Anastomotic Outcomes in Military Exploratory Laparotomies in the Modern Combat Era

Background Intestinal anastomoses in military settings are performed in severely injured patients who often undergo damage control laparotomy in austere environments. We describe anastomotic outcomes of patients from recent wars. Methods Military personnel with combat-related intra-abdominal injuries (June 2009-December 2014) requiring laparotomy with resection and anastomosis were analyzed. Patients were evacuated from Iraq or Afghanistan to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals. Results Among 341 patients who underwent 1053 laparotomies, 87 (25.5%) required ≥1 anastomosis. Stapled anastomosis only was performed in 57.5% of patients, while hand-sewn only was performed in 14.9%, and 9.2% had both stapled and hand-sewn techniques (type unknown for 18.4%). Anastomotic failure occurred in 15% of patients. Those with anastomotic failure required more anastomoses (median 2 anastomoses, interquartile range [IQR] 1-3 vs. 1 anastomosis, IQR 1-2, P = .03) and more total laparotomies (median 5 laparotomies, IQR 3-12 vs. 3, IQR 2-4, P = .01). There were no leaks in patients that had only hand-sewn anastomoses, though a significant difference was not seen with those who had stapled anastomoses. While there was an increasing trend regarding surgical site infections (SSIs) with anastomotic failure after excluding superficial SSIs, it was not significant. There was no difference in mortality. Discussion Military trauma patients have a similar anastomotic failure rate to civilian trauma patients. Patients with anastomotic failure were more likely to have had more anastomoses and more total laparotomies. No definitive conclusions can be drawn about anastomotic outcome differences between hand-sewn and stapled techniques.

Nursing Leadership During COVID-19: Leading an Inpatient Response at a Regional Military Medical Center

ABSTRACT The coronavirus disease 2019 pandemic stressed healthcare systems worldwide and exposed major flaws in military and civilian healthcare systems. Landstuhl Regional Medical Center (LRMC) serves as the only military medical center for over 205,000 U.S. service members, beneficiaries, and coalition partners stationed throughout Europe, Africa, and the Middle East. The pandemic response required LRMC leaders to reconfigure services to meet pandemic concerns while providing lifesaving care to injured service members from combatant commands. The quickly evolving pandemic challenged leaders to ensure healthcare delivery amid constant change and imperfect information. While LRMC senior leaders developed a strategic pandemic response plan, a multidisciplinary team of nurses, doctors, and technicians collaborated to create an inpatient team to support the dual mission of coronavirus disease 2019 response and casualty care for the warfighter. In this manuscript, we discuss how a multidisciplinary clinical working group at a regional medical center prepared and responded to the pandemic, strategically planned patient care, and ensured support to combatant commands for ongoing forward military operations. Additionally, we share our experiences and lessons learned to inform other military facilities across the medical community and global healthcare systems.

The Method and Results of a Treatment Targeting SARS-CoV-2-Activated Inflammasomes

In COVID-19 patients, clinicians should consider an increase in the oxygen requirement from 6 l/min to as high as 100% with a high-flow nasal cannula, as well as dapsone administration. A COVID-19 committee at Hunt Regional Medical Center reviewed the use of dapsone as an off-label medication in the first period. The hospital then revalidated its effectiveness by reporting the findings of 44 (22 cases/22 controls) patients with ARDS treated with dapsone in the second period. In ARDS-onset patients treated with dapsone, there was a decrease in FIO2 requirements in 7 patients and no worsening in 1 patient. In aggravated ARDS patients treated with dapsone, there was a decrease in FIO2 requirements in 6 patients and no worsening in 3 patients. In patients with severe ARDS treated with dapsone, no response to treatment was observed in 2 patients. In the ARDS-onset group not treated with dapsone, eight of twenty patients died, but in the ARDS-onset group treated with dapsone, no one of seventeen patients died throughout the entire study period. There was a significant difference in dapsone treatment results in the ARDS-onset group. We clinically diagnosed transient bulbar palsy of medulla oblongata in the brain associated with SARS-CoV-2 infection in the ARDS-onset group. We confirmed that dapsone clinically treated the onset of ARDS by targeting SARS-CoV-2-activated inflammasomes. Like chemically reacting substances, inflammasome and dapsone are competing, proving that it is only effective in treating early ARDS.

The Method and Results of a Treatment Targeting SARS-CoV-2-Activated Inflammasomes

A COVID-19 committee at Hunt Regional Medical Center reviewed the use of dapsone as an inflammasome competitor. The hospital then revalidated its effectiveness by reporting the findings of 44 (22 cases/22 controls) patients with acute respiratory distress syndrome (ARDS) treated with dapsone. All of 17 ARDS Onset patients who received standard COVID-19 treatment, including dapsone, did not die except one patient not taken dapsone after relapsed, whereas 8/20 patients who received standard COVID-19 treatment without dapsone died; the mortality rates were 5.9% and 40%, respectively. Dapsone treats and prevents SARS-CoV-2 ARDS. We confirmed that dapsone clinically treated the onset of ARDS by targeting SARS-CoV-2-activated inflammasomes.

Breast Cancer Prevalence and Management in Hispanic Women: Comparison to Black and White Women at a Regional Medical Center

Background: While stage and grade of breast cancer determines prognosis and outcome, race also impacts survival. While Black and White women have been studied, data for Hispanic women is sparse. Methods: Age-matched Hispanic, Black and White women diagnosed/treated with breast cancer at a single institution were retrospectively evaluated regarding prevalence, treatments and outcomes. Results: Overall, 120 women were included in the study (40 per race). No demographic/histologic variables were significantly different among races. ER+/PR+ tumors were less frequent in Hispanics than Whites, but higher than Blacks. Prevalence of triple negative breast cancers in Hispanic women was between the Black and White cohorts (p=0.025 and p=0.011, respectively). Stage II and III diagnoses (p=0.025) were more frequent in Hispanics and they opted for chemotherapy more often (p=0.034); however, there were no significant differences in outcomes and mortality among groups. When compared to the State tumor registry, our population had more LCIS diagnoses (p=0.01), earlier stages (I p=0.02; II p=0.006), received more treatment overall (radiation p=0.02, chemotherapy p=0.0001) and experienced better survival (p=0.004). In comparing the study population to the SEER database, higher rates of LCIS and IDC and lower rates of ILC and mixed histology in the study population were noted. LCIS and IDC were more prevalent in our cohort than SEER data (p=0.005, p=0.05, respectively), although we noted less ILC and mixed histology (p=0.03 and p=0.04). Conclusion: These data are the first reported for Hispanics in our state and highlight the need for larger studies to better serve this growing demographic.

SARS-CoV-2 Seroprevalence among Health Care Workers—A Voluntary Screening Study in a Regional Medical Center in Southern Germany

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is associated with a potentially severe clinical manifestation, coronavirus disease 2019 (COVID-19), and currently poses a worldwide challenge. Health care workers (HCWs) are at the forefront of any health care system and thus especially at risk for SARS-CoV-2 infection due to their potentially frequent and close contact with patients suffering from COVID-19. Serum samples from 198 HCWs with direct patient contact of a regional medical center and several outpatient facilities were collected during the early phase of the pandemic (April 2020) and tested for SARS-CoV-2-specific antibodies. Commercially available IgA- and IgG-specific ELISAs were used as screening technique, followed by an in-house neutralization assay for confirmation. Neutralizing SARS-CoV-2-specific antibodies were detected in seven of 198 (3.5%) tested HCWs. There was no significant difference in seroprevalence between the regional medical center (3.4%) and the outpatient institution (5%). The overall seroprevalence of neutralizing SARS-CoV-2-specific antibodies in HCWs in both a large regional medical center and a small outpatient institution was low (3.5%) at the beginning of April 2020. The findings may indicate that the timely implemented preventive measures (strict hygiene protocols, personal protective equipment) were effective to protect from transmission of an airborne virus when only limited information on the pathogen was available.