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Introduction: The military health system (MHS) a unique setting to analyze implementation programs as well as outcomes for colorectal cancer (CRC). Here we look at the efficacy of different CRC screening methods, attributes and results within the MHS, and current barriers to increase compliance.Materials and Methods: A literature search was conducted utilizing PubMed and the Cochrane library. Key-word combinations included colorectal cancer screening, racial disparity, risk factors, colorectal cancer, screening modalities, and randomized control trials. Directed searches were also performed of embedded references.Results: Despite screening guidelines from several national organizations, extensive barriers to widespread screening remain, especially for minority populations. These barriers are diverse, ranging from education and access problems to personal beliefs. Screening rates in MHS have been reported to be generally higher at 71% compared to national averages of 50-65%.Conclusion: CRC screening can be highly effective at improving detection of both pre-malignant and early cancers. Improved patient education and directed efforts are needed to improve CRC screening both nationally and within the MHS.

Objectives: On completion of this article, the reader should be able to recognize that fast-track protocols are safe and costeffective, while improving overall patient outcomes by reducing the surgical stress response; summarize the components of fast-track surgery by each perioperative phase; understand the role of minimally invasive surgery in colon and rectal resections and perioperative adjuncts; and outline future directions for fast-track surgery.In 2010, health-care expenditures in the United States neared $2.6 trillion, 10 times the amount spent in 1980. 1 Current projections show national health expenditures continuing to increase and account for 20% of the gross domestic product by 2020. 2 The reduction in health-care expenditures and more efficient use of medical resources is now an overriding health policy priority with the two-pronged goal of improving patient outcomes while decreasing overall cost. This is especially relevant in the field of colorectal surgery because of a disproportionately higher complication rate and longer length of stay when compared with other operative procedures. Current reports show colorectal surgery accounting for 25% of all operative complications and an average length of stay of 8 to 12 days for a standard elective colon resection. [3][4][5][6] During the last several decades, there has been growing recognition that surgical stress caused by major surgery results in derangements in organ function and subsequently increases postoperative morbidity. To combat this, Kehlet introduced a concept of enhanced recovery after surgery (ERAS) or fast-track pathways, with the goal of using current evidence and multimodal therapies to reduce surgical stress and enhance postoperative recovery. This was achieved by asking the simple question: Why is the patient in the hospital today? 7 The pathway elements are perioperative care interventions that focus on anesthesia, analgesia, reduction of surgical stress (both endocrine-metabolic and inflammatory responses), goal-directed fluid therapy, the prevention of nausea and ileus (return of bowel function), thromboembolic prophylaxis, minimally invasive techniques, nutrition, and early mobilization. 8 The benefits and safety of fast-track protocols (FTPs) are validated in multiple randomized controlled trials. 9 Patients in these studies had faster return of bowel function, shorter length of hospitalization, and decreased complication rates. These findings were confirmed by several meta-analyses and a recent Cochrane Review. [10][11][12][13] The most recent meta-analysis included 7 randomized control trials with 852 patients. Lv et al found patients randomized to FTP care had a significantly decreased length of stay (mean difference: -1.88; 95% confidence interval [CI], -2.91 to 0.86, p ¼ 0.0003) and overall rate of complications (relative risk [RR] ¼ 0.69; 95% CI, 0.51-0.93), Keywords► colorectal surgery ► perioperative protocols ► fast-track surgery ► enhanced recovery after surgery ► ERAS AbstractThe reduction in health-care expenditure...

Abstract-Gene profiling data coupled with adducin polymorphism studies led us to hypothesize that decreased expression of this cytosolic protein in the brain could be a key event in the central control of hypertension. Thus, our objectives in the present study were to (1) determine which adducin subunit gene demonstrates altered expression in the hypothalamus and brainstem (two cardioregulatory-relevant brain areas) in two genetic strains of hypertensive rats and (2) analyze the role of adducins in neurotransmission at the cellular level. All three adducin subunits (␣, ␤, and ␥) were present in the hypothalamus and brainstem of Wistar Kyoto (WKY) and spontaneously hypertensive (SH) rats. However, only the ␥-adducin subunit expression was 40% to 60% lower in the SH rat compared with WKY rat. A similar decrease in ␥-adducin expression was observed in the hypothalamus and brainstem of the renin transgenic rat compared with its normotensive control. Losartan treatment of the SH rat failed to normalize ␥-adducin gene expression.A hypertension-linked decrease of ␥-adducin was confirmed by demonstrating a decrease in ␥-adducin expression in hypothalamic/brainstem neuronal cultures from prehypertensive SH rats. Neuronal firing rate was evaluated to analyze the role of this protein in neurotransmission. Perfusion of a ␥-adducin-specific antibody caused a 2-fold increase in the neuronal firing rate, an effect similar to that observed with angiotensin II. Finally, we observed that preincubation of neuronal cultures for 8 hours with 100 nmol/L angiotensin II caused a 60% decrease in endogenous ␥-adducin and was associated with a 2-fold increase in basal firing rate. These observations support our hypothesis that a decrease in ␥-adducin expression in cardioregulatory-relevant brain areas is linked to hypertension possibly by regulating the release of neurotransmitters. Key Words: hypothalamus/brainstem Ⅲ gene profiling Ⅲ neurons Ⅲ ␥-adducin Ⅲ hypertension T he central nervous system (CNS) plays a key role in the control of cardiovascular functions. Anatomical and physiological evidence have established that specific hypothalamic and brainstem nuclei participate in the control of sympathetic nerve activity (SNA), vasopressin release, and baroreceptor reflexes, which are all aspects involved in normal cardiovascular functions. 1,2 The significance of these pathways in central control of cardiovascular functions is further underscored by the evidence that an increase in SNA and secretion of neurotransmitters/neurohormones is associated with the development and establishment of hypertension. 3 In spite of this evidence, little is known about the cellular and molecular basis of hypertension-linked dysregulation in the CNS. In an attempt to elucidate the molecular basis of this dysregulation, we hypothesized that an inherent change in the expression profiling of gene(s) in cardiovascular-relevant brain nuclei is responsible for the development of hypertension. In this regard, our present studies have indicated that the expression ...

Traumatic diaphragm injuries (TDI) are uncommon but can result in major morbidity or mortality if missed. Penetrating thoracoabdominal injuries carry a high risk of TDI, but can also pose a diagnostic dilemma due to their small size and the frequent lack of an associated hernia. Despite advances in imaging, diagnosis without presence of a hernia remains difficult and a high index of suspicion must be maintained. Chest x-ray remains an important tool in early diagnosis, but primarily relies on the presence of a hernia or a discontinuity of the diaphragm, which is not typically seen with penetrating injuries. Computed tomography has a higher sensitivity and specificity and improves preoperative diagnosis, but most TDI are still diagnosed intra-operatively. Minimally invasive modalities allow for both diagnosis and repair of suspected injuries in hemodynamically stable patients while avoiding the morbidity of an open approach. All penetrating diaphragmatic injuries require repair in order to avoid the major morbidity and mortality of a chronic diaphragmatic hernia. The principles of diaphragmatic injury repair are complete reduction of all abdominal contents, lavage and evacuation of any associated hemothorax or gastrointestinal spillage, and watertight, tension-free closure. Most injuries can be closed primarily, but some may require use of prosthetic material or other advanced reconstructive techniques for larger defects. Mortality remains primarily dependent on the mechanism of injury and the presence and severity of associated injuries, with overall Injury Severity Score serving as an independent predictor of early mortality.