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Study Objectives: Disseminated strongyloides is a rarely reported phenomenon and occurs in immunosuppressed patients with chronic Strongyloides stercoralis infection. Typically, patients present with pulmonary symptoms but subsequently acquire Gram-negative sepsis. Several cases have been noted in Minnesota, and their presentation, diagnostic evaluation, and clinical outcomes were reviewed.Design: A retrospective chart review was conducted of complicated strongyloides infections from 1993 to 2002 in Minneapolis and St. Paul, MN. Cases were identified by reviewing hospital microbiology databases.Setting: Metropolitan hospitals with large immigrant populations.Results: Nine patients, all of Southeast Asian heritage, were identified. Eight patients immigrated to the United States > or = 3 years prior to acute presentation. All patients were receiving antecedent corticosteroids; in five patients, therapy was for presumed asthma. Absolute eosinophil counts > 500/microL occurred in only two patients prior to steroid initiation. Eight patients presented with respiratory distress, and Gram-negative sepsis developed in four patients. Four patients had evidence of right-heart strain on ECG or echocardiography at the time of presentation. Three patients died; all had eosinophil counts of < 400/microL.Conclusions: Serious complications, including death, may occur in patients with chronic strongyloides infection treated with corticosteroids. Strongyloides hyperinfection usually presents as acute respiratory failure and may initially mimic an asthma exacerbation or pulmonary embolism. Southeast Asian patients presenting with new-onset "asthma," acute respiratory distress, and/or Gram-negative sepsis should undergo evaluation to exclude strongyloides infection. [ABSTRACT FROM AUTHOR]

Background: Biliary liver flukes are extremely common parasites in some regions of the world where consumption of raw fresh-water fish is a cultural practice. Clonorchis sinensis and Opisthorchis spp. are the major biliary liver flukes associated with human disease. Some of these parasites are highly associated with cholangiocarcinoma. It was noted that several cases presenting at our center had been in the US for prolonged periods. This prompted us to retrospectively review cases of liver fluke infection diagnosed at our facility.Methods: All cases of biliary liver fluke infection over a 6-year period were retrospectively investigated at a clinic serving international patients, to determine the prevalence and risk factors for infection in a nonendemic area. Cases were identified through review of stool ova and parasite (O&P) records maintained at Regions Hospital/HealthPartners microbiology laboratory. All O&P samples positive for Opisthorchis spp. or Clonorchis sinensis were included in the review.Results: Seventeen cases were identified during the study period. Our center performed approximately 1,800 stool O&P examinations per year on approximately 1,100 individuals per year during the study period. Biliary liver flukes were uncommon, accounting for 1.3% of individuals infected with organisms considered to be potentially pathogenic. Infections were predominantly found in migrants from Laos, Cambodia and Thailand. Cases were also identified in migrants from the former Soviet Union and South America. It is of note that 25% of patients were detected after 5 years of residence in the US. Often, the only clinical clue to infection was a mild absolute eosinophilia (500 to 1000microL).Conclusions: Although biliary liver fluke is an infrequent cause of infection in immigrants to the US, because of the potential long-term consequences of chronic infection, educational information highlighting routes of infection and the fact that asymptomatic infection is common and may eventually lead to cancer should be aimed at high-risk community members and those who have been visiting friends and relatives in endemic areas. [ABSTRACT FROM AUTHOR]

The number of global health (GH) fellowships in the United States has increased over the past two decades. However, there are currently no standard requirements, shared core content, or widespread systems of accreditation. With the growth in programs, it is appropriate to consider these issues. We conducted a national survey to understand GH fellowship leaders' perspectives on the existence of core content and competencies and on the need for accreditation, including by the Accreditation Council of Graduate Medical Education (ACGME). We sent survey invitations to 123 fellowship leaders. Forty-five completed the survey (37%), representing seven specialties. Eighty-nine percent of respondents indicated that there is important core content for fellows to learn regardless of specialty; 30% indicated that accreditation would be "very" or "extremely" beneficial, whereas 21% indicated that it would be "not at all" beneficial. When asked what form of accreditation would result in training the most competent GH practitioners, 35% indicated that accreditation is unnecessary. Of those selecting a form of accreditation, the largest proportion (21%) selected accreditation from a professional society; 52% "disagreed" or "strongly disagreed" that ACGME accreditation is needed. More than 65% indicated that loss of training flexibility, funding restrictions, and increased administrative and fellow funding burdens are "very" or "extremely" important barriers. These results suggest that broad agreement on important core content exists across specialties, with a lack of consensus about the need for accreditation. More discussion with stakeholders, including international partners, is needed to understand their perceptions and build consensus before pursuing fellowship accreditation.

Background: Combat casualties are frequently injured in austere settings where modern imaging modalities are unavailable. Exploratory laparotomies are often performed in these settings when there is suspicion for intra-abdominal injury. Prior studies of combat casualties reported non-therapeutic laparotomy (NTL) rates as high as 32%. Given improvements in combat casualty care over time, we evaluated NTLs performed during later years of the wars in Iraq and Afghanistan., Methods: Military personnel with combat-related injuries (6/1/2009-12/31/2014) who underwent exploratory laparotomy based on concern for abdominal injury (i.e. not performed for proximal vascular control or fecal diversion) and were evacuated to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals were assessed. An NTL was defined as a negative laparotomy without substantial intra-abdominal injuries requiring repair. Characteristics, indications for laparotomy, operative findings, and outcomes were examined., Results: Among 244 patients who underwent laparotomies, 41 (16.8%) had NTLs and 203 (83.2%) had therapeutic laparotomies (i.e. positive findings). Patients with NTLs had more computed tomography scans concerning for injury (48.8% vs 27.1%; p = 0.006), less penetrating injury mechanisms (43.9% vs 71.9%; p < 0.001), and lower Injury Severity Scores (26 vs 33; p = 0.003) compared to patients with therapeutic laparotomies. Patients with NTLs were also less likely to be admitted to the intensive care unit (70.7 vs 89.2% for patients with therapeutic laparotomies; p = 0.007). No patients with NTLs developed abdominal surgical site infections (SSI) compared to 16.7% of patients with therapeutic laparotomies (p = 0.002). There was no significant difference in mortality between the groups (p = 0.198)., Conclusions: Our proportion of NTLs was lower than reported from earlier years during the wars in Iraq and Afghanistan. No infectious complications from NTLs (i.e. abdominal SSIs) were identified. Nevertheless, surgeons should continue to have a low threshold for exploratory laparotomy in military patients in austere settings with concern for intra-abdominal injury., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: Non-iatrogenic aerodigestive injuries are infrequent but potentially fatal. We hypothesize that advances in management and adoption of innovative therapies resulted in improved survival., Methods: Trauma registry review at a university Level 1 center from 2000 to 2020 that identified adults with aerodigestive injuries requiring operative or endoluminal intervention. Demographics, injuries, operations, and outcomes were abstracted. Univariate analysis was performed, P < .05 was statistically significant., Results: 95 patients had 105 injuries: 68 tracheal and 37 esophageal (including 10 combined). Mean age 30.9 (± 14), 87.4% male, 82.1% penetrating, and 28.4% with vascular injuries. Median ISS, chest AIS, admission BP, Shock Index, and lactate were 26 (16-34), 4 (3-4), 132 (113-149) mmHg, .8 (.7-1.1), and 3.1 (2.4-5.6) mmol/L, respectively . There were 46 cervical and 22 thoracic airway injuries; 5 patients in extremis required preoperative ECMO. 66 airway injuries were surgically repaired and 2 definitively managed with endobronchial stents. There were 24 cervical, 11 thoracic, 2 abdominal esophageal injuries-all repaired surgically. Combined tracheoesophageal injuries were individually managed and buttressed. 4 airway complications were successfully managed, and 11 esophageal complications managed conservatively, stented, or resected. Mortality was 9.6%, half from intraoperative hemorrhage. Specific mortality: tracheobronchial 8.8%, esophageal 10.8%, and combined 20%. Mortality was significantly associated with higher ISS (P = .01), vascular injury (P = .007), blunt mechanism (P = .01), bronchial injury (P = .01), and years 2000-2010 (P = .03), but not combined tracheobronchial injury., Conclusion: Mortality is associated with several variables, including vascular trauma and years 2000-2010. The use of ECMO and endoluminal stents in highly selected patients and institutional experience may account for 97.8% survival over the past decade., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The continued increase in global migration compels clinicians to be aware of specific health problems faced by refugees, immigrants, and migrants (RIM). This analysis aimed to characterize RIM evaluated at GeoSentinel sites, their migration history, and infectious diseases detected through screening and diagnostic workups., Methods: A case report form was used to collect data on demographics, migration route, infectious diseases screened, test results, and primary infectious disease diagnosis for RIM patients seen at GeoSentinel sites. Descriptive statistics were performed., Results: Between October 2016 and November 2018, 5,319 RIM patients were evaluated at GeoSentinel sites in 19 countries. Africa was the region of birth for 2,436 patients (46 %), followed by the Americas (1,644, 31 %), and Asia (1,098, 21 %). Tuberculosis (TB) was the most common infection screened and reported as positive (853/2,273, 38 % positive by any method). TB, strongyloidiasis, and hepatitis B surface antigen positivity were observed across all migration administrative categories and regions of birth. Chagas disease was reported only among RIM patients from the Americas (393/394, 100 %) and schistosomiasis predominantly in those from Africa (480/510, 94 %). TB infection (694/5,319, 13 %) and Chagas disease (524/5,319, 10 %) were the leading primary infectious disease diagnoses., Conclusions: Several infections of long latency (e.g. TB, hepatitis B, and strongyloidiasis) with potential for long-term sequelae were seen among RIM patients across all migration administrative categories and regions of origin. Obtaining detailed epidemiologic information from RIM patients is critical to optimize detection of diseases of individual and public health importance, particularly those with long latency periods., Competing Interests: Declaration of competing interest Dr. Barnett receives royalties from UpToDate for her contribution to Evaluation of Newly Arrived Adult Immigrants. Dr. Greenaway acknowledges prior investigator initiated grant funding from Gilead and consulting to produce educational material on hepatitis C for AbbVie. Dr. Walker receives partial chapter royalties from UpToDate for her contribution to Evaluation of Newly Arrived Adult Immigrants. Dr. Grobusch received a speaker fee paid to his institution. Dr. Hamer receives salary support from the GeoSentinel Cooperative Agreement between the USCenters for Disease Control and Prevention and the International Society of Travel Medicine. Dr. Stauffer receives partial chapter royalties from UpToDate and a honorarium from Haymarket for continuing medical educational development; he serves as a consultant for Massachusetts General Hospital on a grant and BCT Partners, a minority-owned business, working on equity and diversity in business and healthcare. All remaining authors have declared no conflicts of interest., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Foreign-born kidney transplant recipients (FBKTRs) are at increased risk for reactivation of latent infections that may impact outcomes. We aimed to compare the etiology of infections and outcomes between FBKTR and United States KTRs (USKTR)., Methods: We performed a retrospective study of patients who underwent kidney transplantation between January 1, 2014 and December 31, 2018 at two transplant centers in Minnesota. Frequency and etiology of infections as well as outcomes (graft function, rejection, and patient survival) at 1-year post-transplant between FBKTR and USKTR were compared., Results: Of the 573 transplant recipients, 124 (21.6%) were foreign-born and 449 (78.4%) US-born. At least one infection occurred in 411 (71.7%) patients (38.2% bacterial, 55% viral, 9.4% fungal). Viral infections were more frequent in FBKTR, particularly BK viremia (38.7% vs. 21.2%, p < .001). No statistical differences were found for bacterial or fungal infections; no parasitic infections were identified in either group. No geographically-restricted infections were noted aside from a single case of Madura foot in a FBKTR. Rejection episodes were more common in USKTR (p = .037), but stable/improving graft function (p = .976) and mortality (p = .451) at 1-year posttransplantation were similar in both groups. After adjusting for covariates, previous transplantation was associated with a higher number of infections (IRR 1.35, 95% confidence intervals 1.05-1.73, p = .020)., Conclusion: Although viral infections were more frequent in FBKTR, overall frequency and etiology of most infections and outcomes were similar between FBKTR and USKTR suggesting that comprehensive transplant care is providing timely prevention, diagnosis, and treatment of latent infections in FBKTR., (© 2023 The Authors. Transplant Infectious Disease published by Wiley Periodicals LLC.)

Background: Systemic inflammatory response remains a poorly understood cause of morbidity and mortality after traumatic injury. Recent nonhuman primate (NHP) trauma models have been used to characterize the systemic response to trauma, but none have incorporated a critical care phase without the use of general anesthesia. We describe the development of a prolonged critical care environment with sedation and ventilation support, and also report corresponding NHP biologic and inflammatory markers., Methods: Eight adult male rhesus macaques underwent ventilation with sedation for 48-96 hours in a critical care setting. Three of these NHPs underwent "sham" procedures as part of trauma control model development. Blood counts, chemistries, coagulation studies, and cytokines/chemokines were collected throughout the study, and histopathologic analysis was conducted at necropsy., Results: Eight NHPs were intentionally survived and extubated. Three NHPs were euthanized at 72-96 hours without extubation. Transaminitis occurred over the duration of ventilation, but renal function, acid-base status, and hematologic profile remained stable. Chemokine and cytokine analysis were notable for baseline fold-change for Il-6 and Il-1ra (9.7 and 42.7, respectively) that subsequently downtrended throughout the experiment unless clinical respiratory compromise was observed., Conclusions: A NHP critical care environment with ventilation support is feasible but requires robust resources. The inflammatory profile of NHPs is not profoundly altered by sedation and mechanical ventilation. NHPs are susceptible to the pulmonary effects of short-term ventilation and demonstrate a similar bioprofile response to ventilator-induced pulmonary pathology. This work has implications for further development of a prolonged care NHP model., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Injury to the inferior vena cava (IVC) can produce bleeding that is difficult to control. Endovascular balloon occlusion provides rapid vascular control without extensive dissection and may be useful in large venous injuries, especially in the juxtarenal IVC. We describe the procedural steps, technical considerations, and clinical scenarios for using the Bridge occlusion balloon (Philips) in IVC trauma. We present a single-center case series of 5 patients in which endovascular balloon occlusion of the IVC was used for hemorrhage control. All 5 patients were men (median age 35, range 22 to 42 years). They all sustained penetrating injuries-4 gunshot wounds and 1 stab wound. Median presenting Shock Index was 0.7 (range 0.5 to 1.5). Median initial lactate was 5.4 mmol/L (range 4.6 to 6.9 mmol/L). There were 2 suprarenal IVC injuries, 2 juxtarenal injuries, and 3 infrarenal injuries. Four patients underwent primary repair of their injury, and one underwent IVC ligation. Four patients had intraoperative Resuscitative Endovascular Balloon Occlusion of the Aorta for inflow control and afterload support. The median number of total blood products transfused during the initial operation was 37 units (range 16 to 77 units). Four patients underwent damage control operations, and one patient had a single definitive operation. Four of the 5 patients (80%) survived to discharge with the lone mortality being due to other injuries. Endovascular balloon occlusion serves as a valuable adjunct in the management of IVC injury and demonstrates the potential of hybrid open-endovascular operative techniques in abdominal vascular trauma., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Popliteal artery injury following knee dislocation is associated with significant morbidity and high amputation rates. The complex and multi-disciplinary input required to manage this injury effectively can take time to arrange, prolonging the time to revascularization. Furthermore, open surgical bypass or interposition graft can be technically challenging in the acute setting, further prolonging ischemic time.Temporary intravascular shunts can be used to temporarily restore flow but require surgical exposure which takes time. Endovascular techniques can decrease the time to revascularization; however, endovascular popliteal stent-grafting is controversial because the biomechanical forces relating to flexion and extension of the knee may increase the risk of stent thrombosis. An ideal operation would result in rapid revascularization, eventually leading to a definitive and durable surgical solution.We hypothesize that a staged approach combing extracorporeal shunting, temporary endovascular covered stent placement, external fixation of bony injury, and definitive open repair provides for a superior approach to popliteal artery injury than current standard of care. We term this approach lower extremity staged revascularization (LESR) and the aim is to minimize the known factors contributing to poor outcomes after traumatic popliteal artery injury., (© 2022. The Author(s).)

Introduction: Transcarotid artery revascularization (TCAR) with flow reversal has substantially changed the management of carotid artery stenosis, enabling an endovascular approach with a periprocedural stroke rate as low as or lower than that of open carotid surgery. The use of TCAR for blunt carotid artery injury has not yet been described., Methods: A review of the use of TCAR for blunt carotid artery injury was performed at a single center from October 2020 to August 2021. The patient demographics, mechanism of injury, and outcomes were collected and compared., Results: Ten carotid stents were placed via TCAR in eight patients for hemodynamically significant blunt carotid artery injuries. No periprocedural neurologic events occurred, and all stents remained patent during short-term follow-up., Conclusions: TCAR is feasible and safe in the management of significant blunt carotid artery injuries. More data are needed regarding the long-term outcomes and ideal surveillance intervals., (© 2022 The Author(s).)

In the United States, there is poor clinician adherence to the American Association for the Study of Liver Disease and other guidelines for chronic hepatitis B virus (CHB) management. This prospective cohort study evaluated whether a CHB registry improves CHB management. We included patients with CHB aged ≥ 18 years and who had a clinical encounter during September 1, 2016-August 31, 2019. We divided patients into three groups based on care received before September 1, 2019: 1) CIH: primary care clinician at HealthPartners Center for International Health, 2) GI: not CIH and seen by gastroenterology within previous 18 months, and 3) primary care (PC): not CIH and not seen by gastroenterology within previous 18 months. We created and implemented a CHB registry at CIH that allowed staff to identify and perform outreach to patients overdue for CHB management. Patients with laboratory testing (i.e., alanine transaminase and hepatitis B virus DNA) and hepatocellular carcinoma screening in the previous 12 months were considered up to date (UTD). We compared UTD rates between groups at baseline (September 1, 2019) and pilot CHB registry end (February 28, 2020). We evaluated 4,872 patients, 52% of whom were female: 213 CIH, 656 GI, and 4,003 PC. At baseline, GI patients were most UTD (69%) followed by CIH (51%) and PC (11%). At pilot end the percent of UTD patients at CIH increased by 11%, GI decreased by 10%, and PC was unchanged. CHB registry use standardized care and increased the percent of CHB patients with recent laboratory testing and HCC screening.

Clinicians in the United States are trained to screen for cancer based on patient age, gender, family history, and environmental risk factors such as smoking. These cancers generally include, breast, cervical, colon, lung, and prostate cancers. We know that refugees and other immigrants to the United States experience dramatic disparities in cancer screening. Additionally, many immigrants experience elevated risks from infection-attributable cancers due to their country or region of origin. U.S.- based clinicians may not routinely consider these unique risk factors. Although this article focuses on refugees, it is also intended to guide clinicians caring for other foreign-born immigrant groups living in the United States (hereafter referred to as "immigrants"). The document contains two sections: 1) special considerations for U.S. Preventive Services Task Force guidelines cancer screening recommendations in immigrants and 2) cancer risks and screening recommendation unique to certain immigrant groups. Disparities in cancer screening and prevalence are often greater for specific immigrant groups than for broader racial or ethnic groups (e.g., Black, Asian, Hispanic) into which they may fit. Disaggregation of data by language or country of origin is useful to identify such disparities and to design intervention opportunities within specific communities that are culturally distinct and/or who have different environmental exposures. Unique cancer risks and disparities in screening support a nuanced approach to cancer screening for immigrant and refugee populations, which is the focus of this narrative review.

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.

Human migration and travel are leading to increasingly diverse populations throughout the world. Data collection practices need to adapt to these changes to expand our understanding of health disparities and to optimize the efforts to address health equity, particularly during public health emergencies such as the current COVID-19 pandemic. Race and ethnicity classifications in the United States have failed to evolve since the 1970s despite an increasingly diverse population. Current commonly collected categories are inadequate to accurately describe the economic, educational, and sociopolitical circumstances of different groups. Further, these categories lend little practical information to inform health policy. More predictive and actionable variables should be routinely collected to improve appropriateness and timeliness of health interventions. The immediate adoption of the collection of primary/preferred language and country of birth/origin by public health organizations, health systems, and clinical providers would be a concrete and valuable first step.

Purpose of Review: There is unprecedented movement of people across international borders and parasitic infections, previously restricted to endemic regions, are now encountered in nonendemic areas of the world., Recent Findings: Migrants may import parasitic infections acquired in their countries of origin. Increasingly, clinicians in nonendemic regions are faced with patients with neglected diseases such as Chagas disease, malaria and strongyloidiasis. There are gaps in knowledge among physicians in nonendemic regions, which lead to missed opportunities for preventive strategies and early treatment. Both primary care and infectious disease physicians should have a broad knowledge of common parasitic infections to improve health outcomes and decrease healthcare disparities through early identification and treatment of disease encountered in migrants., Summary: Migrant health is still a young field in medicine; clinicians should be aware of diseases seen in migrants, and access both educational and clinical resources, including experts in tropical medicine, in order to reduce health disparities among migrants. Collaboration between primary care and infectious disease/tropical medicine experts should be strengthened., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Penetrating cervical carotid artery injury is an uncommon but high-stake scenario associated with stroke and death. The objective of this study was to characterize and compare penetrating carotid injury in the military and civilian setting, as well as provide considerations for management., Methods: Cohorts with penetrating cervical carotid artery injury from the Department of Defense Trauma Registry (2002-2015) and the American Association for the Surgery of Trauma Prospective Observation Vascular Injury Treatment Registry (2012-2018) were analyzed. A least absolute shrinkage and selection operator multivariate analysis using random forest-based imputation was performed to identify risk factors affecting stroke and mortality., Results: There were a total of 157 patients included in the study, of which 56 (35.7%) were military and 101 (64.3%) were civilian. The military cohort was more likely to have been managed with open surgery (87.5% vs. 44.6%, p < 0.001) and to have had any procedure to restore or maintain flow to the brain (71.4% vs. 35.6%, p < 0.001), while the civilian cohort was more likely to undergo nonoperative management (45.5% vs. 12.5%, p < 0.001). Stroke rate was higher within the military cohort (41.1% vs. 13.9%, p < 0.001); however, mortality did not differ between the groups (12.5% vs. 17.8%, p = 0.52). On multivariate analysis, predictors for stroke were presence of a battle injury (log odds, 2.1; p < 0.001) and internal or common carotid artery ligation (log odds 1.5, p = 0.009). For mortality outcome, protective factors included a high Glasgow Coma Scale on admission (log odds, -0.21 per point; p < 0.001). Increased admission Injury Severity Score was a predictor of mortality (log odds, 0.05 per point; p = 0.005)., Conclusion: The stroke rate was higher in the military cohort, possibly reflecting complexity of injury; however, there was no difference in mortality between military and civilian patients. For significant injuries, concerted efforts should be made at carotid reconstruction to reduce the occurrence of stroke., Level of Evidence: Retrospective cohort analysis, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Surgical site infections (SSIs) are well-recognized complications after exploratory laparotomy for abdominal trauma; however, little is known about SSI development after exploration for battlefield abdominal trauma. We examined SSI risk factors after exploratory laparotomy among combat casualties., Methods: Military personnel with combat injuries sustained in Iraq and Afghanistan (June 2009 to May 2014) who underwent laparotomy and were evacuated to participating US military hospitals were included. Log-binominal regression was used to identify SSI risk factors., Results: Of 4,304 combat casualties, 341 patients underwent a total of 1,053 laparotomies. Abdominal SSIs were diagnosed in 49 patients (14.4%): 8% with organ space SSI, 4% with deep incisional SSI, and 4% with superficial SSIs (4 patients had multiple SSIs). Patients with SSIs had more colorectal (p < 0.001), small bowel (p = 0.010), duodenum (p = 0.006), pancreas (p = 0.032), and abdominal vascular injuries (p = 0.040), as well as prolonged open abdomen (p = 0.004) and more infections diagnosed before the SSI (or final exploratory laparotomy) versus non-SSI patients (p < 0.001). Sustaining colorectal injuries (risk ratio [RR], 3.20; 95% confidence interval [CI], 1.58-6.45), duodenum injuries (RR, 6.71; 95% CI, 1.73-25.58), and being diagnosed with prior infections (RR, 10.34; 95% CI, 5.05-21.10) were independently associated with any SSI development. For either organ space or deep incisional SSIs, non-intra-abdominal infections, fecal diversion, and duodenum injuries were independently associated, while being injured via an improvised explosive device was associated with reduced likelihood compared with penetrating nonblast (e.g., gunshot wounds) injuries. Non-intra-abdominal infections and hypotension were independently associated with organ space SSIs development alone, while sustaining blast injuries were associated with reduced likelihood., Conclusion: Despite severity of injuries and the battlefield environment, the combat casualty laparotomy SSI rate is relatively low at 14%, with similar risk factors and rates reported following severe civilian trauma., Level of Evidence: Epidemiological, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Although the relationship between human mobility and global dissemination of antimicrobial resistance (AMR) is well established, there are important aspects regarding dynamics and character of this spread that have not been well described such as the decreasing time from emergence to global dissemination. In addition, AMR spread through migrants is increasingly being discussed and examined. We believe caution should be exercised to not overly focus on this population since we believe migrants play a minor role and there is a history of stigmatizing and blaming migrants for emerging infections and disease outbreaks. International travelers are proportionately much more likely to perpetuate AMR spread due to the vastly greater volume combined with the increasing efficiency and speed at which they travel. Research, infection prevention measures, and policy development are likely to have the greatest impact if focused on the international traveler rather than on migrant populations., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties., Methods: Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals., Results: Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively., Conclusions: Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high., (Published by Elsevier Inc.)

Introduction: For patients on renal replacement therapy (RRT), "travel" and "independence" are rated as 2 of the top 5 factors that inform their choice of treatment modality. While home dialysis modalities offer patients a high degree of independence, the most common RRT in the United States is in-center hemodialysis (IHD). The limits imposed by IHD treatment can present a variety of challenges for patients who wish to travel. This study explored how IHD patients managed their travel and the role of dialysis social workers in executing travel arrangements for patients., Methods: We performed a qualitative descriptive investigation using semi-structured interviews with adults receiving IHD (n = 16) and renal social workers (n = 8) from Iowa, Minnesota, North Dakota, South Dakota, and Wisconsin. Data were analyzed using a constant comparative method., Findings: Three themes emerged from the interviews: travel process, travel-related barriers, and travel-related facilitators. The travel process entailed transient dialysis unit challenges and the need for multiple preparations and precautions. Barriers included comorbidities and not having a relationship with transient dialysis unit staff. Facilitators focused on the importance of travel and staff professionalism at transient dialysis units. Overall, there was lack of uniform protocols to guide the travel process at the patient and the dialysis unit levels., Discussion: This study identified multiple perspectives regarding travel arrangements in chronic IHD patients. There is limited research on travel issues for IHD patients and this investigation is among the first to articulate barriers and facilitators associated with travel from the perspective of patients and social workers. Supporting travel for IHD patients can increase their sense of autonomy and provide opportunities to improve their quality of life., (© 2020 International Society for Hemodialysis.)

We developed and evaluated the Global Health Wizard Hepatitis B Best Practice Alert (BPA) to increase primary care provider adherence to evidence-based guidelines for hepatitis B virus (HBV) infection screening in non-U.S.-born patients. We conducted a pilot study using nine clinics to test BPA effectiveness. Eligible patients were aged ≥ 12 years, from a country of origin with ≥ 2% HBV prevalence, had no electronic health record documentation of HBV screening, and were seen for primary care during July 2012-March 2013. The BPA triggered for > 4,500 patients and identified six previously unrecognized HBV-infected patients. The pilot project demonstrated BPA effectiveness and continued to be used at pilot clinics until 2018 and was expanded to additional clinics in 2019; 29 additional HBV-infected patients were identified. Although successful, BPA usage steadily decreased over time. Poor BPA usage limits the power to achieve the goal of improved population-based HBV screening.

Background: Cervical carotid artery injuries entail high morbidity and mortality and are technically challenging to repair. This retrospective study describes the management and outcomes of cervical carotid injuries sustained during the recent wars in Iraq and Afghanistan., Methods: The Department of Defense Trauma Registry was queried to identify US military personnel who sustained battle-related cervical carotid injury between January 2002 and December 2015. Retrospective chart reviews of the military Electronic Health Record were performed on patients identified. Demographics, injury characteristics, surgical management, and outcomes were reviewed. Statistical analysis was performed to identify associations between injury and management factors, as well as stroke and mortality., Results: In total, 67 patients (100% male; age, 25 ± 7 years) were identified with cervical carotid artery injuries. Fifty-six patients (84%) sustained a common carotid artery (CCA) or internal carotid artery (ICA) injury, and 11 patients (16%) had an isolated external carotid artery (ECA) injury. The anatomic distribution of injury was as follows: CCA, 26 (38.8%); ICA, 24 (35.8%); CCA and ICA 2 (3%); ICA and ECA 3 (4.5%); and CCA, ICA, and ECA 1 (1.5%). Of the 56 CCA or ICA injuries, 39 underwent vascular repair, 9 (16%) were managed with ligation, 1 was treated with a temporary vascular shunt but succumbed to injuries before vascular repair, and 7 (13%) were treated nonoperatively. Seven (23%) of 30 ICA injuries were ligated compared with 2 (7.7%) of 26 injuries isolated to the CCA (p = 0.02). Compared with repair, ligation of the CCA/ICA was associated with a higher rate of stroke (89% vs. 33%, p = 0.003) and increased mortality without statistical significance (22% vs. 10%, p = 0.3). Every patient who underwent ICA ligation had a stroke (7/7). There was no difference in Injury Severity Score between the ligation and repair groups (23.8 ± 10.6 vs. 24.7 ± 13.4, p = 0.9). At a mean follow-up of 34.5 months, 10 of 17 stroke survivors had permanent neurologic deficits., Conclusion: In modern combat, penetrating injuries involving the cervical carotid arteries are relatively infrequent. In this experience, isolated ICA injuries were three times more likely to be ligated than those involving the CCA. As a surgical maneuver, ICA ligation resulted in stroke in all cases., Level of Evidence: Retrospective cohort analysis, level III.

Background: Tranexamic acid (TXA) may be a useful adjunct for military patients with severe traumatic brain injury (TBI). These patients are often treated in austere settings without immediate access to neurosurgical intervention. The purpose of this study was to evaluate any association between TXA use and progression of intracranial hemorrhage (ICH), neurologic outcomes, and venous thromboembolism (VTE) in TBI., Methods: This was a retrospective cohort study of military casualties from October 2010 to December 2015 who were transferred to a military treatment facility (MTF) in the United States. Data collected included: demographics, types of injuries, initial and interval head computerized tomography (CT) scans, Glasgow Coma Scores (GCS), and six-month Glasgow Outcome Scores (GOS). Results were stratified based on TXA administration, progression of ICH, and VTE., Results: Of the 687 active duty service members reviewed, 71 patients had ICH (10.3%). Most casualties were injured in a blast (80.3%), with 36 patients (50.7%) sustaining a penetrating TBI. Mean ISS was 28.2 ± 12.3. Nine patients (12.7%) received a massive transfusion within 24 h of injury, and TXA was administered to 14 (19.7%) casualties. Patients that received TXA had lower initial reported GCS (9.2 ± 4.4 vs. 12.5 ± 3.4, p = 0.003), similar discharge GCS (13.3 ± 4.0 vs. 13.8 ± 3.2, p = 0.58), and a larger improvement between initial and discharge GCS (3.7 ± 3.9 vs. 1.3 ± 3.1, p = 0.02). However, there was no difference in mortality (7.1% vs. 7.0%, p = 1.00), progression of ICH (45.5% vs. 14.7%, p = 0.09), frequency of cranial decompression (50.0% vs. 42.1%, p = 0.76), or mean GOS (3.5 ± 0.9 vs. 3.8 ± 1.0, p = 0.13). Patients administered TXA had a higher rate of VTE (35.7% vs. 7.0%, p = 0.01). On multivariate analysis, however, TXA was not independently associated with VTE., Conclusions: Patients that received TXA were associated with an improvement in GCS but not in progression of ICH or GOS. TXA was not independently associated with VTE, although this may be related to a paucity of patients receiving TXA. Decisions about TXA administration in military casualties with ICH should be considered in the context of the availability of neurosurgical intervention as well as severity of extracranial injuries and need for massive transfusion.

Background: The treatment of venous thoracic outlet syndrome (VTOS) requires surgical decompression often combined with catheter-directed thrombolysis and venoplasty. Surgical options include transaxillary, supraclavicular, or infraclavicular approaches to first rib resection. The optimal method, however, has yet to be defined. The purpose of this study is to compare the outcomes of patients who underwent infraclavicular versus supraclavicular surgical decompression for VTOS., Methods: A retrospective review of patients who underwent surgical management for VTOS from December 2010 to November 2017 was performed. During the study period, supraclavicular and infraclavicular approaches were chosen according to surgeon preference. Patient demographics, pre- and postdecompression interventions, perioperative outcomes for each group of patients were analyzed., Results: Thirty patients underwent surgical management of VTOS, of which 15 (50%) underwent infraclavicular decompression and 15 (50%) supraclavicular decompression. The mean age of patients was 32.1 ± 13.6 years and 80% were male. Twenty-six patients (86.7%) presented with thrombotic VTOS. Acute axillosubclavian vein thrombosis was present in 20 (76.9%) of these patients, 10 patients in each group. Subacute or chronic thrombosis was encountered in the remaining 6 (23%) patients, 2 patients in the infraclavicular group and 4 patients in the supraclavicular group. Preoperative thrombolysis was utilized in 7 (46.7%) and 6 (40%) patients in the infraclavicular and supraclavicular groups, respectively (P = 1.00). Patients without postdecompression venography were removed from analysis and included 1 patient in the infraclavicular group and 5 patients in the supraclavicular group. Initial postdecompression venogram, prior to any endovascular intervention, demonstrated a residual axillosubclavian vein stenosis of greater than 50% in 6 (42.9%) patients in the infraclavicular decompression group and 7 (70%) patients in the supraclavicular decompression group (P = 0.24). Crossing the stenosis after surgical decompression was more easily accomplished in the infraclavicular group, 14 (100%) versus 5 (50%), (P = 0.01). Following endovascular venoplasty, calculated residual stenosis greater than 50% was found in 0 (0%) and 3 (30%) patients in the infraclavicular and supraclavicular approaches, respectively (P = 0.047). Infraclavicular thoracic outlet decompression was associated with fewer patients with postoperative symptoms, 0 of 15 (0%) versus 8 of 15 (53.3%), (P = 0.0022), and infraclavicular thoracic outlet decompression demonstrated improved patency, 15 of 15 (100%) versus 8 of 15 (53.3%), (P = 0.028) at a mean combined follow-up of 8.47 ± 10.8 months., Conclusions: Infraclavicular thoracic outlet decompression for the surgical management of VTOS was associated with fewer postoperative symptoms and improved axillosubclavian vein patency compared to the supraclavicular approach. Prospective analysis is warranted to determine long-term outcomes following infraclavicular decompression., (Published by Elsevier Inc.)

Background: Despite achievements in the reduction of malaria globally, imported malaria cases to the United States by returning international travelers continue to increase. Immigrants to the United States from sub-Saharan Africa (SSA) who then travel back to their homelands to visit friends and relatives (VFRs) experience a disproportionate burden of malaria illness. Various studies have explored barriers to malaria prevention among VFRs and non-VFRs-travelers to the same destinations with other purpose for travel-but few employed robust epidemiologic study designs or performed comparative analyses of these two groups. To better quantify the key barriers that VFRs face to implement effective malaria prevention measures, we conducted a comprehensive community-based, cross-sectional, survey to identify differences in malaria prevention knowledge, attitudes, and practices (KAP) among VFRs and others traveling to Africa and describe the differences between VFRs and other types of international travelers., Methods and Findings: Three distinct populations of travelers with past or planned travel to malaria-endemic countries of SSA were surveyed: VFRs diagnosed with malaria as reported through a state health department; members of the general VFR population (community); and VFR and non-VFR travelers presenting to a travel health clinic, both before their pretravel consultation and again, after return from travel. A Community Advisory Board of African immigrants and prior qualitative research informed survey development and dissemination. Across the three groups, 489 travelers completed surveys: 351 VFRs and 138 non-VFRs. VFRs who reported taking antimalarials on their last trip rated their concern about malaria higher than those who did not. Having taken five or more trips to SSA was reported more commonly among VFRs diagnosed with malaria than community VFRs (44.0% versus 20.4%; p = 0.008). Among travel health clinic patients surveyed before and after travel, VFR travelers were less successful than non-VFRs in adhering to their planned use of antimalarials (82.2% versus 98.7%; p = 0.001) and employing mosquito bite avoidance techniques (e.g., using bed nets: 56.8% versus 81.8%; p = 0.009). VFRs who visited the travel health clinic were more likely than VFR respondents from the community to report taking an antimalarial (83.0% versus 61.9%; p = 0.009), or to report bite avoidance behaviors (e.g., staying indoors when mosquitoes were out: 80.9% versus 59.5%; p = 0.009)., Conclusions: We observed heterogeneity in malaria prevention behaviors among VFRs and between VFR and non-VFR traveler populations. Although VFRs attending the travel health clinic appear to demonstrate better adherence to malaria prevention measures than VFR counterparts surveyed in the community, specialized pretravel care is not sufficient to ensure chemoprophylaxis use and bite avoidance behaviors among VFRs. Even when seeking specialized pretravel care, VFRs experience greater barriers to the use of malaria prevention than non-VFRs. Addressing access to health care and upstream barrier reduction strategies that make intended prevention more achievable, affordable, easier, and resonant among VFRs may improve malaria prevention intervention effectiveness., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Clinical decision support tools capable of predicting which patients are at highest risk for venous thromboembolism (VTE) can assist in guiding surveillance and prophylaxis decisions. The Trauma Embolic Scoring System (TESS) has been shown to model VTE risk in civilian trauma patients. No such support tools have yet been described in combat casualties, who have a high incidence of VTE. The purpose of this study was to evaluate the utility of TESS in predicting VTE in military trauma patients., Methods: A retrospective cohort study of 549 combat casualties from October 2010 to November 2012 admitted to a military treatment facility in the USA was performed. TESS scores were calculated through data obtained from the Department of Defense Trauma Registry and chart reviews. Univariate analysis and multivariate logistic regression were performed to evaluate risk factors for VTE. Receiver operating characteristic (ROC) curve analysis of TESS in military trauma patients was also performed., Results: The incidence of VTE was 21.7% (119/549). The median TESS for patients without VTE was 8 (IQR 4-9), and the median TESS for those with VTE was 10 (IQR 9-11). On multivariate analysis, Injury Severity Score (ISS) (OR 1.03, p=0.007), ventilator days (OR 1.05, p=0.02), and administration of tranexamic acid (TXA) (OR 1.89, p=0.03) were found to be independent risk factors for development of VTE. On ROC analysis, an optimal high-risk cut-off value for TESS was ≥7 with a sensitivity of 0.92 and a specificity of 0.53 (area under the curve 0.76, 95% CI 0.72 to 0.80, p<0.0001)., Conclusions: When used to predict VTE in military trauma, TESS shows moderate discrimination and is well calibrated. An optimal high-risk cut-off value of ≥7 demonstrates high sensitivity in predicting VTE. In addition to ISS and ventilator days, TXA administration is an independent risk factor for VTE development., Level of Evidence: Level III., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Genitourinary tuberculosis (TB) is a rare but well-described form of extrapulmonary TB. We present a case of a 35-year-old man from Ethiopia with scrotal swelling and fever who was found to have epididymo-orchitis due to Mycobacterium tuberculosis . The patient presented to the hospital multiple times before undergoing operative debridement with fine needle aspiration and tissue biopsy to confirm the diagnosis. He improved with antituberculous therapy. Patients with TB risk factors presenting with epididymitis that is refractory to empiric antibiotic therapy warrant consideration of TB epididymitis. Our case demonstrates the high index of suspicion required to establish a diagnosis of genitourinary TB.

Beyond its anti-fibrinolytic mechanism, tranexamic acid has been suggested to have anti-inflammatory properties which may contribute to the survival benefit it provides to trauma patients. The objective of this study was to assess possible immunomodulatory effects of tranexamic acid as well as potential amelioration of end-organ injury in a rodent hemorrhagic shock model. Controlled hemorrhagic shock was induced in adult Sprague Dawley rats to a mean arterial pressure of 30 mmHg. Groups of 10 rats were administered intravenous tranexamic acid (300mg/kg) or vehicle control (normal saline) intravenously 15 minutes after the induction of shock. After 60 minutes of hemorrhagic shock, resuscitation was started. Animals were euthanized at six, 24, or 72 hours from the start of shock. Serum laboratory values to include inflammatory biomarkers were measured, and end organ histology was evaluated. Tranexamic acid treatment was associated with a significant decrease in serum IL-1β at six and 24 hours and IL-10 at 24 hours from start of shock compared to vehicle control. Histologic analysis demonstrated mild decreases in both perivascular pulmonary edema and follicular mesenteric lymph node hyperplasia in the tranexamic acid treatment group but also increased myocardial lymphocytic infiltration with necrosis and degeneration. Tranexamic acid was also associated with a small but significant increase in peripheral neutrophil count as well as a significant decrease in neutrophil aggregation in pulmonary tissue at six hours post-injury. These data thus demonstrate a mixed effect of tranexamic acid. While there was an improvement in pulmonary edema and a suppressive effect on several key inflammatory mediators, there was also increased myocardial degeneration and necrosis, which is possibly related to the pro-thrombotic effect of tranexamic acid., Competing Interests: The authors have declared that no competing interests exist.

The intent of this study was to characterize the management and subsequent complications of combat injury tube thoracostomies and to determine risk factors for the development of pneumonia (PNA) and retained hemothorax (RH). One hundred fifteen patients with 173 tube thoracostomies met the inclusion criteria and were analyzed. The mean injury severity score was 30.8 + 11.6, 23.5 per cent had traumatic amputations, 49.7 per cent had a hemothorax, and 50.3 per cent had a pneumothorax as indications for tube thoracostomy (TT) placement. Within 24 hours of injury, 89.6 per cent were intubated, the majority (54%) were injured by improvised explosive devices, 35.6 per cent sustained rib fractures, and 12.2 per cent had a diaphragm injury. A mean of 1.5 + 0.7(range 1-4) tube thoracostomies were placed, 18.3 per cent of patients had bilateral tube thoracostomies, and the average TT duration was 6.7 + 3.9 days. The incidence of PNA was 27 per cent (n = 31), RH was 9.6 per cent (n = 11), and empyema was 1.7 per cent (n = 2). Multivariable analysis identified the duration of ventilation [OR 1.2, 95% confidence interval (CI): 1.097-1.313, P < 0.001] as independently associated with the development of PNA. Bilateral TT placement (OR 3.848, 95% CI: 1.219-12.143, P = 0.0216) and injury severity score (OR 1.050, 95% CI: 1.001-1.102, P = 0.0443) were independently associated with PNA development when a patient was intubated for eight days or less. The number of tube thoracostomies placed (OR 3.08, 95% CI: 1.03-9.18, P = 0.0439) was independently associated with the development of RH. Further research is warranted to identify modifiable risk factors to reduce the incidence of PNA and RH in patients with TT placed for traumatic injuries.

Objective: Poor retrieval rates for retrievable inferior vena cava filters (R-IVCFs) have been reported throughout the literature, with poor follow-up a common cause. In 2009, we reported a retrieval rate of 18% despite an initial follow-up rate of 85%. Use of a registry has been shown to improve retrieval rates. As a quality improvement project, in May 2012, the vascular surgery fellowship implemented a reiterative registry to track R-IVCFs placed at Walter Reed National Military Medical Center to improve retrieval rates. We report the results in 125 patients after 38 months., Methods: Patients receiving an R-IVCF were entered into a registry. All patients were reviewed monthly using an electronic health record. When there was no longer an indication for the R-IVCF, the patient was scheduled for an outpatient appointment with a vascular surgeon followed by retrieval. Rates of retrieval, technical success, dwell time, indication, complications, and demographics were collected., Results: There were 125 R-IVCFs placed between May 2012 and June 2015; 52 filters were placed for therapeutic and 73 for prophylactic indications. Our follow-up rate improved to 94%. A total of 79 filters were retrieved (63% absolute retrieval rate). Excluding patients who died before retrieval and patients with a permanent indication, 77% of filters were retrieved. The average dwell time was 101.5 days (7-460 days), and 63% of successful R-IVCF retrievals were within 3 months of placement. Technical success for retrieval was 92%. There were two major complications from retrievals (1.5% of retrievals)., Conclusions: The creation of an R-IVCF registry promoted ongoing follow-up with patients. In our earlier experience, retrieval rates were poor despite a high follow-up rate. The use of a reiterative registry improved our retrieval rate by 45% and increased our follow-up rate to 94%. These results emphasize the importance of repetitive follow-up for R-IVCFs. Despite a follow-up rate >90%, around a third of R-IVCFs were not retrieved., (Published by Elsevier Inc.)

Zika virus (ZIKV) is a mosquito-borne flavivirus with a significant public health impact highlighted by the ongoing epidemic in the Americas. We describe a 44-year-old male presenting to our tropical medicine center with complaints of fever, headache, joint pain, and rash after recent travel to Guyana. The patient subsequently developed gait imbalance and lower extremity weakness with clinical examination, cerebrospinal fluid studies, and magnetic resonance imaging of the spine consistent with a diagnosis of Guillain-Barré syndrome (GBS). ZIKV infection was confirmed via detection of ZIKV RNA in urine by polymerase chain reaction. The patient was treated with intravenous immunoglobulin and experienced near-complete neurologic recovery, reporting ongoing mild paresthesia up to 2 months later. This case highlights the diagnostic challenges posed by ZIKV and underscores the need for clinician awareness of the potential for neurological complications such as GBS with ZIKV infection., (© The American Society of Tropical Medicine and Hygiene.)

In this article we review recent advances made in the pathophysiology, diagnosis, and treatment of inhalation injury. Historically, the diagnosis of inhalation injury has relied on nonspecific clinical exam findings and bronchoscopic evidence. The development of a grading system and the use of modalities such as chest computed tomography may allow for a more nuanced evaluation of inhalation injury and enhanced ability to prognosticate. Supportive respiratory care remains essential in managing inhalation injury. Adjuncts still lacking definitive evidence of efficacy include bronchodilators, mucolytic agents, inhaled anticoagulants, nonconventional ventilator modes, prone positioning, and extracorporeal membrane oxygenation. Recent research focusing on molecular mechanisms involved in inhalation injury has increased the number of potential therapies.

The following case report details a case of chikungunya fever in a returning traveler from Haiti. The report highlights the clinical presentation and natural history of the disease, and emphasizes that chikungunya has become established in the western hemisphere, with a resultant need for heightened provider awareness., (© 2014 International Society of Travel Medicine.)