Publications by authors named "James K Aden"

165 Publications

Adjunct Use of Continuous Renal Replacement Therapy with Extracorporeal Membrane Oxygenation Achieves Negative Fluid Balance and Enhances Oxygenation Which Improves Survival in Critically Ill Patients without Kidney Failure.

Blood Purif 2021 Sep 2:1-8. Epub 2021 Sep 2.

Surgery and Trauma Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA.

Introduction: Fluid overload in extracorporeal membrane oxygenation (ECMO) patients has been associated with increased mortality. Patients receiving ECMO and continuous renal replacement therapy (CRRT) who achieve a negative fluid balance have improved survival. Limited data exist on the use of CRRT solely for fluid management in ECMO patients.

Methods: We performed a single-center retrospective review of 19 adult ECMO patients without significant renal dysfunction who received CRRT for fluid management. These patients were compared to a cohort of propensity-matched controls.

Results: After 72 h, the treatment group had a fluid balance of -3840 mL versus + 425 mL (p ≤ 0.05). This lower fluid balance correlated with survival to discharge (odds ratio 2.54, 95% confidence interval 1.10-5.87). Improvement in the ratio of arterial oxygen content to fraction of inspired oxygen was also significantly higher in the CRRT group (102.4 vs. 0.7, p ≤ 0.05). We did not observe any significant difference in renal outcomes.

Conclusions: The use of CRRT for fluid management is effective and, when resulting in negative fluid balance, improves survival in adult ECMO patients without significant renal dysfunction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000517896DOI Listing
September 2021

Early Antibiotic Exposure in Low-Risk Late Preterm and Term Infants.

Am J Perinatol 2021 Sep 7. Epub 2021 Sep 7.

Department of Pediatrics, San Antonio Uniformed Health Services, Brooke Army Medical Center, Fort Sam Houston, Texas.

Objective:  This study aimed to examine the epidemiology of antibiotic exposure and early onset sepsis (EOS) in late preterm and term infants born via cesarean section with rupture of membranes less than 10 minutes.

Study Design:  Retrospective review of 1,187 late preterm and term infants born at Brooke Army Medical Center between January 1, 2012 and August 29, 2019. Subjects were assessed for factors related to antibiotic treatment. Statistical analysis was performed to compare infants treated with antibiotics versus observation.

Result:  An early blood culture was obtained from 234 (19.7%) infants; 170 (14.3%) were treated with antibiotics. Infants treated with antibiotics were significantly younger ( < 0.0001), smaller ( < 0.0001), more often diagnosed with respiratory distress ( < 0.0001), and were more frequently admitted to the neonatal intensive care unit ( < 0.0001). There were no cases of culture proven EOS.

Conclusion:  Although this population lacks risk factors for the development of EOS, a significant percentage was treated with antibiotics. This population may benefit from future antibiotic stewardship efforts.

Key Points: · This population is at risk for respiratory morbidity.. · There were no cases of culture proven early onset sepsis.. · This is a group of interest for antibiotic stewardship..
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0041-1735220DOI Listing
September 2021

The Impact of Military Emergency Medicine Scholarly Activity.

Med J (Ft Sam Houst Tex) 2021 Jul-Sep(PB 8-21-07/08/09):57-62

US Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX; Brooke Army Medical Center, JBSA Ft Sam Houston, TX; 59th Medical Wing, JBSA Lackland, TX; and Uniformed Services University of the Health Sciences, Bethesda, MD.

Background: Emergency medicine is recognized as a critical wartime specialty within the US military. Military emergency medicine contributes to medical literature in unique ways not seen with our civilian counterparts. The impact of this contribution, especially regarding innovations in military medicine, has not been previously examined. This study evaluates the numbers of citations for emergency medicine manuscripts published by members of the US military.

Methods: Utilizing the Scopus database, we identified published manuscripts from 2000 to 2020 with an emergency medicine author affiliated with a US military treatment facility. We sorted manuscripts on the number of citations in Scopus and categorized each paper as to whether it addressed military unique topics.

Results: We identified 1,718 manuscripts through Scopus, and based on a 10-citation minimum, we further analyzed 508 manuscripts. After verification of military affiliation, we included 421 manuscripts. The mean number of citations per manuscript was 31.7 ± 40.5; the Mean Cite Score was 4.75 ± 6.17 with a Field Weighted Citation Index (FWCI) of 2.96 ± 6.25. Citation count of publications has been steadily increasing in recent years with significantly more citations for military relevant publications when compared to non-military relevant publications.

Conclusions: These findings highlight the importance of military emergency medicine scholarly activity which has a history of contributions that address specific medical needs of the warfighter and advance the specialty. Military emergency medicine papers have seen rising numbers of citations in the medical literature, particularly those related to military relevant topics emphasizing combat casualty care and military readiness.
View Article and Find Full Text PDF

Download full-text PDF

Source
August 2021

Umbilical Cord Blood Use for Admission Blood Tests of VLBW Preterm Neonates: A Randomized Control Trial.

Am J Perinatol 2021 Aug 18. Epub 2021 Aug 18.

Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas.

Objective:  Umbilical cord blood (UCB) for admission laboratories is an approach to decrease anemia risk in very low birth weight (VLBW) neonates. We hypothesized that UCB use results in higher hemoglobin concentration [HgB] around 24 hours of life.

Study Design:  A randomized control trial among VLBW infants whose admission laboratories were drawn from UCB ( = 39) or the infant ( = 41) in three U.S. military NICUs (clinicaltrials.gov#NCT02103296).

Results:  No demographic differences were observed between groups. UCB infants had higher [HgB] at 12 to 24 hours of life (15.5 vs. 14.0 g/dL,  = 0.02). The median time to first transfusion was 17 days longer in the experimental group ( = 0.04), and at discharge, their number of donor exposures was lower (1.1 vs. 1.8,  = 0.04).

Conclusion:  In the first 24 hours of life that is a period of higher risk for hemodynamic instability, UCB utilization for admission bloodwork in VLBW infants results in higher [HgB].

Key Points: · Umbilical cord blood laboratory work in preterm infants is feasible.. · Cord blood use for admission laboratories results in increased hemoglobin in the first 24 hours of life.. · Cord blood use for admission laboratories delays time to first transfusion in preterm infants..
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0041-1733781DOI Listing
August 2021

Intraoperative blood transfusions in burn patients.

Transfusion 2021 07;61 Suppl 1:S183-S187

U.S. Army Institute of Surgical Research, Research Directorate, Fort Sam Houston, Texas, USA.

Background: Donated blood is a valuable and limited resource. Excision of burn wounds often leads to significant blood loss requiring transfusion. Accurately estimating blood loss is difficult, so examining the amount of blood products given intraoperatively is a clinically relevant way to measure utilization of this valuable resource. In this study, we examined the factors that influenced the amount of blood given intraoperatively during burn wound excisions.

Study Design And Methods: A retrospective analysis of patients admitted to a single burn center over 5 years who underwent excision of their burn wounds and received intraoperative blood products was performed. Patient and burn characteristics as well as pertinent surgical data and laboratory values on the day of surgery and postoperatively were gathered. A linear regression analysis examined factors influencing the number of units of products given and a predictive model was generated.

Results: A total of 563 operations performed on 166 patients were included. The amount of burn excised was the most influential variable on the amount of blood products given. Hemoglobin level, international normalized ratio, and platelet count on the day of surgery were associated with transfusion of different blood products. A predictive model was generated to aid in preoperative ordering of blood products.

Conclusion: The amount of burn excised and common hematology and coagulation lab values were associated with the amount of different blood products administered during burn surgery. The predictive model generated needs to be validated prospectively to aid in preoperative planning for burn excisions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/trf.16505DOI Listing
July 2021

Procedural Confidence and Usability of a Novel Lateral Canthotomy and Cantholysis Simulator Compared to a Traditional Porcine Model in Emergency Medicine Training.

Med J (Ft Sam Houst Tex) 2021 Apr-Jun(PB 8-21-04/05/06):38-43

Brooke Army Medical Center, JBSA Ft. Sam Houston, TX.

Introduction: Retrobulbar hemorrhage (RBH) occurs in only 0.45% of ocular trauma, but failure to provide timely lateral canthotomy and cantholysis (LCC) risks permanent visual deficits. With ocular trauma rates as high as 8.5-10% amongst modern combat injuries, and more than 2,000 severe eye injuries documented over a 10 year span, this concern increases.12-15 However, given infrequent RBH occurrence in the non-combat environment, emergency medicine residents trained in stateside settings may not receive adequate LCC exposure prior to military deployment. Simulators should be evaluated for procedural confidence compared to expensive and cumbersome traditional live tissue training (LTT) options. We seek to compare procedural confidence and usability of emergency medicine military residents performing LCC on a novel simulator to those using LTT.

Methods: This study randomized 32 emergency physician and physician assistant residents to perform LCC on a simulator or LTT model. All received a standardized brief on RBH recognition and LCC, then completed an 11-question survey using a 100-mm visual numerical rating scale about their ability to correctly identify RBH and perform LCC. The survey was repeated after LCC completion. All volunteers additionally completed a 10-question survey utilizing a 5-point Likert scale on the usability of the model to which they were randomized.

Results: No significant difference in reported confidence changes between groups was found; however, significant increases were found across all reported confidence measures between pre- and post-trainer use in the overall sample population. LCC simulator users reported significantly higher usability in 7 of 10 ratings.

Conclusion: The lack of a statistically significant difference between groups in procedural confidence suggests artificial LCC simulators may offer an attractive alternative to logistically-complicated porcine models. Further research is needed to evaluate non-inferiority and procedural performance.
View Article and Find Full Text PDF

Download full-text PDF

Source
July 2021

Impact of dermal matrix thickness on split-thickness skin graft survival and wound contraction in a single-stage procedure.

Int Wound J 2021 Jul 9. Epub 2021 Jul 9.

Department of Surgery, Brooke Army Medical Center, San Antonio, Texas, USA.

Optimal treatment of full-thickness skin injuries requires dermal and epidermal replacement. To spare donor dermis, dermal substitutes can be used ahead of split-thickness skin graft (STSG) application. However, this two-stage procedure requires an additional general anaesthetic, often prolongs hospitalisation, and increases outpatient services. Although a few case series have described successful single-stage reconstructions, with application of both STSG and dermal substitute at the index operation, we have little understanding of how the physical characteristics of dermal substitutes affects the success of a single-stage procedure. Here, we evaluated several dermal substitutes to optimise single-stage skin replacement in a preclinical porcine model. A porcine full-thickness excisional wound model was used to evaluate the following dermal substitutes: autologous dermal graft (ADG; thicknesses 0.15-0.60 mm), Integra (0.4-0.8 mm), Alloderm (0.9-1.6 mm), and chitosan-based hydrogel (0.1-0.2 mm). After excision, each wound was treated with either a dermal substitute followed by STSG or STSG alone (control). Endpoints included graft take at postoperative days (PODs) 7 and 14, wound closure at POD 28, and wound contracture from POD 28-120. Graft take was highest in the STSG alone and hydrogel groups at POD 14 (86.9% ± 19.5% and 81.3% ± 12.3%, respectively; P < .001). There were no differences in graft take at POD 7 or in wound closure at POD 28, though highest rates of wound closure were seen in the STSG alone and hydrogel groups (93.6% ± 9.1% and 99.8% ± 0.5%, respectively). ADG-treated wounds demonstrated the least amount of wound contracture at each time point. Increase dermal substitute thickness was associated with worse percent graft take at PODs 14 and 28 (Spearman ρ of -0.50 and -0.45, respectively; P < .001). In this preclinical single-stage skin reconstruction model, thinner ADG and hydrogel dermal substitutes outperformed thicker dermal substitutes. Both substitute thickness and composition affect treatment success. Further preclinical and clinical studies to optimise this treatment modality are warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/iwj.13637DOI Listing
July 2021

Rates of nosocomial infection associated with interhospital transfer of patients receiving extracorporeal membrane oxygenation.

Infect Control Hosp Epidemiol 2021 Jun 25:1-6. Epub 2021 Jun 25.

Infectious Disease Service, Department of Internal Medicine, JBSA-Ft Sam Houston, San Antonio, Texas.

Objectives: Critically ill patients requiring extracorporeal membrane oxygenation (ECMO) frequently require interhospital transfer to a center that has ECMO capabilities. Patients receiving ECMO were evaluated to determine whether interhospital transfer was a risk factor for subsequent development of a nosocomial infection.

Design: Retrospective cohort study.

Setting: A 425-bed academic tertiary-care hospital.

Patients: All adult patients who received ECMO for >48 hours between May 2012 and May 2020.

Methods: The rate of nosocomial infections for patients receiving ECMO was compared between patients who were cannulated at the ECMO center and patients who were cannulated at a hospital without ECMO capabilities and transported to the ECMO center for further care. Additionally, time to infection, organisms responsible for infection, and site of infection were compared.

Results: In total, 123 patients were included in analysis. For the primary outcome of nosocomial infection, there was no difference in number of infections per 1,000 ECMO days (25.4 vs 29.4; P = .03) by univariate analysis. By Cox proportional hazard analysis, transport was not significantly associated with increased infections (hazard ratio, 1.7; 95% confidence interval, 0.8-4.2; P = .20).

Conclusion: In this study, we did not identify an increased risk of nosocomial infection during subsequent hospitalization. Further studies are needed to identify sources of nosocomial infection in this high-risk population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/ice.2021.251DOI Listing
June 2021

Posterior Segment Injuries in Operation Iraqi Freedom and Operation Enduring Freedom: 2001-2011.

Retina 2021 May 27. Epub 2021 May 27.

Department of Ophthalmology, Brooke Army Medical Center, San Antonio, TX, USA Department of Ophthalmology, Walter Reed National Military Medical Center, Bethesda, MD, USA Department of Surgery, Uniformed Services University of the Health Science, Bethesda, MD, USA Department of Ophthalmology, Wilford Hall Eye Center, San Antonio, TX, USA Department of Ophthalmology, Wake Forest Medical Center, Winston-Salem, NC, USA Department of Graduate Medical Education, Travis Air Force Base, Fairfield, CA, USA Department of Graduate Medical Education, Brooke Army Medical Center, San Antonio, TX, USA Warfighter Refractive Eye Surgery Program and Research Center, Fort Belvoir, Virginia, USA Retina Group of Washington D.C., Greenbelt, MD, USA Department of Surgery, Uniformed Services University of the Health Science, Bethesda, MD, USA Department of Ophthalmology, Madigan Army Medical Center, Tacoma, WA, USA.

Objective: To characterize the nature of posterior segment ocular injuries in combat trauma.

Methods: Eyes in the Walter Reed Ocular Trauma Database were evaluated for the presence of posterior segment injury. Final visual outcomes in open- versus closed-globe injuries and by zone of injury, and the types of posterior segment injuries in open- versus closed-globe injuries were assessed.

Results: 452 of 890 eyes (50.8%) had at least one posterior segment injury. The mechanism of injury was most commonly an improvised explosive device in 280 (62.0%) eyes. 61 (13.5%) patients had a Zone I injury, 50 (11.1%) a Zone II injury and 341 (75.4%) a Zone III injury. Patients with Zone I injuries were more likely to have a final VA of 20/200 or better compared to patients with either a Zone II (p<0.001) or Zone III injury (p=0.007). Eyes with a closed-globe injury were more likely to have a final VA of 20/200 or better compared to those with an open-globe injury (p < 0.001). Further, closed-globe compared to open-globe injury had a lower risk of vitreous hemorrhage (OR 0.32, p < 0.001), proliferative vitreoretinopathy (OR 0.14, p < 0.001), and retinal detachment (OR 0.18, p < 0.001), but higher risk of chorio-retinal rupture (OR 2.82, p < 0.001), and macular hole (OR 3.46, p=0.004).

Conclusions: Patients with combat ophthalmic trauma had similar posterior segment injury patterns to civilian trauma in open- versus closed-globe injuries. Zone II and III injuries were associated with a worse visual prognosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IAE.0000000000003221DOI Listing
May 2021

Optimizing contrast-enhanced echocardiography by employing a sonographer driven protocol.

J Echocardiogr 2021 Sep 2;19(3):173-178. Epub 2021 Apr 2.

Division of Cardiology, Brooke Army Medical Center, San Antonio, TX, 78234, USA.

Background: The use of enhancing agents in echocardiography has been shown to facilitate improved study quality. Despite the known benefits, its use remains limited by institutional policies.

Methods: We aimed to retrospectively evaluate if allowing sonographers to place a peripheral intravenous catheter and administer enhancing agent led to a decrease in time to complete outpatient transthoracic echocardiograms in comparison to using nursing personnel. Three separate protocols were employed. The 'nurse driven protocol' utilized nurses to place a peripheral intravenous catheter and inject enhancing agent. In a 'mixed protocol,' a nurse placed a peripheral intravenous catheter and the sonographer gave the enhancing agent. The 'sonographer driven protocol' involved the sonographer placing the peripheral intravenous catheter and delivering enhancing agent.

Results: A total of 232 echocardiograms were included for analysis. Patient characteristics across the three protocols were not statistically significant. The 'mixed protocol' had an average study time that was significantly less than the 'nurse driven protocol' (49.4 min ± 11.4 vs 54.6 min ± 12.9; p = 0.024). The 'sonographer driven protocol' also showed a significant reduction in study time (50.3 min ± 12.6) when compared to the 'nurse driven protocol' (p = 0.017). The additional task for the sonographer to place the peripheral intravenous catheter did not significantly increase the time to complete the study.

Conclusion: Allowing sonographers to administer enhancing agent reduced individual echocardiogram study times by approximately 5 min, supporting that a 'sonographer driven protocol' is more efficient with potential downstream economic benefits.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12574-021-00523-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8352799PMC
September 2021

Diagnostic Lobectomy for Bethesda III Thyroid Nodules: Pathological Outcomes and Risk Factors for Malignancy.

Ann Otol Rhinol Laryngol 2021 Sep 10;130(9):1064-1068. Epub 2021 Feb 10.

Department of Otolaryngology, San Antonio Military Medical Center, San Antonio, TX, USA.

Objective: An indeterminate thyroid nodule fine-needle aspiration (FNA) presents a unique dilemma. We evaluated our institution's experience with Bethesda III thyroid nodules, including the risk of malignancy (ROM) of these nodules removed for diagnostic lobectomy and radiologic and clinical risk factors for malignancy.

Study Design: Retrospective chart review.

Setting: San Antonio Military Medical Center (SAMMC; 483 bed Military Treatment Facility and Level 1 Trauma Center).

Methods: We identified all patients with a Bethesda III thyroid FNA at our institution from 2010 to 2018 and determined which nodules were removed. The final histological diagnosis was recorded. Whether or not age, gender, body mass index (BMI), race, nodule size, margin regularity, rate of nodule growth, vascularity, internal calcifications, family history of thyroid cancer, personal history of radiation, and history of repeated AUS/FLUS on FNA had a significant impact on malignancy risk was evaluated with chi square and rank sum Wilcoxon tests.

Results: 492 patients had 1 or more AUS result. 52% (258/492) underwent repeat FNA. This resulted in Bethesda II or III in 90% (232/258). In 10% (26/258), the repeat FNA resulted in a higher Bethesda grade. 183 lobectomies were performed on the side containing an AUS nodule. The malignancy percentage was 38.3% (70/183). Age less than 30 was the only variable showing statistical significance for increased risk of malignancy ( = .04).

Conclusion: The ROM of nodules characterized as AUS/FLUS on FNA may be higher than expected. Age may be a better predictor of malignancy than repeat FNA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0003489421993976DOI Listing
September 2021

Continuous Venovenous Hemofiltration is Associated with Improved Survival in Burn Patients with Shock: A Subset Analysis of a Multicenter Observational Study.

Blood Purif 2021 2;50(4-5):473-480. Epub 2020 Dec 2.

Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.

Introduction: Acute kidney injury (AKI) is associated with high mortality in burn patients. Previously, we reported that timely initiation of renal replacement therapy (RRT) with an individualized preference toward continuous modes at relatively higher than recommended doses has become standard practice in critically ill burn patients with AKI and is associated with a historically low mortality. The purpose of this cohort analysis was to determine if modality choice impacted survival in burn patients.

Methods: After Institutional Review Board approval, a subset analysis was performed on de-identified data collected during a multicenter, observational study. All patients (n = 170) were 18 years or older, admitted with severe burn injuries and started on RRT. Comparisons were made utilizing χ2 or Fisher's exact test. Kaplan-Meier plots were utilized to assess survival. Sample size determinations to aid future research were calculated utilizing χ2 test with a Yates Correction Factor.

Results: Demographics and revised Baux were similar between groups. When continuous venovenous hemofiltration (CVVH) was compared to all other modalities, there was no statistically significant difference in survival (56 vs. 43%, p = 0.124). However, survival was significantly improved (54 vs. 37%, p = 0.032) in the subset of patients requiring vasopressors (n = 77). There was no statistically significant survival difference in patients with inhalation injury (38 vs. 29%, p = 0.638) or acute lung injury/acute respiratory distress syndrome (51 vs. 33%, p = 0.11).

Discussion/conclusion: Survival may be improved if CVVH is chosen as the preferred modality in burn patients with shock and requiring RRT. Differences in other subsets were promising, but analysis was underpowered. Further research should determine if modality choice provides survival benefit in any other subset of burn injury.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000512101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315671PMC
December 2020

Population Geography and Emergency Contraception Access in Louisiana.

Pharmacy (Basel) 2020 Nov 20;8(4). Epub 2020 Nov 20.

Department of Pediatrics, Louisiana State University Health Sciences Center, New Orleans, LA 70118, USA.

We assessed the same-day availability of oral emergency contraception (EC) in five Louisiana communities, and evaluated this data for relationships between availability and local population demographics. Researchers called all retail pharmacies in five municipalities of varying sizes in order to inquire about the same-day stockage of EC products and their availability to teens. Individual pharmacies were then geolocated to a census tract, and call data was analyzed against neighborhood census data regarding population size, income, gender, race, family structure, and educational level. A multivariable logistic regression model was performed to predict the same-day availability of emergency contraception. EC was available on the same day in 66% of all pharmacies. The same-day availability of EC decreased with the local population size ( < 0.001), and the availability increased with higher levels of educational attainment ( = 0.0015). The largest census level predictor of access to same-day EC was the city population, with the availability increasing by 6.6% for every 10,000 person increase in population. Despite changing to over-the-counter sales in 2013, EC is still not widely available in all geographic areas. Its availability is partially predictable by local population demographics, and this difference may represent a health disparity for teens and women seeking EC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/pharmacy8040224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7712539PMC
November 2020

Differences in Rate of Gestational Diabetes Between Active Duty and Non-active Duty Beneficiaries at a Military Treatment Facility.

Mil Med 2021 07;186(7-8):e756-e759

Department of Graduate Medical Education, Statistician, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA.

Introduction: Gestational diabetes mellitus (GDM) affects approximately 1-14% of all pregnancies in the United States and has significant maternal and neonatal consequences. Developing GDM can increase a patient's risk of developing overt diabetes in the future which may impact a soldier's readiness. The purpose of this study is to compare the incidence of GDM in active duty females compared with civilian dependents.

Materials And Methods: This retrospective cohort analysis was performed at a military medical center with IRB approval. Active duty and dependent status women who delivered between June 1, 2014 and April 30, 2015 were identified along with incidence of GDM. Sample size calculation determined a need for 391 women in each group to observe a 5% difference in rate of GDM with a power of 80%. Chi-squared analysis was used to compare rates of GDM.

Results: Rates of GDM were similar between the two cohorts (active duty = 9.95%, dependent = 9.72%, P = .91). Age, gravidity, and prepregnancy BMI were also similar between groups. The rate of diet-controlled GDM were different between the two cohorts (active duty = 53.8%, dependent = 34.2%, P = .02).

Conclusions: This study highlights active duty females have similar rates of GDM as dependents. Gestational diabetes mellitus is known to affect short- and long-term maternal and neonatal outcomes and can impact a soldier's readiness. Further research is required to determine the long-term impact of GDM in active duty females and best practices to decrease rates of GDM in the military population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/milmed/usaa400DOI Listing
July 2021

The Impact of Graduate Medical Education on Scholarly Activity at a Military Medical Treatment Facility.

Mil Med 2021 02;186(3-4):415-420

San Antonio Uniformed Services Health Education Consortium (SAUSHEC), Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX 78234, USA.

Introduction: Graduate medical education (GME) faculty and trainees have required scholarly activities to meet accreditation requirements. The impact of this contribution to the Military Health System, especially regarding innovations in military medicine, has not been previously examined. This study measured the contribution of GME in published manuscripts from a tertiary military medical center.

Materials And Methods: Utilizing the Scopus database, published manuscripts from the primary military GME institutions for the San Antonio Uniformed Services Health Education Consortium were identified from 2008 to 2018. Manuscripts were sorted based on the number of citations in Scopus and analyzed for their overall impact in medicine to include military unique topics.

Results: A total of 3,700 manuscripts were identified through Scopus and based on a 10 citation minimum, 1,365 manuscripts were further analyzed; 1,152 (84.4%) included authors with GME affiliation and 554 (40.6%) had direct applicability to unique aspects of military medicine. The mean number of citations per manuscript was 39.2 ± 63.6; Mean Cite Score was 2.97 ± 2.14 and Field Weighted Citation Index of 2.22 ± 3.27. Analysis of number of citations (10-19; 20-39; or >40) did not show any significant differences in Cite Score or military relevance, whereas the percentage of military relevant articles remained consistent yearly.

Conclusions: These findings highlight the importance of military medical research and addressing specific medical needs of the warfighter. Graduate medical education in a tertiary Military Health System facility has enormous impact in scholarly activity, in particular the importance related to military medicine topics that emphasize combat casualty care and military readiness.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/milmed/usaa406DOI Listing
February 2021

Validation of an Endometrial Tumor Diameter Model for Risk Assessment in the Absence of Lymph Node Mapping.

J Patient Cent Res Rev 2020 23;7(4):323-328. Epub 2020 Oct 23.

Gynecologic Oncology, Aurora St. Luke's Medical Center, Milwaukee, WI.

Purpose: This study aimed to assess the optimal tumor diameter for predicting lymphatic metastasis and to determine intraoperatively the need for lymph node dissection in patients with endometrioid endometrial cancer.

Methods: Military beneficiaries diagnosed with stage I-III endometrioid endometrial cancer during 2003-2016 who had at least 7 pelvic and/or paraaortic lymph nodes removed during the time of hysterectomy were studied. Tumor diameter was compared against the presence of positive nodes, using the prior models of 20 mm (ie, Mayo model) and 50 mm (ie, Milwaukee model), to determine the false-negative rate of each threshold. A separate analysis was completed to determine the optimal diameter for our population. Receiver operating characteristic curve analysis models of tumor diameter were evaluated for model fit and predictive power of lymph node involvement.

Results: Of the 1224 patients with endometrioid endometrial cancer included, 13% (n=160) had positive lymph node involvement. Tumor sizes ranged from 1 mm to 100 mm. In contrast to Mayo and Milwaukee models (ie, Mayo, Milwaukee), the optimal tumor diameter independent of myometrial invasion and grade of tumor to predict lymph node metastasis was found to be 35 mm.

Conclusions: Endometrioid endometrial cancer tumor diameter of 35 mm was found to be the optimal threshold for lymphadenectomy when the operating surgeon has no knowledge of tumor invasion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.17294/2330-0698.1768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644130PMC
October 2020

An Analysis of Exertional Safety After Blood Donation in Active Duty Military Personnel-A Feasibility Study.

Mil Med 2021 05;186(5-6):e464-e468

Department of Emergency Medicine, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX.

Introduction: Whole blood (WB) is the optimal resuscitation fluid in hemorrhagic shock. Military research focuses on mortality benefits of WB acquired through walking blood banks (WBBs). Few military-based studies on donation effects exist, almost exclusively performed on small special operation forces. No Department of Defense regulations for postdonation precautions in nonaviation crew members exist. Further study is warranted regarding safety and limitations in postdonation populations.

Materials And Methods: A feasibility (n = 25) prospective interventional study examined the safety of exertion (defined as a 1.6-km treadmill run at volunteers' minimum passing pace for the Army Physical Fitness Test) following 1 unit of WB donation. Subjects served as their own controls, performing baseline testing 7 days before donation, with repeat testing 1 h following donation conducted by Armed Services Blood Program personnel. Adverse events, pre- and postexertion vital signs (VS) were evaluated.

Results: There were no adverse events throughout testing. Only resting heart rate (68 vs. 73 beats · min-1, p < 0.01) and postexertion heart rate were significantly different among pre- and postdonation VS. Additional significant findings were time to attain postexertion normocardia (116 vs. 147 seconds, p < 0.01). A small but statistically significant change in Borg perceived exertional scores was noted (10.3 vs. 10.8, p < 0.05).

Conclusions: This feasibility study demonstrates the first safety test of regular military populations performing exertion immediately following the standardized WB donation. VS changes may translate into a small but significant increase in perceived postdonation exertion. Future studies should expand duration and intensity of exertion to match combat conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/milmed/usaa234DOI Listing
May 2021

Use of the BIG score to predict mortality in pediatric trauma.

Am J Emerg Med 2021 07 6;45:472-475. Epub 2020 Oct 6.

Brooke Army Medical Center, Department of Pediatrics, MCHE-ZDP, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, United States of America.

Objective: The BIG score, which is comprised of admission base deficit (B), International Normalized Ratio (I), and GCS (G), is a severity of illness score that can be used to rapidly predict in-hospital mortality in pediatric patients presenting following traumatic injury. We sought to compare the mortality prediction of the pediatric trauma BIG score with other well-established pediatric trauma severity of illness scores: the pediatric logistic organ dysfunction (PELOD); the pediatric index of mortality 2 (PIM2); and the pediatric risk of mortality (PRISM III).

Methods: In this retrospective cohort study, data from 2009 to 2015 was collected using a multi-institutional database. All pediatric patients admitted following traumatic injury with a recorded initial GCS were included. BIG, PELOD, PIM2, and PRISM III scores were calculated, and Receiver Operator Characteristic curves were derived for all severity of illness scores. Mortality prediction performance for each score was compared by the area under the curve (AUC).

Results: A total of 29,204 patients were included in this analysis. AUC for BIG, PELOD, PIM2, and PRISM III scores were 0.97 (0.97-0.98), 0.98 (0.98-0.98), 0.98 (0.97-0.98), and 0.99 (0.98-0.99), respectively. At the optimum cut-off point of 16, the BIG score had a sensitivity of 0.937, specificity of 0.938, positive predictive value of 0.514, and negative predictive value of 0.995.

Conclusions: In this massive cohort of pediatric trauma patients, the BIG score using imputation of missing variables performed similarly to the PELOD, PIM2, and PRISM III, further validating the score as a predictor of mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2020.09.060DOI Listing
July 2021

Pharyngoesophageal Segment Distention Across Volumes and Pathology.

J Speech Lang Hear Res 2020 11 30;63(11):3594-3599. Epub 2020 Sep 30.

Department of Otolaryngology-Head and Neck Surgery, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX.

Purpose Patients receive multiple bolus trials during a videofluoroscopic swallowing study (VFSS) to assess swallow function, inclusive of narrowing within the pharyngoesophageal segment (PES). While differences in the narrowest and widest segments are visualized, the ratio of distention across boluses is not well understood. Method A retrospective review of 50 consecutive VFSSs with five boluses of varied viscosity and volume was performed. Still images at maximal PES distention were captured and scaled using a 19-mm disk. Measurements of the narrowest and widest segments were obtained, and a distention ratio was calculated. Studies were categorized by PES phenotype as normal, esophageal web, cricopharyngeal bar, or narrow PES. PES distention ratios were evaluated across bolus trials and within PES phenotypes using a mixed-methods repeated-measures analysis of variance. Results Of the 50 studies, there were 11 normal, 16 web, 10 bar, and 13 narrow PES. Quantitative differences were present for the narrowest ( = .01) and widest ( = .002) points across bolus volumes. No difference was present in distention ratio ( = .2) across volumes. Evaluating the PES phenotype, web, normal, bar, and narrow PES distention ratios differed ( = .03). Bar and PES narrow distention ratios were lower compared to that of the normal group ( = .01 for normal vs. bar and = .02 for normal vs. PES narrow). Conclusions PES distention ratio stability across varying bolus volumes and phenotypes suggests that a reduction in trials during a VFSS may permit an equivalent PES evaluation to traditional exams. Ultimately, this could improve our understanding and accurate diagnosis of PES dysfunction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1044/2020_JSLHR-19-00401DOI Listing
November 2020

Adverse Childhood Experience, Genes, and PTSD Risk in Soldiers: A Methylation Study.

Mil Med 2020 03;185(3-4):377-384

Department of Neurology, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234.

Introduction: Epigenetics can serve as a marker of susceptibility to many known psychiatric diseases. DNA methylation patterns of multiple genes have been studied in both civilian populations and military personnel with post-traumatic stress disorder (PTSD). Many of these genes serve various functions that span the hypothalamic-pituitary-adrenal axis, immune system, and central nervous system (CNS) growth factors and neurotransmission. It is thought that the methylation levels of such genes may be able to identify individuals who are at higher risk of developing PTSD. Our study seeks to establish whether previously reported PTSD genes possess a particular methylation pattern that is predictive of PTSD in active duty military members with combat exposure.

Materials And Methods: This is an institutional review board (IRB)-approved, cross-sectional, case control, gene-environment interaction study. About 170 active military members with and without PTSD were recruited. Patients with a history of structural brain damage, traumatic brain injury (TBI) resulting in loss of consciousness, predeployment diagnosis of PTSD or anxiety disorder, and predeployment prescription of an antidepressant or psychoactive medication were excluded. Validated measures of childhood trauma and adversity (adverse childhood experience [ACE] score), PTSD symptoms (PTSD check-list military version [PCL-M]), and combat exposure scales (CES) were measured via validated questionnaires for all subjects. After extracting DNA from peripheral blood provided by the 170 subjects, we determined methylation percentages, via pyrosequencing assays, for nine target areas within the following seven genes: BDNF, NR3C1, MAN2C1, TLR8, SLC6A4, IL-18, and SKA2. These genes are commonly reported in the literature as being highly correlated with PTSD and early-life traumatic experiences.Methylation levels were measured as a percentage at specific sites within the previously mentioned genes. Data were examined with SPSS v 22.0 Statistics and JMP v13.1 software using a general linear model for methylation × trauma (CES scores) split by diagnosis of PTSD or not, methylation versus childhood trauma (ACE scores), and methylation versus PTSD severity (PCL-M score). Two-way ANOVA was performed to control for antidepressant use. A two-tailed Student t-test was performed for PTSD analyses and was correlated with PTSD diagnosis, demographic information as well as ACE score, PCL-M score, and CES scores.

Results: Differentially methylated sites that were highly associated with PTSD diagnosis were found in three of seven candidate genes: BDNF, NR3C1, and MAN2C1. When compared to controls, patients with PTSD diagnosis had significantly lower levels of methylation, even after controlling for antidepressant use. PCL-M, ACE, and CES scores were significantly associated with PTSD diagnosis.

Conclusion: Our study suggests that methylation of key genes involved in synaptic plasticity and the hypothalamic-pituitary-adrenal axis is associated with lower levels of methylation in military PTSD subjects exposed to combat when compared to their non-PTSD counterparts. Strengths of this study include controlling for antidepressant use and excluding TBI patients. Similar studies in an active duty population of this size are scarce. What is not clear is whether methylation changes are driving PTSD symptomology or whether they are merely a marker of disease. Future areas of research include prospective studies that measure methylation pre- and postcombat exposure in the same individual.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/milmed/usz292DOI Listing
March 2020

Conversion: Simulated Method of Exchanging Tourniquet Use for Pressure Dressing Use.

J Spec Oper Med 2020 ;20(3):44-51

Background: Given little data to assess guidelines, we sought a way to exchange one type of intervention, field tourniquet use, for another, use of a pressure dressing. The study purpose was to test performance of controlling simulated bleeding with a stepwise procedure of tourniquet conversion.

Methods: An experiment was designed to assess 15 tests of a caregiver making tourniquet-dressing conversions. Tests were divided into trials: tourniquet use and its conversion. In laboratory conditions, the tourniquet trial was care under gunfire; then, the conversion trial was emergency healthcare. A HapMed Leg Tourniquet Trainer simulated a limb amputation. An investigator provided healthcare.

Results: Mean (± standard deviation [SD]) test time and blood loss were 9 ± 3.6 minutes and 334 ± 353.9mL, respectively. The first test took 17 minutes. By test number, times decreased; the last six took ≤7 minutes. All tourniquet trials controlled bleeding. Mean (±SD) tourniquet pressure and blood loss were 222 ± 18.0mmHg and 146 ± 40.9mL, respectively. Bleeding remained uncontrolled in one conversion. Initial attempts to wrap a dressing were effective in 73% of tries (n = 11 of 15). Four of 15 wrap attempts (27%) were repeated to troubleshoot bleeding recurrence, and the first three tests required a repetition. Mean (±SD) dressing pressures and blood losses were 141 ± 17.6mmHg and 188 ± 327.4mL, respectively. Unsatisfactory conversion trials had a dressing pressure <137mmHg. Dressings and wraps hid the wound to impair assessment of bleeding.

Conclusions: In testing a method of converting a limb tourniquet to a pressure dressing, the caregiver performed faster with experience accrual. The tourniquet results were uniformly good, but conversion results were worse and more varied. Simulating conversion was disappointing on a manikin and indicated that its redesign might be needed to suit this method. The procedural method constituted a start for further development.
View Article and Find Full Text PDF

Download full-text PDF

Source
November 2020

Extubation Failure in a Burn Intensive Care Unit: Examination of Contributing Factors.

J Burn Care Res 2021 03;42(2):177-181

United States Army Institute of Surgical Research, Fort Sam Houston, Texas.

Extubation failure is associated with negative outcomes making the identification of risk factors for failure paramount. Burn patients experience a high incidence of respiratory failure requiring mechanical ventilation. There is no consensus on the acceptable rate of extubation failure and many conventional indices do not accurately predict extubation outcomes in burn patients. The purpose of this study was to examine the rate of extubation failure in the burned population and to examine the impact of factors on extubation outcomes. Burn patients from a single center over 9 years were examined and included if they were intubated prior to arrival or within 48 hours of admission and underwent a planned extubation. From this cohort, a matched case-control analysis based on age, TBSA, and sex was performed of patients who succeeded after extubation, defined as not requiring reintubation within 72 hours, to those who failed. Characteristics and clinical parameters were compared to determine whether any factors could predict extubation failure. There was a 12.3% incidence of extubation failure. In the matched case-control analysis, the presence of inhalation injury was associated with extubation success. Higher heart rate and lower serum pH were associated with extubation failure. ANCOVA analysis demonstrated that a sodium trending higher before extubation was associated with more successes, possibly indicative of a lower volume status. Classic extubation criteria do not accurately predict extubation outcomes in burn patients; analysis of other parameters may be able to provide better predictions. A constellation of these parameters needs to be studied prospectively.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jbcr/iraa162DOI Listing
March 2021

Semi-rigid ureteroscope as a dilator in renal stone ureteroscopic treatment.

Can J Urol 2020 08;27(4):10317-10321

Brooke Army Medical Center, JBSA Fort Sam, Houston, Texas, USA.

Introduction: To determine the efficacy and safety of using the semi-rigid ureteroscope as the only ureteral dilator for primary ureteroscopy (URS) in the treatment of renal stones.

Materials And Methods: A retrospective review of primary URS for renal stone disease was performed on consecutive patients treated by a single provider from 2013 to 2017. Utilizing wire placement under fluoroscopic guidance and direct visual ureteroscopic dilation with a semi-rigid ureteroscope, primary outcome was successful completion of stone treatment. In addition, perioperative safety was evaluated.

Results: A total of 126 consecutive cases of primary URS using the semi-rigid ureteroscope as the only ureteral dilator were attempted for renal stone treatment. The renal stones were treated in 124 (98.4%) patients without other forms of active ureteral dilation. Two (1.6%) patients required ureteral stent placement for passive dilation despite attempted other dilating techniques. No intraoperative ureteral perforations were identified. Postoperative radiographic follow up was available for 67% patients with a 91% stone free rate and no hydronephrosis or ureteral strictures were detected.

Conclusion: Utilizing direct visual semi-rigid ureteroscopic dilation with a semi-ridged ureteroscope prior to flexible ureteroscopy leads to successful primary ureteroscopy for renal stone treatment in most patients. This technique is an effective, safe and possibly cost-effective method of obtaining ureteral access to facilitate primary URS for renal stone treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
August 2020

Extending Peer Support Across the Military Health System to Decrease Clinician Burnout.

Mil Med 2021 01;186(Suppl 1):153-159

Department of Pediatrics, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX 78234.

Introduction: Clinician burnout is widespread throughout medicine, affecting professionalism, communication, and increases the risk of medical errors, thus impacting safe quality patient care. Previous studies have shown Peer Support Programs (PSPs) promote workforce wellness by supporting clinicians during times of heightened stress and vulnerability. Although these programs have been implemented in large institutions, they have not been used in military hospitals, which have high staff turnover and added stressors of deployments.

Materials And Methods: In December 2018, 50 physicians received 5 hours of PSP training at a military hospital from a nationally recognized PSP expert, following the programmatic structure described by Shapiro and Galowitz (2016). Utilization of the program was tracked from December 2018 to December 2019, recording only classification of provider type, triggering event, and provider specialty to maintain confidentiality. Qualitative comments from recipients and supporters were saved anonymously for quality improvement purposes.

Results: In the first year of our PSP, 254 clinicians (102 [40.2%] residents/fellows, 91 [35.8%] staff physicians, 4 [1.6%] medical students, 35 [13.8%] nurses, 22 [8.7%] allied health) received 1:1 peer support. Primary specialties utilizing peer support included 135 (52.9%) medical, 59 (23.2%) surgical, 43 (16.9%) obstetric, and 18 (7.1%) pediatric. Patient death (25%), risk management notification (22%), medical error/complication (15%), and poor patient outcome (13%) were the most common events triggering peer support. Peer support was provided at 8 locations across the continental United States with universally positive comments from recipients.

Conclusions: Implementation of a PSP at our institution led to rapid utilization across multiple hospitals in the military health system, a model that could easily expand to deployed settings and remote locations. Access to peer support across the military health system could both mitigate the increased risks of military clinician burnout, and improve patient safety, healthcare worker resilience, and service member readiness.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/milmed/usaa225DOI Listing
January 2021

Electronic trauma resuscitation documentation and decision support using T6 Health Systems Mobile Application: A combat trauma center pilot program.

J Trauma Acute Care Surg 2020 12;89(6):1172-1176

From the Department of Surgery, Division of Trauma Critical Care (L.M.A., R.A.H., D.A.V., J.S.F., V.G.S.), Department of Graduate Medical Education (J.K.A.), and Department of Emergency Medicine (K.R.B., J.M.N.), Brooke Army Medical Center, Fort Sam Houston, Texas; St. Louis University Center for Sustainment of Trauma and Readiness Skills, Department of Surgery (C.N.S.), Division of Traua Critical Care, St. Louis, MO.

Background: The care of trauma patients in combat operations is handwritten on a five-page flow sheet. The process requires the manual scanning and uploading of paper documents to bridge the gap between electronic and paper record management. There is an urgent operational need for an information technology solution that will enable medics to better capture patient treatment information, which will improve long-term health care without impacting short-term care responsibilities.

Methods: We conducted a process improvement project to evaluate the ability of T6 Health Systems Mobile Application to improve combat casualty care data collection at a deployed trauma hospital. We performed a head-to-head comparison of the completeness and accuracy of data capture of electronic versus handwritten records to determine noninferiority.

Results: During the 90-day pilot, there were 131 trauma evaluations of which 53 casualty resuscitations (40.5%) were also documented in the electronic application. We compared completeness and accuracy of admit, prehospital, primary survey, secondary survey, interventions, and trends data. We found an overall 13% increase in data capture at 96% accuracy compared with the written record, suggesting that the electronic record was superior. Completion of electronic documentation compared with paper by section was statistically significantly higher for admitting data, 119.7% (p < 0.0001); prehospital, 116.2% (p = 0.0039); primary, 109.6% (p < 0.001); and secondary, 125.5% (p < 0.001). We also had the medical evacuation teams document prehospital and en route care and then synchronize the record in the trauma bay, allowing the trauma teams there to continue documenting on the same casualty record, likely contributing to superiority because teams did not have to redocument based on an oral report.

Conclusion: Our pilot program in the deployed environment demonstrated a mobile technology that actually enhanced the completeness and accuracy of paper trauma documentation that has the capability of providing patient-specific decision support and real-time data analysis.

Level Of Evidence: Care Management, level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000002909DOI Listing
December 2020

Long-Term Outcomes of Thoracic Trauma in U.S. Service Members Involved in Combat Operations.

Mil Med 2020 12;185(11-12):e2131-e2136

Pulmonary/Critical Care Service, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA-Sam Houston, San Antonio, TX 78234.

Introduction: Nearly 10% of all combat injuries during the most recent conflicts in Iraq and Afghanistan involve thoracic trauma. The long-term outcomes of these combat-related injuries with respect to lung function have not been fully evaluated. Limited research in civilian polytrauma patients have shown significant obstructive physiology in nearly half of their population without clear etiology. We sought to further characterize the extent to which these active duty service members (ADSM) are chronically affected by their thoracic injuries.

Materials And Methods: We conducted a retrospective chart review and analysis of ADSM who sustained thoracic injuries while deployed in support combat operations from 2003 to 2013. Using the Department of Defense Trauma Registry, 2,049 patients were found to have sustained thoracic trauma during these conflicts, of which we were able to identify 298 patients with postinjury pulmonary function testing (PFT) available for analysis. Following standardization of these tests using the established reference values, PFT was compared to a representative population of ADSM. Additional analysis was completed to detect incidence of abnormal PFTs when compared to both type of injury (burn, blunt, penetrating, and other) and also Injury Severity Score.

Results: In our patient population, there was a significant increase in abnormal PFTs when compared to a representative population. Of these, 31.8% of patients displayed obstructive physiology versus 3.7% in the control (P < 0.001), 24.5% displayed restrictive or restrictive pattern (those without full lung volumes available utilizing forced vital capacity) versus 4.9% (P < 0.0001), and 7.9% displaying mixed pattern. Further, increasing rates of abnormal PFTs were identified in comparison to Injury Severity Score (odds ratio 1.03). There was no significant increase in abnormal PFTs when stratified by type of injury. Finally, there was no significant change identified in pulmonary function before and after injury in our limited population of 19 patients.

Conclusions: There is a significant increase in the percent of abnormal PFTs in ADSM following thoracic injury when compared to patients with similar risk factors and baseline health. It is unclear why the rates of obstruction are high in our population as previous research has not definitively shown increased rates of asthma in previously deployed, uninjured ADSM; however, this finding is consistent with limited previous research in civilian trauma patients. Further research into the long-term outcomes of thoracic trauma and occupational exposures of combat is paramount for improved outcomes going forward.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/milmed/usaa165DOI Listing
December 2020

Individual Variation of Spirometry Before and After Deployment From the STAMPEDE II Cohort.

Respir Care 2020 07;65(7):1053-1054

Pulmonary/Critical Care Service Walter Reed National Military Medical Center Bethesda, Maryland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4187/respcare.07820DOI Listing
July 2020

Step Duration Effects on Blood Loss in Simulated Designs of Tourniquet Use Procedure.

J Spec Oper Med 2020 ;20(2):76-82

Background: We sought new knowledge by further developing a model of using calculations in the simulation of a first-aid task. The purpose of this study was to develop the model to investigate the performance of tourniquet use in its component steps.

Methods: We aimed to design an experiment on a desktop computer by mathematically manipulating simulated data in tourniquet use. A time factor of tourniquet use was ranged widely through time challenges in five degrees from ideal to worst performances. Redesigning the task was assessed by time costs and blood losses.

Results: The step of tourniquet application took 17% of the trial time and securing the tourniquet after bleeding control took the longest amount of the trial time, 31%. A minority of the time (48% [17% + 31%] to apply tourniquet plus secure it) was spent after the tourniquet touched the patient, whereas most of the time (52%) was spent before the tourniquet touched the patient. The step of tourniquet application lost 14% of the total blood lost, whereas no blood was lost during securing the tourniquet, because that was the moment of bleeding control despite securing the tourniquet taking much time (31%). Most (86%) of blood lost occurred before the tourniquet touched the patient. But blood losses differed 10-fold, with a maximum of 2,434mL, which, when added to a pretask indication blood loss of 177mL, summed to 2,611mL. Before redesigning the task, costs of donning gloves and calling 9-1-1 included uncontrolled bleeding, but gloving mitigated risk of spreading pathogens among people. By step and person, redesigns of the task altered the risk-benefit profile.

Conclusions: The model was useful because it simulated where most of the bleeding occurred before the tourniquet touched the patient. Modeling simulated redesigns of the task, which showed changes in the task's risk-benefit profile by step and among persons. The model generated hypotheses for future research, including the capability to screen candidate ideas among task designs.
View Article and Find Full Text PDF

Download full-text PDF

Source
July 2020

Tourniquets Last to Tourniquets First.

J Spec Oper Med Summer 2020;20(2):20-21

View Article and Find Full Text PDF

Download full-text PDF

Source
July 2020

Tranexamic acid in pediatric combat trauma requiring massive transfusions and mortality.

J Trauma Acute Care Surg 2020 08;89(2S Suppl 2):S242-S245

From the Department of Pediatrics-Critical Care (M.H.), Tripler Army Medical Center, Honolulu, Hawaii; Brooke Army Medical Center Fort Sam Houston (J.K.A., M.A.B.), Houston, Texas; and Department of Pediatrics (M.H., M.A.B.), Uniformed Services University, Services University, Bethesda, Maryland.

Background: Tranexamic acid (TXA) has been demonstrated to decrease mortality in adult trauma, particularly in those with massive transfusions needs sustained in combat injury. Limited data are available for the efficacy of TXA in pediatric trauma patients outside of a single combat support hospital in Afghanistan.

Methods: The Department of Defense Trauma Registry was queried for trauma patients younger than 18 years from Iraq and Afghanistan requiring 40 mL/kg or greater of blood product within 24 hours of injury. Burns and fatal head traumas were excluded. Primary outcome was in-hospital mortality. Secondary outcomes were hospital, ventilator, and intensive care unit-free days, as well as total blood product volume.

Results: Among those pediatric patients receiving massive transfusions, those who received TXA were less likely to die in hospital (8.5% vs. 18.3%). Patients who received TXA and those who did not have similar hospital-free days (19 vs. 20), ventilator-free days (27 vs. 27), and intensive care unit-free days (25 vs. 24). Those who received TXA had higher 24-hour blood product administration (100 mL/kg vs. 75 mL/kg). None of our results rose to the level of statistical significance. The TXA administration significantly reduced odds of death on logistic regression (odds ratio, 0.35; 95% confidence interval, 0.123-0.995; p = 0.0488).

Conclusion: Use of TXA in pediatric patients with combat trauma requiring massive transfusions trended toward a significant improvement in in-hospital mortality (p = 0.055). This mortality benefit is similar to that seen in adult studies and a less well characterized cohort in another pediatric study suggesting TXA administration confers mortality benefit in massively transfused pediatric combat trauma victims.

Level Of Evidence: Evidence (retrospective cohort), Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000002701DOI Listing
August 2020
-->