Naval Medical Center San Diego

Pediatric generalized pustular psoriasis (GPP) is a rare, severe, and potentially life‐threatening variant of childhood psoriasis. Early‐onset GPP has a well‐known association with deficiency of the interleukin‐36 receptor antagonist (DITRA). We present a case of a pediatric patient diagnosed with GPP found to have a heterozygous variant in the Mediterranean fever gene ( MEFV ) that was successfully treated with adalimumab. MEFV variants are a newly identified genetic risk factor for GPP. Our case highlights the need for ongoing genomic studies for childhood autoinflammatory diseases and the call for evidence‐based management for these challenging cases.

Base of fifth metatarsal fractures are treated according to fracture zones. Proximal tuberosity avulsions (zone 1) are typically treated conservatively, while proximal metaphyseal-diaphyseal junction fractures (zone 2) or proximal diaphyseal fractures (zone 3) are usually treated with intramedullary screw fixation. We performed a systematic review and meta-analysis of plate fixation of base of fifth metatarsal fractures by zones to estimate mean time to union, mean time to return to daily activities, mean 1-year American Orthopaedic Foot and Ankle Society (AOFAS) score, and complication rate. Outcomes were pooled to determine aggregate outcomes if standard errors were included and there were at least 2 studies. Six studies examined zone 1 and 2 fractures treated with plate fixation. Zone 1 fractures had a mean of 6.88 weeks union time, 11.34 weeks to return to daily activities, 1-year AOFAS score of 94.91, and 5.97% complications. Zone 2 fractures had a mean of 7.0 weeks union time and 20.45% complications. Zone 1 and 2 plate fixation demonstrated union rates comparable to those for traditional fifth metatarsal base fracture management. Level 3, Prognostic.

Introduction The diagnosis of traumatic arthrotomy is often accomplished using the saline load test. The introduction of large volumes of saline into the joint is uncomfortable for the patient and has been reported to have low sensitivity and specificity. Computed tomography (CT) scan has been previously validated as a fast and reliable method of detecting free air in the knee joint. The primary objective of this study was to evaluate the use of CT scan for the detection of intra-articular free air in the ankle joint. Methods Eighteen fresh-frozen cadaver distal lower extremities were thawed, and then CT scans were obtained at their baseline harvested state. The tibiotalar joint was injected with 0.05cc free air, and then repeat CT scans of each specimen were obtained. Specimens with instrumentation, intra-articular air, or ambiguous free air prior to intervention were excluded from the study. Scans were performed from the mid leg through the entire foot at institution standard radiation dose (120 kV, 170 mA) and a slice thickness of 0.6 mm. Images were anonymized, randomized, and sent to 4 reviewers (2 orthopedic surgeons, 1 musculoskeletal radiologist, and 1 radiology resident) for evaluation of free air. Sensitivity and specificity of CT to detect free air were calculated, and Fleiss’s Kappa coefficient was used to determine interobserver reliability. Results The sensitivity and specificity of CT to detect free air in cadaver ankles was 100%. Twenty-two CT scans (11 natural state and 11 with simulated air arthrotomies) were correctly identified for the presence or absence of intra-articular free air by all reviewers with kappa coefficient 1.0 (complete agreement). Conclusions Computed tomography is a fast, reproducible method for detecting small volumes of free air in the ankle and may offer clinical benefit in evaluation of traumatic arthrotomy of the ankle.

Background Acute Kidney Injury (AKI) is common in critically ill trauma patients and is associated with increased morbidity and mortality. A subset of these patients requires Continuous Renal Replacement Therapy (CRRT) for severe AKI. This study investigates the incidence of AKI and CRRT and identifies predictors for AKI progression in trauma patients. Methods We conducted a 10‐year retrospective review of trauma ICU patients at a Level I trauma center from 2014 to 2023. Patients were classified into three groups: no AKI, AKI without CRRT, and AKI requiring CRRT. Statistical analyses, including logistic regression and Kaplan–Meier survival estimates, were used to assess risk factors and survival. Variables analyzed included age, injury severity score (ISS), admission hemodynamics, and procedural interventions. Results Of 8427 patients, 5.5% developed AKI, and 1% required CRRT. AKI patients showed decreased survival (83% vs. 88%, p = 0.003). Survival was lower in CRRT compared to AKI only (73% v 83%, p < 0.001). Older age (OR 1.01, 95% CI 1.003, 1.012, p < 0.001), ISS (OR 1.02, 95% CI 1.01, 1.02, p < 0.001), and lower systolic blood pressure on admission (OR 0.98, 95% CI 0.98, 0.99, p < 0.001) were predictive of AKI. In AKI, tachycardia on admission was predictive of CRRT need (OR 1.01, 95% CI 1.01, 1.03, p = 0.04). The most common procedure with AKI was laparotomy ( n = 42) with 40% requiring CRRT. Conclusions AKI and CRRT are associated with mortality in trauma. Identifying predictors like age, injury severity, and hemodynamic changes can aid in early intervention. Further research should explore the timing and impact of CRRT in trauma‐specific settings.

Dual-energy lateral chest radiography enables creation of images that can demonstrate coronary artery calcium with relatively high accuracy in detection.

A 3-year-old male presented with a history of a nasal dermoid cyst with intracranial extension as well as a concomitant isolated intracranial dermoid cyst of the middle cranial fossa. Initially, at 2 years of age, he underwent successful transnasal endoscopic resection of an anterior skull base dermoid cyst. He then presented for a staged dermoid cyst resection of the right sphenoid bone at the lesser wing because of interval growth between imaging studies. A right-sided transorbital neuroendoscopic approach (TONES) was utilized for lesion resection. A gross-total resection was achieved, with no complications. Excellent neurological and cosmetic outcome was achieved. The video can be found here: https://stream.cadmore.media/r10.3171/2025.1.FOCVID24157

U.S. military regulatory bodies have identified the crucial need for standardized Joint Austere Resuscitative Surgical Care curricula focused on training small surgical teams. The Joint Trauma System and Service-appointed subject matter experts analyzed current available curricula and courses and developed the first joint Austere Resuscitative Care curriculum for Role 2 surgical teams.

Objectives To explore associations of recent moderate-to-vigorous aerobic exercise (MVAE) participation and lifetime mild traumatic brain injury (mTBI) history with measures of brain gray matter volumes among military service members and Veterans (SMVs). Methods Participants (n = 1,340; aged 41.3 ± 10.3 years; 13% female) were SMV’s who participated in the Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium Prospective Longitudinal Study (LIMBIC-CENC PLS). MVAE participation was self-reported via the Behavioral Risk Factor Surveillance System and categorized according to current MVAE recommendations (Inactive, Insufficiently Active, Active, and Highly Active). Lifetime mTBI history was queried via validated structured interview and categorized as 0 mTBI, 1-2 mTBIs, 3 + mTBIs. Structural MRI (T1- and T2-weighted images) were used to measure gray matter volumetrics: ventricle-to-brain ratio (VBR); bilateral volumes of the frontal, parietal, temporal, occipital, cingulate, hippocampus, amygdala, and thalamus regions. Multivariable linear regression models were fit to test associations of MVAE participation, mTBI history, and their interaction on each of the volumetric outcomes while controlling for age, sex, education attainment, and PTSD symptoms. Effects were considered statistically significant if the corresponding unstandardized beta (B) and 95% CI did not include 0. Results Regarding main effects, participants in the Inactive MVAE group had significantly larger VBR values (worse outcome) than those in the Insufficiently Active group (B[95%CI] = -0.137[-0.260, -0.014]). Interaction effects showed participants with no lifetime mTBIs in the Highly Active group had larger VBR values (worse outcome) when compared to those in the Inactive and Insufficiently Active groups. SMVs with 3 + lifetime mTBIs who were Highly Active also had smaller VBR values (better outcome) when compared to Highly Active SMVs with fewer lifetime mTBIs. There were no other statistically significant differences for MVAE participation, mTBI history, or their interactions. Conclusions History of one or more lifetime mTBIs was not associated with measures of brain gray matter volumes, suggesting that declines in structural brain health are not expected for the most SMVs with mTBI(s). Although MVAE may benefit brain health, a positive association between self-reported MVAE participation and gray matter volumes was not observed.

Nonoperative management has been established as a safe, effective treatment strategy for blunt solid organ injury. The guiding principle is that patients should be managed by their hemodynamic status as opposed to their radiographic grade of injury. The literature regarding nonoperative management is quite robust, and success rates have been reported to be greater than 95%. This has also resulted in further de-escalation of other therapies including decreasing ICU utilization, blood draws, and length of stay. Angioembolization can be a useful adjunct for blunt solid organ injuries; however, there is far less data regarding its indications and benefits.

Anterior glenohumeral joint (shoulder) dislocations are common orthopedic injuries that require timely recognition and effective reduction to prevent long-term complications. Traditional reduction techniques are typically performed on land where inherent mechanical advantage is present. This case study explores a novel in-water, prehospital technique used to reduce a shoulder dislocation during a high surf event in San Diego, California. The case involves a 36-year-old male who sustained an anterior shoulder dislocation while surfing. After initial reduction attempts using commonly described techniques were unsuccessful due to an inability to achieve adequate leverage while afloat, an improvised reduction technique was implemented, which successfully reduced the joint while floating on the ocean surface. The novel maneuver and subsequent clinical course are outlined in this case report. This technique has applications in neutral buoyancy or low-gravity environments in which the typical reduction maneuvers that require gravity or friction as leverage may not be feasible.

Introduction Antibiotic overuse and subsequent antibiotic resistance lead to worse infection outcomes in cirrhosis. Secondary spontaneous bacterial peritonitis prophylaxis (SecSBBPr) is associated with higher SBP recurrence but impact on non-SBP infections is unclear. Methods We studied patients with cirrhosis and SBP who were given SecSBPPr or not between 2009-2019 in two complementary national cohorts [Veterans affairs corporate data warehouse (VA-CDW) and non-VA TriNetX]. Development of total non-SBP infections and specifically urinary tract infections (UTI), bacteremia, pneumonia, and C.difficile using validated codes over 2 years was compared between those on SecSBPPr versus not. Multi-variable regression for non-SBP infections was performed. Results VA-CDW: Of 4673 Veterans with index SBP, 2539 (54.3%) were started on SecSBPPr. 1406 (30.1%) developed non-SBP infections (13.5% UTI, 12.4% pneumonia, 8.5% bacteremia and 6.8% C.difficile ). On multi-variable regression, SecSBPPr was significantly associated with any non-SBP infection (OR 1.26, 95% CI:1.10-1.44, p<0.0001) and UTI (OR 1.21, 95% CI:1.01-1.45, p=0.036). TriNetX: Of 6708 patients with index SBP, 3261 (48.6%) were started on SecSBPPr. 1932 (28.8%) patients developed non-SBP infections (13.4% UTI, 12.9% pneumonia, 8.6% bacteremia and 5.9% C.difficile ). On multi-variable regression, SecSBPPr was significantly associated with any non-SBP infection (OR 1.33, 95% CI:1.12-1.59, p<0.0001), UTI (OR 1.35, 95% CI:1.07-1.71, p=0.010), pneumonia (OR 1.35, 95% CI:1.06-1.72, p=0.017), and bacteremia (OR 1.47, 95% CI:1.10-1.97, p=0.009). Conclusions In two diverse US-based national cohorts of patients with cirrhosis and SBP, use of secondary SBP prophylaxis was associated with a higher risk of non-SBP infections , especially urinary tract infections.

The Military Health System (MHS) in the United States currently faces a crisis: maintaining medical readiness during a time of relative peace in the face of an increasingly hostile and unstable geopolitical environment. Collaboration through partnerships—with civilian academic medical centers, with academic medical societies and scientific journals, and with advocates for improved policy and supporting legislation—represents one important strategy to stave off the peacetime effect that threatens to erode our combat casualty care skills. This panel session held during the 2022 Excelsior Surgical Society Symposium at the American College of Surgeons Clinical Congress explored the way forward for the MHS amidst these historic challenges with important action items and take-home points for civilian and military surgeons alike.

OBJECTIVE The global need for neurosurgical care is significant and often unmet. Building partnerships between high-income countries (HICs) and lower-middle-income countries (LMICs) can help bridge the gap. Six features of sustainable global surgical partnerships have been identified; however, their application in neurosurgery has not been studied. The authors analyzed how the 6 pillars of sustainability are applied to neurosurgical partnerships established by the Neurosurgery Outreach Foundation (NOF) with hospitals in LMICs in Asia. METHODS NOF is an all-volunteer, nonprofit US foundation with the mission to advance neurosurgical care in underserved communities through education, service, and support. The authors examined the NOF programs and identified the characteristics associated with the 6 pillars of sustainability, which are community engagement, multidisciplinary collaboration, education and training, outcome measurement, multisource funding, and bilateral authorship. The authors discuss how these pillars contribute to the establishment of sustainable partnerships. RESULTS From 2010 to 2024, NOF has established partnerships at 4 sites: Cebu, Manila, and Davao, the Philippines; and Ulaanbaatar, Mongolia. Partnerships were established with tertiary or quaternary government hospitals to develop neurosurgical programs tailored to the needs of each site and remained sustained and active. Educational surgical missions were in-person outreach activities conducted annually or biennially and were supplemented with online or remote collaboration. The 5 pillars of sustainable partnerships present at all sites include community engagement, multidisciplinary collaboration, education and training, outcome measurement, and multisource funding. The sixth pillar, bilateral authorship, was present at University of the Philippines–Philippine General Hospital in Manila. CONCLUSIONS Using the 6 pillars of sustainable global partnerships, neurosurgical partnerships can be developed and maintained by all-volunteer nonprofit organizations such as NOF. Incorporating these pillars during the planning and executing of global neurosurgical partnerships are essential for long-term success.

Background Intra-articular corticosteroid (IACS) injection and peri-articular corticosteroid injection are commonly used to treat musculoskeletal conditions. Results vary by musculoskeletal region, but most studies report short-term benefit with mixed results on long-term relief. Publications showed adverse events from single corticosteroid injections. Recommended effective doses were lower than those currently used by clinicians. Methods Development of the practice guideline for joint injections was approved by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine and the participating societies. A Corticosteroid Safety Work Group coordinated the development of three guidelines: peripheral nerve blocks and trigger points; joints; and neuraxial, facet, and sacroiliac joint injections. The topics included safety of the technique in relation to landmark-guided, ultrasound-guided, or radiology-aided injections; effect of the addition of the corticosteroid on the efficacy of the injectate; and adverse events related to the injection. Experts on the topics were assigned to extensively review the literature and initially develop consensus statements and recommendations. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed. A modified Delphi process was adhered to in arriving at a consensus. Results This guideline focuses on the safety and efficacy of corticosteroid joint injections for managing joint chronic pain in adults. The joints that were addressed included the shoulder, elbow, hand, wrist, hip, knee, and small joints of the hands and feet. All the statements and recommendations were approved by all participants and the Board of Directors of the participating societies after four rounds of discussion. There is little evidence to guide the selection of one corticosteroid over another. Ultrasound guidance increases the accuracy of injections and reduces procedural pain. A dose of 20 mg triamcinolone is as effective as 40 mg for both shoulder IACS and subacromial subdeltoid bursa corticosteroid injections. The commonly used dose for hip IACS is 40 mg triamcinolone or methylprednisolone. Triamcinolone 40 mg is as effective as 80 mg for knee IACS. Overall, IACS injections result in short-term pain relief from a few weeks to a few months. The adverse events include an increase in blood glucose, adrenal suppression, detrimental effect on cartilage lining the joint, reduction of bone mineral density, and postoperative joint infection. Conclusions In this practice guideline, we provided specific recommendations on the role of corticosteroids in joint, bursa, and peritendon injections for musculoskeletal pain.

Minimally invasive lumbar decompression surgery offers many advantages including reduced patient morbidity and quicker return to normal life. Endoscopic lumbar spine surgery, sometimes termed “ultra” minimally invasive, further pushes the envelope on reducing operative time, blood loss, and recovery time. Endoscopy offers the additional advantage to the surgeon of placing the surgeon's eye not 50 cm away through the lens of loupes or a microscope, but right at the spine pathology in high definition. Uniportal approach involves a single incision through which the endoscope and instruments are passed. Biportal approach involves two incisions, one for the endoscope and one for the instruments. In what follows we review the indications and efficacy of these procedures with case examples.