This commentary critically examines the five strategies proposed by the NCI to accelerate the war on cancer in this era of budget deficits.
The Carpathian Mountains in Europe are a biodiversity hot spot; harbor many relatively undisturbed ecosystems; and are still rich in seminatural, traditional landscapes. Since the fall of the Iron Curtain, the Carpathians have experienced widespread land use change, affecting biodiversity and ecosystem services. Climate change, as an additional driver, may increase the effect of such changes in the future. Based on a workshop organized by the Science for the Carpathians network, this paper reviews the current status of global change research in the Carpathians, identifies knowledge gaps, and suggests avenues for future research.
Willem J. Kolff, M.D., 97, inventor of the first artificial organ to reliably sustain life, died of congestive heart failure on February 11, 2009, in Newtown Square, PA. Dr. Kolff is widely considered the “father of artificial organs.” His rotating drum artificial kidney was initially reported in 1943 and, for the first time, offered an effective intervention for the treatment of acute renal failure.1 It was in The Netherlands during World War II at the height of German occupation that he began work on the first dialysis machine. He had moved to a small hospital in Kampen, on the Zuider Zee, to escape the Nazi sympathizers who had been put in charge of his hospital at Groningen. There, conducting bench experiments with sausage casing (Visking Casing Corporation), saline, and urea, he saw that urea moved down its concentration gradient and equilibrated across this cellulosic membrane. He then cobbled together his rotating drum artificial kidney from miscellaneous available parts including bed slats, a bathtub, and sundry tubing connectors of considerable sophistication. It is the only artificial kidney where uremic blood is circulated through tubing that itself is moving through a stationary noncirculating dialysis bath. The membrane area employed was 2 to …
Blasts are responsible for about two-thirds of the combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom, which include at least 1,200 traumatic brain injuries. Blasts inflict damage to the brain directly and by causing injuries to other organs, resulting in air emboli, hypoxia, and shock. Direct injuries to the brain result from rapid shifts in air pressure (primary blast injury), from impacts with munitions fragments and other objects propelled by the explosion (secondary blast injury), and from collisions with objects and rapid acceleration of individuals propelled by the explosion (tertiary blast injury). Tertiary injury can occur from a building or other structure collapsing and from an individual being thrown by the blast wind. The pathological consequences of secondary and tertiary blast injuries are very likely to be similar to those of other types of mechanical trauma seen in civilian life. The damage attributable to the specific effects of a blast, however, has received little study, although it has been assumed to include the focal and diffuse lesions characteristic of closed head injuries. Available clinical studies of blast injuries show focal damage similar to that found in other types of closed head injuries but have not determined whether diffuse axonal injury also occurs. In this article, we will try to reach a better understanding of the specific pathology of blast-related brain injury by reviewing the available experimental studies and the autopsy reports of victims of terrorist attacks and military casualties dating back to World War I.
Soldiers with a traumatic brain injury (TBI) present with an array of neuropsychiatric symptoms that can be grouped into nosological clusters: (1) cognitive dysfunctions: difficulties in memory, attention, language, visuospatial cognition, sensory-motor integration, affect recognition, and/or executive function typically associated with neocortical damage; (2) neurobehavioral disorders: mood, affect, anxiety, posttraumatic stress, and psychosis, as well as agitation, sleep problems, and libido loss, that may have been caused by damage to the cortex, limbic system, and/or brain stem monoaminergic projection systems; (3) somatosensory disruptions: impaired smell, vision, hearing, equilibrium, taste, and somatosensory perception frequently caused by trauma to the sensory organs or their projections through the brain stem to central processing systems; (4) somatic symptoms: headache and chronic pain; and (5) substance dependence. TBI-related cognitive impairment is common in veterans who have served in recent conflicts in the Middle East and is often related to blasts from improvised explosive devices. Although neurobehavioral disorders such as depression and posttraumatic stress disorder commonly occur after combat, the presentation of such disorders in those with head injury may pass undetected with use of current diagnostic criteria and neuropsychological instruments. With a multidimensional approach (such as the biopsychosocial model) applied to each symptom cluster, psychological, occupational, and social dysfunction can be delineated and managed.
Of veterans from the U.S. Global War on Terrorism who have sought care in the Department of Veterans Affairs, approximately 12% have an infectious disease diagnosis. Infections in those veterans with traumatic brain injury (TBI) include infections associated with blast injuries and burns, such as skin and soft tissue infections; infections as a result of retained bullet or shrapnel fragments; pulmonary infections resulting from lung injury, intubation, or resultant tracheostomy; hospital-acquired infections, such as those associated with methicillin-resistant Staphylococcus aureus and other antimicrobial resistant organisms such as Acinetobacter baumannii; and infections from implanted prosthetic devices, such as metal hardware or skull flaps. Longer-term cognitive impairment may result in behaviors that place veterans with TBI at risk for human immunodeficiency virus or hepatitis C virus infections. Finally, chronic infections acquired abroad, such as cutaneous leishmaniasis or Q-fever, may be diagnosed after veterans return to the United States. These infections present challenges in terms of added morbidity and costs associated with complex antimicrobial management; isolation requirements; and surgical procedures, such as those to remove infected retained fragments or prosthetic devices. In this review, providers will become more familiar with the scope and complexity of infectious disease management in veterans with TBI.
The nature of current combat situations that U.S. military forces encounter and the use of unconventional weaponry have dramatically increased service personnel's risks of sustaining a traumatic brain injury (TBI). Although the true incidence and prevalence of combat-related TBI are unknown, service personnel returning from deployment have reported rates of concussion between 10% and 20%. The Department of Defense has recently released statistics on TBI dating back to before the wars in Iraq and Afghanistan to better elucidate the impact and burden of TBI on America's warriors and veterans. Patients with severe TBI move through a well-established trauma system of care, beginning with triage of initial injury by first-responders in the war zone to acute care to rehabilitation and then returning home and to the community. Mild and moderate TBIs may pose different clinical challenges, especially when initially undetected or if treatment is delayed because more serious injuries are present. To ensure identification and prompt treatment of mild and moderate TBI, the U.S. Congress has mandated that military and Department of Veterans Affairs hospitals screen all service personnel returning from combat. Military health professionals must evaluate them for concussion and then treat the physical, emotional, and cognitive problems that may surface. A new approach to health management and care coordination is needed that will allow medical transitions between networks of care to become more centralized and allow for optimal recovery at all severity levels. This article summarizes the care systems available for the acute management of TBI from point of injury to stateside military treatment facilities. We describe TBI assessment, treatment, and overall coordination of care, including innovative clinical initiatives now used.
Posttraumatic epilepsy (PTE) is a major long-term complication of traumatic brain injury (TBI). PTE usually develops within 5 years of head injury. The risk for developing PTE varies with TBI type. Both Korean and Vietnam war veterans with penetrating TBI had a 53% risk of developing PTE. The risk of developing PTE is between 10% and 25% in combat-associated closed-head trauma with positive brain imaging and about 5% in moderately severe closed-head injury without imaging finding. We do not know the risk of PTE among Operation Iraqi Freedom/Operation Enduring Freedom veterans with minimal TBI because of blast exposure.Partial seizures may manifest with subtle behavioral alterations that can be mistaken for manifestations of posttraumatic stress disorder and improperly treated. Accidents and medical complications commonly occur during seizures. Sudden unexpected death in epilepsy is most frequent among 20- to 40-year-olds. Seizures increase the likelihood of refractory seizures years after TBI. Seizures are also a social stigma that compromise veterans' reintegration into society. People with uncontrolled epilepsy are not allowed to drive and have difficulty obtaining or maintaining employment. Optimal seizure control is essential to the physical and emotional health of veterans with TBI and to their ability to lead productive lives.
Traumatic brain injury (TBI) is one of the foremost medical problems resulting from the wars in Afghanistan and Iraq. In 2006, 13,969 active-duty servicemen and servicewomen with incident TBI were treated in the military medical system; of those, 7.6 percent were hospitalized [1]. While the consequences of moderate to severe TBI capture public and media attention, the majority of brain injuries are mild. Mild TBI (mTBI) represents 85 to 90 percent of civilians with TBI and a large majority with war-related TBI [2-5]. Our current ability to accurately diagnose war-related mTBI is greatly challenged because much of our knowledge of this injury is based on experience accrued from civilian patients, even though the conditions under which war-related injuries occur differ vastly from those of civilian injuries. TBIs of civilian patients typically result from falls or motor-vehicle or sports-related incidents, whereas war-related TBIs are more often sustained under emotionally traumatic circumstances. Furthermore, since a major portion of current war-related injuries result from blast exposure, inherently different mechanical processes are involved. Although the definition of mTBI varies, it typically refers to injuries that are associated with loss or alteration of consciousness for Postconcussive syndrome (PCS) is diagnosed when patients with mTBI present with ongoing symptomatic complaints. Those who experience multiple TBIs are more likely to have long-lasting symptoms [7]. PCS can occur with any level of head injury severity. According to recent reports, U.S. soldiers returning from Iraq have a high rate of coexistence of mTBI-related complaints and posttraumatic stress disorder (PTSD) [8]. PTSD is an anxiety disorder that may develop after exposure to a traumatic event in which grave harm occurred or was threatened [9]. PCS and PTSD have many symptoms in common, but a hallmark of PTSD is reexperiencing the traumatic event. As expected, PTSD is more prevalent than TBI in combat veterans. An important issue that complicates differentiating traumatic stress and TBI is the retrospective diagnosis of war-related mTBI. The diagnosis is difficult because it requires documenting the history of an injury that would typically have involved alteration of consciousness or amnesia for events before, during, or after injury in the midst of a battle. Despite their overlapping symptoms, PTSD and mTBI may be two distinct disease entities with differential responses to various treatment approaches. Patients who survive severe TBI commonly suffer cognitive impairments (e.g., memory, executive functions, and processing speed), language difficulties, emotional problems, sensory-motor losses, posttraumatic epilepsy, and a variety of other impairments and disabilities. Unlike the symptoms of a majority of patients with mTBI, these problems, in spite of some initial improvement, may persist and become chronic. These chronic cognitive, physical, and emotional impairments often interfere with individuals' abilities to function independently and resume their prior family, workplace, and social roles and responsibilities. Currently, no well-validated therapies exist to treat war-related TBI other than existing TBI rehabilitation programs and careful supportive care. …