Brooke Army Medical Center Research Articles

Risk Factors for Delayed Treatment of Gonorrhea and Chlamydia in Active-Duty Service Members.

Sexually transmitted infections including gonorrhea and chlamydia are common in the active-duty military population, with historically higher rates than their civilian counterparts. Prevention and screening are 2 of the main strategies used to reduce the chronic medical complications and costs associated with untreated gonorrhea and chlamydia; however, there is little information in the literature regarding treatment time after a positive screening. To our knowledge, there has not yet been a study regarding delayed treatment of gonorrhea and chlamydia in the active-duty population. We performed a population-based retrospective observational study on active-duty service members (ADSMs) diagnosed with gonorrhea and chlamydia from 2010-2019. Statistical analysis was performed to determine differences in treatment times for key demographics. This study was reviewed and approved by the Brooke Army Medical Center Institutional Review Board. Average treatment time was 3.5 days for individuals with chlamydia and 5 days for those with gonorrhea. Treatment within 2 weeks was met for 94% of people diagnosed with chlamydia and 91% of people diagnosed with gonorrhea. Delay in treatment times for chlamydia were seen in men, ages 25-34, full-time active-duty service members, those with a history of prior infection, and soldiers in the Army. Gonorrhea treatment times were delayed in men, members of the Coast Guard, ages 35-44, and those with a history of prior infection. Significant differences in treatment time were seen based on sex, age, branch of service, rank, and history of prior infection.

Etiology of Leukemoid Reaction in Patients Undergoing Extracorporeal Membrane Oxygenation.

Nosocomial infections are frequent in patients receiving extracorporeal membrane oxygenation (ECMO). Leukemoid reaction, defined as >50,000 white blood cells (WBCs) per microliter, has been associated with infections in some populations. As ECMO is associated with significant inflammation activation between the patient's immune system and the circuit components, it is hypothesized that leukemoid reactions may have low specificity for identifying new infections in patients receiving ECMO. A retrospective cohort study was performed on all adult patients admitted to the Brooke Army Medical Center who received ECMO for greater than 72 hours between 2018 and 2022. Maximum WBCs were obtained for all charts. For those with leukemoid reaction, demographic information and clinical management was obtained. This study was determined to be exempt by Brooke Army Medical Center Institutional Review Board. Among 182 patients receiving ECMO for greater than 72 hours, 15 (8%) developed a leukemoid reaction while on ECMO. The median (Interquartile range, IQR) WBC was 53.94 (50.98 to 62.55). Fourteen (93%) patients underwent an infectious evaluation. Patients had a median of 2 (IQR: 2 to 3) etiologies contributing to their leukemoid reaction. At the time of leukemoid reaction, 11 (73%) patients were receiving treatment for a known infection, 6 (40%) were found to have a new thrombus, and 4 (27%) were receiving glucocorticoids. Only 1 (7%) patient was found to have a new infection, an Acinetobacter baumannii bacteremia. Leukemoid reactions occur infrequently in patients receiving ECMO and are generally multifactorial. In this cohort, leukemoid reactions rarely occurred in the setting of a new infection and suggest low utility to starting or broadening antimicrobials for these patients. Future studies identifying useful infectious markers are needed for patients receiving ECMO.

Pediatric Human Papillomavirus Vaccination Rates Within a Tertiary Military Medical Center.

To determine our center's human papillomavirus (HPV) vaccination rate and identify common negative perceptions surrounding the vaccine to guide more effective HPV vaccine counseling. We reviewed immunization records for patients ages 11 to 26 that receive care at Brooke Army Medical Center. Vaccine uptake rate was determined by dividing the number of patients who had completed the HPV vaccine series by the total target population. From October 2021 to December 2022, a clinic survey was distributed to parents (for patients ages 11-17) or patients themselves (ages 18-26) during otolaryngology visits to poll vaccination status and attitudes toward the vaccine. A total of 3038 patients ages 11 to 26 are enrolled for primary care at Brooke Army Medical Center, but only 962 (32%) are vaccine complete. Thirty-five surveys were collected during the study period. Twenty-two surveys (63%) from patients/parents reported they/their child had received the HPV vaccine. Concerns about vaccine safety, sexual behaviors, lack of immunization requirement for school, and difficulty getting scheduled were the most common reasons patients were unvaccinated. Counseling patients on the HPV vaccine can be difficult given the common misconceptions surrounding vaccination, but understanding these attitudes will allow otolaryngologists to educate patients more effectively. This matters since patients more knowledgeable about HPV are more likely to receive the vaccine. Our clinic has developed new strategies in partnership with primary care departments to facilitate more streamlined vaccination for eligible patients, and moving forward we plan to trend HPV vaccination rates over time to determine our impact on uptake.

Incidence of Surgically Managed Post-Tonsillectomy Hemorrhage Associated With NSAID Prescribing for Postoperative Pain Management.

Tonsillectomy ranks high among the most common pediatric surgical procedures in the United States. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, are routinely prescribed to manage post-tonsillectomy pain, but may carry the risk of hemorrhage. This retrospective, longitudinal, secondary-data analysis study compared the incidence of surgically managed post-tonsillectomy hemorrhage (sPTH) in pediatric patients prescribed ibuprofen at Brooke Army Medical Center (BAMC) after tonsillectomy compared to a similar cohort of pediatric patients at the Children's Hospital of Philadelphia (CHOP) not prescribed ibuprofen. Additional regression analysis examined predictors of sPTH at BAMC. The odds of sPTH was lower in patients who were prescribed ibuprofen at BAMC, relative to patients who were not at CHOP (OR 0.57, 95% CI, 0.37, 0.87; P < 0.01). In a generalized linear model evaluating BAMC patient data, there was a lack of a relationship between reason for tonsillectomy (tonsillitis versus tonsillar obstruction), primary procedure (tonsillectomy-only versus tonsillectomy with adenoidectomy), and presence of a co-occurring procedure. Post-tonsillectomy ibuprofen prescribing practices were not associated with an elevated risk of sPTH, relative to patients at CHOP not exposed to ibuprofen.

Is Resectoscopic Hysteroscopy a Dying Art? Creation of an Educational Instructional Video [ID 2683474

INTRODUCTION: Resectoscopic hysteroscopy is a valuable surgical technique for addressing intrauterine pathology. Within our institution, most operative hysteroscopies are performed using newer non-resectoscopic systems, potentially creating a gap in resident surgical education. We developed a novel instructional video demonstrating the components and capabilities of the resectoscopic hysteroscope. Our aim is to assess whether the instructional video increased surgeon comfort using the resectoscopic hysteroscope. METHODS: A pilot cohort study was performed with gynecologic surgery and obstetrics (GS&amp;O) residents and staff physicians at Brooke Army Medical Center. Participants were provided access to the resectoscope surgical set throughout the study, completed a baseline survey assessing surgeon comfort, and then repeated the survey after watching the instructional video. The survey used a 5-point Likert scale with 1) very uncomfortable, 3) neutral, and 5) very comfortable. RESULTS: Of the 20 participants, 85% lacked formal resectoscope training and 45% had no prior resectoscope experience. Prior experience was limited: 55% used it less than five times and 64% had no use in the last year. At baseline, few were comfortable with setup (15%) and troubleshooting (5%). The instructional video significantly increased surgeon comfort with resectoscope setup (P&lt;.001) and troubleshooting (P&lt;.001). Surgeon comfort supervising a resident doubled after the instructional video (33–66%). All participants felt the video was helpful and would recommend it to others (100%; P&lt;.01). Finally, 80% of participants would like more formal training opportunities for other surgical devices. CONCLUSION: This survey demonstrated a gap in surgical experience and comfort using the resectoscope at our institution. The novel instructional resectoscope video improved GS&amp;O resident and staff comfort with setting up and troubleshooting the resectoscope. Staff comfort with supervising a resident using the resectoscope also increased. Future directions include expanding study population to include operating room staff and assessing post-intervention resectoscope utilization rates.

Effect of Updated Colposcopy Guidelines for Endocervical Curettage at Time of Colposcopy [ID 2683668

INTRODUCTION: The American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines were updated in January 2023 to broaden the use of endocervical curettage (ECC) at the time of colposcopy. We aimed to determine how our practice at a single military institution aligned with the new recommendations. METHODS: After receiving approval from our institutional quality improvement (QI) office, a retrospective chart review was completed for all colposcopies performed at Brooke Army Medical Center from March 1, 2022 to December 31, 2022. Demographic and dysplasia history was extracted for each encounter. Cases were sorted into ASCCP-defined categories of ECC preferred, recommended, acceptable, omission acceptable, and unacceptable. The rate of endocervical curettage completion was compared across each category. RESULTS: Colposcopies were performed in 120 nonpregnant patients. ECC was performed in 95 cases (79%). Based on 2023 guidelines, ECC would be recommended for 57, preferred for 23, acceptable for 25, and omission acceptable for 15. The rates of ECC for recommended (84%) and preferred groups (82.5%) and omission acceptable group (73%) were not significantly different (P=NS). CONCLUSION: Prior to release of the 2023 ASCCP guidelines, ECC at our institution was commonly done in higher-risk groups. To mitigate overall health care burden and unindicated procedures, ECCs should be redistributed away from the omission acceptable groups towards the higher-risk groups. This would lead to an estimated 2.5% increase in overall ECC rate and a 20% increase in high-risk groups. A prospective evaluation of the implication of these guidelines is ongoing.

Ethnicity and In Vitro Fertilization Outcomes in an Equal Access to Care Setting [ID 2683634

INTRODUCTION: Many studies report racial disparities in assisted reproductive technology (ART) outcomes, specifically, lower pregnancy rates and higher miscarriage rates in Black women. In an equal access to care setting, we wanted to delineate causes of this ongoing racial disparity. METHODS: This is a retrospective review of ART cycles at Brooke Army Medical Center (BAMC) from 2013 to 2021 via the Society for Assisted Reproductive Technology database. This study received a nonresearch designation from the BAMC IRB. RESULTS: A total of 1,211 in vitro fertilization (IVF) cycles were reviewed, comparing outcomes by race from first-time embryo transfers, fresh or frozen after “freeze-all” IVF cycles. Black women (19% of all cycles) experienced a lower live birth rate (27.3% versus 34.6%; risk ratio [RR] 0.75; 95% CI 0.6–0.94), but did not experience a statistically significant increase in pregnancy loss (36.8% versus 30.6%; RR 1.26; 95% CI, 0.94–1.68] compared to all other patients. Black women were found to have a higher prevalence of uterine factor infertility (RR 2.87; 95% CI, 2.24–3.66) and tubal factor infertility (RR 1.79; 95% CI, 1.51–2.12). When controlling for uterine factor infertility, Black racial identity was no longer a risk factor for decreased live birth rate (adjusted RR 0.85; 95% CI, 0.69–1.07). CONCLUSION: Recent literature demonstrates poorer ART outcomes for Black women. Our study suggests that this may be attributable to uterine fibroids, and an increased research focus on uterine fibroid treatment in patients desiring fertility may improve ART outcomes in Black women.

Game On: Team-Based Competition to Enhance Engagement in Obstetrics and Gynecology Graduate Medical Education [ID 2683471

INTRODUCTION: Surgeon General Dr. Vivek Murthy called attention to what he declares a public health crisis of loneliness, isolation, and lack of connection in our country. Three years into the COVID pandemic, the medical profession has experienced a huge increase in burnout that has only exacerbated this crisis. Consistent with national trends, lack of faculty engagement and overall well-being was noted to have suffered on our 2022 Accreditation Council for Graduate Medical Education (ACGME) Resident Survey. METHODS: The Brooke Army Medical Center Gynecologic Surgery and Obstetrics residency program implemented a themed team competition for the 2022–2023 academic year, “GYN of Thrones.” Residents and staff were divided into five families, modeled after Game of Thrones to compete for the “Throne of Hysteros.” Points were awarded for participating in program activities, receiving kudos for patient care, and demonstrating clinical excellence. The data from the 2021–2022 and 2022–2023 ACGME surveys were compared to evaluate the effect of this new competition. RESULTS: Faculty interest in resident education increased 41% (P=.002), from 59% to 100% after implementation. Similarly, only 59% felt there was an appropriate amount of teaching in clinical and didactic activities in 2021–2022, whereas this improved to 89% in 2022–2023 (P=.041). Residents were also more satisfied with faculty feedback: 53% prior to the competition improved to 84% after (P=.047). CONCLUSION: Resident perception of faculty engagement in academics and quality of teaching drastically improved after implementation of this program-wide competition. Faculty well-being scores improved as well, indicating this may decrease burnout in the workforce and improve morale and connection.

Pneumococcal Perplexity: Improving Awareness of Updated Pneumococcal Vaccination Recommendations in Two Large Military Treatment Facilities.

Vaccinations are an essential aspect of preventive medicine. In October 2021, the pneumococcal conjugate vaccine-20 (PCV-20) and PCV-15 were authorized for use in adults by the U.S. FDA. In 2022, the Advisory Committee on Immunization Practices (ACIP) subsequently published updated pneumococcal vaccination recommendations that incorporate both PCV-20 and PCV-15. Pneumococcal vaccination is effective in reducing pneumococcal disease, particularly in high-risk patient groups such as those with chronic lung disease; however, the updated dosing schedule for pneumococcal vaccinations can be quite confusing, especially if patients have previously received "older" vaccinations, such as pneumococcal polysaccharide vaccine-23 or PCV-13. The purpose of this quality improvement project was to increase providers' knowledge of current ACIP pneumococcal vaccination recommendations, including indications and dosing schedule, and to improve pneumococcal vaccination rates among eligible adults and children. Focused education sessions were presented to primary care and subspecialty residents, fellows, and staff at Brooke Army Medical Center and Wilford Hall Ambulatory Surgical Center regarding current ACIP pneumococcal vaccination recommendations. Sessions included information about PCV-15 and PCV-20 vaccines, indications for vaccination, and dosing schedules. Subjective knowledge of updated ACIP pneumococcal vaccination recommendations was assessed among primary care and subspecialty residents, fellows, and staff via an anonymous survey both pre- and post-intervention. Number of PCV-20 vaccinations given and estimated vaccination rates of patients aged 19 to 64 years with asthma were assessed pre- and post-intervention over a 6 month time span. Of surveyed providers, only 9% discussed vaccinations at every visit and 11% did not discuss vaccinations at all. There was a statistically significant increase in providers' knowledge of pneumococcal vaccination guidelines for children post-intervention (P = .01) but no statistically significant increase in knowledge for guidelines for adults, for patients that have received prior pneumococcal vaccines, or in overall confidence in recommending pneumococcal vaccines. There was a 17% increase in the number of PCV-20 vaccinations given post-intervention (198 pre-intervention, 232 post-intervention). The estimated PCV-20 vaccination rate for adults aged 19 to 64 years with asthma increased from 14.9% pre-intervention to 19.5% post-intervention (P = .33). There is a significant knowledge gap regarding ACIP pneumococcal vaccination recommendations among military providers and a low pneumococcal vaccination rate for adults aged 19 to 64 years with asthma at Joint Base-San Antonio MTFs. Focused education sessions were effective in increasing providers' knowledge of updated pneumococcal vaccination recommendations, confidence in recommending vaccines, total number of pneumococcal vaccinations given, and estimated pneumococcal vaccination rate for adults with asthma. The validity of conclusions drawn from our data were limited because of discordant numbers of survey respondents as well as potentially inaccurate estimates of pneumococcal vaccination rates pre- and post-intervention. Despite this, the results warrant continued education of pneumococcal vaccines, indications, and dosing schedules.

Tube Thoracostomy Complications inPatients With ARDS Requiring ECMO: Worse inCOVID-19 Patients?

The incidence and management outcomes of COVID-19 patients with acute respiratory distress syndrome (ARDS) on veno-venous extracorporeal membrane oxygenation (V-V ECMO) requiring chest tubes are not well-described. This study sought to explore differences in tube thoracostomy rates and subsequent complications between patients with and without COVID-19 ARDS on V-V ECMO. This study is a single institution, retrospective cohort study of patients with COVID-19 ARDS requiring V-V ECMO. The control cohort consisted of patients who required V-V ECMO for ARDS-related diagnoses from January 2018 to January 2021. The primary outcome was any complication following initial tube thoracostomy placement. Study approval was obtained from the Brooke Army Medical Center Institutional Review Board (C.2017.152d). Twenty-five COVID-19 patients and 38 controls were included. Demographic parameters did not differ between the groups. The incidence of pneumothorax was not significantly different between the two groups (44% COVID-19 vs. 22% control, OR 2.8, 95% CI 0.95-7.9, P = 0.09). Patients with COVID-19 were as likely to receive tube thoracostomy as controls (36% vs. 24%, OR 1.8, 95% CI 0.55-5.7). Complications, however, were more likely to occur in the COVID-19 group (89% vs. 33%, OR 16, 95% CI, 1.6-201, P = 0.0498). Tube thoracostomy placement in COVID-19 patients with ARDS requiring V-V ECMO is common, as are complications following initial placement. Clinicians should anticipate the need for re-intervention in this patient population. Small-bore (14Fr and smaller) pigtail catheters appeared to be safe and efficacious in this setting, but further study on tube thoracostomy management in ECMO patients is needed.

Utility of the Neonatal Early-Onset Sepsis Calculator in a Low-Risk Population.

To compare early-onset sepsis (EOS) risk estimation and recommendations for infectious evaluation and/or empiric antibiotics using a categorical risk assessment versus the Neonatal Early-Onset Sepsis Calculator in a low-risk population. Retrospective chart review of late preterm (≥350/7-366/7 weeks' gestational age) and term infants born at the Brooke Army Medical Center between January 1, 2012 and August 29, 2019. We evaluated those born via cesarean section with rupture of membranes (ROM) < 10 minutes. Statistical analysis was performed to compare recommendations from a categorical risk assessment versus the calculator. We identified 1,187 infants who met inclusion criteria. A blood culture was obtained within 72 hours after birth from 234 (19.7%) infants and 170 (14.3%) received antibiotics per routine clinical practice, using categorical risk assessment. Respiratory distress was the most common indication for evaluation, occurring in 173 (14.6%) of patients. After applying the Neonatal Early-Onset Sepsis Calculator to this population, the recommendation was to obtain a blood culture on 166 (14%), to start or strongly consider starting empiric antibiotics on 164 (13.8%), and no culture or antibiotics on 1,021 (86%). Utilizing calculator recommendations would have led to a reduction in frequency of blood culture (19.7 vs. 14%, p < 0.0001) but no reduction in empiric antibiotics (14.3 vs. 13.8%, p = 0.53). There were no cases of culture-proven EOS. This population is low risk for development of EOS; however, 19.7% received an evaluation for infection and 14.3% received antibiotics. Utilization of the Neonatal Early-Onset Sepsis Risk Calculator would have led to a significant reduction in the evaluation for EOS but no reduction in antibiotic exposure. Consideration of delivery mode and indication for delivery may be beneficial to include in risk assessments for EOS. · Cesarean section with rupture of membranes at delivery confers low risk for EOS.. · Respiratory distress often triggers an EOS evaluation.. · Delivery mode should be considered in EOS risk..

1535. Persistence With Human Immunodeficiency Virus Pre-exposure Prophylaxis in an Active-Duty Military Population

Abstract Background There is limited data on Human Immunodeficiency Virus Pre-exposure Prophylaxis (PrEP) use and persistence in the military. Despite universal access to care, there is concern that PrEP persistence may be lower in military populations due to frequent deployments, need for relocations, and perceived stigma. This study evaluated the persistence rates as well as reasons for PrEP discontinuation in a military cohort. Methods The Brooke Army Medical Center Infectious Diseases clinic provides PrEP to service members at Joint Base San Antonio. This study evaluated all active-duty service members who received PrEP between 2020-2022. All charts were examined to determine patient demographics and years on PrEP. If a patient stopped PrEP, they were contacted to determine etiology of discontinuation and invited to restart PrEP. Results In total, 112 service members received PrEP during the study period. The cohort was predominantly male (99%) with median age 30 [IQR: 26-34] and a median of 2 years [IQR: 0-3] receiving PrEP (Table 1). The most common indication was multiple sexual partners with less than 100% condom use (n=98, 88%). At the end of the study, most (n=88, 79%) patients were still receiving PrEP including 33 (37%) at other military or civilian facilities. Of the 24 service members who were no longer receiving PrEP, 18 (75%), were able to be contacted (Table 2). Two (1%) patients seroconverted while off PrEP with reasons for discontinuation being abstinence and difficulty making appointments. No patients contacted during this study were interested in restarting PrEP. Demographic Information of 112 Active-Duty Service Members Receiving PrEP at Brooke Army Medical Center 2020-2022 Reasons for PrEP Discontinuation at Brooke Army Medical Center 2020-2022 Conclusion This is the first study to evaluate PrEP persistence in an active-duty population. In this cohort with universal access to care, PrEP persistence rates and years receiving PrEP were greater than seen in other populations. While the most common reason for discontinuation was changes in sexual behavior, systemic factors still contributed to PrEP discontinuation. Future studies should elucidate the challenges to PrEP care in the military. Disclosures All Authors: No reported disclosures

2442. Etiology of Leukemoid Reaction in Patients Undergoing Extracorporeal Membrane Oxygenation

Abstract Background Infections are a common in patients undergoing extracorporeal membrane oxygenation (ECMO), yet there is limited literature describing best practices for identifying infections. Leukemoid reaction, defined as &amp;gt; 50,000 white blood cells (WBC) per microliter, has been associated with infection in some populations. However, the etiology of leukemoid reactions in ECMO is unknown. Methods A retrospective cohort study was performed of all adult patients admitted to Brooke Army Medical Center who received ECMO for greater than 72 hours between the years of 2018-2022. Maximum WBC was obtained for all charts. For patients with a leukemoid reaction, charts were examined to determine both demographic information as well as clinical management of patient at time of leukemoid reaction. Results Among 182 patients receiving ECMO for greater than 72 hours, 181 (99%) of patients had a WBC greater than 10,000 cells per microliter during their ECMO course. 15 (8%) developed a leukemoid reaction while on ECMO and were included for further analysis. In this cohort, the median age was 38 [32-44.5] with median [IQR] WBC of 53.94 [50.98-62.55]. Among these patients, 14 (93%) underwent an infectious workup with infectious disease being consulted in 10 (67%) cases. Two (13%) patients had antibiotics started and 2 (13%) had their antibiotics broadened. Patients had a median of 2 [IQR: 2-3] contributing factors to their leukemoid reaction. Of these contributing etiologies, eleven (73%) patients were receiving treatment for a known infection, 6 (40%) were found to have a new thrombus, and 4 (27%) were receiving glucocorticoids (Table). One (7%) patient was found to have a new infection, an Acinetobacter bacteremia.Table 3.Contributing Etiologies of Leukemoid Reaction in patients receiving ECMO at Brooke Army Medical Center Conclusion Leukocytosis is almost universal in ECMO and leukemoid reactions occur frequently. In this cohort, infectious workups were common for leukemoid reaction, yet new infections were rarely identified. Future studies are needed to determine better infectious markers in this patient population. Disclosures All Authors: No reported disclosures

Correlation of Impulse Oscillometry with Spirometry in Deployed Military Personnel with Airway Obstruction.

Evaluation of chronic respiratory symptoms in deployed military personnel has been conducted at Brooke Army Medical Center as part of the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures III study. Although asthma and airway hyperreactivity have been the most common diagnoses, the clinical findings in these patients may be multifactorial. This study aims to evaluate the utility of impulse oscillometry (IOS) in diagnosing airway obstruction in patients undergoing multiple pulmonary function testing (PFT) studies. Military personnel referred for deployed-related pulmonary symptoms underwent a standardized evaluation at Brooke Army Medical Center and Walter Reed National Military Medical Center over a 5-year span. Initial studies included laboratory tests, high-resolution computed tomography imaging, cardiac evaluation with electrocardiogram, and echocardiography. PFT consisted of full PFTs, forced inspiratory/expiratory pressures, post-spirometry bronchodilator testing, IOS, exhaled nitric oxide, and methacholine challenge testing. A total of 360 patients have completed an evaluation to date. In this cohort, 108 patients (30.0%) have evidence of obstruction by spirometry, whereas 74 (20.6%) had IOS values of both an R5 > 150% and X5 < -1.5. Only 32 (8.9%) had evidence of obstruction by both spirometry and IOS, whereas 210 (57.3%) had neither. A comparison among R5 (resistance at 5 Hz), R20 (resistance at 20 Hz), and X5 (reactance at 5 Hz) was performed in those individuals with and without spirometric obstruction. R5 (% predicted) was 156.2 ± 57.4% (obstruction) vs. 129.1 ± 39.6% (no obstruction) (P < .001); R20 (% predicted) was 138.1 ± 37.7% (obstruction) vs. 125.3 ± 31.2% (no obstruction) (P = .007); and X5 (cmH2O/L/s) was -1.62 ± 1.28 (obstruction) vs. -1.25 ± 0.55 (no obstruction) (P < .001). Impulse oscillometry has been advocated as a supplemental pulmonary function test to aid in the diagnosis of airway obstruction. The use of IOS has been primarily used in pediatrics and elderly populations as a validated tool to establish a diagnosis of airway obstruction but is limited in the adult population because of a well-validated set of reference values. Prior studies in adults have most often demonstrated a correlation with an elevated R5 > 150%, elevated resonant frequency, and a negative X5 < -1.5 or a decrease of 30 to 35% in R5 post-bronchodilator. Impulse oscillometry may serve as an adjunct to diagnosis but likely cannot replace a standard spirometric evaluation. Our study highlights the future utility for diagnosing early obstructive disease in the symptomatic individual.

Epidemiology, clinical characteristics, and outcomes of nontuberculous mycobacterial skin, soft tissue, and bone infections from a single center over a 10-year period

IntroductionNon-tuberculous mycobacteria (NTM) cause a wide variety of clinical syndromes. Data guiding diagnosis and treatment of NTM skin and soft tissue infections (SSTI) and bone infections are limited. We sought to better understand SSTI and bone infections caused by NTM. MethodsAll NTM clinical isolates recovered at Brooke Army Medical Center from 2012 to 2022 were screened; SSTI and bone isolates were included. Electronic health records were reviewed for epidemiologic, microbiologic, and clinical data. Infections were defined as recovery of one or more NTM isolate from skin, soft tissue, or bone cultures with a corresponding clinical syndrome. ResultsForty isolates of skin, soft tissue, or bone origin from 29 patients were analyzed. Twenty (69 %) patients, majority female (14/20, 70 %), had infecting isolates, most commonly secondary to surgery (35 %) or trauma (35 %). Six of 20 (30 %) had bone infections. Time from symptom onset to isolate recovery was a median 61 days (IQR 43–95). Eight (40 %) had combined medical/surgical therapy, 8 (40 %) had surgery alone, and 4 (20 %) had medical therapy alone. M. abscessus was more frequently isolated from patients with true infections. ConclusionsData supporting diagnosis and treatment decisions in NTM SSTI/bone infections is sparse.In this study the majority of NTM isolated were true infections. We confirm that surgery and trauma are the most common routes of exposure. The delay between symptom onset and directed therapy and the wide variety of treatment regimens highlight a need for additional studies delineating criteria for diagnosis and treatment.

Practice patterns of hepatobiliary surgery within the military.

The purpose of this study is to evaluate the trends of hepatobiliary surgeries performed at military hospitals and to discuss potential implications on resident training and military readiness. While there is data to suggest centralization of surgical specialty services leads to improved patient outcomes, the military does not currently have a specific centralization policy. Implementation of such a policy could potentially impact resident training and readiness of military surgeons. Even in the absence of such a policy, there may still be a trend toward centralization of more complex surgeries like hepatobiliary surgeries. The present study evaluates the numbers and types of hepatobiliary procedures performed at military hospitals. This study is a retrospective review of de-identified data from Military Health System Mart (M2) from 2014 to 2020. The M2 database contains patient data from all Defense Health Agency treatment facilities, encompassing all branches of the United States Military. Variables collected include number and types of hepatobiliary procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each medical facility. Linear regression was used to evaluate significant trends in numbers of surgeries over time. Fifty-five military hospitals performed hepatobiliary surgeries from 2014 to 2020. A total of 1,087 hepatobiliary surgeries were performed during this time; cholecystectomies, percutaneous procedures, and endoscopic procedures were excluded. There was no significant decrease in overall case volume. The most commonly performed hepatobiliary surgery was "unlisted laparoscopic liver procedure." The military training facility with the most hepatobiliary cases was Brooke Army Medical Center. The number of hepatobiliary surgeries performed in military hospitals has not significantly decreased over the years 2014-2020, despite a national trend toward centralization. Centralization of hepatobiliary surgeries in the future may impact residency training as well as military medical readiness.

Increasing Mental Health Screening inPediatric Subspecialty Clinics: An Improvement Project at Brooke Army Medical Center.

Mental health screening allows for the early identification of patients at risk of mental health disorders such as anxiety and depression. The Defense Health Administration Procedures Manual 6025.01 established that patients older than 12 years of age should receive annual mental health screening assessing suicidality risk with a standardized screening tool. To improve rates of mental health screening in this at-risk population, an A3 Lean approach to quality improvement was undertaken in the Pediatric Subspecialty Clinics at Brooke Army Medical Center. Baseline data of Patient Health Questionnaire-9 or General Anxiety Disorder-7 screening from pediatric pulmonology and cardiology clinics were 6.3%. Plan-Do-Study-Act quality improvement methods evaluated possible interventions to improve screening. A standard operating procedure (SOP) outlining scoring and interpretation recommendations was distributed in pediatric pulmonology and cardiology clinics. Using the Armed Forces Health Longitudinal Technology Application, a post-implementation chart review was conducted for 8 weeks. With the initiation of Military Health System Genesis, the SOP was adjusted and a root cause analysis was performed. The pediatric gastroenterology clinic cares for patients presenting with functional abdominal pain; therefore, the clinic was added to the second iteration to determine if anxiety or depression may play a role. Providers were educated on documentation and coding. A second post-implementation chart review was conducted for 8 weeks. Over two iterations, mental health screening of new adolescent patients in pediatric subspecialty clinics increased by 794% from baseline. Our providers screened 50% of the adolescent patients. With increased surveillance of an at-risk population, more adolescents will receive the standard of care. With refinement of the SOP and expansion to other subspecialties, this project has the potential to expand within Brooke Army Medical Center and other clinics in the Defense Health Administration.

Eosinophilic Fasciitis: A Rare Mimicker of Systemic Sclerosis.

From the Department of Rheumatology, Brooke Army Medical Center, San Antonio, TX. The authors declare no conflict of interest. Disclaimer: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force and Department of Defense, or the US Government. Correspondence: Seth J. VanDerVeer, DO, Department of Rheumatology, Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234. E-mail: [email protected].

Aggressive intravenous fluid resuscitation for acute pancreatitis.

Academic Emergency MedicineAccepted Articles THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE Aggressive Intravenous Fluid Resuscitation for Acute Pancreatitis Brit Long MD, Corresponding Author Brit Long MD [email protected] orcid.org/0000-0003-4770-8869 Brooke Army Medical Center, Department of Emergency Medicine, 3551 Roger Brooke Dr, Fort Sam Houston, TX, United States Correspondence Brit Long, MD, Present Address: 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234. Email: [email protected]Search for more papers by this authorMichael Gottlieb MD, Michael Gottlieb MD orcid.org/0000-0003-3276-8375 Department of Emergency Medicine, Rush University Medical CenterSearch for more papers by this author Brit Long MD, Corresponding Author Brit Long MD [email protected] orcid.org/0000-0003-4770-8869 Brooke Army Medical Center, Department of Emergency Medicine, 3551 Roger Brooke Dr, Fort Sam Houston, TX, United States Correspondence Brit Long, MD, Present Address: 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234. Email: [email protected]Search for more papers by this authorMichael Gottlieb MD, Michael Gottlieb MD orcid.org/0000-0003-3276-8375 Department of Emergency Medicine, Rush University Medical CenterSearch for more papers by this author First published: 20 April 2023 https://doi.org/10.1111/acem.14741 Supervising Editor: Shahriar Zehtabchi This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/acem.14741. AboutPDF ToolsExport 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 Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

Newborn medication adherence and childhood under-immunization in military beneficiaries.

The American Academy of Pediatrics recommends birth doses of vitamin K, erythromycin ointment, and the hepatitis B vaccine, but the relationship between birth medication administration and childhood immunization compliance is understudied. The objective of this study is to evaluate rates of newborn medication administration, and risk factors for refusal in military beneficiaries and determine the relationship between medication refusal and under-immunization at 15months. A retrospective chart review was completed for all term and late preterm infants born at Brooke Army Medical Center, San Antonio, TX, from January 1, 2016, to December 31, 2019. The electronic medical record was queried for birth medication administration, maternal age, active-duty status, rank, and birth order. Childhood immunization records were extracted for all patients who continued care at our facility. A patient was considered completely immunized if they had received at least 22 vaccines by 15months: three doses of the hepatitis B vaccine [PediarixTM], two doses of the rotavirus vaccine [RotarixTM], four doses of the DTAP vaccine [PediarixTM and Acel-ImmuneTM], three doses of Haemophilus influenza B vaccine [PedvaxhibTM], four doses of pneumococcal [Prevnar 13TM], three doses of IPV [PediarixTM], one dose of measles, mumps, and rubella [MMRTM], one dose of varicella [VarivaxTM] and one dose of hepatitis A vaccine [HarvixTM]. Seven thousand one hundred and forty infants were included; 99.3% received vitamin K, 98.8% received erythromycin ointment, and 93.8% received the hepatitis B vaccine. Refusal of the erythromycin ointment and hepatitis B vaccine was associated with older maternal age and higher birth order. Childhood immunization records were available for 607 infants; 7.2% (n=44) were under-immunized by 15months, with no infants being non-immunized. Refusal of the hepatitis B vaccine (RR: 2.9 (CI 1.16-7.31)) only at birth was associated with a higher risk of being under-immunized. Refusal of the hepatitis B vaccine in the nursery is associated with a risk of being under-immunized in childhood. Obstetric and pediatric providers should be aware of this association for appropriate family counseling.