each DPT injection (P = 0.01); (P = 0.025); (P < 0.0001). There were no reported adverse events. Concomitant use of NSAIDS with dextrose prolotherapy injections is safe and well-tolerated with no adverse events and results in improvements in pain, symptoms, and overall quality of life associated with chronic knee OA. Controlled trials of this treatment are warranted.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) may provide temporary hemodynamic support for patients with severe vasodilatory shock due to toxicologic ingestion. In a series of 10 cases of children less than 18 years of age who received VA ECMO support for toxicologic-induced vasodilatory shock, there were eight survivors and two nonsurvivors who died of significant neurologic injury. Upon initiation of ECMO support, survivors had decline in Vasoactive-Inotrope Scores (VIS). With the exception of one survivor who had a VIS range of 5-10, the seven remaining survivors had reduction in VIS by half at a median of 5.3 (interquartile range [IQR]: 3.7-12) hours. Nonsurvivors demonstrated no VIS reduction on ECMO before death. Six of 10 patients received continuous renal replacement therapy (CRRT) while on ECMO and potentially had augmentation of toxin clearance or treatment of severe acidosis as a result. Of the eight survivors, four patients had ECMO-related bleeding or thrombotic complications (three patients with stroke and one patient with extremity compartment syndrome). Venoarterial extracorporeal membrane oxygenation, with and without CRRT, may have potential utility and benefit in supporting poisoned patients with vasodilatory shock.

Spastic wrist flexion deformities both limit the functional use of the hand for grasp and pinch producing a stigmatizing appearance. Tendon transfers and total wrist arthrodesis are treatment options for this condition depending on the patient's characteristics, the latter the most commonly used in patients with severe wrist flexion deformities. Tendon transfers alone in this scenario have the tendency for recurrent deformity due to tenorrhaphy failure or soft tissue creep and resultant loss of tension. Total wrist arthrodesis is a more invasive procedure, which can have hardware or fusion problems and that is irreversible. We propose a novel technique that incorporates a distally based wrist extensor tendon slip and suture tape tenodesis to the distal radius. The rationale of this technique is to act as a protective, internal splint to prevent recurrent deformity after primary or revision tendon transfer for moderate to severe spastic flexed wrist deformities, avoiding the need to perform a total wrist arthrodesis.