Consider thinking outside the lower body for pelvic pain. Also today, treating obstructive sleep apnea with positive airway pressure decreased amyloid levels, spending on medical marketing increased by more than $12 billion over that past two decades, and one expert has advice on how you can get your work published.

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Consider thinking outside the lower body for pelvic pain. Also today, treating obstructive sleep apnea with positive airway pressure decreased amyloid levels, spending on medical marketing increased by more than $12 billion over that past two decades, and one expert has advice on how you can get your work published.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify
 

Consider thinking outside the lower body for pelvic pain. Also today, treating obstructive sleep apnea with positive airway pressure decreased amyloid levels, spending on medical marketing increased by more than $12 billion over that past two decades, and one expert has advice on how you can get your work published.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify
 

Transdermal hormone replacement therapy is associated with the lowest risk of venous thromboembolism, yet still is relatively underused compared to oral preparations, researchers say.

Alexander Raths/Fotolia

Writing in the BMJ, Yana Vinogradova, PhD, of the University of Nottingham (England) and her associates reported the results of two nested case-control studies of hormone replacement therapy (HRT) and venous thromboembolism (VTE) from Jan. 1998 to Feb. 2017 that altogether included 80,396 women aged 40-79 years with a primary diagnosis of VTE matched to 391,494 female controls.

Overall, 7% of the women with VTE had been exposed to HRT in the 90 days before the index date versus 5.5% of controls.

The greatest increase in risk of VTE, compared with no exposure, was seen with oral conjugated equine estrogen with medroxyprogesterone acetate, which was associated with a more than twofold increase in risk (odds ratio, 2.10; 95% confidence interval, 1.92-2.31; P less than .01).

However transdermal HRT use was not associated with any increase in risk, compared with no HRT exposure. The data even pointed to a slight decrease in risk, which the authors suggested may be the result of some residual confounding or indication bias.

Oral HRT generally was associated with a 58% increased risk of VTE, which amounted to a number needed to harm of 1,076 and nine extra cases of VTE per 10,000 women taking oral HRT.

Dr. Vinogradova and her colleagues noted that the vast majority of women in the study were being prescribed oral HRT for menopausal symptoms despite previous studies showing transdermal HRT has much lower risk.

“When women with menopausal symptoms already have an increased VTE risk because of comorbidities or obesity, these women and their doctors should give greater consideration to transdermal HRT,” they wrote.

Lubna Pal, MBBS, director of the menopause program and professor of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., commented in an interview, “These data are tremendously reassuring. The reported findings are: 1) reaffirm what we have already known , i.e. that advancing age, higher body mass index, and higher doses of exogenous systemic estrogen therapy are associated with increased risk for VTE; 2) offer greater granularity in risk for VTE with different formulations of estrogens and progestins and different regimens than understood thus far, 3) reaffirm that, unlike oral estrogen, transdermal estrogen formulations in doses commonly utilized in clinical practice are not associated with VTE risk, and 4) provide reassurance that the absolute risk, while exaggerated with oral estrogen or combination estrogen and progestin use, is nonetheless small as reflected in the number needed to harm with oral hormone therapy being 1,076, and the number of extra VTE cases attributable to oral HT being 9 per 10,000 woman years. 

“The authors are to be commended on this massive analytic undertaking that allows an improved understanding of HRT-related risk for VTE and offers meaningful guidance to the practitioner,” said Dr. Pal, who was not involved in the study.*

Estrogen-only preparations had a 40% higher risk and combined preparations had a 73% higher risk, compared with no exposure.

In estrogen-only preparations, the lowest risk was seen with estradiol, compared with conjugated equine estrogens or combined preparations.

The lowest risk of VTE among oral preparations was seen with estradiol plus dydrogesterone, which only showed a nonsignificant 18% increase in risk.

In an attempt to account for possible increased risk of VTE, the authors conducted a sensitivity analysis in a subgroup of women who had not previously used anticoagulants, but they found similar results to the main analysis.

“This sensitivity analysis indicates that most of the excluded women had probably used anticoagulants because of atrial fibrillation or hip replacement operations rather than an earlier unrecorded VTE,” they wrote.

One author declared directorship of a clinical software company, but no other conflicts of interest were declared. There was no external funding. Dr. Pal reported that she was a coinvestigator in the Kronos Early Estrogen Prevention Study and on an AMAG Pharmaceuticals advisory board and member of their speaker’s bureau. 

SOURCE: Vinogradova Y et al. BMJ. 2019 Jan 9. doi: 10.1136/bmj.k4810.

*This article was updated 1/11/19.
 

Transdermal hormone replacement therapy is associated with the lowest risk of venous thromboembolism, yet still is relatively underused compared to oral preparations, researchers say.

Alexander Raths/Fotolia

Writing in the BMJ, Yana Vinogradova, PhD, of the University of Nottingham (England) and her associates reported the results of two nested case-control studies of hormone replacement therapy (HRT) and venous thromboembolism (VTE) from Jan. 1998 to Feb. 2017 that altogether included 80,396 women aged 40-79 years with a primary diagnosis of VTE matched to 391,494 female controls.

Overall, 7% of the women with VTE had been exposed to HRT in the 90 days before the index date versus 5.5% of controls.

The greatest increase in risk of VTE, compared with no exposure, was seen with oral conjugated equine estrogen with medroxyprogesterone acetate, which was associated with a more than twofold increase in risk (odds ratio, 2.10; 95% confidence interval, 1.92-2.31; P less than .01).

However transdermal HRT use was not associated with any increase in risk, compared with no HRT exposure. The data even pointed to a slight decrease in risk, which the authors suggested may be the result of some residual confounding or indication bias.

Oral HRT generally was associated with a 58% increased risk of VTE, which amounted to a number needed to harm of 1,076 and nine extra cases of VTE per 10,000 women taking oral HRT.

Dr. Vinogradova and her colleagues noted that the vast majority of women in the study were being prescribed oral HRT for menopausal symptoms despite previous studies showing transdermal HRT has much lower risk.

“When women with menopausal symptoms already have an increased VTE risk because of comorbidities or obesity, these women and their doctors should give greater consideration to transdermal HRT,” they wrote.

Lubna Pal, MBBS, director of the menopause program and professor of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., commented in an interview, “These data are tremendously reassuring. The reported findings are: 1) reaffirm what we have already known , i.e. that advancing age, higher body mass index, and higher doses of exogenous systemic estrogen therapy are associated with increased risk for VTE; 2) offer greater granularity in risk for VTE with different formulations of estrogens and progestins and different regimens than understood thus far, 3) reaffirm that, unlike oral estrogen, transdermal estrogen formulations in doses commonly utilized in clinical practice are not associated with VTE risk, and 4) provide reassurance that the absolute risk, while exaggerated with oral estrogen or combination estrogen and progestin use, is nonetheless small as reflected in the number needed to harm with oral hormone therapy being 1,076, and the number of extra VTE cases attributable to oral HT being 9 per 10,000 woman years. 

“The authors are to be commended on this massive analytic undertaking that allows an improved understanding of HRT-related risk for VTE and offers meaningful guidance to the practitioner,” said Dr. Pal, who was not involved in the study.*

Estrogen-only preparations had a 40% higher risk and combined preparations had a 73% higher risk, compared with no exposure.

In estrogen-only preparations, the lowest risk was seen with estradiol, compared with conjugated equine estrogens or combined preparations.

The lowest risk of VTE among oral preparations was seen with estradiol plus dydrogesterone, which only showed a nonsignificant 18% increase in risk.

In an attempt to account for possible increased risk of VTE, the authors conducted a sensitivity analysis in a subgroup of women who had not previously used anticoagulants, but they found similar results to the main analysis.

“This sensitivity analysis indicates that most of the excluded women had probably used anticoagulants because of atrial fibrillation or hip replacement operations rather than an earlier unrecorded VTE,” they wrote.

One author declared directorship of a clinical software company, but no other conflicts of interest were declared. There was no external funding. Dr. Pal reported that she was a coinvestigator in the Kronos Early Estrogen Prevention Study and on an AMAG Pharmaceuticals advisory board and member of their speaker’s bureau. 

SOURCE: Vinogradova Y et al. BMJ. 2019 Jan 9. doi: 10.1136/bmj.k4810.

*This article was updated 1/11/19.
 

Transdermal hormone replacement therapy is associated with the lowest risk of venous thromboembolism, yet still is relatively underused compared to oral preparations, researchers say.

Alexander Raths/Fotolia

Writing in the BMJ, Yana Vinogradova, PhD, of the University of Nottingham (England) and her associates reported the results of two nested case-control studies of hormone replacement therapy (HRT) and venous thromboembolism (VTE) from Jan. 1998 to Feb. 2017 that altogether included 80,396 women aged 40-79 years with a primary diagnosis of VTE matched to 391,494 female controls.

Overall, 7% of the women with VTE had been exposed to HRT in the 90 days before the index date versus 5.5% of controls.

The greatest increase in risk of VTE, compared with no exposure, was seen with oral conjugated equine estrogen with medroxyprogesterone acetate, which was associated with a more than twofold increase in risk (odds ratio, 2.10; 95% confidence interval, 1.92-2.31; P less than .01).

However transdermal HRT use was not associated with any increase in risk, compared with no HRT exposure. The data even pointed to a slight decrease in risk, which the authors suggested may be the result of some residual confounding or indication bias.

Oral HRT generally was associated with a 58% increased risk of VTE, which amounted to a number needed to harm of 1,076 and nine extra cases of VTE per 10,000 women taking oral HRT.

Dr. Vinogradova and her colleagues noted that the vast majority of women in the study were being prescribed oral HRT for menopausal symptoms despite previous studies showing transdermal HRT has much lower risk.

“When women with menopausal symptoms already have an increased VTE risk because of comorbidities or obesity, these women and their doctors should give greater consideration to transdermal HRT,” they wrote.

Lubna Pal, MBBS, director of the menopause program and professor of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., commented in an interview, “These data are tremendously reassuring. The reported findings are: 1) reaffirm what we have already known , i.e. that advancing age, higher body mass index, and higher doses of exogenous systemic estrogen therapy are associated with increased risk for VTE; 2) offer greater granularity in risk for VTE with different formulations of estrogens and progestins and different regimens than understood thus far, 3) reaffirm that, unlike oral estrogen, transdermal estrogen formulations in doses commonly utilized in clinical practice are not associated with VTE risk, and 4) provide reassurance that the absolute risk, while exaggerated with oral estrogen or combination estrogen and progestin use, is nonetheless small as reflected in the number needed to harm with oral hormone therapy being 1,076, and the number of extra VTE cases attributable to oral HT being 9 per 10,000 woman years. 

“The authors are to be commended on this massive analytic undertaking that allows an improved understanding of HRT-related risk for VTE and offers meaningful guidance to the practitioner,” said Dr. Pal, who was not involved in the study.*

Estrogen-only preparations had a 40% higher risk and combined preparations had a 73% higher risk, compared with no exposure.

In estrogen-only preparations, the lowest risk was seen with estradiol, compared with conjugated equine estrogens or combined preparations.

The lowest risk of VTE among oral preparations was seen with estradiol plus dydrogesterone, which only showed a nonsignificant 18% increase in risk.

In an attempt to account for possible increased risk of VTE, the authors conducted a sensitivity analysis in a subgroup of women who had not previously used anticoagulants, but they found similar results to the main analysis.

“This sensitivity analysis indicates that most of the excluded women had probably used anticoagulants because of atrial fibrillation or hip replacement operations rather than an earlier unrecorded VTE,” they wrote.

One author declared directorship of a clinical software company, but no other conflicts of interest were declared. There was no external funding. Dr. Pal reported that she was a coinvestigator in the Kronos Early Estrogen Prevention Study and on an AMAG Pharmaceuticals advisory board and member of their speaker’s bureau. 

SOURCE: Vinogradova Y et al. BMJ. 2019 Jan 9. doi: 10.1136/bmj.k4810.

*This article was updated 1/11/19.
 

Torrent Pharmaceuticals is expanding its recall of losartan potassium tablets from 2 lots to 12 lots, according to a Safety Alert from the Food and Drug Administration.

Wikimedia Commons/FitzColinGerald/Creative Commons License

The recall was based on the discovery of N-nitrosodiethylamine (NDEA) above recommended levels in seven 100-mg lots of losartan, four 50-mg lots, and one 25-mg lot. NDEA is a naturally occurring substance that has been classified as a probable human carcinogen by the International Agency for Research on Cancer. Torrent Pharmaceuticals has not reported any adverse events related to the recall.

Losartan currently is indicated to treat hypertension, hypertensive patients with left ventricular hypertrophy, and nephropathy in type 2 diabetic patients. Patients who are taking losartan should continue to do so, as stopping treatment without an alternative could represent a greater health risk.

“Patients should contact their pharmacist or physician who can advise them about an alternative treatment prior to returning their medication,” the FDA said in the press release.

Find the full press release on the FDA website.

lfranki@mdedge.com

Torrent Pharmaceuticals is expanding its recall of losartan potassium tablets from 2 lots to 12 lots, according to a Safety Alert from the Food and Drug Administration.

Wikimedia Commons/FitzColinGerald/Creative Commons License

The recall was based on the discovery of N-nitrosodiethylamine (NDEA) above recommended levels in seven 100-mg lots of losartan, four 50-mg lots, and one 25-mg lot. NDEA is a naturally occurring substance that has been classified as a probable human carcinogen by the International Agency for Research on Cancer. Torrent Pharmaceuticals has not reported any adverse events related to the recall.

Losartan currently is indicated to treat hypertension, hypertensive patients with left ventricular hypertrophy, and nephropathy in type 2 diabetic patients. Patients who are taking losartan should continue to do so, as stopping treatment without an alternative could represent a greater health risk.

“Patients should contact their pharmacist or physician who can advise them about an alternative treatment prior to returning their medication,” the FDA said in the press release.

Find the full press release on the FDA website.

lfranki@mdedge.com

Torrent Pharmaceuticals is expanding its recall of losartan potassium tablets from 2 lots to 12 lots, according to a Safety Alert from the Food and Drug Administration.

Wikimedia Commons/FitzColinGerald/Creative Commons License

The recall was based on the discovery of N-nitrosodiethylamine (NDEA) above recommended levels in seven 100-mg lots of losartan, four 50-mg lots, and one 25-mg lot. NDEA is a naturally occurring substance that has been classified as a probable human carcinogen by the International Agency for Research on Cancer. Torrent Pharmaceuticals has not reported any adverse events related to the recall.

Losartan currently is indicated to treat hypertension, hypertensive patients with left ventricular hypertrophy, and nephropathy in type 2 diabetic patients. Patients who are taking losartan should continue to do so, as stopping treatment without an alternative could represent a greater health risk.

“Patients should contact their pharmacist or physician who can advise them about an alternative treatment prior to returning their medication,” the FDA said in the press release.

Find the full press release on the FDA website.

lfranki@mdedge.com

Negligent management of labor is the top cause of lawsuits against ob.gyns, a study of legal claims shows.

Researchers with national medical liability insurer, Coverys, analyzed 472 ob.gyn.–related claims from their database that closed between 2013 and 2017. Of the claims, 37% stemmed from alleged negligence during labor management, while 14% resulted from inappropriate management of pregnancy, and 12% were associated with negligent patient monitoring. And 11% resulted from an alleged delay in performing cesarean section, according to the report.

More than half of the obstetric-related claims involved patients with at least one known comorbidity (58%), most commonly diabetes and obesity. Hypertension was the third most frequent risk factor associated with patient claims, followed by post-40 week gestation and macrosomia. Vaginal births were responsible for more claims than cesarean sections (52% vs. 45%); vaginal births also resulted in more than three times as many claims as did emergency cesareans.

Nearly all obstetrics claims resulted in injuries or death to babies (90%), with 41% of claims associated with neurologic injuries, 37% related to shoulder dystocia/brachial plexus injuries, and 34% ending in fetal demise, including stillbirth. Other claims included congenital injuries, chorioamnionitis, and lacerations/contusions.

Of 60 claims that included communication breakdowns as a key factor, 28% were associated with communication failures between physicians, while 28% were associated with communication breakdowns between doctors and nurses. Of the communication mishap cases, 17% were associated with communication failures among physicians and mid-level providers and 10% were associated with breakdowns in communication between physicians and patients.

The Coverys report includes guidance for ob.gyns. on reducing their legal risk when caring for patients in labor. Some primary tips include:

• Require fetal heart rate (FHR) interpretation training. All obstetric providers and staff should undergo training on the interpretation of FHR patterns before treating obstetric patients.
• Strengthen communication. Health professionals should use the same language when describing electronic fetal-monitoring patterns. Such terminology should be used consistently through all medical record entries and communications regarding patient cases.
• Craft and maintain fetal-monitoring policies. Develop evidence-based policies and procedures around fetal monitoring during labor that outline when each type of monitoring should be used based on each patient case and circumstance.
• Keep doctors informed. Develop protocols that ensure physicians remain in the loop regarding the condition of the patient and which includes communication strategies for contacting doctors when the patient’s condition changes or requires oversight.

Negligent management of labor is the top cause of lawsuits against ob.gyns, a study of legal claims shows.

Researchers with national medical liability insurer, Coverys, analyzed 472 ob.gyn.–related claims from their database that closed between 2013 and 2017. Of the claims, 37% stemmed from alleged negligence during labor management, while 14% resulted from inappropriate management of pregnancy, and 12% were associated with negligent patient monitoring. And 11% resulted from an alleged delay in performing cesarean section, according to the report.

More than half of the obstetric-related claims involved patients with at least one known comorbidity (58%), most commonly diabetes and obesity. Hypertension was the third most frequent risk factor associated with patient claims, followed by post-40 week gestation and macrosomia. Vaginal births were responsible for more claims than cesarean sections (52% vs. 45%); vaginal births also resulted in more than three times as many claims as did emergency cesareans.

Nearly all obstetrics claims resulted in injuries or death to babies (90%), with 41% of claims associated with neurologic injuries, 37% related to shoulder dystocia/brachial plexus injuries, and 34% ending in fetal demise, including stillbirth. Other claims included congenital injuries, chorioamnionitis, and lacerations/contusions.

Of 60 claims that included communication breakdowns as a key factor, 28% were associated with communication failures between physicians, while 28% were associated with communication breakdowns between doctors and nurses. Of the communication mishap cases, 17% were associated with communication failures among physicians and mid-level providers and 10% were associated with breakdowns in communication between physicians and patients.

The Coverys report includes guidance for ob.gyns. on reducing their legal risk when caring for patients in labor. Some primary tips include:

• Require fetal heart rate (FHR) interpretation training. All obstetric providers and staff should undergo training on the interpretation of FHR patterns before treating obstetric patients.
• Strengthen communication. Health professionals should use the same language when describing electronic fetal-monitoring patterns. Such terminology should be used consistently through all medical record entries and communications regarding patient cases.
• Craft and maintain fetal-monitoring policies. Develop evidence-based policies and procedures around fetal monitoring during labor that outline when each type of monitoring should be used based on each patient case and circumstance.
• Keep doctors informed. Develop protocols that ensure physicians remain in the loop regarding the condition of the patient and which includes communication strategies for contacting doctors when the patient’s condition changes or requires oversight.

Negligent management of labor is the top cause of lawsuits against ob.gyns, a study of legal claims shows.

Researchers with national medical liability insurer, Coverys, analyzed 472 ob.gyn.–related claims from their database that closed between 2013 and 2017. Of the claims, 37% stemmed from alleged negligence during labor management, while 14% resulted from inappropriate management of pregnancy, and 12% were associated with negligent patient monitoring. And 11% resulted from an alleged delay in performing cesarean section, according to the report.

More than half of the obstetric-related claims involved patients with at least one known comorbidity (58%), most commonly diabetes and obesity. Hypertension was the third most frequent risk factor associated with patient claims, followed by post-40 week gestation and macrosomia. Vaginal births were responsible for more claims than cesarean sections (52% vs. 45%); vaginal births also resulted in more than three times as many claims as did emergency cesareans.

Nearly all obstetrics claims resulted in injuries or death to babies (90%), with 41% of claims associated with neurologic injuries, 37% related to shoulder dystocia/brachial plexus injuries, and 34% ending in fetal demise, including stillbirth. Other claims included congenital injuries, chorioamnionitis, and lacerations/contusions.

Of 60 claims that included communication breakdowns as a key factor, 28% were associated with communication failures between physicians, while 28% were associated with communication breakdowns between doctors and nurses. Of the communication mishap cases, 17% were associated with communication failures among physicians and mid-level providers and 10% were associated with breakdowns in communication between physicians and patients.

The Coverys report includes guidance for ob.gyns. on reducing their legal risk when caring for patients in labor. Some primary tips include:

• Require fetal heart rate (FHR) interpretation training. All obstetric providers and staff should undergo training on the interpretation of FHR patterns before treating obstetric patients.
• Strengthen communication. Health professionals should use the same language when describing electronic fetal-monitoring patterns. Such terminology should be used consistently through all medical record entries and communications regarding patient cases.
• Craft and maintain fetal-monitoring policies. Develop evidence-based policies and procedures around fetal monitoring during labor that outline when each type of monitoring should be used based on each patient case and circumstance.
• Keep doctors informed. Develop protocols that ensure physicians remain in the loop regarding the condition of the patient and which includes communication strategies for contacting doctors when the patient’s condition changes or requires oversight.

Low-dose treatment with plerixafor, a CXC chemokine receptor 4 antagonist, was well tolerated and markedly improved severe presentations of warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) syndrome in three patients who could not receive granulocyte colony-stimulating factor therapy, investigators reported.

“Myelofibrosis, panleukopenia, anemia, and thrombocytopenia were ameliorated, the wart burden and frequency of infection declined, human papillomavirus–associated oropharyngeal squamous-cell carcinoma stabilized, and quality of life improved markedly,” David H. McDermott, MD, of the National Institute of Allergy and Infectious Diseases and his colleagues wrote in the New England Journal of Medicine.

WHIM syndrome is a primary immunodeficiency disorder characterized by panleukopenia and caused by autosomal dominant gain-of-function mutations in CXC chemokine receptor 4 (CXCR4). Granulocyte colony-stimulating factor (G-CSF) therapy improves neutropenia in these patients, but not other cytopenias.

Previously, the investigators treated three WHIM syndrome patients with plerixafor (Mozobil), which was well tolerated and led to sustained increases in circulating neutrophils, lymphocytes, and monocytes. The current report is of three patients with advanced WHIM syndrome who received open-label plerixafor because they were ineligible for a randomized trial of this drug.

After treatment initiation, infection frequency dropped by 85% in one patient and declined markedly in all three patients. Lymphocyte counts improved the most in two patients while neutrophils were most responsive in the third patient. Warts partially resolved in two patients, of which one patient also experienced partial resolution of head and neck squamous cell carcinoma. This patient later died of a multidrug-resistant Pseudomonas aeruginosa infection after undergoing a 9-hour surgery.

In the third patient, plerixafor therapy led to clearance of TSPyV and 17 human papillomavirus (HPV) infections, with consequent resolution of chronic, progressive, multifocal eczematoid and follicular lesions, the researchers reported. The study dose was relatively low – about 10% of the stem-cell mobilization dose – and did not cause bone pain or other treatment-emergent adverse events, despite the relatively long treatment course (19-52 months).

A separate, phase 3 trial (NCT02231879) has enrolled 19 patients. Primary results are expected in 2020.

The National Institutes of Health funded the work. Dr. McDermott reported a pending patent to reduce CXCR4 expression and/or function to enhance engraftment of hematopoietic stem cells.

SOURCE: McDermott DH et al. N Engl J Med. 2019;380:163-70.
 

Low-dose treatment with plerixafor, a CXC chemokine receptor 4 antagonist, was well tolerated and markedly improved severe presentations of warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) syndrome in three patients who could not receive granulocyte colony-stimulating factor therapy, investigators reported.

“Myelofibrosis, panleukopenia, anemia, and thrombocytopenia were ameliorated, the wart burden and frequency of infection declined, human papillomavirus–associated oropharyngeal squamous-cell carcinoma stabilized, and quality of life improved markedly,” David H. McDermott, MD, of the National Institute of Allergy and Infectious Diseases and his colleagues wrote in the New England Journal of Medicine.

WHIM syndrome is a primary immunodeficiency disorder characterized by panleukopenia and caused by autosomal dominant gain-of-function mutations in CXC chemokine receptor 4 (CXCR4). Granulocyte colony-stimulating factor (G-CSF) therapy improves neutropenia in these patients, but not other cytopenias.

Previously, the investigators treated three WHIM syndrome patients with plerixafor (Mozobil), which was well tolerated and led to sustained increases in circulating neutrophils, lymphocytes, and monocytes. The current report is of three patients with advanced WHIM syndrome who received open-label plerixafor because they were ineligible for a randomized trial of this drug.

After treatment initiation, infection frequency dropped by 85% in one patient and declined markedly in all three patients. Lymphocyte counts improved the most in two patients while neutrophils were most responsive in the third patient. Warts partially resolved in two patients, of which one patient also experienced partial resolution of head and neck squamous cell carcinoma. This patient later died of a multidrug-resistant Pseudomonas aeruginosa infection after undergoing a 9-hour surgery.

In the third patient, plerixafor therapy led to clearance of TSPyV and 17 human papillomavirus (HPV) infections, with consequent resolution of chronic, progressive, multifocal eczematoid and follicular lesions, the researchers reported. The study dose was relatively low – about 10% of the stem-cell mobilization dose – and did not cause bone pain or other treatment-emergent adverse events, despite the relatively long treatment course (19-52 months).

A separate, phase 3 trial (NCT02231879) has enrolled 19 patients. Primary results are expected in 2020.

The National Institutes of Health funded the work. Dr. McDermott reported a pending patent to reduce CXCR4 expression and/or function to enhance engraftment of hematopoietic stem cells.

SOURCE: McDermott DH et al. N Engl J Med. 2019;380:163-70.
 

Low-dose treatment with plerixafor, a CXC chemokine receptor 4 antagonist, was well tolerated and markedly improved severe presentations of warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) syndrome in three patients who could not receive granulocyte colony-stimulating factor therapy, investigators reported.

“Myelofibrosis, panleukopenia, anemia, and thrombocytopenia were ameliorated, the wart burden and frequency of infection declined, human papillomavirus–associated oropharyngeal squamous-cell carcinoma stabilized, and quality of life improved markedly,” David H. McDermott, MD, of the National Institute of Allergy and Infectious Diseases and his colleagues wrote in the New England Journal of Medicine.

WHIM syndrome is a primary immunodeficiency disorder characterized by panleukopenia and caused by autosomal dominant gain-of-function mutations in CXC chemokine receptor 4 (CXCR4). Granulocyte colony-stimulating factor (G-CSF) therapy improves neutropenia in these patients, but not other cytopenias.

Previously, the investigators treated three WHIM syndrome patients with plerixafor (Mozobil), which was well tolerated and led to sustained increases in circulating neutrophils, lymphocytes, and monocytes. The current report is of three patients with advanced WHIM syndrome who received open-label plerixafor because they were ineligible for a randomized trial of this drug.

After treatment initiation, infection frequency dropped by 85% in one patient and declined markedly in all three patients. Lymphocyte counts improved the most in two patients while neutrophils were most responsive in the third patient. Warts partially resolved in two patients, of which one patient also experienced partial resolution of head and neck squamous cell carcinoma. This patient later died of a multidrug-resistant Pseudomonas aeruginosa infection after undergoing a 9-hour surgery.

In the third patient, plerixafor therapy led to clearance of TSPyV and 17 human papillomavirus (HPV) infections, with consequent resolution of chronic, progressive, multifocal eczematoid and follicular lesions, the researchers reported. The study dose was relatively low – about 10% of the stem-cell mobilization dose – and did not cause bone pain or other treatment-emergent adverse events, despite the relatively long treatment course (19-52 months).

A separate, phase 3 trial (NCT02231879) has enrolled 19 patients. Primary results are expected in 2020.

The National Institutes of Health funded the work. Dr. McDermott reported a pending patent to reduce CXCR4 expression and/or function to enhance engraftment of hematopoietic stem cells.

SOURCE: McDermott DH et al. N Engl J Med. 2019;380:163-70.
 

MONTREAL – For the second time in the past year, an anticoagulant failed to show superiority when it was compared with aspirin for preventing a second stroke in patients who had had an index embolic stroke of undetermined source (ESUS). But the most recent results gave a tantalizing suggestion that the anticoagulant approach might be effective for older patients, those at least 75 years old, possibly because these patients have the highest incidence of atrial fibrillation.

Mitchel L. Zoler/MDedge News

“The fact that we saw a treatment benefit in patients 75 and older [in a post hoc, subgroup analysis] means that development of atrial fibrillation (AF) is probably the most important factor,” Hans-Christoph Diener, MD, said at the World Stroke Congress. Another clue that incident AF drove a treatment benefit hidden in the new trial’s overall neutral result was that a post hoc, landmark analysis showed that, while the rate of second strokes was identical during the first year of follow-up in patients on either aspirin or the anticoagulant dabigatran (Pradaxa) after an index ESUS, patients on dabigatran had significantly fewer second strokes during subsequent follow-up.

More follow-up time was needed to see a benefit from anticoagulation because “it takes time for AF to develop, and then once a patient has AF, it takes time for a stroke to occur,” explained Dr. Diener, professor of neurology at the University of Duisburg-Essen in Essen, Germany.

The RE-SPECT ESUS (Dabigatran Etexilate for Secondary Stroke Prevention in Patients With Embolic Stroke of Undetermined Source) trial randomized 5,390 patients at more than 500 sites in 41 countries, including the United States, within 6 months of an index ESUS who had no history of AF and no severe renal impairment. All enrollees had to have less than 6 minutes of AF episodes during at least 20 hours of cardiac monitoring, and they had to be free of flow-limiting stenoses (50% or more) in arteries supplying their stroke region. Patients received either 150 mg or 110 mg of dabigatran twice daily depending on their age and renal function or 100 mg of aspirin daily. About a quarter of patients randomized to dabigatran received the lower dosage. The enrolled patients averaged 66 years old, almost two-thirds were men, and they started treatment a median of 44 days after their index stroke.

During a median 19 months’ follow-up, the incidence of a second stroke of any type was 4.1%/year among the patients on dabigatran and 4.8%/year among those on aspirin, a difference that was not statistically significant. However, the post hoc landmark analysis showed a significant reduction in second strokes with dabigatran treatment after the first year. In addition, a post hoc subgroup analysis showed that, among patients aged at least 75 years old, treatment with dabigatran linked with a statistically significant 37% reduction in second strokes, compared with treatment with aspirin, Dr. Diener reported.

The primary safety endpoint was major bleeds, as defined by the International Society on Thrombosis and Haemostasis, which occurred in 1.7%/year of patients on dabigatran and 1.4%/year of those on aspirin, a difference that was not statistically significant. Patients on dabigatran had a significant excess of major bleeds combined with clinically significant nonmajor bleeds: 3.3%/year versus 2.3%/year among those on aspirin.

A little over 4 months before Dr. Diener’s report, a separate research group published primary results from the NAVIGATE ESUS (Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source) trial, which compared the anticoagulant rivaroxaban (Xarelto) with aspirin for prevention of a second stroke in 7,213 ESUS patients. The results showed no significant efficacy difference between rivaroxaban and aspirin (N Engl J Med. 2018 June 7;378[23]:2191-2201).

RE-SPECT ESUS was funded by Boehringer Ingelheim, the company that markets dabigatran (Pradaxa). Dr. Diener has been a consultant to and has received research funding from Boehringer Ingelheim, as well as several other companies.

mzoler@mdedge.com

SOURCE: Diener H-C et al. Int J Stroke. 2018;13(2_suppl):27. Abstract 100.

MONTREAL – For the second time in the past year, an anticoagulant failed to show superiority when it was compared with aspirin for preventing a second stroke in patients who had had an index embolic stroke of undetermined source (ESUS). But the most recent results gave a tantalizing suggestion that the anticoagulant approach might be effective for older patients, those at least 75 years old, possibly because these patients have the highest incidence of atrial fibrillation.

Mitchel L. Zoler/MDedge News

“The fact that we saw a treatment benefit in patients 75 and older [in a post hoc, subgroup analysis] means that development of atrial fibrillation (AF) is probably the most important factor,” Hans-Christoph Diener, MD, said at the World Stroke Congress. Another clue that incident AF drove a treatment benefit hidden in the new trial’s overall neutral result was that a post hoc, landmark analysis showed that, while the rate of second strokes was identical during the first year of follow-up in patients on either aspirin or the anticoagulant dabigatran (Pradaxa) after an index ESUS, patients on dabigatran had significantly fewer second strokes during subsequent follow-up.

More follow-up time was needed to see a benefit from anticoagulation because “it takes time for AF to develop, and then once a patient has AF, it takes time for a stroke to occur,” explained Dr. Diener, professor of neurology at the University of Duisburg-Essen in Essen, Germany.

The RE-SPECT ESUS (Dabigatran Etexilate for Secondary Stroke Prevention in Patients With Embolic Stroke of Undetermined Source) trial randomized 5,390 patients at more than 500 sites in 41 countries, including the United States, within 6 months of an index ESUS who had no history of AF and no severe renal impairment. All enrollees had to have less than 6 minutes of AF episodes during at least 20 hours of cardiac monitoring, and they had to be free of flow-limiting stenoses (50% or more) in arteries supplying their stroke region. Patients received either 150 mg or 110 mg of dabigatran twice daily depending on their age and renal function or 100 mg of aspirin daily. About a quarter of patients randomized to dabigatran received the lower dosage. The enrolled patients averaged 66 years old, almost two-thirds were men, and they started treatment a median of 44 days after their index stroke.

During a median 19 months’ follow-up, the incidence of a second stroke of any type was 4.1%/year among the patients on dabigatran and 4.8%/year among those on aspirin, a difference that was not statistically significant. However, the post hoc landmark analysis showed a significant reduction in second strokes with dabigatran treatment after the first year. In addition, a post hoc subgroup analysis showed that, among patients aged at least 75 years old, treatment with dabigatran linked with a statistically significant 37% reduction in second strokes, compared with treatment with aspirin, Dr. Diener reported.

The primary safety endpoint was major bleeds, as defined by the International Society on Thrombosis and Haemostasis, which occurred in 1.7%/year of patients on dabigatran and 1.4%/year of those on aspirin, a difference that was not statistically significant. Patients on dabigatran had a significant excess of major bleeds combined with clinically significant nonmajor bleeds: 3.3%/year versus 2.3%/year among those on aspirin.

A little over 4 months before Dr. Diener’s report, a separate research group published primary results from the NAVIGATE ESUS (Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source) trial, which compared the anticoagulant rivaroxaban (Xarelto) with aspirin for prevention of a second stroke in 7,213 ESUS patients. The results showed no significant efficacy difference between rivaroxaban and aspirin (N Engl J Med. 2018 June 7;378[23]:2191-2201).

RE-SPECT ESUS was funded by Boehringer Ingelheim, the company that markets dabigatran (Pradaxa). Dr. Diener has been a consultant to and has received research funding from Boehringer Ingelheim, as well as several other companies.

mzoler@mdedge.com

SOURCE: Diener H-C et al. Int J Stroke. 2018;13(2_suppl):27. Abstract 100.

MONTREAL – For the second time in the past year, an anticoagulant failed to show superiority when it was compared with aspirin for preventing a second stroke in patients who had had an index embolic stroke of undetermined source (ESUS). But the most recent results gave a tantalizing suggestion that the anticoagulant approach might be effective for older patients, those at least 75 years old, possibly because these patients have the highest incidence of atrial fibrillation.

Mitchel L. Zoler/MDedge News

“The fact that we saw a treatment benefit in patients 75 and older [in a post hoc, subgroup analysis] means that development of atrial fibrillation (AF) is probably the most important factor,” Hans-Christoph Diener, MD, said at the World Stroke Congress. Another clue that incident AF drove a treatment benefit hidden in the new trial’s overall neutral result was that a post hoc, landmark analysis showed that, while the rate of second strokes was identical during the first year of follow-up in patients on either aspirin or the anticoagulant dabigatran (Pradaxa) after an index ESUS, patients on dabigatran had significantly fewer second strokes during subsequent follow-up.

More follow-up time was needed to see a benefit from anticoagulation because “it takes time for AF to develop, and then once a patient has AF, it takes time for a stroke to occur,” explained Dr. Diener, professor of neurology at the University of Duisburg-Essen in Essen, Germany.

The RE-SPECT ESUS (Dabigatran Etexilate for Secondary Stroke Prevention in Patients With Embolic Stroke of Undetermined Source) trial randomized 5,390 patients at more than 500 sites in 41 countries, including the United States, within 6 months of an index ESUS who had no history of AF and no severe renal impairment. All enrollees had to have less than 6 minutes of AF episodes during at least 20 hours of cardiac monitoring, and they had to be free of flow-limiting stenoses (50% or more) in arteries supplying their stroke region. Patients received either 150 mg or 110 mg of dabigatran twice daily depending on their age and renal function or 100 mg of aspirin daily. About a quarter of patients randomized to dabigatran received the lower dosage. The enrolled patients averaged 66 years old, almost two-thirds were men, and they started treatment a median of 44 days after their index stroke.

During a median 19 months’ follow-up, the incidence of a second stroke of any type was 4.1%/year among the patients on dabigatran and 4.8%/year among those on aspirin, a difference that was not statistically significant. However, the post hoc landmark analysis showed a significant reduction in second strokes with dabigatran treatment after the first year. In addition, a post hoc subgroup analysis showed that, among patients aged at least 75 years old, treatment with dabigatran linked with a statistically significant 37% reduction in second strokes, compared with treatment with aspirin, Dr. Diener reported.

The primary safety endpoint was major bleeds, as defined by the International Society on Thrombosis and Haemostasis, which occurred in 1.7%/year of patients on dabigatran and 1.4%/year of those on aspirin, a difference that was not statistically significant. Patients on dabigatran had a significant excess of major bleeds combined with clinically significant nonmajor bleeds: 3.3%/year versus 2.3%/year among those on aspirin.

A little over 4 months before Dr. Diener’s report, a separate research group published primary results from the NAVIGATE ESUS (Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source) trial, which compared the anticoagulant rivaroxaban (Xarelto) with aspirin for prevention of a second stroke in 7,213 ESUS patients. The results showed no significant efficacy difference between rivaroxaban and aspirin (N Engl J Med. 2018 June 7;378[23]:2191-2201).

RE-SPECT ESUS was funded by Boehringer Ingelheim, the company that markets dabigatran (Pradaxa). Dr. Diener has been a consultant to and has received research funding from Boehringer Ingelheim, as well as several other companies.

mzoler@mdedge.com

SOURCE: Diener H-C et al. Int J Stroke. 2018;13(2_suppl):27. Abstract 100.

Military dermatologists complete their residency training at 1 of 3 large military medical centers across the country: Walter Reed National Military Medical Center (Bethesda, Maryland), San Antonio Military Health System (San Antonio, Texas), or Naval Medical Center San Diego (San Diego, California). While in training, army dermatology residents in particular fall under the US Army Medical Command, or MEDCOM, which provides command and control of the army’s medical, dental, and veterinary treatment facilities. Upon graduating from residency, army dermatologists often are stationed with MEDCOM units but become eligible for deployment with US Army Forces Command (FORSCOM) units to both combat and noncombat zones depending on each individual FORSCOM unit’s mission.

The process by which dermatologists and other army physicians are tasked to a deploying FORSCOM unit is referred to as the Professional Filler System, or PROFIS, which was designed to help alleviate the financial cost and specialty skill degradation of having a physician assigned to a FORSCOM unit while not deployed.¹ In general, the greater the amount of time that an army medical officer has not been deployed, the more likely they are to be selected for deployment with a FORSCOM unit. For the army dermatologist, deployment often comes shortly after completing residency or fellowship.

In this article, we review the various functions of the deployed dermatologist and also highlight the importance of maintaining basic emergency medical skills that could be generalized to the civilian population in case of local or national emergencies.

THE FIELD SURGEON

With rare exceptions, the US Army does not deploy dermatologists for their expertise in diagnosing and managing cutaneous diseases. Typically, a dermatologist will be assigned to a FORSCOM unit in the role of field surgeon. Other medical specialties including emergency medicine, family practice, internal medicine, pediatrics, and obstetrics and gynecology also are eligible for deployment as field surgeons.² Field surgeons typically are assigned to a battalion-sized element of 300 to 1000 soldiers and are responsible for all medical care rendered under their supervision. Duties include combat resuscitation, primary care services, preventive medicine, medical training of battalion medical personnel, and serving as the medical adviser to the battalion commander.¹ In some instances, a field surgeon will be stationed at a higher level of care co-located with a trauma surgeon; in those cases, the field surgeon also may be expected to assist in trauma surgery cases.

ARMY DEPLOYMENT MEDICAL SYSTEM

To better understand the responsibilities of a field surgeon, it is important to discuss the structure of the army’s deployment medical system. The US Military, including the army, has adopted a system of “roles” that have specific requirements regarding their associated medical capabilities.³ There are 4 roles designated within the army. Role 1 facilities are known as battalion aid stations (BASs). Capabilities include initial treatment, triage, and evacuation, with a goal of returning soldiers to combat or stabilizing and evacuating them to a higher-role facility. Role 2 facilities are capable of providing a higher level of emergency care, including basic radiology, laboratory services, transfusion of blood products, and surgical interventions when co-located with a forward surgical team (Figure 1). Role 3 facilities, also known as combat support hospitals, have inpatient hospitalization capabilities including subspecialty surgery and intensive care. Role 4 facilities are fully capable medical centers located in the United States and other noncombat locations.³

Role of the Field Surgeon

Within the broader structure of the army, approximately 5 battalions (each composed of 300 to 1000 soldiers) comprise a single brigade combat team. Role 1 medical facilities typically have a single battalion surgeon assigned to them. Field surgeons most commonly serve in this battalion surgeon position. Additionally, Role 2 facilities may have slots for up to 2 battalion surgeons; however, field surgeons are less commonly tasked with this assignment.¹ Occasionally, in one author’s (N.R.M.) personal experience, these roles are more fluid than one might expect. A field surgeon tasked initially with a Role 1 position may be shifted to a Role 2 assignment on an as-needed basis. This ability for rapid change in roles and responsibilities underscores the need for a fluid mind-set and thorough predeployment training for the field surgeon.

PREDEPLOYMENT TRAINING

As one might expect, dermatologists who have just graduated residency or fellowship are unlikely to have honed their trauma support skills to the degree needed to support a deployed battalion actively engaging in combat. Fortunately, there are many opportunities for military dermatologists to practice these skills prior to joining their FORSCOM colleagues. The initial exposure to trauma support comes during medical internship at the mandatory Combat Casualty Care Course (C4), an 8-day program designed to enhance the operational medical readiness and predeployment trauma training skills of medical officers.⁴ The C4 program includes 3 days of classroom training and 5 days of intensive field training. During C4, medical officers become certified in Advanced Trauma Life Support, a 3-day course organized by the American College of Surgeons.⁵ This course teaches medical officers how to quickly and judiciously triage, treat, and transport patients who have sustained potentially life-threatening traumas.

The next components of predeployment training, Tactical Combat Casualty Care and Tactical Combat Medical Care, occur in the months to weeks immediately preceding deployment.^1,6 Tactical Combat Casualty Care prepares participants in the initial stabilization of trauma to occur at the point of injury.⁶ Tactical Combat Casualty Care principles generally are employed by medics (enlisted personnel trained in point-of-care medical support) rather than physicians; however, these principles are still critical for medical officers to be aware of when encountering severe traumas.⁶ In addition, the physician is responsible for ensuring his/her medics are fully trained in Tactical Combat Casualty Care. Tactical Combat Medical Care is geared more toward the direct preparation of medical officers. During the 5-day course, medical officers learn the gold standard for trauma care in both the classroom and in hands-on scenarios.¹ This training not only allows medical officers to be self-sufficient in providing trauma support, but it also enables them to better maintain quality control of the performance of their medics continuously throughout the deployment.¹

DEPLOYMENT RESPONSIBILITIES

Dermatologists who have completed the above training typically are subsequently deployed as field surgeons to a Role 1 facility. Field surgeons are designated as the officer in charge of the BAS and assume the position of medical platoon leader. A field surgeon usually will have both a physician assistant and a field medical assistant/medical plans officer (MEDO) to assist in running the BAS. The overarching goal of the field surgeon is to maintain the health and readiness of the battalion. In addition to addressing the day-to-day health care needs of individual soldiers, a field surgeon is expected to attend all staff meetings, advise the commander on preventative health and epidemiological trends, identify the scope of practice of the medics, ensure the BAS is prepared for mass casualties, and take responsibility for all controlled substances.

To illustrate the value that the properly trained dermatologist can provide in the deployed setting, we will outline field surgeon responsibilities and provide case examples of the first-hand experiences of one of the authors (N.R.M.) as a Role 2 officer in charge and field surgeon. The information presented in the case examples may have been altered to ensure continued operational security and out of respect to US servicemembers and coalition forces while still conveying important learning points.

Sick Call

In the deployed environment, military sick call functions as an urgent care center that is open continuously and serves the active-duty population, US government civilians and contractors, and coalition forces. In general, the physician assistant should treat approximately two-thirds of sick call patients under the supervision of the field surgeon, allowing the field surgeon to focus on his/her ancillary duties and ensure overall medical supervision of the unit. As a safeguard, patients with more than 2 visits for the same concern must be evaluated by the field surgeon. Sick call concerns range from minor traumas and illnesses to much more serious disease processes and injuries (as outlined in Medical Emergencies). As a field surgeon, it is critical to track disease nonbattle illnesses to ensure medical readiness of the unit. In the deployed environment, close quarters and austere environments commonly lend themselves to gastrointestinal illnesses, respiratory diseases, heat injuries, vector-borne diseases, and sexually transmitted infections.

Case Examples 
During an 8-month deployment in Afghanistan, one of the authors (N.R.M.) provided or assisted in the care of more than 2300 routine sick call appointments, or approximately 10 patients per day. Epidemiology of disease was tracked, and the condition of the unit was presented daily to the battalion commander for consideration in upcoming operations. The top 5 most common categories of diagnoses included musculoskeletal injuries, gastrointestinal diseases, dermatologic concerns (eg, dermatitis, bacterial infections [cellulitis/abscess], fungal infections, arthropod assault, abrasions, lacerations, verruca vulgaris), respiratory illnesses, and mental health care, respectively. Maintaining a familiarity with general medicine is critical for the military dermatologist, and an adequate medical library or access to online medical review sources is critical for day-to-day sick call.

Medical Emergencies

In the event of a more serious injury or illness, a Role 1 BAS has very little capability in performing anything beyond the most basic interventions. Part of the art of being an effective field surgeon lies in stabilization, triage, and transport of these sometimes very ill patients. Both the decision to transport to a higher level of care (eg, Role 2 or 3 facility) as well as selection of the means of transportation falls on the field surgeon. The MEDO plays an essential role in assisting in the coordination of the transfer; however, the responsibility ultimately falls on the field surgeon.^1,6 The field surgeon at the Role 2 BAS may be expected to perform more advanced medical and surgical interventions. More advanced pharmacotherapies include thrombolytics, antivenin, and vasopressors. Some procedural interventions include intubations, central lines, and laceration repairs. The Role 2 BAS has the capability to hold patients for up to 72 hours.

Case Examples
Specific conditions one of the authors (N.R.M.) treated include heat injury, myocardial infarction, disseminated tuberculosis, appendicitis, testicular torsion, malaria, suicidal ideation, burns, and status epilepticus. Over 8 months, the Role 2 BAS received 91 medical emergencies, with 53 necessitating evacuation to a higher level of care. Often, the more serious or rare conditions presented in the foreign contractor and coalition force populations working alongside US troops.

In one particular case, a 35-year-old man with an electrocardiogram-confirmed acute ST-segment elevation myocardial infarction was administered standard therapy consisting of intravenous morphine, oxygen, sublingual nitroglycerin, an angiotensin-converting enzyme inhibitor, and a beta-blocker. Given the lack of a cardiac catheterization laboratory at the next highest level of care as well as a low suspicion for aortic dissection (based on the patient’s history, physical examination, and chest radiograph), fibrinolysis with tenecteplase was performed in the deployed environment. After a very short observation for potential hemorrhage, the patient was then evacuated to the Role 3 hospital, where he made a near-complete recovery. Preparation with advanced cardiac life support courses and a thorough algorithmic review of the 10 most common causes of presentation to the emergency department helped adequately prepare the dermatologist to succeed.

Trauma Emergencies

The same principles of triage and transport apply to trauma emergencies. Mass casualties are an inevitable reality in combat, so appropriate training translating into efficient action is essential to ensure the lowest possible mortality. This training and the actions that stem from it are an additional responsibility that the field surgeon must maintain. During deployment, continued training organized by the field surgeon could quite literally mean the difference between life and death. In addition to the organizational responsibilities, field surgeons should be prepared to perform initial stabilization in trauma patients, including application of tourniquets, establishment of central lines, reading abdominal ultrasounds for free fluid, placement of chest tubes, intubation, and ventilator management. The Joint Trauma System Clinical Practice Guidelines also offer extensive and invaluable guidance on the most up-to-date approach to common trauma conditions arising in the deployed environment.⁷ At the Role 2 level, the field surgeon also must be prepared to coordinate ancillary services, manage the Role 2/forward surgical team intensive care unit, and serve as first assist in the operating room, as needed (Figure 2).

Case Examples 
One of the authors (N.R.M.) assisted or provided care in approximately 225 trauma cases while deployed. A mass casualty event occurred, in which the Role 2 BAS received 34 casualties; of these casualties, 11 were immediate, 10 were delayed, 11 were minimal, and 2 were expectant. Injury patterns included mounted and dismounted improvised explosive device injuries (eg, blast, shrapnel, and traumatic brain injuries) as well as gunshot wounds. Direct care was provided for 13 casualties, including 10 abdominal ultrasound examinations for free fluid, placement of 2 chest tubes, 1 intubation, establishment of 3 central lines, and first-assisting 1 exploratory laparotomy. Of the casualties, 22 were evacuated to the Role 3 hospital, 8 were dispositioned to a coalition hospital, 2 were returned to active duty, and 2 died due to their injuries. The military trauma preparation as outlined in the predeployment training can help adequately prepare the military dermatologist to assist in these cases.

Ancillary Services

An important part of the efficacy of initial evaluation and stabilization of both medical and traumatic emergencies involves expedited laboratory tests, imaging, and the delivery of life-saving blood products to affected patients. The field surgeon is responsible for the readiness of these services and may play a critical role in streamlining these tasks for situations where a delay in care by minutes can be lethal. The MEDO assists the field surgeon to ensure the readiness of the medical equipment, and the field surgeon must ensure the readiness of the medics and technicians utilizing the equipment. In a deployed environment, only a finite amount of blood products may be stored. As a result, the design and implementation of an efficient and precise walking blood bank is critical. To help mitigate this issue, servicemembers are prescreened for their blood types and bloodborne illnesses. If a situation arises in which whole blood is needed, the prescreened individuals are screened again, and their blood is collected and transfused to the patient under the supervision of the physician. This task is critical in saving lives, and this process is the primary responsibility of the field surgeon.

Case Example 
A 37-year-old man presented to the BAS with abdominal and pelvic gunshot wounds, as well as tachycardia, rapidly decreasing blood pressure, and altered consciousness. An exploratory laparotomy was performed to look for the sources of bleeding. The patient’s blood type was confirmed with a portable testing kit. Due to the injury pattern and clinical presentation, a call was immediately placed to begin screening and preparing servicemembers to donate blood for the walking blood bank. As expected, the Role 2 supply of blood products was exhausted during the exploratory laparotomy. With servicemembers in place and screened, an additional 12 units of whole blood were collected and administered in a timely fashion. The patient was stabilized and transported to the next highest level of care. Due to the process optimization performed by the laboratory team, whole-blood transfusions were ready within an average of 22 minutes, well ahead of the 45-minute standard of care. Local process was studied by the military leadership and implemented throughout Afghanistan.

Operating Room First Assist

If a field surgeon is stationed at a Role 2 BAS with a forward surgical team, he/she may be required to adopt the role of operating room first assist for the trauma surgeon or orthopedic surgeon on the team, which is especially true for isolated major traumas when triage and initial stabilization measures for multiple patients are of less concern. Dermatologists receive surgical training as part of the Accreditation Council for Graduate Medical Education requirements to graduate residency, making them more than capable of surgical assisting when needed.⁸ In particular, dermatologists’ ability to utilize instruments appropriately and think procedurally as well as their skills in suturing are helpful.

Case Example 
A 22-year-old man with several shrapnel wounds to the abdomen demonstrated free fluid in the left lower quadrant. The field surgeon (N.R.M.) assisted the trauma surgeon in opening the abdomen and running the bowel for sources of bleeding. The trauma surgeon identified the bleed and performed a ligation. The patient was then packed, closed, and prepared for transfer to a higher level of care.

Preventive Medicine

As a result of the field surgeon being on the front line of medical care in an austere environment, implementation of preventive medicine practices and disease pattern recognition are his/her responsibility. Responsibilities may include stray animal euthanasia due to prevalence of rabies, enforcement of malaria prophylaxis, medical training and maintenance of snake antivenin, and assistance with other local endemic disease. The unique skill set of dermatologists in organism identification can further bolster the speed with which vector-borne diseases are recognized and prevention and treatment measures are implemented.

Case Example 
As coalition forces executed a mission in Afghanistan, US servicemembers began experiencing abdominal distress, chills, fevers (temperature >40°C), debilitating headaches, myalgia, arthralgia, and tachycardia. Initially, these patients were evacuated to the Role 2 BAS, hindering the mission. Upon inspection, patients had numerous bug bites; one astute soldier collected the arthropod guilty of the assault and brought it to the aid station. Upon inspection, the offender was identified as the Phlebotomus genus of sandflies, organisms that are well known to dermatologists as a cause of leishmaniasis. Clinical correlation resulted in the presumed diagnosis of Pappataci fever, and vector-borne disease prevention measures were then able to be further emphasized and implemented in at-risk areas, allowing the mission to continue.⁹ Subsequent infectious disease laboratory testing confirmed the Phlebovirus transmitted by the sandfly as the underlying cause of the illness.

CONCLUSION

The diverse role of the field surgeon in the deployed setting makes any one specialist underprepared to completely take on the role from the outset; however, with appropriate and rigorous trauma training prior to deployment, dermatologists will continue to perform as invaluable assets to the US military in conflicts now and in the future.

Military dermatologists complete their residency training at 1 of 3 large military medical centers across the country: Walter Reed National Military Medical Center (Bethesda, Maryland), San Antonio Military Health System (San Antonio, Texas), or Naval Medical Center San Diego (San Diego, California). While in training, army dermatology residents in particular fall under the US Army Medical Command, or MEDCOM, which provides command and control of the army’s medical, dental, and veterinary treatment facilities. Upon graduating from residency, army dermatologists often are stationed with MEDCOM units but become eligible for deployment with US Army Forces Command (FORSCOM) units to both combat and noncombat zones depending on each individual FORSCOM unit’s mission.

The process by which dermatologists and other army physicians are tasked to a deploying FORSCOM unit is referred to as the Professional Filler System, or PROFIS, which was designed to help alleviate the financial cost and specialty skill degradation of having a physician assigned to a FORSCOM unit while not deployed.¹ In general, the greater the amount of time that an army medical officer has not been deployed, the more likely they are to be selected for deployment with a FORSCOM unit. For the army dermatologist, deployment often comes shortly after completing residency or fellowship.

In this article, we review the various functions of the deployed dermatologist and also highlight the importance of maintaining basic emergency medical skills that could be generalized to the civilian population in case of local or national emergencies.

THE FIELD SURGEON

With rare exceptions, the US Army does not deploy dermatologists for their expertise in diagnosing and managing cutaneous diseases. Typically, a dermatologist will be assigned to a FORSCOM unit in the role of field surgeon. Other medical specialties including emergency medicine, family practice, internal medicine, pediatrics, and obstetrics and gynecology also are eligible for deployment as field surgeons.² Field surgeons typically are assigned to a battalion-sized element of 300 to 1000 soldiers and are responsible for all medical care rendered under their supervision. Duties include combat resuscitation, primary care services, preventive medicine, medical training of battalion medical personnel, and serving as the medical adviser to the battalion commander.¹ In some instances, a field surgeon will be stationed at a higher level of care co-located with a trauma surgeon; in those cases, the field surgeon also may be expected to assist in trauma surgery cases.

ARMY DEPLOYMENT MEDICAL SYSTEM

To better understand the responsibilities of a field surgeon, it is important to discuss the structure of the army’s deployment medical system. The US Military, including the army, has adopted a system of “roles” that have specific requirements regarding their associated medical capabilities.³ There are 4 roles designated within the army. Role 1 facilities are known as battalion aid stations (BASs). Capabilities include initial treatment, triage, and evacuation, with a goal of returning soldiers to combat or stabilizing and evacuating them to a higher-role facility. Role 2 facilities are capable of providing a higher level of emergency care, including basic radiology, laboratory services, transfusion of blood products, and surgical interventions when co-located with a forward surgical team (Figure 1). Role 3 facilities, also known as combat support hospitals, have inpatient hospitalization capabilities including subspecialty surgery and intensive care. Role 4 facilities are fully capable medical centers located in the United States and other noncombat locations.³

Role of the Field Surgeon

Within the broader structure of the army, approximately 5 battalions (each composed of 300 to 1000 soldiers) comprise a single brigade combat team. Role 1 medical facilities typically have a single battalion surgeon assigned to them. Field surgeons most commonly serve in this battalion surgeon position. Additionally, Role 2 facilities may have slots for up to 2 battalion surgeons; however, field surgeons are less commonly tasked with this assignment.¹ Occasionally, in one author’s (N.R.M.) personal experience, these roles are more fluid than one might expect. A field surgeon tasked initially with a Role 1 position may be shifted to a Role 2 assignment on an as-needed basis. This ability for rapid change in roles and responsibilities underscores the need for a fluid mind-set and thorough predeployment training for the field surgeon.

PREDEPLOYMENT TRAINING

As one might expect, dermatologists who have just graduated residency or fellowship are unlikely to have honed their trauma support skills to the degree needed to support a deployed battalion actively engaging in combat. Fortunately, there are many opportunities for military dermatologists to practice these skills prior to joining their FORSCOM colleagues. The initial exposure to trauma support comes during medical internship at the mandatory Combat Casualty Care Course (C4), an 8-day program designed to enhance the operational medical readiness and predeployment trauma training skills of medical officers.⁴ The C4 program includes 3 days of classroom training and 5 days of intensive field training. During C4, medical officers become certified in Advanced Trauma Life Support, a 3-day course organized by the American College of Surgeons.⁵ This course teaches medical officers how to quickly and judiciously triage, treat, and transport patients who have sustained potentially life-threatening traumas.

The next components of predeployment training, Tactical Combat Casualty Care and Tactical Combat Medical Care, occur in the months to weeks immediately preceding deployment.^1,6 Tactical Combat Casualty Care prepares participants in the initial stabilization of trauma to occur at the point of injury.⁶ Tactical Combat Casualty Care principles generally are employed by medics (enlisted personnel trained in point-of-care medical support) rather than physicians; however, these principles are still critical for medical officers to be aware of when encountering severe traumas.⁶ In addition, the physician is responsible for ensuring his/her medics are fully trained in Tactical Combat Casualty Care. Tactical Combat Medical Care is geared more toward the direct preparation of medical officers. During the 5-day course, medical officers learn the gold standard for trauma care in both the classroom and in hands-on scenarios.¹ This training not only allows medical officers to be self-sufficient in providing trauma support, but it also enables them to better maintain quality control of the performance of their medics continuously throughout the deployment.¹

DEPLOYMENT RESPONSIBILITIES

Dermatologists who have completed the above training typically are subsequently deployed as field surgeons to a Role 1 facility. Field surgeons are designated as the officer in charge of the BAS and assume the position of medical platoon leader. A field surgeon usually will have both a physician assistant and a field medical assistant/medical plans officer (MEDO) to assist in running the BAS. The overarching goal of the field surgeon is to maintain the health and readiness of the battalion. In addition to addressing the day-to-day health care needs of individual soldiers, a field surgeon is expected to attend all staff meetings, advise the commander on preventative health and epidemiological trends, identify the scope of practice of the medics, ensure the BAS is prepared for mass casualties, and take responsibility for all controlled substances.

To illustrate the value that the properly trained dermatologist can provide in the deployed setting, we will outline field surgeon responsibilities and provide case examples of the first-hand experiences of one of the authors (N.R.M.) as a Role 2 officer in charge and field surgeon. The information presented in the case examples may have been altered to ensure continued operational security and out of respect to US servicemembers and coalition forces while still conveying important learning points.

Sick Call

In the deployed environment, military sick call functions as an urgent care center that is open continuously and serves the active-duty population, US government civilians and contractors, and coalition forces. In general, the physician assistant should treat approximately two-thirds of sick call patients under the supervision of the field surgeon, allowing the field surgeon to focus on his/her ancillary duties and ensure overall medical supervision of the unit. As a safeguard, patients with more than 2 visits for the same concern must be evaluated by the field surgeon. Sick call concerns range from minor traumas and illnesses to much more serious disease processes and injuries (as outlined in Medical Emergencies). As a field surgeon, it is critical to track disease nonbattle illnesses to ensure medical readiness of the unit. In the deployed environment, close quarters and austere environments commonly lend themselves to gastrointestinal illnesses, respiratory diseases, heat injuries, vector-borne diseases, and sexually transmitted infections.

Case Examples 
During an 8-month deployment in Afghanistan, one of the authors (N.R.M.) provided or assisted in the care of more than 2300 routine sick call appointments, or approximately 10 patients per day. Epidemiology of disease was tracked, and the condition of the unit was presented daily to the battalion commander for consideration in upcoming operations. The top 5 most common categories of diagnoses included musculoskeletal injuries, gastrointestinal diseases, dermatologic concerns (eg, dermatitis, bacterial infections [cellulitis/abscess], fungal infections, arthropod assault, abrasions, lacerations, verruca vulgaris), respiratory illnesses, and mental health care, respectively. Maintaining a familiarity with general medicine is critical for the military dermatologist, and an adequate medical library or access to online medical review sources is critical for day-to-day sick call.

Medical Emergencies

In the event of a more serious injury or illness, a Role 1 BAS has very little capability in performing anything beyond the most basic interventions. Part of the art of being an effective field surgeon lies in stabilization, triage, and transport of these sometimes very ill patients. Both the decision to transport to a higher level of care (eg, Role 2 or 3 facility) as well as selection of the means of transportation falls on the field surgeon. The MEDO plays an essential role in assisting in the coordination of the transfer; however, the responsibility ultimately falls on the field surgeon.^1,6 The field surgeon at the Role 2 BAS may be expected to perform more advanced medical and surgical interventions. More advanced pharmacotherapies include thrombolytics, antivenin, and vasopressors. Some procedural interventions include intubations, central lines, and laceration repairs. The Role 2 BAS has the capability to hold patients for up to 72 hours.

Case Examples
Specific conditions one of the authors (N.R.M.) treated include heat injury, myocardial infarction, disseminated tuberculosis, appendicitis, testicular torsion, malaria, suicidal ideation, burns, and status epilepticus. Over 8 months, the Role 2 BAS received 91 medical emergencies, with 53 necessitating evacuation to a higher level of care. Often, the more serious or rare conditions presented in the foreign contractor and coalition force populations working alongside US troops.

In one particular case, a 35-year-old man with an electrocardiogram-confirmed acute ST-segment elevation myocardial infarction was administered standard therapy consisting of intravenous morphine, oxygen, sublingual nitroglycerin, an angiotensin-converting enzyme inhibitor, and a beta-blocker. Given the lack of a cardiac catheterization laboratory at the next highest level of care as well as a low suspicion for aortic dissection (based on the patient’s history, physical examination, and chest radiograph), fibrinolysis with tenecteplase was performed in the deployed environment. After a very short observation for potential hemorrhage, the patient was then evacuated to the Role 3 hospital, where he made a near-complete recovery. Preparation with advanced cardiac life support courses and a thorough algorithmic review of the 10 most common causes of presentation to the emergency department helped adequately prepare the dermatologist to succeed.

Trauma Emergencies

The same principles of triage and transport apply to trauma emergencies. Mass casualties are an inevitable reality in combat, so appropriate training translating into efficient action is essential to ensure the lowest possible mortality. This training and the actions that stem from it are an additional responsibility that the field surgeon must maintain. During deployment, continued training organized by the field surgeon could quite literally mean the difference between life and death. In addition to the organizational responsibilities, field surgeons should be prepared to perform initial stabilization in trauma patients, including application of tourniquets, establishment of central lines, reading abdominal ultrasounds for free fluid, placement of chest tubes, intubation, and ventilator management. The Joint Trauma System Clinical Practice Guidelines also offer extensive and invaluable guidance on the most up-to-date approach to common trauma conditions arising in the deployed environment.⁷ At the Role 2 level, the field surgeon also must be prepared to coordinate ancillary services, manage the Role 2/forward surgical team intensive care unit, and serve as first assist in the operating room, as needed (Figure 2).

Case Examples 
One of the authors (N.R.M.) assisted or provided care in approximately 225 trauma cases while deployed. A mass casualty event occurred, in which the Role 2 BAS received 34 casualties; of these casualties, 11 were immediate, 10 were delayed, 11 were minimal, and 2 were expectant. Injury patterns included mounted and dismounted improvised explosive device injuries (eg, blast, shrapnel, and traumatic brain injuries) as well as gunshot wounds. Direct care was provided for 13 casualties, including 10 abdominal ultrasound examinations for free fluid, placement of 2 chest tubes, 1 intubation, establishment of 3 central lines, and first-assisting 1 exploratory laparotomy. Of the casualties, 22 were evacuated to the Role 3 hospital, 8 were dispositioned to a coalition hospital, 2 were returned to active duty, and 2 died due to their injuries. The military trauma preparation as outlined in the predeployment training can help adequately prepare the military dermatologist to assist in these cases.

Ancillary Services

An important part of the efficacy of initial evaluation and stabilization of both medical and traumatic emergencies involves expedited laboratory tests, imaging, and the delivery of life-saving blood products to affected patients. The field surgeon is responsible for the readiness of these services and may play a critical role in streamlining these tasks for situations where a delay in care by minutes can be lethal. The MEDO assists the field surgeon to ensure the readiness of the medical equipment, and the field surgeon must ensure the readiness of the medics and technicians utilizing the equipment. In a deployed environment, only a finite amount of blood products may be stored. As a result, the design and implementation of an efficient and precise walking blood bank is critical. To help mitigate this issue, servicemembers are prescreened for their blood types and bloodborne illnesses. If a situation arises in which whole blood is needed, the prescreened individuals are screened again, and their blood is collected and transfused to the patient under the supervision of the physician. This task is critical in saving lives, and this process is the primary responsibility of the field surgeon.

Case Example 
A 37-year-old man presented to the BAS with abdominal and pelvic gunshot wounds, as well as tachycardia, rapidly decreasing blood pressure, and altered consciousness. An exploratory laparotomy was performed to look for the sources of bleeding. The patient’s blood type was confirmed with a portable testing kit. Due to the injury pattern and clinical presentation, a call was immediately placed to begin screening and preparing servicemembers to donate blood for the walking blood bank. As expected, the Role 2 supply of blood products was exhausted during the exploratory laparotomy. With servicemembers in place and screened, an additional 12 units of whole blood were collected and administered in a timely fashion. The patient was stabilized and transported to the next highest level of care. Due to the process optimization performed by the laboratory team, whole-blood transfusions were ready within an average of 22 minutes, well ahead of the 45-minute standard of care. Local process was studied by the military leadership and implemented throughout Afghanistan.

Operating Room First Assist

If a field surgeon is stationed at a Role 2 BAS with a forward surgical team, he/she may be required to adopt the role of operating room first assist for the trauma surgeon or orthopedic surgeon on the team, which is especially true for isolated major traumas when triage and initial stabilization measures for multiple patients are of less concern. Dermatologists receive surgical training as part of the Accreditation Council for Graduate Medical Education requirements to graduate residency, making them more than capable of surgical assisting when needed.⁸ In particular, dermatologists’ ability to utilize instruments appropriately and think procedurally as well as their skills in suturing are helpful.

Case Example 
A 22-year-old man with several shrapnel wounds to the abdomen demonstrated free fluid in the left lower quadrant. The field surgeon (N.R.M.) assisted the trauma surgeon in opening the abdomen and running the bowel for sources of bleeding. The trauma surgeon identified the bleed and performed a ligation. The patient was then packed, closed, and prepared for transfer to a higher level of care.

Preventive Medicine

As a result of the field surgeon being on the front line of medical care in an austere environment, implementation of preventive medicine practices and disease pattern recognition are his/her responsibility. Responsibilities may include stray animal euthanasia due to prevalence of rabies, enforcement of malaria prophylaxis, medical training and maintenance of snake antivenin, and assistance with other local endemic disease. The unique skill set of dermatologists in organism identification can further bolster the speed with which vector-borne diseases are recognized and prevention and treatment measures are implemented.

Case Example 
As coalition forces executed a mission in Afghanistan, US servicemembers began experiencing abdominal distress, chills, fevers (temperature >40°C), debilitating headaches, myalgia, arthralgia, and tachycardia. Initially, these patients were evacuated to the Role 2 BAS, hindering the mission. Upon inspection, patients had numerous bug bites; one astute soldier collected the arthropod guilty of the assault and brought it to the aid station. Upon inspection, the offender was identified as the Phlebotomus genus of sandflies, organisms that are well known to dermatologists as a cause of leishmaniasis. Clinical correlation resulted in the presumed diagnosis of Pappataci fever, and vector-borne disease prevention measures were then able to be further emphasized and implemented in at-risk areas, allowing the mission to continue.⁹ Subsequent infectious disease laboratory testing confirmed the Phlebovirus transmitted by the sandfly as the underlying cause of the illness.

CONCLUSION

The diverse role of the field surgeon in the deployed setting makes any one specialist underprepared to completely take on the role from the outset; however, with appropriate and rigorous trauma training prior to deployment, dermatologists will continue to perform as invaluable assets to the US military in conflicts now and in the future.

Military dermatologists complete their residency training at 1 of 3 large military medical centers across the country: Walter Reed National Military Medical Center (Bethesda, Maryland), San Antonio Military Health System (San Antonio, Texas), or Naval Medical Center San Diego (San Diego, California). While in training, army dermatology residents in particular fall under the US Army Medical Command, or MEDCOM, which provides command and control of the army’s medical, dental, and veterinary treatment facilities. Upon graduating from residency, army dermatologists often are stationed with MEDCOM units but become eligible for deployment with US Army Forces Command (FORSCOM) units to both combat and noncombat zones depending on each individual FORSCOM unit’s mission.

The process by which dermatologists and other army physicians are tasked to a deploying FORSCOM unit is referred to as the Professional Filler System, or PROFIS, which was designed to help alleviate the financial cost and specialty skill degradation of having a physician assigned to a FORSCOM unit while not deployed.¹ In general, the greater the amount of time that an army medical officer has not been deployed, the more likely they are to be selected for deployment with a FORSCOM unit. For the army dermatologist, deployment often comes shortly after completing residency or fellowship.

In this article, we review the various functions of the deployed dermatologist and also highlight the importance of maintaining basic emergency medical skills that could be generalized to the civilian population in case of local or national emergencies.

THE FIELD SURGEON

With rare exceptions, the US Army does not deploy dermatologists for their expertise in diagnosing and managing cutaneous diseases. Typically, a dermatologist will be assigned to a FORSCOM unit in the role of field surgeon. Other medical specialties including emergency medicine, family practice, internal medicine, pediatrics, and obstetrics and gynecology also are eligible for deployment as field surgeons.² Field surgeons typically are assigned to a battalion-sized element of 300 to 1000 soldiers and are responsible for all medical care rendered under their supervision. Duties include combat resuscitation, primary care services, preventive medicine, medical training of battalion medical personnel, and serving as the medical adviser to the battalion commander.¹ In some instances, a field surgeon will be stationed at a higher level of care co-located with a trauma surgeon; in those cases, the field surgeon also may be expected to assist in trauma surgery cases.

ARMY DEPLOYMENT MEDICAL SYSTEM

To better understand the responsibilities of a field surgeon, it is important to discuss the structure of the army’s deployment medical system. The US Military, including the army, has adopted a system of “roles” that have specific requirements regarding their associated medical capabilities.³ There are 4 roles designated within the army. Role 1 facilities are known as battalion aid stations (BASs). Capabilities include initial treatment, triage, and evacuation, with a goal of returning soldiers to combat or stabilizing and evacuating them to a higher-role facility. Role 2 facilities are capable of providing a higher level of emergency care, including basic radiology, laboratory services, transfusion of blood products, and surgical interventions when co-located with a forward surgical team (Figure 1). Role 3 facilities, also known as combat support hospitals, have inpatient hospitalization capabilities including subspecialty surgery and intensive care. Role 4 facilities are fully capable medical centers located in the United States and other noncombat locations.³

Role of the Field Surgeon

Within the broader structure of the army, approximately 5 battalions (each composed of 300 to 1000 soldiers) comprise a single brigade combat team. Role 1 medical facilities typically have a single battalion surgeon assigned to them. Field surgeons most commonly serve in this battalion surgeon position. Additionally, Role 2 facilities may have slots for up to 2 battalion surgeons; however, field surgeons are less commonly tasked with this assignment.¹ Occasionally, in one author’s (N.R.M.) personal experience, these roles are more fluid than one might expect. A field surgeon tasked initially with a Role 1 position may be shifted to a Role 2 assignment on an as-needed basis. This ability for rapid change in roles and responsibilities underscores the need for a fluid mind-set and thorough predeployment training for the field surgeon.

PREDEPLOYMENT TRAINING

As one might expect, dermatologists who have just graduated residency or fellowship are unlikely to have honed their trauma support skills to the degree needed to support a deployed battalion actively engaging in combat. Fortunately, there are many opportunities for military dermatologists to practice these skills prior to joining their FORSCOM colleagues. The initial exposure to trauma support comes during medical internship at the mandatory Combat Casualty Care Course (C4), an 8-day program designed to enhance the operational medical readiness and predeployment trauma training skills of medical officers.⁴ The C4 program includes 3 days of classroom training and 5 days of intensive field training. During C4, medical officers become certified in Advanced Trauma Life Support, a 3-day course organized by the American College of Surgeons.⁵ This course teaches medical officers how to quickly and judiciously triage, treat, and transport patients who have sustained potentially life-threatening traumas.

The next components of predeployment training, Tactical Combat Casualty Care and Tactical Combat Medical Care, occur in the months to weeks immediately preceding deployment.^1,6 Tactical Combat Casualty Care prepares participants in the initial stabilization of trauma to occur at the point of injury.⁶ Tactical Combat Casualty Care principles generally are employed by medics (enlisted personnel trained in point-of-care medical support) rather than physicians; however, these principles are still critical for medical officers to be aware of when encountering severe traumas.⁶ In addition, the physician is responsible for ensuring his/her medics are fully trained in Tactical Combat Casualty Care. Tactical Combat Medical Care is geared more toward the direct preparation of medical officers. During the 5-day course, medical officers learn the gold standard for trauma care in both the classroom and in hands-on scenarios.¹ This training not only allows medical officers to be self-sufficient in providing trauma support, but it also enables them to better maintain quality control of the performance of their medics continuously throughout the deployment.¹

DEPLOYMENT RESPONSIBILITIES

Dermatologists who have completed the above training typically are subsequently deployed as field surgeons to a Role 1 facility. Field surgeons are designated as the officer in charge of the BAS and assume the position of medical platoon leader. A field surgeon usually will have both a physician assistant and a field medical assistant/medical plans officer (MEDO) to assist in running the BAS. The overarching goal of the field surgeon is to maintain the health and readiness of the battalion. In addition to addressing the day-to-day health care needs of individual soldiers, a field surgeon is expected to attend all staff meetings, advise the commander on preventative health and epidemiological trends, identify the scope of practice of the medics, ensure the BAS is prepared for mass casualties, and take responsibility for all controlled substances.

To illustrate the value that the properly trained dermatologist can provide in the deployed setting, we will outline field surgeon responsibilities and provide case examples of the first-hand experiences of one of the authors (N.R.M.) as a Role 2 officer in charge and field surgeon. The information presented in the case examples may have been altered to ensure continued operational security and out of respect to US servicemembers and coalition forces while still conveying important learning points.

Sick Call

In the deployed environment, military sick call functions as an urgent care center that is open continuously and serves the active-duty population, US government civilians and contractors, and coalition forces. In general, the physician assistant should treat approximately two-thirds of sick call patients under the supervision of the field surgeon, allowing the field surgeon to focus on his/her ancillary duties and ensure overall medical supervision of the unit. As a safeguard, patients with more than 2 visits for the same concern must be evaluated by the field surgeon. Sick call concerns range from minor traumas and illnesses to much more serious disease processes and injuries (as outlined in Medical Emergencies). As a field surgeon, it is critical to track disease nonbattle illnesses to ensure medical readiness of the unit. In the deployed environment, close quarters and austere environments commonly lend themselves to gastrointestinal illnesses, respiratory diseases, heat injuries, vector-borne diseases, and sexually transmitted infections.

Case Examples 
During an 8-month deployment in Afghanistan, one of the authors (N.R.M.) provided or assisted in the care of more than 2300 routine sick call appointments, or approximately 10 patients per day. Epidemiology of disease was tracked, and the condition of the unit was presented daily to the battalion commander for consideration in upcoming operations. The top 5 most common categories of diagnoses included musculoskeletal injuries, gastrointestinal diseases, dermatologic concerns (eg, dermatitis, bacterial infections [cellulitis/abscess], fungal infections, arthropod assault, abrasions, lacerations, verruca vulgaris), respiratory illnesses, and mental health care, respectively. Maintaining a familiarity with general medicine is critical for the military dermatologist, and an adequate medical library or access to online medical review sources is critical for day-to-day sick call.

Medical Emergencies

In the event of a more serious injury or illness, a Role 1 BAS has very little capability in performing anything beyond the most basic interventions. Part of the art of being an effective field surgeon lies in stabilization, triage, and transport of these sometimes very ill patients. Both the decision to transport to a higher level of care (eg, Role 2 or 3 facility) as well as selection of the means of transportation falls on the field surgeon. The MEDO plays an essential role in assisting in the coordination of the transfer; however, the responsibility ultimately falls on the field surgeon.^1,6 The field surgeon at the Role 2 BAS may be expected to perform more advanced medical and surgical interventions. More advanced pharmacotherapies include thrombolytics, antivenin, and vasopressors. Some procedural interventions include intubations, central lines, and laceration repairs. The Role 2 BAS has the capability to hold patients for up to 72 hours.

Case Examples
Specific conditions one of the authors (N.R.M.) treated include heat injury, myocardial infarction, disseminated tuberculosis, appendicitis, testicular torsion, malaria, suicidal ideation, burns, and status epilepticus. Over 8 months, the Role 2 BAS received 91 medical emergencies, with 53 necessitating evacuation to a higher level of care. Often, the more serious or rare conditions presented in the foreign contractor and coalition force populations working alongside US troops.

In one particular case, a 35-year-old man with an electrocardiogram-confirmed acute ST-segment elevation myocardial infarction was administered standard therapy consisting of intravenous morphine, oxygen, sublingual nitroglycerin, an angiotensin-converting enzyme inhibitor, and a beta-blocker. Given the lack of a cardiac catheterization laboratory at the next highest level of care as well as a low suspicion for aortic dissection (based on the patient’s history, physical examination, and chest radiograph), fibrinolysis with tenecteplase was performed in the deployed environment. After a very short observation for potential hemorrhage, the patient was then evacuated to the Role 3 hospital, where he made a near-complete recovery. Preparation with advanced cardiac life support courses and a thorough algorithmic review of the 10 most common causes of presentation to the emergency department helped adequately prepare the dermatologist to succeed.

Trauma Emergencies

The same principles of triage and transport apply to trauma emergencies. Mass casualties are an inevitable reality in combat, so appropriate training translating into efficient action is essential to ensure the lowest possible mortality. This training and the actions that stem from it are an additional responsibility that the field surgeon must maintain. During deployment, continued training organized by the field surgeon could quite literally mean the difference between life and death. In addition to the organizational responsibilities, field surgeons should be prepared to perform initial stabilization in trauma patients, including application of tourniquets, establishment of central lines, reading abdominal ultrasounds for free fluid, placement of chest tubes, intubation, and ventilator management. The Joint Trauma System Clinical Practice Guidelines also offer extensive and invaluable guidance on the most up-to-date approach to common trauma conditions arising in the deployed environment.⁷ At the Role 2 level, the field surgeon also must be prepared to coordinate ancillary services, manage the Role 2/forward surgical team intensive care unit, and serve as first assist in the operating room, as needed (Figure 2).

Case Examples 
One of the authors (N.R.M.) assisted or provided care in approximately 225 trauma cases while deployed. A mass casualty event occurred, in which the Role 2 BAS received 34 casualties; of these casualties, 11 were immediate, 10 were delayed, 11 were minimal, and 2 were expectant. Injury patterns included mounted and dismounted improvised explosive device injuries (eg, blast, shrapnel, and traumatic brain injuries) as well as gunshot wounds. Direct care was provided for 13 casualties, including 10 abdominal ultrasound examinations for free fluid, placement of 2 chest tubes, 1 intubation, establishment of 3 central lines, and first-assisting 1 exploratory laparotomy. Of the casualties, 22 were evacuated to the Role 3 hospital, 8 were dispositioned to a coalition hospital, 2 were returned to active duty, and 2 died due to their injuries. The military trauma preparation as outlined in the predeployment training can help adequately prepare the military dermatologist to assist in these cases.

Ancillary Services

An important part of the efficacy of initial evaluation and stabilization of both medical and traumatic emergencies involves expedited laboratory tests, imaging, and the delivery of life-saving blood products to affected patients. The field surgeon is responsible for the readiness of these services and may play a critical role in streamlining these tasks for situations where a delay in care by minutes can be lethal. The MEDO assists the field surgeon to ensure the readiness of the medical equipment, and the field surgeon must ensure the readiness of the medics and technicians utilizing the equipment. In a deployed environment, only a finite amount of blood products may be stored. As a result, the design and implementation of an efficient and precise walking blood bank is critical. To help mitigate this issue, servicemembers are prescreened for their blood types and bloodborne illnesses. If a situation arises in which whole blood is needed, the prescreened individuals are screened again, and their blood is collected and transfused to the patient under the supervision of the physician. This task is critical in saving lives, and this process is the primary responsibility of the field surgeon.

Case Example 
A 37-year-old man presented to the BAS with abdominal and pelvic gunshot wounds, as well as tachycardia, rapidly decreasing blood pressure, and altered consciousness. An exploratory laparotomy was performed to look for the sources of bleeding. The patient’s blood type was confirmed with a portable testing kit. Due to the injury pattern and clinical presentation, a call was immediately placed to begin screening and preparing servicemembers to donate blood for the walking blood bank. As expected, the Role 2 supply of blood products was exhausted during the exploratory laparotomy. With servicemembers in place and screened, an additional 12 units of whole blood were collected and administered in a timely fashion. The patient was stabilized and transported to the next highest level of care. Due to the process optimization performed by the laboratory team, whole-blood transfusions were ready within an average of 22 minutes, well ahead of the 45-minute standard of care. Local process was studied by the military leadership and implemented throughout Afghanistan.

Operating Room First Assist

If a field surgeon is stationed at a Role 2 BAS with a forward surgical team, he/she may be required to adopt the role of operating room first assist for the trauma surgeon or orthopedic surgeon on the team, which is especially true for isolated major traumas when triage and initial stabilization measures for multiple patients are of less concern. Dermatologists receive surgical training as part of the Accreditation Council for Graduate Medical Education requirements to graduate residency, making them more than capable of surgical assisting when needed.⁸ In particular, dermatologists’ ability to utilize instruments appropriately and think procedurally as well as their skills in suturing are helpful.

Case Example 
A 22-year-old man with several shrapnel wounds to the abdomen demonstrated free fluid in the left lower quadrant. The field surgeon (N.R.M.) assisted the trauma surgeon in opening the abdomen and running the bowel for sources of bleeding. The trauma surgeon identified the bleed and performed a ligation. The patient was then packed, closed, and prepared for transfer to a higher level of care.

Preventive Medicine

As a result of the field surgeon being on the front line of medical care in an austere environment, implementation of preventive medicine practices and disease pattern recognition are his/her responsibility. Responsibilities may include stray animal euthanasia due to prevalence of rabies, enforcement of malaria prophylaxis, medical training and maintenance of snake antivenin, and assistance with other local endemic disease. The unique skill set of dermatologists in organism identification can further bolster the speed with which vector-borne diseases are recognized and prevention and treatment measures are implemented.

Case Example 
As coalition forces executed a mission in Afghanistan, US servicemembers began experiencing abdominal distress, chills, fevers (temperature >40°C), debilitating headaches, myalgia, arthralgia, and tachycardia. Initially, these patients were evacuated to the Role 2 BAS, hindering the mission. Upon inspection, patients had numerous bug bites; one astute soldier collected the arthropod guilty of the assault and brought it to the aid station. Upon inspection, the offender was identified as the Phlebotomus genus of sandflies, organisms that are well known to dermatologists as a cause of leishmaniasis. Clinical correlation resulted in the presumed diagnosis of Pappataci fever, and vector-borne disease prevention measures were then able to be further emphasized and implemented in at-risk areas, allowing the mission to continue.⁹ Subsequent infectious disease laboratory testing confirmed the Phlebovirus transmitted by the sandfly as the underlying cause of the illness.

CONCLUSION

The diverse role of the field surgeon in the deployed setting makes any one specialist underprepared to completely take on the role from the outset; however, with appropriate and rigorous trauma training prior to deployment, dermatologists will continue to perform as invaluable assets to the US military in conflicts now and in the future.

Degarelix, the gonadotropin-releasing hormone (GnRH) antagonist approved for prostate cancer, was more effective than a GnRH agonist in achieving ovarian function suppression in women with breast cancer, results of a randomized trial show.

Ovarian function suppression was achieved more rapidly and maintained more effectively with degarelix, compared with triptorelin, in the premenopausal women who were receiving letrozole for neoadjuvant endocrine therapy, investigators said.

Adverse events including hot flashes and injection site reactions were reported more often with degarelix versus the GnRH agonist in this randomized, phase 2 trial of 51 subjects.

Additional research is needed to determine whether degarelix results in superior disease control versus the current standard of care, reported Silvia Dellapasqua, MD, of the European Institute of Oncology IRCCS in Milan, Italy, and coinvestigators.

“The study is hypothesis-generating, and supports later studies to assess whether maintenance of ovarian function suppression with degarelix translates into a better clinical outcome and is worth a trade-off of increased rate of some adverse events,” the researchers wrote. The report is in the Journal of Clinical Oncology.

Patients were randomly assigned to receive degarelix plus letrozole or triptorelin plus letrozole for six 28-day cycles. Degarelix was administered subcutaneously on day 1 of each cycle, while triptorelin was administered intramuscularly on day 1 of each cycle, and oral letrozole was to be taken daily. Surgery was performed a few weeks after the last injection.

All patients achieved optimal ovarian function suppression by the end of the first cycle. However, that endpoint was achieved significantly faster among patients in the degarelix arm, at a median of 3 days, versus a median of 14 days for the GnRH agonist, the investigators reported.

The optimal ovarian function suppression was seen three times faster with degarelix (hazard ratio, 3.05; 95% confidence interval, 1.65-5.65; P less than 001), they added.

One hundred percent of patients receiving degarelix and letrozole maintained optimal ovarian function suppression throughout the study, while about 15% of patients assigned to triptorelin had suboptimal suppression after that first cycle.

The group of patients receiving degarelix had a higher rate of node-negative disease at surgery, and a higher rate of breast-conserving surgery compared with the triptorelin group, the investigators said.

There were two grade 3 adverse events, hypertension and anemia, which both occurred in the triptorelin group, and no grade 4 adverse events. The most common adverse events reported were hot flashes, occurring in 80.0% and 69.2% of the degarelix and triptorelin groups, respectively; arthralgias in 32.0% and 53.8%; insomnia in 24.0% and 11.5%; injection site reactions in 24.0% and 0%; and nausea in 16.0% and 3.8%.

The study was supported by Ferring, and by the International Breast Cancer Study Group via Frontier Science and Technology Research Foundation, Swiss Group for Clinical Cancer Research, Cancer Research Switzerland, Oncosuisse, Swiss Cancer League, and the Foundation for Clinical Cancer Research of Eastern Switzerland. The authors reported disclosures related to Ferring, Novartis, Ipsen, DVAX, Roche, Genentech, Pfizer, Celgene, and Merck, among others.

SOURCE: Dellapasqua S et al. J Clin Oncol. 2018 Dec 27. doi: 10.1200/JCO.18.00296.

Degarelix, the gonadotropin-releasing hormone (GnRH) antagonist approved for prostate cancer, was more effective than a GnRH agonist in achieving ovarian function suppression in women with breast cancer, results of a randomized trial show.

Ovarian function suppression was achieved more rapidly and maintained more effectively with degarelix, compared with triptorelin, in the premenopausal women who were receiving letrozole for neoadjuvant endocrine therapy, investigators said.

Adverse events including hot flashes and injection site reactions were reported more often with degarelix versus the GnRH agonist in this randomized, phase 2 trial of 51 subjects.

Additional research is needed to determine whether degarelix results in superior disease control versus the current standard of care, reported Silvia Dellapasqua, MD, of the European Institute of Oncology IRCCS in Milan, Italy, and coinvestigators.

“The study is hypothesis-generating, and supports later studies to assess whether maintenance of ovarian function suppression with degarelix translates into a better clinical outcome and is worth a trade-off of increased rate of some adverse events,” the researchers wrote. The report is in the Journal of Clinical Oncology.

Patients were randomly assigned to receive degarelix plus letrozole or triptorelin plus letrozole for six 28-day cycles. Degarelix was administered subcutaneously on day 1 of each cycle, while triptorelin was administered intramuscularly on day 1 of each cycle, and oral letrozole was to be taken daily. Surgery was performed a few weeks after the last injection.

All patients achieved optimal ovarian function suppression by the end of the first cycle. However, that endpoint was achieved significantly faster among patients in the degarelix arm, at a median of 3 days, versus a median of 14 days for the GnRH agonist, the investigators reported.

The optimal ovarian function suppression was seen three times faster with degarelix (hazard ratio, 3.05; 95% confidence interval, 1.65-5.65; P less than 001), they added.

One hundred percent of patients receiving degarelix and letrozole maintained optimal ovarian function suppression throughout the study, while about 15% of patients assigned to triptorelin had suboptimal suppression after that first cycle.

The group of patients receiving degarelix had a higher rate of node-negative disease at surgery, and a higher rate of breast-conserving surgery compared with the triptorelin group, the investigators said.

There were two grade 3 adverse events, hypertension and anemia, which both occurred in the triptorelin group, and no grade 4 adverse events. The most common adverse events reported were hot flashes, occurring in 80.0% and 69.2% of the degarelix and triptorelin groups, respectively; arthralgias in 32.0% and 53.8%; insomnia in 24.0% and 11.5%; injection site reactions in 24.0% and 0%; and nausea in 16.0% and 3.8%.

The study was supported by Ferring, and by the International Breast Cancer Study Group via Frontier Science and Technology Research Foundation, Swiss Group for Clinical Cancer Research, Cancer Research Switzerland, Oncosuisse, Swiss Cancer League, and the Foundation for Clinical Cancer Research of Eastern Switzerland. The authors reported disclosures related to Ferring, Novartis, Ipsen, DVAX, Roche, Genentech, Pfizer, Celgene, and Merck, among others.

SOURCE: Dellapasqua S et al. J Clin Oncol. 2018 Dec 27. doi: 10.1200/JCO.18.00296.

Degarelix, the gonadotropin-releasing hormone (GnRH) antagonist approved for prostate cancer, was more effective than a GnRH agonist in achieving ovarian function suppression in women with breast cancer, results of a randomized trial show.

Ovarian function suppression was achieved more rapidly and maintained more effectively with degarelix, compared with triptorelin, in the premenopausal women who were receiving letrozole for neoadjuvant endocrine therapy, investigators said.

Adverse events including hot flashes and injection site reactions were reported more often with degarelix versus the GnRH agonist in this randomized, phase 2 trial of 51 subjects.

Additional research is needed to determine whether degarelix results in superior disease control versus the current standard of care, reported Silvia Dellapasqua, MD, of the European Institute of Oncology IRCCS in Milan, Italy, and coinvestigators.

“The study is hypothesis-generating, and supports later studies to assess whether maintenance of ovarian function suppression with degarelix translates into a better clinical outcome and is worth a trade-off of increased rate of some adverse events,” the researchers wrote. The report is in the Journal of Clinical Oncology.

Patients were randomly assigned to receive degarelix plus letrozole or triptorelin plus letrozole for six 28-day cycles. Degarelix was administered subcutaneously on day 1 of each cycle, while triptorelin was administered intramuscularly on day 1 of each cycle, and oral letrozole was to be taken daily. Surgery was performed a few weeks after the last injection.

All patients achieved optimal ovarian function suppression by the end of the first cycle. However, that endpoint was achieved significantly faster among patients in the degarelix arm, at a median of 3 days, versus a median of 14 days for the GnRH agonist, the investigators reported.

The optimal ovarian function suppression was seen three times faster with degarelix (hazard ratio, 3.05; 95% confidence interval, 1.65-5.65; P less than 001), they added.

One hundred percent of patients receiving degarelix and letrozole maintained optimal ovarian function suppression throughout the study, while about 15% of patients assigned to triptorelin had suboptimal suppression after that first cycle.

The group of patients receiving degarelix had a higher rate of node-negative disease at surgery, and a higher rate of breast-conserving surgery compared with the triptorelin group, the investigators said.

There were two grade 3 adverse events, hypertension and anemia, which both occurred in the triptorelin group, and no grade 4 adverse events. The most common adverse events reported were hot flashes, occurring in 80.0% and 69.2% of the degarelix and triptorelin groups, respectively; arthralgias in 32.0% and 53.8%; insomnia in 24.0% and 11.5%; injection site reactions in 24.0% and 0%; and nausea in 16.0% and 3.8%.

The study was supported by Ferring, and by the International Breast Cancer Study Group via Frontier Science and Technology Research Foundation, Swiss Group for Clinical Cancer Research, Cancer Research Switzerland, Oncosuisse, Swiss Cancer League, and the Foundation for Clinical Cancer Research of Eastern Switzerland. The authors reported disclosures related to Ferring, Novartis, Ipsen, DVAX, Roche, Genentech, Pfizer, Celgene, and Merck, among others.

SOURCE: Dellapasqua S et al. J Clin Oncol. 2018 Dec 27. doi: 10.1200/JCO.18.00296.

LOS ANGELES – People have unique postprandial glucose responses to identical meals, according to results from ongoing research examining the connection between the gut microbiome and nutrition.

Doug Brunk/MDedge News

“The reason we got interested in nutrition in general is for its important role in health and disease, but also because, reading the literature on nutrition in general, it seemed that the science was relatively poor,” Eran Segal, PhD, said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “As a testament, you can see how frequently dietary recommendations for the public are changed. For example, 30 years ago, the cover of Time magazine said that eating cholesterol in the diet is very bad for you. Fifteen years later, Time magazine said that some cholesterol is actually good for you. There are other questions, like should you be eating dairy products? I think it shows that we have a poor understanding of what healthy nutrition is for human individuals. That’s why we wanted to start a study which would collect the right amount and the right kind of data to try to answer the question of what is a healthy diet for human individuals.”

In what is believed to be the first study of its kind, Dr. Segal, professor of computer science and applied mathematics at the Weizmann Institute of Science in Rehovot, Israel, and his associates recruited 1,000 individuals and asked them to wear a continuous glucose monitor (CGM) for 1 week (Cell 2015;163[5]:1079-94). For the study, known as The Personalized Nutrition Project, participants were asked to log everything they ate into a mobile app the researchers developed. “They would select a meal from a database of 10,000 foods,” Dr. Segal explained. “Each meal has full nutritional value so at the end of the study, we had about 50,000 meals that we had measurements of postprandial glucose response to, coupled with full nutritional values.” They also collected a comprehensive profile of individuals, which included body measurements, blood tests, medical background, food frequency questionnaires, and a measurement of the microbiome by both 16S rRNA sequencing and shotgun metagenomics.

For the first part of the study, researchers supplied a breakfast to all participants: either bread, bread with butter, glucose, or fructose, in each case 50 g of available carbohydrates. “The participants were asked to consume these the morning after the night fast,” Dr. Segal said. “This allowed us to compare how the same individual responds to eating the exact same food versus how different individuals respond to eating the same food.” The researchers found that, when the same person ate the same meal on 2 different days, the glucose response was highly reproducible. In contrast, different people had widely different postmeal glucose responses to identical meals. “Some individuals responded most highly to glucose; others responded most highly to bread,” Dr. Segal said. “There was about 10% of individuals who responded to bread and butter, compared to the other test foods. These results mean that any universal diet is going to have limited efficacy in its ability to balance blood glucose levels, because some foods will spike glucose levels in one person but not in another person. It also means that the concepts we’ve been using like the glycemic index are also going to have limited efficacy.”

Next, the researchers aimed to determine what factors influence the variability in people’s responses to the same food. “We found many different correlations between the various blood markers and physical measurements that we obtained, but what was most novel was the variability in postmeal glucose response across people associated with microbiota composition and function,” Dr. Segal said. From this, he and his colleagues developed a machine-learning algorithm that integrates blood parameters, dietary habits, anthropometrics, physical activity, and gut microbiota. Using this algorithm, the prediction accuracy of personalized glucose responses achieved an r value of 0.68, which explains about 50% of the variability. For the final component of the study, the researchers randomized 26 participants to one of five dietary arms and followed for 1 week by continuous glucose monitoring. They were able to demonstrate that personally tailored diets lower the postprandial glucose response.

As a follow-up to this work, Dr. Segal and his associates enrolled 200 people with an hemoglobin A_1c between 5.7% and 6.5% into the Personalized Nutrition Project for Prediabetes (PNP3) study, which investigates whether personalized diet intervention will improve postprandial blood glucose levels and other metabolic health factors in individuals with prediabetes, compared with the standard Mediterranean-style low-fat diet (NCT03222791). Participants were randomized to 6 months of standard of care following Dietary Guidelines for Americans 2015-2020, Eighth Edition, or to an algorithm diet. Primary outcomes are reduction in average glucose levels and evaluation of the total daily time of plasma glucose levels were below 140 mg/dL. Participants wore the continuous glucose monitor for the entire 6 months of intervention. “I don’t think this was ever done before,” he said. “We’re also looking at secondary metabolic endpoints and exploratory endpoints such as changes in the microbiome. We’re asking people to log everything they eat for the entire 6 months of intervention. It gives us a lot of power in terms assessing compliance. It’s an immense amount of data.”

Evaluation of the data are not yet complete, but interim results are promising. For example, he discussed results from one study participant on the algorithm diet. “Across 1 month, this person was able to entirely reduce the peaks in glucose levels and dramatic reductions in the time above 140 mg/dL in the 6-month treatment period,” said Dr. Segal, who is one of the study’s principal investigators. He disclosed that he is a paid consultant to DayTwo.

dbrunk@mdedge.com

LOS ANGELES – People have unique postprandial glucose responses to identical meals, according to results from ongoing research examining the connection between the gut microbiome and nutrition.

Doug Brunk/MDedge News

“The reason we got interested in nutrition in general is for its important role in health and disease, but also because, reading the literature on nutrition in general, it seemed that the science was relatively poor,” Eran Segal, PhD, said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “As a testament, you can see how frequently dietary recommendations for the public are changed. For example, 30 years ago, the cover of Time magazine said that eating cholesterol in the diet is very bad for you. Fifteen years later, Time magazine said that some cholesterol is actually good for you. There are other questions, like should you be eating dairy products? I think it shows that we have a poor understanding of what healthy nutrition is for human individuals. That’s why we wanted to start a study which would collect the right amount and the right kind of data to try to answer the question of what is a healthy diet for human individuals.”

In what is believed to be the first study of its kind, Dr. Segal, professor of computer science and applied mathematics at the Weizmann Institute of Science in Rehovot, Israel, and his associates recruited 1,000 individuals and asked them to wear a continuous glucose monitor (CGM) for 1 week (Cell 2015;163[5]:1079-94). For the study, known as The Personalized Nutrition Project, participants were asked to log everything they ate into a mobile app the researchers developed. “They would select a meal from a database of 10,000 foods,” Dr. Segal explained. “Each meal has full nutritional value so at the end of the study, we had about 50,000 meals that we had measurements of postprandial glucose response to, coupled with full nutritional values.” They also collected a comprehensive profile of individuals, which included body measurements, blood tests, medical background, food frequency questionnaires, and a measurement of the microbiome by both 16S rRNA sequencing and shotgun metagenomics.

For the first part of the study, researchers supplied a breakfast to all participants: either bread, bread with butter, glucose, or fructose, in each case 50 g of available carbohydrates. “The participants were asked to consume these the morning after the night fast,” Dr. Segal said. “This allowed us to compare how the same individual responds to eating the exact same food versus how different individuals respond to eating the same food.” The researchers found that, when the same person ate the same meal on 2 different days, the glucose response was highly reproducible. In contrast, different people had widely different postmeal glucose responses to identical meals. “Some individuals responded most highly to glucose; others responded most highly to bread,” Dr. Segal said. “There was about 10% of individuals who responded to bread and butter, compared to the other test foods. These results mean that any universal diet is going to have limited efficacy in its ability to balance blood glucose levels, because some foods will spike glucose levels in one person but not in another person. It also means that the concepts we’ve been using like the glycemic index are also going to have limited efficacy.”

Next, the researchers aimed to determine what factors influence the variability in people’s responses to the same food. “We found many different correlations between the various blood markers and physical measurements that we obtained, but what was most novel was the variability in postmeal glucose response across people associated with microbiota composition and function,” Dr. Segal said. From this, he and his colleagues developed a machine-learning algorithm that integrates blood parameters, dietary habits, anthropometrics, physical activity, and gut microbiota. Using this algorithm, the prediction accuracy of personalized glucose responses achieved an r value of 0.68, which explains about 50% of the variability. For the final component of the study, the researchers randomized 26 participants to one of five dietary arms and followed for 1 week by continuous glucose monitoring. They were able to demonstrate that personally tailored diets lower the postprandial glucose response.

As a follow-up to this work, Dr. Segal and his associates enrolled 200 people with an hemoglobin A_1c between 5.7% and 6.5% into the Personalized Nutrition Project for Prediabetes (PNP3) study, which investigates whether personalized diet intervention will improve postprandial blood glucose levels and other metabolic health factors in individuals with prediabetes, compared with the standard Mediterranean-style low-fat diet (NCT03222791). Participants were randomized to 6 months of standard of care following Dietary Guidelines for Americans 2015-2020, Eighth Edition, or to an algorithm diet. Primary outcomes are reduction in average glucose levels and evaluation of the total daily time of plasma glucose levels were below 140 mg/dL. Participants wore the continuous glucose monitor for the entire 6 months of intervention. “I don’t think this was ever done before,” he said. “We’re also looking at secondary metabolic endpoints and exploratory endpoints such as changes in the microbiome. We’re asking people to log everything they eat for the entire 6 months of intervention. It gives us a lot of power in terms assessing compliance. It’s an immense amount of data.”

Evaluation of the data are not yet complete, but interim results are promising. For example, he discussed results from one study participant on the algorithm diet. “Across 1 month, this person was able to entirely reduce the peaks in glucose levels and dramatic reductions in the time above 140 mg/dL in the 6-month treatment period,” said Dr. Segal, who is one of the study’s principal investigators. He disclosed that he is a paid consultant to DayTwo.

dbrunk@mdedge.com

LOS ANGELES – People have unique postprandial glucose responses to identical meals, according to results from ongoing research examining the connection between the gut microbiome and nutrition.

Doug Brunk/MDedge News

“The reason we got interested in nutrition in general is for its important role in health and disease, but also because, reading the literature on nutrition in general, it seemed that the science was relatively poor,” Eran Segal, PhD, said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “As a testament, you can see how frequently dietary recommendations for the public are changed. For example, 30 years ago, the cover of Time magazine said that eating cholesterol in the diet is very bad for you. Fifteen years later, Time magazine said that some cholesterol is actually good for you. There are other questions, like should you be eating dairy products? I think it shows that we have a poor understanding of what healthy nutrition is for human individuals. That’s why we wanted to start a study which would collect the right amount and the right kind of data to try to answer the question of what is a healthy diet for human individuals.”

In what is believed to be the first study of its kind, Dr. Segal, professor of computer science and applied mathematics at the Weizmann Institute of Science in Rehovot, Israel, and his associates recruited 1,000 individuals and asked them to wear a continuous glucose monitor (CGM) for 1 week (Cell 2015;163[5]:1079-94). For the study, known as The Personalized Nutrition Project, participants were asked to log everything they ate into a mobile app the researchers developed. “They would select a meal from a database of 10,000 foods,” Dr. Segal explained. “Each meal has full nutritional value so at the end of the study, we had about 50,000 meals that we had measurements of postprandial glucose response to, coupled with full nutritional values.” They also collected a comprehensive profile of individuals, which included body measurements, blood tests, medical background, food frequency questionnaires, and a measurement of the microbiome by both 16S rRNA sequencing and shotgun metagenomics.

For the first part of the study, researchers supplied a breakfast to all participants: either bread, bread with butter, glucose, or fructose, in each case 50 g of available carbohydrates. “The participants were asked to consume these the morning after the night fast,” Dr. Segal said. “This allowed us to compare how the same individual responds to eating the exact same food versus how different individuals respond to eating the same food.” The researchers found that, when the same person ate the same meal on 2 different days, the glucose response was highly reproducible. In contrast, different people had widely different postmeal glucose responses to identical meals. “Some individuals responded most highly to glucose; others responded most highly to bread,” Dr. Segal said. “There was about 10% of individuals who responded to bread and butter, compared to the other test foods. These results mean that any universal diet is going to have limited efficacy in its ability to balance blood glucose levels, because some foods will spike glucose levels in one person but not in another person. It also means that the concepts we’ve been using like the glycemic index are also going to have limited efficacy.”

Next, the researchers aimed to determine what factors influence the variability in people’s responses to the same food. “We found many different correlations between the various blood markers and physical measurements that we obtained, but what was most novel was the variability in postmeal glucose response across people associated with microbiota composition and function,” Dr. Segal said. From this, he and his colleagues developed a machine-learning algorithm that integrates blood parameters, dietary habits, anthropometrics, physical activity, and gut microbiota. Using this algorithm, the prediction accuracy of personalized glucose responses achieved an r value of 0.68, which explains about 50% of the variability. For the final component of the study, the researchers randomized 26 participants to one of five dietary arms and followed for 1 week by continuous glucose monitoring. They were able to demonstrate that personally tailored diets lower the postprandial glucose response.

As a follow-up to this work, Dr. Segal and his associates enrolled 200 people with an hemoglobin A_1c between 5.7% and 6.5% into the Personalized Nutrition Project for Prediabetes (PNP3) study, which investigates whether personalized diet intervention will improve postprandial blood glucose levels and other metabolic health factors in individuals with prediabetes, compared with the standard Mediterranean-style low-fat diet (NCT03222791). Participants were randomized to 6 months of standard of care following Dietary Guidelines for Americans 2015-2020, Eighth Edition, or to an algorithm diet. Primary outcomes are reduction in average glucose levels and evaluation of the total daily time of plasma glucose levels were below 140 mg/dL. Participants wore the continuous glucose monitor for the entire 6 months of intervention. “I don’t think this was ever done before,” he said. “We’re also looking at secondary metabolic endpoints and exploratory endpoints such as changes in the microbiome. We’re asking people to log everything they eat for the entire 6 months of intervention. It gives us a lot of power in terms assessing compliance. It’s an immense amount of data.”

Evaluation of the data are not yet complete, but interim results are promising. For example, he discussed results from one study participant on the algorithm diet. “Across 1 month, this person was able to entirely reduce the peaks in glucose levels and dramatic reductions in the time above 140 mg/dL in the 6-month treatment period,” said Dr. Segal, who is one of the study’s principal investigators. He disclosed that he is a paid consultant to DayTwo.

dbrunk@mdedge.com

Eucalyptus eulogy

(“Taps” quietly plays in the background ... ) In some sad news, Quincy the diabetic koala has passed on to that great eucalyptus tree in the sky. The furry type 1 diabetic lived in San Diego, where he was recently fitted with a cutting-edge continuous glucose monitor (CGM). This allowed Quincy more time for his favorite activities (chewing and sleeping) and less time spent with pesky skin pricks.

Courtesy San Diego Zoo

Quincy died of pneumonia, and it is unclear whether his death was diabetes related. All we know is that he will be missed greatly. He was beloved by those with diabetes everywhere, animal or otherwise. Quincy’s successful CGM procedure also gives endocrinologists hope that the technology could eventually be used for similarly fragile humans, like babies. R.I.P., Quincy; we loved you. In lieu of flowers, donations may be made to his favorite charity, the Drop Bear Awareness Association.
 

What’s Latin for ‘poop’?

The study of the human microbiota has become incredibly important in recent years, but there’s no getting away from the fact that it entails experimenting on poop. Remarkably, no one’s come up with a proper technical name for this unsavory activity. However, thanks to a collaboration between a gastroenterologist and a classics professor at the University of North Carolina, that deficiency is no more. You’ve met the in vivo and in vitro study. Now, please welcome the “in vimo” study!

ventdusud/iStock/Getty Images Plus

Why in vimo? The term fecal or “in feco” might seem obvious. But the Latin root word never referred to poop, and if there’s one thing scientists can’t have, it’s improper Latin usage. The Romans, it turns out, had lots of words for poop. The root word of laetamen referred to fertility, richness, and happiness – a tempting prospect – but was mostly used to refer to farm animal dung. Merda mostly referred to smell or stench, and stercus shared the same root word as scatology, which refers to obscene literature. Fimus, which specifically refers to manure, was thus the most precise, and it was used by literary giants such as Livy, Virgil, and Tacitus. A clear winner, and the in vimo study flushed the rest of the competition away.

And just in case you think these researchers are no fun, the name they chose for the active enzymes collected from their in vimo samples? Poopernatants. Yes, even doctors enjoy a good poop joke.
 

The new Breakfast Club

Researchers at the University of Illinois and the University of Texas have collaborated to study something that most of us fear greatly: high school cliques. The researchers, who may or may not have peaked in high school, took a look at high school peer crowds and influences that form those tight-knit bonds that last all of 4 years.

monkeybusinessimages/iStock/Getty Images Plus

The study found that most of the classic cliques – the jocks, the popular crowd, the brains, the stoners, the loners – are still alive and well in today’s American school system. However, at least one new group has emerged in the last decade: the “anime/manga fans.” Researchers noted that although schools have become much more diverse, racial and ethnic stereotypes are alive and well. Thank God we only have to do high school once.
 

Resistance is fecal

And now, just in case you were wondering how long it would take to put our newfound knowledge of “in vimo” to use, here comes a study that has “in vimo” written all over it (metaphorically speaking, of course).

Researchers in Sweden and Finland decided to take a look at antibiotic resistance genes in sewage, because “antibiotics consumed by humans and animals are released into the environment in urine and fecal material contained in treated wastewaters and sludge applied to land.” Then they compared the abundance of the mobile antibiotic resistance genes with the abundance of a human fecal pollution marker.

SutidaS/iStock/Getty Images Plus

That marker – a virus that infects bacteria in human feces but is rare in other animals – was “highly correlated to the abundance of antibiotic resistance genes in environmental samples,” they said in a separate written statement, which “indicates that fecal pollution can largely explain the increase in resistant bacteria often found in human-impacted environments.” The name of that marker, the virus found in feces, happens to be “crAssphage.” And yes, the A really is capitalized. Really. We are not making this up.
 

Gout wins a Golden Globe

Gout has a new poster girl: Great Britain’s Queen Anne. She’s been dead for more than 4 centuries, but a Hollywood version of this stout monarch is turning a famously royal affliction into the disease of the moment.

The credit goes to actress Olivia Colman, who just won a Golden Globe award for her brilliant performance in the earthy comedy “The Favourite.” Ms. Colman transforms the pain-wracked Queen Anne into a needy, manipulative, and loopy monarch who still manages to draw our sympathy.

Besides flummoxing American spell-checkers with its title, The Favourite glories in stretching the truth about the queen’s private life. But she really does seem to have had the “disease of kings,” which has long been linked to the rich, fatty diets enjoyed by blue bloods.

Now, there’s talk that high-protein, meat-friendly keto and paleo diets are boosting rates among the young. This theory got an airing last week in a New York Magazine article titled “Why Gout Is Making a Comeback.”

The truth may be more complicated. Over the last few years, researchers have cast doubt on the keto-leads-to-gout theory and suggested that fructose in sugar may be the real culprit. According to this hypothesis, gout afflicted British royals as they developed a communal sweet tooth during the early days of the sugar trade. Gout then spread to the general population as sugar became more accessible.

The gout debate will continue. As for Olivia Colman, she will soon grace smaller screens with her performance as Queen Elizabeth II in Netflix’s series “The Crown.”

QE II isn’t known for having suffered from any major diseases. But at her next checkup, we do think she should have that stiff upper lip looked at.

imnews@mdedge.com

Eucalyptus eulogy

(“Taps” quietly plays in the background ... ) In some sad news, Quincy the diabetic koala has passed on to that great eucalyptus tree in the sky. The furry type 1 diabetic lived in San Diego, where he was recently fitted with a cutting-edge continuous glucose monitor (CGM). This allowed Quincy more time for his favorite activities (chewing and sleeping) and less time spent with pesky skin pricks.

Courtesy San Diego Zoo

Quincy died of pneumonia, and it is unclear whether his death was diabetes related. All we know is that he will be missed greatly. He was beloved by those with diabetes everywhere, animal or otherwise. Quincy’s successful CGM procedure also gives endocrinologists hope that the technology could eventually be used for similarly fragile humans, like babies. R.I.P., Quincy; we loved you. In lieu of flowers, donations may be made to his favorite charity, the Drop Bear Awareness Association.
 

What’s Latin for ‘poop’?

The study of the human microbiota has become incredibly important in recent years, but there’s no getting away from the fact that it entails experimenting on poop. Remarkably, no one’s come up with a proper technical name for this unsavory activity. However, thanks to a collaboration between a gastroenterologist and a classics professor at the University of North Carolina, that deficiency is no more. You’ve met the in vivo and in vitro study. Now, please welcome the “in vimo” study!

ventdusud/iStock/Getty Images Plus

Why in vimo? The term fecal or “in feco” might seem obvious. But the Latin root word never referred to poop, and if there’s one thing scientists can’t have, it’s improper Latin usage. The Romans, it turns out, had lots of words for poop. The root word of laetamen referred to fertility, richness, and happiness – a tempting prospect – but was mostly used to refer to farm animal dung. Merda mostly referred to smell or stench, and stercus shared the same root word as scatology, which refers to obscene literature. Fimus, which specifically refers to manure, was thus the most precise, and it was used by literary giants such as Livy, Virgil, and Tacitus. A clear winner, and the in vimo study flushed the rest of the competition away.

And just in case you think these researchers are no fun, the name they chose for the active enzymes collected from their in vimo samples? Poopernatants. Yes, even doctors enjoy a good poop joke.
 

The new Breakfast Club

Researchers at the University of Illinois and the University of Texas have collaborated to study something that most of us fear greatly: high school cliques. The researchers, who may or may not have peaked in high school, took a look at high school peer crowds and influences that form those tight-knit bonds that last all of 4 years.

monkeybusinessimages/iStock/Getty Images Plus

The study found that most of the classic cliques – the jocks, the popular crowd, the brains, the stoners, the loners – are still alive and well in today’s American school system. However, at least one new group has emerged in the last decade: the “anime/manga fans.” Researchers noted that although schools have become much more diverse, racial and ethnic stereotypes are alive and well. Thank God we only have to do high school once.
 

Resistance is fecal

And now, just in case you were wondering how long it would take to put our newfound knowledge of “in vimo” to use, here comes a study that has “in vimo” written all over it (metaphorically speaking, of course).

Researchers in Sweden and Finland decided to take a look at antibiotic resistance genes in sewage, because “antibiotics consumed by humans and animals are released into the environment in urine and fecal material contained in treated wastewaters and sludge applied to land.” Then they compared the abundance of the mobile antibiotic resistance genes with the abundance of a human fecal pollution marker.

SutidaS/iStock/Getty Images Plus

That marker – a virus that infects bacteria in human feces but is rare in other animals – was “highly correlated to the abundance of antibiotic resistance genes in environmental samples,” they said in a separate written statement, which “indicates that fecal pollution can largely explain the increase in resistant bacteria often found in human-impacted environments.” The name of that marker, the virus found in feces, happens to be “crAssphage.” And yes, the A really is capitalized. Really. We are not making this up.
 

Gout wins a Golden Globe

Gout has a new poster girl: Great Britain’s Queen Anne. She’s been dead for more than 4 centuries, but a Hollywood version of this stout monarch is turning a famously royal affliction into the disease of the moment.

The credit goes to actress Olivia Colman, who just won a Golden Globe award for her brilliant performance in the earthy comedy “The Favourite.” Ms. Colman transforms the pain-wracked Queen Anne into a needy, manipulative, and loopy monarch who still manages to draw our sympathy.

Besides flummoxing American spell-checkers with its title, The Favourite glories in stretching the truth about the queen’s private life. But she really does seem to have had the “disease of kings,” which has long been linked to the rich, fatty diets enjoyed by blue bloods.

Now, there’s talk that high-protein, meat-friendly keto and paleo diets are boosting rates among the young. This theory got an airing last week in a New York Magazine article titled “Why Gout Is Making a Comeback.”

The truth may be more complicated. Over the last few years, researchers have cast doubt on the keto-leads-to-gout theory and suggested that fructose in sugar may be the real culprit. According to this hypothesis, gout afflicted British royals as they developed a communal sweet tooth during the early days of the sugar trade. Gout then spread to the general population as sugar became more accessible.

The gout debate will continue. As for Olivia Colman, she will soon grace smaller screens with her performance as Queen Elizabeth II in Netflix’s series “The Crown.”

QE II isn’t known for having suffered from any major diseases. But at her next checkup, we do think she should have that stiff upper lip looked at.

imnews@mdedge.com

Eucalyptus eulogy

(“Taps” quietly plays in the background ... ) In some sad news, Quincy the diabetic koala has passed on to that great eucalyptus tree in the sky. The furry type 1 diabetic lived in San Diego, where he was recently fitted with a cutting-edge continuous glucose monitor (CGM). This allowed Quincy more time for his favorite activities (chewing and sleeping) and less time spent with pesky skin pricks.

Courtesy San Diego Zoo

Quincy died of pneumonia, and it is unclear whether his death was diabetes related. All we know is that he will be missed greatly. He was beloved by those with diabetes everywhere, animal or otherwise. Quincy’s successful CGM procedure also gives endocrinologists hope that the technology could eventually be used for similarly fragile humans, like babies. R.I.P., Quincy; we loved you. In lieu of flowers, donations may be made to his favorite charity, the Drop Bear Awareness Association.
 

What’s Latin for ‘poop’?

The study of the human microbiota has become incredibly important in recent years, but there’s no getting away from the fact that it entails experimenting on poop. Remarkably, no one’s come up with a proper technical name for this unsavory activity. However, thanks to a collaboration between a gastroenterologist and a classics professor at the University of North Carolina, that deficiency is no more. You’ve met the in vivo and in vitro study. Now, please welcome the “in vimo” study!

ventdusud/iStock/Getty Images Plus

Why in vimo? The term fecal or “in feco” might seem obvious. But the Latin root word never referred to poop, and if there’s one thing scientists can’t have, it’s improper Latin usage. The Romans, it turns out, had lots of words for poop. The root word of laetamen referred to fertility, richness, and happiness – a tempting prospect – but was mostly used to refer to farm animal dung. Merda mostly referred to smell or stench, and stercus shared the same root word as scatology, which refers to obscene literature. Fimus, which specifically refers to manure, was thus the most precise, and it was used by literary giants such as Livy, Virgil, and Tacitus. A clear winner, and the in vimo study flushed the rest of the competition away.

And just in case you think these researchers are no fun, the name they chose for the active enzymes collected from their in vimo samples? Poopernatants. Yes, even doctors enjoy a good poop joke.
 

The new Breakfast Club

Researchers at the University of Illinois and the University of Texas have collaborated to study something that most of us fear greatly: high school cliques. The researchers, who may or may not have peaked in high school, took a look at high school peer crowds and influences that form those tight-knit bonds that last all of 4 years.

monkeybusinessimages/iStock/Getty Images Plus

The study found that most of the classic cliques – the jocks, the popular crowd, the brains, the stoners, the loners – are still alive and well in today’s American school system. However, at least one new group has emerged in the last decade: the “anime/manga fans.” Researchers noted that although schools have become much more diverse, racial and ethnic stereotypes are alive and well. Thank God we only have to do high school once.
 

Resistance is fecal

And now, just in case you were wondering how long it would take to put our newfound knowledge of “in vimo” to use, here comes a study that has “in vimo” written all over it (metaphorically speaking, of course).

Researchers in Sweden and Finland decided to take a look at antibiotic resistance genes in sewage, because “antibiotics consumed by humans and animals are released into the environment in urine and fecal material contained in treated wastewaters and sludge applied to land.” Then they compared the abundance of the mobile antibiotic resistance genes with the abundance of a human fecal pollution marker.

SutidaS/iStock/Getty Images Plus

That marker – a virus that infects bacteria in human feces but is rare in other animals – was “highly correlated to the abundance of antibiotic resistance genes in environmental samples,” they said in a separate written statement, which “indicates that fecal pollution can largely explain the increase in resistant bacteria often found in human-impacted environments.” The name of that marker, the virus found in feces, happens to be “crAssphage.” And yes, the A really is capitalized. Really. We are not making this up.
 

Gout wins a Golden Globe

Gout has a new poster girl: Great Britain’s Queen Anne. She’s been dead for more than 4 centuries, but a Hollywood version of this stout monarch is turning a famously royal affliction into the disease of the moment.

The credit goes to actress Olivia Colman, who just won a Golden Globe award for her brilliant performance in the earthy comedy “The Favourite.” Ms. Colman transforms the pain-wracked Queen Anne into a needy, manipulative, and loopy monarch who still manages to draw our sympathy.

Besides flummoxing American spell-checkers with its title, The Favourite glories in stretching the truth about the queen’s private life. But she really does seem to have had the “disease of kings,” which has long been linked to the rich, fatty diets enjoyed by blue bloods.

Now, there’s talk that high-protein, meat-friendly keto and paleo diets are boosting rates among the young. This theory got an airing last week in a New York Magazine article titled “Why Gout Is Making a Comeback.”

The truth may be more complicated. Over the last few years, researchers have cast doubt on the keto-leads-to-gout theory and suggested that fructose in sugar may be the real culprit. According to this hypothesis, gout afflicted British royals as they developed a communal sweet tooth during the early days of the sugar trade. Gout then spread to the general population as sugar became more accessible.

The gout debate will continue. As for Olivia Colman, she will soon grace smaller screens with her performance as Queen Elizabeth II in Netflix’s series “The Crown.”

QE II isn’t known for having suffered from any major diseases. But at her next checkup, we do think she should have that stiff upper lip looked at.

imnews@mdedge.com