Mild traumatic brain injury (TBI) accounts for the vast majority of the nearly two million brain injuries suffered in the United States each year. Mild TBI is commonly classified as complicated (radiographic evidence of intracranial injury) or uncomplicated (radiographically negative). Such a distinction is important because it helps to determine the need for further neuroimaging, potential admission, or neurosurgical intervention. Unfortunately, imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) are costly and not without some risk. The purpose of this study was to screen 87 serum biomarkers to identify a select panel of biomarkers that would predict the presence of intracranial injury as determined by initial brain CT. Serum was collected from 110 patients who sustained a mild TBI within 24 hours of blood draw. Two models were created. In the broad inclusive model, 72kDa type IV collagenase (MMP-2), C-reactive protein (CRP), creatine kinase B type (CKBB), fatty acid binding protein—heart (hFABP), granulocyte-macrophage colony-stimulating factor (GM-CSF) and malondialdehyde modified low density lipoprotein (MDA-LDL) significantly predicted injury visualized on CT, yielding an overall c-statistic of 0.975 and a negative predictive value (NPV) of 98.6. In the parsimonious model, MMP-2, CRP, and CKBB type significantly predicted injury visualized on CT, yielding an overall c-statistic of 0.964 and a negative predictive value (NPV) of 97.2. These results suggest that a serum based biomarker panel can accurately differentiate patients with complicated mild TBI from those with uncomplicated mild TBI. Such a panel could be useful to guide early triage decisions, including the need for further evaluation or admission, especially in those environments in which resources are limited.
Psoriasis is a chronic immune-mediated dermatologic disorder affecting approximately 2% of the general population. Under current U.S. Army regulation, the diagnosis of psoriasis is a bar to enlistment or appointment and, if poorly controlled, is grounds for referral to a Medical Evaluation Board and potential discharge from military service, according to Army Regulation 40-501. However, between 2008 and 2015, over 3,600 soldiers sought care for psoriasis while deployed to combat theaters, indicating that psoriasis remains a significant medical concern in the U.S. military. Although mild psoriasis is treatable with topical agents, moderate to severe psoriasis may require systemic treatment. Prior to Food and Drug Administration approval of apremilast (Otezla) in 2014, the standard systemic treatment options were methotrexate and biologic agents such as anti-Tumor Necrosis Factor-alpha medications. Active use of methotrexate or biologic immunomodulatory medications automatically disqualifies soldiers from deployment due to monitoring requirements, the need for refrigeration, and the risk for immune compromise. Apremilast offers treatment efficacy similar to that of methotrexate, and it may be taken while deployed because it does not require monitoring or refrigeration. However, efficacy must be evaluated in the context of its much higher unit cost. Nonetheless, we argue that apremilast may be a useful treatment option for psoriasis in a select group of soldiers who must deploy despite suffering from moderate to severe psoriasis.
Objectives As hospitals are increasingly consolidating into larger health systems, they are becoming better positioned to have far reaching and material impacts on safety and quality of care. When the Mount Sinai Health System (MSHS) was formed in 2013, it sought to ensure the delivery of safe, high-quality care to every patient. In 2014, the MSHS addressed hand hygiene as the first major system-wide process improvement project focused on quality and safety. The goals of this study were to evaluate a system-wide hand hygiene program and to create a foundation for future process improvement projects. Methods The MSHS implemented the Joint Commission’s Targeted Solutions Tool as a way to improve hand hygiene compliance and reduce harm from hospital-acquired infections, specifically Clostridium difficile infections. A multifaceted approach was used to improve hand hygiene and promote a culture of patient safety. Results The MSHS improved hand hygiene compliance by approximately 20% from a baseline compliance of 63.3% to an intervention compliance of 82.8% (P < 0.001). Additional correlation analysis revealed a significant correlation between increasing hand hygiene compliance and reduction in C. difficile infections. Conclusions Through a focus on leadership engagement, data transparency, data and observer management, and system-wide communication of best practices, the MSHS was able to improve hand hygiene compliance, reduce infection rates, and build an effective foundation for future process improvement programs.
Introduction: Management of comorbid diseases in patients with cancer is often unclear. The purpose of our study was to identify differences and similarities between primary care providers and oncologists' knowledge, attitudes, and beliefs regarding coordination of care and comorbid disease management for patients undergoing active cancer treatment. Methods: We conducted a cross-sectional study using an anonymous self-administered survey which was available to approximately 600 providers in primary care and medical oncology practicing in both outpatient and inpatient settings from March to December 2014 at three academic hospitals in New York City (Mount Sinai Hospital, Mount Sinai Beth Israel, and Weill Cornell). Our survey instrument assessed physician knowledge, attitudes, and beliefs using a clinical vignette of a cancer patient undergoing active treatment. Descriptive statistics were used to summarize the demographic and practice details of survey responses, and univariate analyses were used to assess differences in responses between primary care providers and oncologists. Results: The survey was completed by 203 providers, including 127 primary care providers (62.5%), 32 medical oncologists (15.8%), 11 palliative care physicians (5.4%), and 33 nurse practitioners or physician assistants (16.3%). Medical oncologists admitted more uncertainty regarding who should manage preventive care as compared to primary care providers (34.4% vs. 16.5%, p ¼ 0.02), whereas primary care providers were more concerned about duplicated care (22.8% vs. 6.3%, p ¼ 0.03). Both primary care providers and medical oncologists agreed that diabetes should be actively managed during cancer treatment. More primary care providers felt less strict glycemic control was allowable (56.8% vs. 37.5%, p ¼ 0.05) and that it is allowable for patients to miss some diabetes-related visits (80.6% vs. 56.3%, p ¼ 0.01). Discussion: Primary care providers and medical oncologists differ in their knowledge, attitudes, and beliefs regarding coordination of care and management of comorbid conditions in patients undergoing cancer treatment. These differences reflect systemic challenges to provision of care to cancer patients and the need for a model of care coordination.
Skin cancer rates have been steadily increasing among the American public for decades, but multiple studies have demonstrated that the U.S. military suffers from higher rates of skin cancer than the general public. As with so many aspects of health, simple preventive measures made early on can dramatically improve long-term health outcomes. Ample research has demonstrated that ultraviolet protection reduces skin damage and cancer rates. Although further research is needed to fully understand current barriers to soldiers’ use of sun protection, we recommend a variety of simple measures the U.S. military can implement to reduce skin cancer risk for our soldiers. Early education and intervention to reduce skin cancer risk and promote sun-protective strategies is critical. These include improving sun protection offered by uniform items, such as increasing the availability of the sun hat, using eye protection with tinted inserts, and testing and publicizing the ultraviolet protection level of uniform items. We also recommend increasing sunscreen access for soldiers. Options to do so include issuing soldiers small portable packets or bottles of sunscreen to carry on their person, incorporating small packets of sunscreen in MREs, and issuing sunscreen to commands to distribute before field exercises. Unit and medical leadership should encourage the use of sunscreen and sun-protective strategies when possible; leadership engagement is critical to overcoming current behavioral barriers to change. Finally, we recommend that units attempt to reduce sun exposure during training by encouraging soldiers to seek shade and avoiding outdoor training in the middle of the day.
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