Volume 110, Issue 9

Context: Studies have revealed the rates of posttraumatic stress disorder (PTSD) and concussion among US soldiers returning from combat, but only one study has focused on the subpopulation of soldiers with headache. Objectives: To determine the rate of PTSD among US soldiers with comorbid chronic posttraumatic headache attributed to head injury, to identify common mechanisms of head injury, and to identify the common challenges a healthcare provider must face when treating US soldiers with chronic posttraumatic headache attributed to head injury. Methods: Between July 2007 and December 2008, the author examined 42 US Army soldiers with complaint of chronic headache. In March 2009, the author retrospectively reviewed the outpatient records for diagnoses, mechanisms of injury, and challenges to treatment. Results: The rate of concussion, defined by the Defense and Veterans Brain Injury Center Working Group on the Acute Management of Mild Traumatic Brain Injury in Military Operational Settings, was 95%. The rate of PTSD, as determined either with the PTSD Checklist or by confirming a prior diagnosis by another healthcare provider, was 97.9%. Both rates are remarkably higher than rates reported in the literature. The most common mechanisms of injury were proximity to blast (18 [45.2%]) and direct target of blast (15 [35.7%]). The most common treatment challenges were overuse of headache-abortive medications (10 [23.8%]) and poor patient followup (7 [16.7%]). Conclusion: Physicians should be aware that the rates of PTSD and concussion for US soldiers, most often linked to involvement in or proximity to a blast, are higher for soldiers complaining of chronic headache. Physicians should also be aware of the potential for overuse of medications in this patient population.

More US military service members have been deployed since 9/11 than in the previous 40 years. A greater number of these deployed service members are surviving, which has increased the incidence of combat-related mental health disorders among veterans of “The Long War.” The societal cost of caring for veterans with such disorders is expected to surpass that of the Global War on Terror, which is estimated at $600 billion. Because the prospect of stopping all deployment is remote, standardized prevention and treatment methods must be used to eliminate these “invisible wounds of war.” It is imperative that high-quality, evidence-based, and cost-effective treatments—pharmaceutical and nonpharmaceutical—be developed. Although no approved medication currently exists for the prevention of posttraumatic stress disorder, the blood pressure medication propranolol has shown promise in erasing the behavioral expression of fear memory and may be useful for preventing more severe emotional disorders. In addition, a nonpharmaceutical method known as stress inoculation training is ideally suited to military populations and should be incorporated into military training programs. Furthermore, osteopathic physicians can improve resilience in the communities they serve by considering the dynamic of body, mind, and spirit in their patients. Applying these methods, teaching self-regulation traits, and removing barriers to care will build resiliency among service personnel for The Long War.

Objective: Type 2 diabetes mellitus is a chronic, progressive disease that necessitates comprehensive and individualized patient treatment strategies. Daily glycemic measures, including measures of postprandial glucose and fasting plasma glucose levels, in combination with measures of glycated hemoglobin (HbA 1c ) levels may be a more reliable indicator of blood glucose control and the long-term risk of complications than measures of HbA 1c levels alone. Emerging treatment strategies for type 2 diabetes support the rationale for using dipeptidyl peptidase-4 (DPP-4) inhibitors in combination with other oral antidiabetic drugs for early and aggressive management of type 2 diabetes. Data Sources: Information was gathered through a search of MEDLINE, Derwent Drug File, BIOSIS, and EMBASE databases for DPP-4 inhibitors and postprandial hyperglycemia in patients with type 2 diabetes. Study Selection: Studies published from 2003 to the present and in any language were included. Additional sources were relevant conference poster presentations. Data Synthesis: Early in the disease process, more intensive glucose-lowering intervention prior to the onset of advanced disease and cardiovascular events may be necessary to demonstrate effective reduction in macrovascular risk. Recent advances in pharmacotherapy allow physicians to target glucose excursions and variability. Data support the use of a combination of drugs with a complementary mechanism of action; to achieve an HbA 1c level of less than 7% of total hemoglobin, use a drug with a primary mechanism of action that targets postprandial glucose levels in combination with a drug that primarily lowers fasting plasma glucose levels. Based on the glucose-dependent action of incretins, DPP-4 inhibitors demonstrate a low propensity for hypoglycemia, are generally weight neutral, and have a low risk of interactions with other drugs, which makes them appropriate candidates for combination therapy, particularly with other oral antidiabetic drugs including metformin, thiazolidinediones, and sulfonylureas. Conclusion: The complementary mechanism of action of DPP-4 inhibitors with other oral antidiabetic drugs affords clinicians an effective and well-tolerated treatment option for early and more aggressive management of hyperglycemia in patients with type 2 diabetes.

Shiga toxin–producing Escherichia coli (STEC) was first discovered in 1977 and since has caused serious complications including the life-threatening condition of hemolytic uremic syndrome (HUS). While HUS is most common in children, adults and especially elderly patients experience a higher incidence of death and disability. Because the majority of HUS cases have been described in children, pediatric treatment options have been used to treat adult and elderly patients with HUS. More research regarding the treatment, risk factors, and prognosis of HUS in adults needs to be performed to ensure that optimal care is provided. The authors present a case series of 5 adults with HUS who were part of the largest outbreak of E coli 0111 reported in the United States. To date, there are no published cases of HUS secondary to E coli 0111 in adults. The authors also include a literature review of HUS secondary to STEC.

Metabolic acidosis after acute acetaminophen overdose is typically attributed to either transient lactic acidosis without evidence of hepatic injury or hepatic failure. High levels of the organic acid 5-oxoprolinuria are usually reported in patients with predisposing conditions, such as sepsis, who are treated in a subacute or chronic fashion with acetaminophen. The authors report a case of a 40-year-old woman who developed anion gap metabolic acidosis and somnolence after an acute acetaminophen overdose. Substantial hepatic damage did not occur, which ruled out acetaminophen-induced hepatic insufficiency as a cause of the patient's acidosis or altered mental status. Urinalysis revealed elevated levels of 5-oxoproline, suggesting that the patient's acute acetaminophen overdose was associated with marked anion gap metabolic acidosis due solely to 5-oxoproline without hepatic complications. The acidosis fully resolved with N -acetylcysteine treatment and supportive care including hydration.