Evans Army Community Hospital

The role of the cerebellum in cognitive function and psychiatric symptoms is poorly understood and particularly understudied in patients with cerebellar pathologies such as Chiari malformation type I (CM-I). Additionally, it is unclear if interventions targeted toward the cerebellum might impact these life-altering symptoms. The authors sought to characterize pre- and postoperative cognitive and psychiatric function in CM-I patients as evidence for targeted cerebellar treatment for some cognitive and psychiatric conditions. This prospective study included surgical patients with CM-I who reported cognitive or psychiatric dysfunction. Patients completed a preoperative assessment and a parallel assessment 6 months following surgery. Neuropsychological evaluations included a 90-minute standardized assessment of cognitive function across multiple domains and a self-reported assessment of psychiatric symptoms. This clinical sample consisted of 54 patients (mean age 34.17 years, median 14.15 years). Any patient demonstrating preoperative performance below 3.5 SDs within any cognitive domain was excluded (n = 1). All patients underwent preoperative neuropsychological assessment comprising standard clinical tests of processing speed, attention, memory, executive function, and psychiatric symptoms. Preoperatively, CM-I patients performed significantly worse than a representative normative sample on measures of executive function and visuospatial memory and reported more psychiatric symptoms across all domains. On postoperative assessment, 89% of patients showed clinically significant improvements (> 1 SD) in cognitive and/or psychiatric domains. The authors demonstrate significant, often unrecognized, impairments in cognitive function and psychiatric symptoms in a cohort of CM-I patients. Following targeted surgical posterior fossa decompression, these symptoms improved, suggesting that at least in a subgroup of symptomatic CM-I patients, these symptoms may be treatable. This study highlights the potential role of the cerebellum in cognitive and psychiatric dysfunction.

Very-low-carbohydrate diets (LCHF; <50 g/day) have been debated for their potential to lower pre-exercise muscle and liver glycogen stores and metabolic efficiency, risking premature fatigue. It is also hypothesized that carbohydrate ingestion during prolonged exercise delays fatigue by increasing carbohydrate oxidation, thereby sparing muscle glycogen. Leveraging a randomized crossover design, we evaluated performance during strenuous time-to-exhaustion (70% V̇o2max) tests in trained triathletes following 6-wk high-carbohydrate (HCLF, 380 g/day) or very-low-carbohydrate (LCHF, 40 g/day) diets to determine 1) if adoption of the LCHF diet impairs time-to-exhaustion performance, 2) whether carbohydrate ingestion (10 g/h) 6-12× lower than current CHO fueling recommendations during low glycogen availability (>15-h pre-exercise overnight fast and/or LCHF diet) improves time to exhaustion by preventing exercise-induced hypoglycemia (EIH; <3.9 mmol/L; <70 mg/dL), and 3) the "keto-adaptation" time course through continuous substrate monitoring while caloric intake, physical activity, and fat-free mass are maintained. Time-to-exhaustion performance was similar across both dietary interventions. Minimal carbohydrate supplementation prevented EIH and significantly increased time to exhaustion equivalently in LCHF and HCLF interventions (22%). The LCHF diet significantly lowered 24-h glucose concentrations, which normalized after 4 wk, at the same timepoint peak blood ketone (R-β-hydroxybutyrate) concentrations normalized. These findings 1) demonstrate that an LCHF diet sustains strenuous endurance performance, 2) establish that minimal carbohydrate supplementation was sufficient to enhance exercise performance on LCHF and HCLF diets by mitigating EIH, and 3) indicate that a minimum 4-wk adaptation period to an LCHF diet is required to ensure normalization of metabolic homeostasis, glycemic control, and exercise performance.NEW & NOTEWORTHY This study examines the belief that very-low-carbohydrate diets (LCHF) impair prolonged exercise performance during strenuous exercise by comparing it with high-carbohydrate diets in competitive triathletes. After 6-wk diet adaptation, time-to-exhaustion (TTE) performance was similar across both diets. Minimal carbohydrate supplementation (10 g/h) during exercise eliminated exercise-induced hypoglycemia and improved TTE by 22% on both diets. These findings suggest that LCHF diets do not impair exercise performance and require a 4-wk adaptation period for metabolic homeostasis.

PurposeThe purpose of this study was to evaluate patient outcomes following anterior cruciate ligament reconstruction (ACLR) complicated by septic arthritis treated with graft retention versus graft removal protocols. Secondarily, this study aimed to evaluate surgical, demographic and microbial surgical indications for graft retention versus graft removal. We hypothesised that patients who underwent graft removal would have worse outcomes and that patients with septic arthritis caused by more virulent organisms, such as methicillin‐resistant Staphylococcus aureus or Pseudomonas aeruginosa, would be more likely to undergo graft removal.MethodsA systematic review and meta‐analysis of literature in the PubMed and Ovid databases regarding the treatment of septic arthritis following ACLR reporting graft retention versus graft removal was conducted. The included studies were published in English, in peer‐reviewed journals, with an average minimum follow‐up of 1 year, and reported on arthroscopic ACLR, surgical management of infection, graft retention versus graft removal during treatment and outcome measures. Patient demographic, surgical and outcome data were analysed.ResultsTwenty‐four studies reporting on 307 patients were included for analysis. Patients who underwent allograft ACLR (p = 0.02) and patients with septic arthritis caused by P. aeruginosa (p = 0.03) were more likely to undergo graft removal. Patients treated with graft removal were treated with more irrigation and debridement procedures (2.7 ± 0.8 vs. 2. ± 1.5, p < 0.01). Patients treated with graft removal had increased laxity on KT‐1000 measurement (3.30 ± 134 vs. 1.55 ± 1.23, p < 0.01), and lower 2000 International Knee Documentation Committee Subjective Knee Evaluation scores (66.57 ± 17.08 vs. 80.18 ± 15.21, p = 0.02).ConclusionsSeptic arthritis following ACLR is a devastating complication. Both graft retention and graft removal protocols have been reported and are viable options. Patients treated with graft removal had poorer outcome measures. Septic arthritis caused by P. aeruginosa and allograft ACLR were more likely to be treated with graft removal.Clinical RelevanceSeptic arthritis following ACLR remains an uncommon, but difficult problem. There is minimal literature guiding graft retention versus graft removal treatment protocols.Level of EvidenceLevel IV systematic review of lower‐level studies.

Background: Displaced talar neck fractures are subject to avascular necrosis and degenerative joint disease. A single-lateral-incision approach may avoid damage to the remaining blood supply to the talar body provided by the deltoid artery. The purpose of this paper is to describe the surgical technique for a single approach to talar neck fractures, to evaluate the outcomes in a cohort of patients, and to review the literature on the topic. Method: A retrospective review. Patients were identified at a single medical center and met the following inclusion criteria: closed fracture, type-II talar neck fracture with displacement of the subtalar joint, single lateral operative approach, and radiographic follow-up of at least 6 months. Results: Five patients were identified meeting the inclusion criteria. The mean follow-up was 18 months (12–25). The mean VAS (Visual Analog Score) score at the final follow-up was 1.2 (0–3). Four of five patients returned to running at the final follow-up. The one patient who did not return to running was able to bike and hike. There were no cases of avascular necrosis and no cases of degenerative joint disease. Conclusions: Although a two-incision approach could be considered for all displaced talar neck fractures, there are certain fractures that can be anatomically reduced and stabilized through a single lateral incision which may limit the risk of avascular necrosis.

Introduction: Military Role 1 practitioners have difficulty maintaining skill competency by working solely in military medical treatment facilities. Recognizing this, the Army Medical Department has renewed focus on physician specialty-specific Individual Critical Task Lists (ICTL) and is increasing the number of military-civilian partnerships, wherein small military treatment teams work full-time in civilian trauma centers. Yet, data to validate this approach is lacking. We hypothesize military Role 1 practitioners working full-time at a civilian Level 1 trauma center would attain similar resuscitation-specific procedural frequency to providers deployed to an active combat zone, and use the emergency medicine (EM) ICTL to compare select procedural frequency between a cohort of trauma patients from a civilian Level 1 trauma center and a cohort of combat casualties from the Department of Defense Trauma Registry (DODTR). We compared a selected subset of critically-injured, military-aged (18-35 years) trauma patients who were seen in a Level I Trauma Center emergency department (ED) between January 1, 2016 and December 31, 2017 and dispositioned directly either to the operating room, intensive care unit, or morgue to a selected cohort from the Department of Defense Trauma Registry (DODTR) who were seen in EDs in Iraq and Afghanistan between January 2007 and August 2016 using descriptive statistics. The primary outcome was the frequency of ICTL procedures performed, and the secondary outcome was injury severity. We identified 843 civilian patients meeting inclusion criteria, of 1,719 military-aged patients captured by the trauma registry during the study. The selected cohort from the DODTR included 27,359 patients. Demographics were similar between the 2 groups, except the DODTR cohort included significantly more patients with blast trauma (55% versus 0.4%). We found similar ICTL procedural frequency (1 procedure for every 1.84 patients in the civilian cohort compared to one procedure/1.52 patients in the military cohort). Role-1 ICTL trauma procedures were performed at similar frequencies between civilian patients seen at a Level 1 trauma center and combat casualties. With proper practice implementation, the opportunity exists for Role 1 practitioners to maintain their trauma resuscitation skills at civilian trauma centers.

Traumatic brain injury (TBI) continues to be a major source of military-related morbidity and mortality. The insidious short- and long-term sequelae of mild TBIs (mTBIs) have come to light, with ongoing research influencing advances in patient care from point of injury onward. Although the DoDI 6490.11 outlines mTBI care in the deployed setting, there is currently no standardized training requirement on mTBI care in the far-forward deployed setting. As the Joint Trauma System (JTS) is considered to be one of the leaders in standard of care trauma medicine in the deployed environment and is often the go-to resource for forward-deployed medical providers, it is our goal that this review be utilized by the JTS with prominent mTBI resources to disseminate a clinical practice guideline (CPG) appropriate for the far-forward operational environment. The resources used for this review reflect the most current data, knowledge, and recommendations associated with research and findings from reputable sources as the Traumatic Brain Injury Center of Excellence (TBI CoE; formerly the Defense and Veterans Brain Injury Center), the Center for Disease Control and Prevention, as well as prominent journals such as Academic Emergency Medicine, British Journal of Sports Medicine, and JAMA. We searched for articles under keyword searches, limiting results to less than 5 years old, and had military relevance. About 1,740 articles were found using keywords; filters on our search yielded 707 articles, 100 of which offered free full text. The topic of far-forward deployed management of mTBI does not have a robust academic background at this time, and recommendations are derived from a combination of academic evidence in more traditional clinical settings, as well as author's direct experience in managing mTBI casualties in the austere environment. At the time of this writing, there is no JTS CPG for management of mTBI and there is no pre-deployment training requirement for medical providers for treating mTBI casualties in the far-forward deployed setting. The TBI CoE does, however, have a multitude of resources available to medical providers to assist with post-mTBI care. In this article, we review these clinical tools, pre-planning considerations including discussions and logistical planning with medical command, appropriate evaluation and treatment for mTBI casualties based on TBI CoE recommendations, the need for uniform and consistent documentation and diagnosis in the acute period, tactical and operational considerations, and other considerations as a medical provider in an austere setting with limited resources for treating casualties with mTBIs. Given the significant morbidity and mortality associated with mTBIs, as well as operational and tactical considerations in the austere deployed setting, improved acute and subacute care, as well as standardization of care for these casualties within their area of operations is necessary. The far-forward deployed medical provider should be trained in management of mTBI, incorporate mTBI-associated injuries into medical planning with their command, and discuss the importance of mTBI management with servicemembers and their units. Proper planning, training, standardization of mTBI management in the deployed setting, and inter-unit cooperation and coordination for mTBI care will help maintain servicemember readiness and unit capability on the battlefield. Standardization in care and documentation in this austere military environment may also assist future research into mTBI management. As there is currently no JTS CPG covering this type of care, the authors recommend sharing the TBI CoE management guideline with medical providers who will be reasonably expected to evaluate and manage mTBI in the austere deployed setting.

The prevalence of mild traumatic brain injury (mTBI) is commonly estimated based on indirect metrics such as emergency department visits and self-reporting tools. The study of postconcussive symptoms faces similar challenges because of their unspecific character and indistinct causality. In this article, we compare two nonclinical, epidemiological studies that addressed these two elements and were performed within a relatively narrow period in the state of Colorado. De-identified datasets were obtained from a random digit-dialed survey study conducted by the Craig Hospital and a study surveying soldiers returning from deployment by Defense and Veteran Traumatic Brain Injury Center. Information pertinent to participants' demographics, a history of mTBI, and symptom endorsement was extracted and homogenized in order to establish a parallel comparison between the populations of the two studies. From the 1,558 (Warrior Strong, 679; Craig Hospital, 879) records selected for analysis, 43% reported a history of at least one mTBI. The prevalence was significantly higher among individuals from the Defense and Veteran Traumatic Brain Injury Center study independent of gender or race. Repetitive injuries were reported by 15% of the total combined cohort and were more prevalent among males. Symptom endorsement was significantly higher in individuals with a positive history of mTBI, but over 80% of those with a negative history of mTBI endorsed at least one of the symptoms interrogated. Significant differences were observed between the military and the civilian populations in terms of the types and frequencies of the symptoms endorsed. The prevalence of mTBI and associated symptoms identified in the two study populations is higher than that of previously reported. This suggests that not all individuals sustaining concussion seek medical care and highlights the limitations of using clinical reports to assess such estimates. The lack of appropriate mechanisms to determine symptom presence and causality remains a challenge. However, the differences observed in symptom reporting between cohorts raise questions about the nature of the symptoms, the impact on the quality of life for different individuals, and the effects on military health and force readiness.

Post-traumatic headaches are a common sequela of mild traumatic brain injury (concussion). It is unclear whether or how these headaches differ phenotypically from primary headaches. Determine whether there is an overarching unobserved latent trait that drives the expression of observed features of post-traumatic headache and other headaches. Data from this post-hoc analysis come from the Warrior Strong Cohort Study conducted from 2010 through 2015. Approximately 25,000 soldiers were screened for concussion history at routine post-deployment health assessments. A random sample was invited to participate, enrolling 1567. Twelve observed headache phenotypic features were used to measure "headache complexity", the latent trait of clinical interest, using single factor confirmatory factor analysis. We compared headache complexity between groups and determined whether headache complexity predicted accessing medical care for headache. Of 1094 soldiers with headaches, 198 were classified as having post-traumatic headache. These headaches were compared to those in the other soldiers (647 without concussion history and 249 with concussion history). Soldiers with post-traumatic headache had greater endorsement of all 12 headache features compared to the soldiers with non-concussive headaches. The confirmatory factor analysis showed good model fit (χ2 (51) = 95.59, p = 0.0002, RMSEA = 0.03, comparative fit index = 0.99, and Tucker-Lewis index = 0.99), providing empirical support for the headache complexity construct. Soldier groups differed in their mean headache complexity level (p < 0.001) such that post-traumatic headache soldiers had greater headache complexity compared to non-concussed soldiers (standardized mean difference = 0.91, 95% confidence interval: 0.72-1.09, p < 0.001 and to concussed soldiers with coincidental headaches standardized mean difference = 0.75, 95% confidence interval: 0.53-0.96, p < 0.001). Increasing headache complexity predicted medical encounters for headache (odds ratio = 1.87, 95% confidence interval: 1.49-2.35, p < 0.001) and migraine (odds ratio = 3.74, 95% confidence interval: 2.33-5.98, p < 0.001) during the year following deployment.Conclusions and relevance: The current study provided support for a single latent trait, characterized by observed headache symptoms, that differentiates between concussive and non-concussive headaches and predicts use of medical care for headache. The single trait confirmatory factor analysis suggests that post-traumatic headaches differ from non-concussive headaches by severity more than kind, based on the symptoms assessed.ClinicalTrials.gov identifier NCT01847040.

To describe and compare phenotypic features of posttraumatic headaches (PTH) and headaches unrelated to concussion. Participants are a random sample of recently deployed soldiers from the Warrior Strong cohort, consisting of soldiers with (n = 557) and without (n = 1,030) a history of a recent mild traumatic brain injury (mTBI; concussion). mTBI+ soldiers were subdivided as PTH+ (n = 230) and PTH- (n = 327). Headache classification was based on a detailed phenotypic questionnaire. Medical encounters for headache were documented for the year after deployment. The findings here are limited to the soldiers with headaches, consisting of 94% of the mTBI+ soldiers and 76% of the mTBI- soldiers. Other than headache duration, all headache/migraine features were more common or more severe in the PTH+ group compared to the nonconcussed group (mTBI-) and compared to the concussed group with nontraumatic headaches (PTH-). Headaches were largely similar in the mTBI- and PTH- groups. The features most specific to PTH+ included allodynia, visual aura, sensory aura, daily headache, and continuous headache. Medical consultation for headache was most common in the PTH+ group (62%) vs the PTH- group (20%) or the mTBI- group (13%) (p < 0.008). In this cohort of recently deployed soldiers, PTHs are more severe, frequent, and migraine-like and more often associated with medical consultation compared to headaches presumed unrelated to concussion. Future observational studies are needed to verify and characterize the PTH phenotype, which could be followed by treatment trials with appropriate and possibly novel outcomes for prespecified subgroups. NCT01847040.

We analyzed data from a cohort of recently deployed soldiers from 2 US Army bases, Fort Carson and Fort Bragg (2009 to 2015). Soldiers with and without a recent history of mild traumatic brain injury (mTBI) on deployment were evaluated within days of return and at 3, 6, and 12 months. Those with mTBI were more likely than those without to endorse ≥1 postconcussive symptom as "severe" and/or "very severe" (47% vs. 21%, baseline; adjusted relative risk (RR) = 1.71, 95% confidence interval: 1.51, 1.93, all time points), which remained significant after adjusting for posttraumatic stress disorder (adjusted RR = 1.34, 95% confidence interval: 1.20, 1.50). Prevalence and relative risks for 3 of the most common baseline symptoms remained constant over time: sleep problems (RR = 2.19), forgetfulness (RR = 2.56), and irritability (RR = 2.73). The pattern was slightly different for headache (baseline, RR = 3.44; 12 months, RR = 3.26), due to increased prevalence of headache in those without mTBI. The prevalence of clinically relevant postconcussive symptoms remained relatively constant over 1 year of follow-up, whether or not symptoms were associated with concussion. Service members with recent mTBI reported more symptoms than those without at all time points.