INTRODUCTION:Catchment populations have several uses. A method using catchment population to estimate the incidence of sporadic Creutzfeldt-Jakob disease (sCJD) is described. MATERIALS AND METHODS:A cohort of nine consecutive patients diagnosed with sCJD, symptom onset spanning 26 months, were observed at a rural tertiary university medical center that has approximately 40,000 hospital discharges annually. An effective catchment population was determined using surrounding county utilization frequency that captured all nine sCJD patients and accounted for over 87% of discharges. RESULTS:The effective sCJD hospital catchment population was 1.266 million, implying an annual sCJD incidence rate of 3.39 per million (95% CIs, 1.55-6.43), assuming a Poisson distribution for sCJD occurrence. CONCLUSIONS:This annual incidence rate suggests that many sCJD patients are unrecognized and unreported. An advantage of this catchment population method is independence from death certificate accuracy, important in rare diseases that are both rapidly and invariably fatal. The relative absence of significant healthcare systems competition in this rural population enhances the reliability of this finding. The most likely explanation for the high sCJD incidence rate suggested by this study is enhanced clinical suspicion and improved diagnostic accuracy.

• Max Ellenberg coined the phrase diabetic truncal mononeuropathy in 1978 in the inaugural issue of Diabetes Care referring to a diabetic neuropathy affecting nerves of the trunk. • In a series of 40 cases, the syndrome, characterized by the abrupt onset of severe unilateral pain, raises clinical concern for intrathoracic or intra-abdominal pathology. • Ellenberg emphasized that diabetic truncal mononeuropathy typically occurs in the setting of long-standing diabetes and had a good prognosis with the pain abating within a few months. • Ellenberg also emphasized, “There was virtually no motor involvement.” • This latter assertion has evoked case reports illustrating examples of abdominal protrusions due to abdominal wall muscle weakness associated with diabetic truncal neuropathy. • Ellenberg, however, did not use electromyography to look for evidence of non–clinically obvious motor involvement in his cases. • An example of diabetic truncal neuropathy with abrupt onset of excruciating unilateral abdominal pain, unilateral abdominal protrusion, and good prognosis is provided. • Far from rare, motor involvement in diabetic truncal neuropathy is likely frequent.

Objective: To describe a case-series of three adult men with rapid resolution of myositis. Background: Acute viral myositis is characterized by muscle pain, weakness and elevated serum creatinine kinase after a suspected viral illness. It is a known, but rare, entity that occurs more commonly in children than adults. Design/Methods: Not applicable. Results: Three men ranging in age from 37 to 41 years presented within a span of 18 days in late summer of 2018 with a similar clinical course. Each had a fever (ranging from 101 to 103 °F) and then developed significant muscle weakness (e.g. inability to pick up or open items, ambulate without falling or climb stairs) over the course of 1–4 days. On examination, one man had bilateral wrist/hand weakness and the other two had bilateral full arm and proximal leg weakness (weakness ranged from 3–4/5). Creatinine kinase (peak ranged from 957 to 2121 U/L), C - reactive protein (ranged from 13.7 to 25.3 mg/L), serum myoglobin (ranged from 158 to 250 mcg/L), serum aldolase (ranged from 9.7 to 11.3 U/L) was elevated in all three men. Two of the three men had elevated thyroid peroxidase antibodies (general population has elevation in 8 to 27%). One man had positive Coxsackie antibodies; the other two had negative respiratory viral panels. Electromyogram/nerve conduction study in all three revealed no definite abnormalities. Each patient was discharged from the hospital in 2–3 days with resolution or near-resolution of his weakness. Conclusions: A syndrome of acute myositis with rapid resolution in three middle-aged men is described. Although a viral etiology was suspected, the role of thyroid peroxidase antibodies in two is unexplained. Disclosure: Dr. Danielson has nothing to disclose. Dr. Ranasinghe has nothing to disclose. Dr. Sultan has nothing to disclose. Dr. Riggs has nothing to disclose.

August in the Kuwait desert; I was hot, sweating profusely, and jet-lagged. And this was going to be my home for nearly a year. Even in the "air-conditioned" command tent, it was above 90 degrees. The current commanding officer was a seasoned active duty Navy Medical Corps captain. Looking calm, cool, and dry and with his legs propped up on his desk, he described for me his duties and responsibilities. I was so miserable and tired that I was having difficulty keeping my eyes open and focusing on his words. The temperature was 126 degrees Fahrenheit outside, and I was not acclimated. I had taken off the jacket of my desert cammies. My brown T-shirt was soaking wet with sweat.

Clinical Correspondence When Treatment Establishes Diagnosis: A Case Report of Posttraumatic Chronic Paroxysmal Hemicrania Sneha Jacob MD, Sneha Jacob MD orcid.org/0000-0002-1941-1075 Department of Neurology, West Virginia University, Morgantown, WV, USASearch for more papers by this authorDavid Watson MD, Corresponding Author David Watson MD dwatson@hsc.wvu.edu Department of Neurology, West Virginia University, Morgantown, WV, USAAddress all correspondence to David Watson, Department of Neurology, West Virginia University, PO Box 9180, Morgantown, WV 26505-9180, USA, email: dwatson@hsc.wvu.eduSearch for more papers by this authorJack E. Riggs MD, Jack E. Riggs MD Department of Neurology, West Virginia University, Morgantown, WV, USASearch for more papers by this author Sneha Jacob MD, Sneha Jacob MD orcid.org/0000-0002-1941-1075 Department of Neurology, West Virginia University, Morgantown, WV, USASearch for more papers by this authorDavid Watson MD, Corresponding Author David Watson MD dwatson@hsc.wvu.edu Department of Neurology, West Virginia University, Morgantown, WV, USAAddress all correspondence to David Watson, Department of Neurology, West Virginia University, PO Box 9180, Morgantown, WV 26505-9180, USA, email: dwatson@hsc.wvu.eduSearch for more papers by this authorJack E. Riggs MD, Jack E. Riggs MD Department of Neurology, West Virginia University, Morgantown, WV, USASearch for more papers by this author First published: 30 April 2018 https://doi.org/10.1111/head.13308Citations: 3 Conflict of Interest: No conflicts to report for each author. Financial Support: None. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume58, Issue6June 2018Pages 894-895 RelatedInformation

“How can you come to a war and not bring a weapon? Every soldier must have a weapon. That's the rule!” My boss was emphatic. “You people are pathetic.”

Corpsmen rushed the severely injured young soldier into casualty receiving of our tent combat support hospital in Kuwait. The army combat medic from the Black Hawk that had delivered this wounded soldier was drenched in sweat, having just performed cardiopulmonary resuscitation (CPR) for 45 minutes in 120°-plus heat. A senior chief corpsman pulled this medic away, telling him, "We have it now."

“Doctor, please don't send me home!” the major begged.

Background Owing to their severity, large vessel occlusion (LVO) strokes may be associated with higher costs that are not reflected in current coding systems. This study aimed to determine whether intravenous thrombolysis costs are related to the presence or absence of LVO. Methods Patients who had undergone intravenous thrombolysis over a 9-year period were divided into LVO and no LVO (nLVO) groups based on admission CT angiography. The primary outcome was hospital cost per admission. Secondary outcomes included admission duration, 90-day clinical outcome, and discharge destination. Results 119 patients (53%) had LVO and 104 (47%) had nLVO. Total mean±SD cost per LVO patient was $18 815±14 262 compared with $15 174±11 769 per nLVO patient (p=0.04). Hospital payments per admission were $17 338±13 947 and $15 594±16 437 for LVO and nLVO patients, respectively (p=0.4). A good outcome was seen in 33 LVO patients (27.7%) and in 69 nLVO patients (66.4%) (OR 0.2, 95% CI 0.1 to 0.3, p<0.0001). Hospital mortality occurred in 31 LVO patients (26.1%) and in 7 nLVO patients (6.7%) (OR 0.2, 95% CI 0.08 to 0.5, p<0.0001). 31 LVO patients (32.6%) were discharged to home versus 64 nLVO patients (61.5%) (OR 4.5, 95% CI 2.6 to 8, p<0.0001). Admission duration was 7.5±6.9 days in LVO patients versus 4.9±4.2 days in nLVO patients (p=0.0009). Multivariate regression analysis after controlling for comorbidities showed the presence of LVO to be an independent predictor of higher total hospital costs. Conclusions The presence or absence of LVO is associated with significant differences in hospital costs, outcomes, admission duration, and home discharge. These differences can be important when developing systems of care models for acute ischemic stroke.

“Nice picture, Gunny,” I said as I handed the photo back to the gunnery sergeant. I recognized immediately that my objectivity had just been compromised. I knew better than to look at some of the photos thrust at me by the soldiers, marines, and sailors that I encountered as patients. Far too often, those photos were trophies. The enemy may have hurt us, but look at what we did to him. What were they thinking? Photos like that can later haunt their possessor.

Between 1940 and 2005, in the United States, the rate of unnatural death declined about 75 percent in infant and young child boys and girls; a remarkable indicator of successful child protection. During this same period, the rate of reported homicide in infant boys increased 64.0 percent, in infant girls increased 43.5 percent, in young child boys increased 333.3 percent, and in young child girls increased 300.0 percent, a dismal and disturbing indicator of failed child protection. Can these simultaneously encouraging and discouraging observations be reconciled? The four categories of unnatural death, homicide, suicide, motor vehicle accident (MVA), and non-MVA, are mutually exclusive classifications. Correlations between the four categories of unnatural death among U.S. men and woman in all age groups for the years 1940 through 2005 were calculated. A negative correlation between homicide and non-MVA death rates was shown for all age groups, encompassing the entire human lifespan, in both genders. This consistently observed negative correlation was only observed between homicide and non-MVA death rates, and was not demonstrated between other causes of unnatural deaths. Moreover, this negative correlation was strongest (less than −0.7) in infants and young children. These observations are consistent with the suggestion that as the rate of unnatural death in infants and young children dramatically declined, society gave greater scrutiny to those fewer occurring unnatural deaths and demonstrated an increasing propensity to assign blame for those fewer deaths.

OBJECTIVE: An unintended consequence of linking physician compensation to patient satisfaction is illustrated. BACKGROUND: In accordance with patient-centered healthcare, payers and physician-employers have demonstrated a propensity to link physician compensation to patient satisfaction as one intervention intended to increase healthcare value and quality. DESIGN/METHODS: Responses to HCAHPS Survey Question 6 ("During this hospital stay how often did doctors listen carefully to you?") were the single parameter analyzed by varying (linearly and exponentially) the linkage between physician compensation and patient satisfaction. RESULTS: As physician compensation is increasingly impacted by patient responses to HCAHPS Survey Question 6, the patient/physician relationship would more likely evolve to the point where physicians ask patients what they want; and act accordingly. That course of action would maximize both physician compensation and patient satisfaction in this simple model. CONCLUSIONS: The patient/physician relationship is characterized by information asymmetry. If physician behavior conforms to patient expectations, the physician is likely to be perceived by the patient as listening carefully. If physician behavior does not conform to patient expectations, the physician is likely to be perceived as not listening carefully. Although physicians should listen carefully to their patients, a reliable correlation between patient satisfaction surveys and healthcare value and quality should be established prior to linking physician compensation with patient satisfaction. No one would rationally suggest that physicians should always do what patients want as a means to enhance healthcare value and quality. Policy misalignment could produce unintended adverse consequences on healthcare value and quality. As new policies aimed to improve healthcare value and quality and decrease costs are suggested and/or implemented, these policies should be modeled in simple systems to reveal unintended consequences and, if necessary, demonstrate the need for counterbalancing policies. Healthcare is a complex system that is increasingly being subjected to new rules. Although new policies may seem simple, their impact in complex systems can be unpredictable and counterproductive. Study Supported by: Not applicable.

On Being a Doctor2 December 2014This Little Girl Dies Today, in Front of the AmericansJack E. Riggs, MDJack E. Riggs, MDFrom West Virginia University, Morgantown, West Virginia.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M14-1310 Audio Reading - “This Little Girl Dies Today, in Front of the Americans” Audio. Michael A. LaCombe, MD, Annals Associate Editor, reads "This Little Girl Dies Today, in Front of the Americans," by J.E. Riggs. Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Having returned from the war in the Middle East, where I commanded a combat support hospital, I was looking forward to the less stressful task of commanding a Navy Reserve medical unit. Our annual tasking included staffing several medical readiness training exercises for U.S. Southern Command in Central and South America. Although advertised as humanitarian missions, these exercises provided U.S. military personnel with experience working with military and civil authorities from host nations. My unit would provide 25 to 30 sailors for each exercise. Because I had been involved in their planning and preparation, I was aware of one Honduran ... Author, Article, and Disclosure InformationAffiliations: From West Virginia University, Morgantown, West Virginia.Disclaimer: Any assertions and opinions, explicit or implicit, are those of the author and should not be construed to represent those of the U.S. Navy or Army.Corresponding Author: Jack E. Riggs, MD, Department of Neurology, School of Medicine, West Virginia University, Morgantown, WV 26506-9180; e-mail, [email protected]edu. PreviousarticleNextarticle Advertisement Audio Reading - “This Little Girl Dies Today, in Front of the Americans” Audio. Michael A. LaCombe, MD, Annals Associate Editor, reads "This Little Girl Dies Today, in Front of the Americans," by J.E. Riggs. Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ FiguresReferencesRelatedDetails Metrics 2 December 2014Volume 161, Issue 11Page: 837-838KeywordsAppendicitisArmed forcesBeerCyclic adenosine monophosphateDrugsExerciseGlobal healthHealth careNursesTechnicians ePublished: 2 December 2014 Issue Published: 2 December 2014 Copyright & PermissionsCopyright © 2014 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...