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      Borrasca Filomena: pie de trinchera en España en tiempos de paz Translated title: Storm «Philomena»: trench foot in peacetime in Spain

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          Abstract

          RESUMEN El pie de trinchera es considerada la lesión militar más frecuente no relacionada con el combate y conocemos de su existencia desde tiempos de Napoleón. Sin embargo, esta vasoneuropatía sigue siendo una condición poco conocida y, por ende, un desafío diagnóstico. Con la presentación de dos casos clínicos atendidos en nuestro hospital durante la borrasca Filomena, ocurrida en España en enero del 2021, con Madrid como una de las zonas más afectadas, pretendemos aportar un poco más de conocimiento, en aras de mejorar la identificación de los casos y el correcto manejo terapeútico que, a buen seguro, mejorará el pronóstico de nuestros pacientes, sin olvidar las medidas preventivas. En nuestra experiencia ha sido determinante un riguroso estudio diagnóstico (vascular y electroneurofisiológico) y el tratamiento vasodilatador con bloqueo ciático poplíteo, inhibidores de la 5 fosfodiesterasa y calcioantagonistas dihidropiridínicos.

          Translated abstract

          ABSTRACT Trench foot is considered the most common non-combat related military injury and we have known of its existance since Napoleon’s time. However, this vasoneuropathy remains a poorly understood condition and, therefore, a diagnostic challenge. With the report of 2 clinical cases treated in our hospital during Filomena storm, which occurred in Spain in January 2021, with Madrid as one of the most affected areas, we intend to contribute a little more knowledge, in order to improve cases identification and the correct management that, surely will improve our patients prognosis, without forgetting preventive measures. In our experience, a rigorous diagnostic study (vascular and electroneurophysiological) and a vasodilatador treatment with sciatic popliteal block, 5-phosphodiesterase inhibitors and dihydropyridine calcium antagonists have been decisive.

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          Most cited references14

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          Trench Foot or Non-Freezing Cold Injury As a Painful Vaso-Neuropathy: Clinical and Skin Biopsy Assessments

          Background Trench foot, or non-freezing cold injury (NFCI), results from cold exposure of sufficient severity and duration above freezing point, with consequent sensory and vascular abnormalities which may persist for years. Based on observations of Trench foot in World War II, the condition was described as a vaso-neuropathy. While some reports have documented nerve damage after extreme cold exposure, sensory nerve fibres and vasculature have not been assessed with recent techniques in NFCI. Objective To assess patients with chronic sensory symptoms following cold exposure, in order to diagnose any underlying small fibre neuropathy, and provide insight into mechanisms of the persistent pain and cold hypersensitivity. Methods Thirty soldiers with cold exposure and persistent sensory symptoms (>4 months) were assessed with quantitative sensory testing, nerve conduction studies, and skin biopsies. Immunohistochemistry was used to assess intraepidermal (IENF) and subepidermal (SENF) nerve fibres with a range of markers, including the pan-neuronal marker protein gene product 9.5 (PGP 9.5), regenerating fibres with growth-associated protein 43 (GAP43), and nociceptor fibres with transient receptor potential cation channel subfamily V member 1 (TRPV1), sensory neuron-specific receptor (SNSR), and calcitonin gene-related peptide (CGRP). von Willebrand factor (vWF), endothelial nitric oxide synthase (eNOS), and vascular endothelial growth factor (VEGF) were used for assessing blood vessels, and transient receptor potential cation channel, subfamily A member 1 (TRPA1) and P2X purinoceptor 7 (P2X7) for keratinocytes, which regulate nociceptors via release of nerve growth factor. Results Clinical examination showed pinprick sensation was abnormal in the feet of 20 patients (67%), and between 67 and 83% had abnormalities of thermal thresholds to the different modalities. 7 patients (23%) showed reduced sensory action potential amplitude of plantar nerves. 27 patients (90%) had decreased calf skin PGP 9.5 IENF (p < 0.0001), the remaining 3 patients had decreased nerve markers in subepidermis or foot skin. There were marked increases of all vascular markers (for vWF in calf skin, p < 0.0001), and increased sensory or regenerating SENF (for calf skin, GAP43, p = 0.002). TRPA1 (p = 0.0012) and P2X7 (p < 0.0001) were increased in basal keratinocytes. Conclusion A range of skin biopsy markers and plantar nerve conduction studies are useful objective assessments for the diagnosis of peripheral neuropathy in NFCI. Our results suggest that an increase in blood vessels following tissue ischaemia/hypoxia could be associated with disproportionate and abnormal nerve fibres (irritable nociceptors), and may lead to NFCI as a “painful vaso-neuropathy.”
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            The Use of High-Risk Criteria to Assess Mortality Risk among Unsheltered Homeless Persons

            We assessed the ability of high-risk criteria developed by Boston Health Care for the Homeless Program to identify increased mortality during a 10-year cohort study (January 2000–December 2009) of 445 unsheltered adults. To qualify as high-risk for mortality, an individual slept unsheltered for six consecutive months or longer plus had one or more of the following characteristics: tri-morbidity, defined as co-occurring medical, psychiatric, and addiction diagnoses; one or more inpatient or respite admissions; three or more emergency department visits; 60 years old or older; HIV/AIDS; cirrhosis; renal failure; frostbite, hypothermia, or immersion foot. A total of 119 (26.7%) individuals met the high-risk criteria. The remaining 326 individuals in the cohort were considered lower-risk. During the study, 134 deaths occurred; 52 (38.8%) were among high-risk individuals. Compared with sheltered individuals, the age-standardized mortality ratio for the high-risk group was 4.0 (95% confidence interval 3.0, 5.2) times higher and for the lower-risk group was 2.2 (1.8, 2.8) times higher. The hazard ratio, a measure of survival, for the high-risk group was 1.7 (1.2, 2.4) times that of the lower-risk group. High-risk criteria predicted an increased likelihood of mortality among unsheltered individuals. The lower-risk group also had high mortality rates compared with sheltered individuals.
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              Battlefield Trauma-Induced Hypothermia: Transitioning the Preferred Method of Casualty Rewarming.

              For centuries, cold and wet weather has affected military combat operations leading to tremendous loss of manpower caused by cold-weather-related injuries including trench foot, frostbite, and hypothermia. The initial battlefield management of hypothermia in military personnel had not advanced significantly following many wars and conflicts until 2006. The aim of this review is to: 1) provide an overview of trauma-induced hypothermia (TIH); 2) highlight the Department of Defense strategy for the implementation of a hypothermia clinical management program for battlefield (prehospital) casualties; 3) highlight the research and development of the Hypothermia Prevention and Management Kit (HPMK) as the preferred field rewarming system for battlefield TIH; and 4) emphasize how the HPMK can be easily transitioned to the civilian sector for active rewarming of both accidental and TIH patients. The HPMK is ideal for those working in civilian Emergency Medical Services and austere prehospital care environments. This kit is a low cost, lightweight, small dimension commercial product that can provide effective passive management or active rewarming for both accidental (primary) and trauma-induced (secondary) hypothermia patients.
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                Author and article information

                Journal
                sm
                Sanidad Militar
                Sanid. Mil.
                Ministerio de Defensa (Madrid, Madrid, Spain )
                1887-8571
                December 2022
                : 78
                : 4
                : 253-257
                Affiliations
                [1] Madrid orgnameHospital Central de la Defensa Gómez-Ulla orgdiv1Servicio de Angiología y Cirugía Vascular España
                [2] Madrid orgnameHospital Central de la Defensa Gómez-Ulla orgdiv1Comité de Trombosis y Anticoagulación España
                [6] Madrid orgnameHospital Central de la Defensa Gómez-Ulla orgdiv1Servicio de Angiología y Cirugía Vascular España
                [4] Madrid orgnameHospital Central de la Defensa Gómez-Ulla orgdiv1Servicio de Anestesiología, Reanimación y Terapeútica del Dolor España
                [5] Madrid orgnameHospital Central de la Defensa Gómez-Ulla orgdiv1Servicio de Neurofisiologia Clínica España
                [3] Madrid orgnameEjército del Aire orgdiv1UMAER orgdiv2Urgencias y Emergencias España
                Article
                S1887-85712022000400008 S1887-8571(22)07800400008
                10.4321/s1887-85712022000400008
                a424f1c2-e7cc-41e6-9bf4-753b810b8ef7

                http://creativecommons.org/licenses/by/4.0/

                History
                : 19 September 2021
                : 23 October 2022
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 14, Pages: 5
                Product

                SciELO Spain

                Categories
                Comunicación Breve

                trench foot,disaster medicine,vasculitis,neuropathy,nerve conduction study,vasodilators,pie de trinchera,medicina de desastres,neuropatía,estudio de conducción nerviosa,vasodilatadores

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