Brooke Army Medical Center Research Articles

Pars Plana Vitrectomy following Traumatic Ocular Injury and Initial Globe Repair: A Retrospective Analysis of Clinical Outcomes.

Penetrating and perforating ocular trauma are often devastating and may lead to complete visual loss in the traumatized eye and subsequent compromise of the fellow eye. A significant proportion of traumatic injuries are complex, often requiring vitreoretinal intervention to preserve vision. A retrospective analysis at a level 1 trauma center was performed to evaluate the time course, incidence, and outcomes following pars plana vitrectomy (PPV) after traumatic ocular injury and initial globe repair. Eyes that underwent open globe repair following ocular trauma at Brooke Army Medical Center, between January 1, 2014 and December 30, 2016 were analyzed. Specific factors evaluated include mechanism of injury, defect size and complexity, ocular trauma score, zone of injury, associated orbital trauma, and time from injury to surgical intervention. A subset analysis was conducted specifically on eyes requiring subsequent PPV for vision preservation because of vitreoretinal disease. Surgical outcomes, time to secondary intervention, and complication rates were then assessed. In total, 70 eyes requiring open globe repair were examined, with 43 having undergone PPV. Average and median time to vitrectomy were 18.8 and 8 days, respectively. Eyes that underwent PPV were more likely to have an afferent papillary defect, vitreous hemorrhage, intraocular foreign body, and retinal detachment at the time of initial injury (although the latter two factors were not statistically significant), and were more likely to receive penetrating keratoplasty. Proliferative vitreoretinopathy occurred in 37.2% of eyes that underwent PPV, versus 3.7% of those that did not (P = 0.0013). Timing of PPV (i.e., before or after 14 days) had no statistically significant effect on the rate of PVR (Table I). Eyes that underwent PPV showed an improvement of visual acuity from average 2.5 logMAR following initial injury to 1.5 logMAR 6 months after PPV, equivalent to 18.7 Early Treatment Diabetic Retinopathy Study (ETDRS) letters gained, versus 37.7 ETDRS letters gained in eyes without PPV. Among PPV eyes, early repair (<14 days) was associated with greater improvement in visual acuity. Overall, patients requiring PPV following open globe repair generally had more severe injuries and worse 6-month postoperative visual acuity. Patients who underwent more expedited vitrectomy showed greater improvement in visual acuity as measured by ETDRS letters gained.

An Analysis of Prolonged, Continuous Ketamine Infusions.

Opioids carry high risk of dependence, and patients can rapidly build tolerance after repetitive dosing. Low-dose ketamine is an analgesic agent alternative that provides more hemodynamic stability. We sought to describe the effects of prolonged ketamine use in non-burn patients. We queried the electronic health system at the Brooke Army Medical Center for patient encounters with ketamine infusions lasting >72 hours. We abstracted data describing demographics, vital signs, ketamine infusion dose and duration, and discharge diagnoses potentially relevant to ketamine side effects. We identified 194 subjects who met the study inclusion criteria. The median age was 39 years, most were male (67.0%), and most were primarily admitted for a non-trauma reason (59.2%). The mean ketamine drip strength was 43.9 mg/h (95% CI, 36.7-51.1; range 0.1-341.6) and the mean drip length was 130.8 hours (95% CI, 120.3-141.2; range 71-493). Most subjects underwent mechanical ventilation (56.1%) at some point during the infusion and most survived to hospital discharge (83.5%). On a per-day basis, the average heart rate was 93 beats per minute, systolic blood pressure was 128 mmHg, diastolic blood pressure was 71 mmHg, oxygen saturation was 96%, and respiratory rate was 22 respirations per minute. We demonstrate that continuous ketamine infusions provide a useful adjunct for analgesia and/or sedation. Further development of this adjunct modality may serve as an alternative agent to opioids.

Patient Perception of Physician Attire in a Military Ophthalmology Clinic.

IntroductionThe purpose of this study is to investigate patient preferences of physician attire in an outpatient military ophthalmology clinic to determine how these preferences affect patients’ perceptions of physician competence and their overall clinical experience.Materials and methodsThis study is a prospective survey administered to patients at the ophthalmology clinic at Brooke Army Medical Center. USA. Patients who were willing to participate in a volunteer survey were included in this study. Demographic information and survey questions were utilized in this study along with words and pictures for patients to select a preference in physician attire in the clinic setting (scrubs, military uniform, or civilian professional attire) and surgical setting (surgical cap or a surgical bouffant). The survey asks patients if physician attire impacts patient confidence in physician abilities (yes or no) and if surgeon attire impacts the likelihood of the patient taking the surgeon’s advice (yes or no).ResultsThe demographic distribution includes 57-77 years old participants (53%), females (61%), retirees (49%), and dependent spouses (40%). The racial distribution includes 46% - Caucasian, 20% - African American, 22% - Hispanic, 6 - % Asian, and 6% - other. Most patient appointment types were established follow-up (77%) with only 12% new and 11% walk-in. The survey results (N=308) indicate that most patients (64%) did not have a preference in physician clinical attire, while 22% preferred scrubs, 11% preferred military uniform, and 3% preferred civilian attire. Most patients (66%) did not have a preference for surgical headwear, while 27% preferred the surgical cap, and 7% preferred the surgical bouffant. Only 9% of the patients surveyed indicated that physician attire impacted their confidence in their physician’s ability, and 12% reported that attire impacted the likelihood of taking advice.ConclusionsMost patients in an outpatient military ophthalmology clinic do not have a preference for physician attire or surgical headwear when surveyed. The majority of patients did not feel physician attire impacted their perception of physician's ability or their likelihood of taking advice. When indicating a preference, patients tended to prefer scrubs to outpatient civilian attire or military attire and trended towards preferring surgical cap over surgical bouffant for headwear.

Lymph node ratio is a reliable prognostic marker after neoadjuvant therapy and pancreaticoduodenectomy for pancreatic cancer, but does not predict the utility of adjuvant therapy

Presenter: Alexandra Adams MD, MPH | Brooke Army Medical Center Background: Neoadjuvant chemotherapy (NAT) has been increasingly utilized for patients with pancreatic ductal adenocarcinoma (PDAC). However, the role of additional adjuvant chemotherapy (AT) after NAT and surgical resection remains unclear. The lymph node ratio (LNR), defined as the number of positive nodes divided by total resected nodes, is a well-established prognostic indicator for patients with resected PDAC, and could potentially help decipher which patients could avoid AT after NAT. The objective of this analysis was to determine if LNR predicts survival benefit from receipt of AT following NAT and surgical resection. Methods: Patients who underwent pancreaticoduodenectomy after NAT from 2006-2017 and had pathologically node positive PDAC were identified using the National Cancer Database. Patients with metastatic disease or unknown lymph node status were excluded. Patients were grouped as receiving NAT plus AT, or NAT only. The LNR within the node-positive groups were compared, with a cutoff of 0.15. Five-year overall survival was determined by Kaplan-Meier analysis and multivariate (MV) Cox proportional hazards modeling. Results: A total of 1,182 patients were included: 623 patients with LNR=0.01-0.14 and 559 with LNR>=0.15. Median survival was higher among patients with LNR=0.01-0.14 than those with LNR>=0.15 (28.8 vs 20.5 months, log-rank p=0.15, receipt of additional AT was associated with improved median survival of 23.3 months vs 18.2 months without AT (log-rank p=0.0024). MV analysis by Cox proportional hazards revealed similar survival benefit from AT, with hazard ratios of 0.807 (95% CI 0.678-0.960, p=0.0156) for LNR=0.01-0.14 and 0.794 (95% CI 0.669-0.942, p=0.0084) for LNR>=0.15. Conclusion: Although LNR is a reliable prognostic indicator for PDAC, it does not predict the utility of AT after receipt of NAT. Thus, while LNR may be useful in counseling patients regarding prognosis, we advise against using it as a discriminator for decisions regarding adjuvant therapy. Further investigation is needed into the best selection criteria for patients that would benefit from additional AT after receipt of NAT and pancreaticoduodenectomy.

The benefit of adjuvant chemotherapy following pancreaticoduodenectomy for pancreatic adenocarcinoma depends on response to neoadjuvant therapy

Presenter: Patrick McCarthy MD | Brooke Army Medical Center Background: Neoadjuvant therapy (NT) is increasingly offered to patients with pancreatic ductal adenocarcinoma (PDAC) who may undergo resection. However, it remains unclear which patients who have received NT and surgical resection should receive additional adjuvant therapy (AT). We sought to determine which patients benefit from further AT following NT and pancreatectomy. Methods: The 2004-2017 National Cancer Database was queried for patients with non-metastatic PDAC who received NT followed by pancreaticoduodenectomy. Only patients with reported data regarding receipt of AT were included. Patients were categorized by their change from clinical to pathologic stage; if pathologic stage (T, N, or overall) was lower than their clinical stage, they were considered downstaged. We then classified patients as to whether they had nodal down-staging specifically, or any downstaging (T, N, or overall). Propensity score weighting according to demographics, treatment location, tumor stage, grade, location, and readmission rate was used with generalized boosted models to adjust for pretreatment covariate imbalance between the treatment groups. Weighted Kaplan-Meir method was used to estimate the cumulative survival with weighted log-rank test to compare the staging groups. Results: A total of 2,901 patients were identified, of which 1,102 (38.0%) patients received AT and 1,799 (62.0%) did not receive AT. On final pathology, 1,427 patients (49.1%) were pathologically node negative and 125 patients (4.3%) had a pathologic complete response. With regard to downstaging, 312 patients (10.8%) achieved nodal downstaging and 822 (28.3%) patients achieved any downstaging. In all patients that received NT, the group that received AT had a significantly improved overall survival (OS) (p=0.002). When stratified by final nodal status, patients receiving AT had improved survival amongst node positive patients (p=0.002), and node negative patients (p=0.012). For patients without downstaging, those who received AT had improved OS (nodal down-staging: p=0.002; any downstaging: p<0.001, respectively). In patients with downstaging after NT, however, those receiving AT did not have improved survival with nodal downstaging (p=0.128) or any downstaging (p=0.323). Conclusion: Response to NT appears to determine benefit attained from the addition of AT following pancreaticoduodenectomy for PDAC; patients who have a favorable response to NT may not benefit from additional chemotherapy. Future trials should examine the relationship between tumor regression after NT and benefit from AT, including regimens identical to and different from the patient’s NT regimen. Additionally, this analysis calls for future randomized trials examining the benefit of AT in patients who have had significant response to NT.

807. Effect of Inter-Hospital Transfer on Nosocomial Infection Rates in Patients Receiving Extracorporeal Membrane Oxygenation

BackgroundExtracorporeal Oxygenation (ECMO) has been increasingly used as a life support modality for cardiac and pulmonary failure. Due to improved survival in patients treated in high volume ECMO centers, inter-hospital transport of these critically ill patients is on the rise. These patients may be transported via ambulance locally, or by aircraft over long distances. However, potential risks of nosocomial infectious complications associated with transfers has not been reported. We evaluated the impact of transfers on nosocomial infections for patients who received ECMO at Brooke Army Medical Center (BAMC).MethodsAll patients who received ECMO for ≥48 hours at BAMC between May 2012 and October 2019 were included. Chart review was performed to determine transport status, infectious complications while on ECMO, and antimicrobial susceptibility of isolated organisms. Statistical analyses were performed using Chi-squared, Fisher’s exact, or Mann-Whitney U tests as appropriate. Factors associated with nosocomial infections were evaluated by multivariate logistic regression.ResultsCompared to patients who were cannulated locally (n=33), patients who underwent cannulation at referral facility and inter-hospital transfer (n=76) had no difference in infections per 1000 ECMO days (33.1 vs. 30.5, p=0.74) or in infections with multidrug resistant organisms (MDRO) (50% vs. 55%, p=1). Of transferred patients, those transferred by aircraft (n=11) had no difference in infection rate (22.4 vs. 31.8 per 1000 ECMO days, p= 0.39) or MDRO incidence (52% vs 75%, p=0.61) compared to those only transferred by ambulance (n=65). Multivariate analysis showed the greatest risk factor for nosocomial infection was time on ECMO (OR 12.2 for longest tertile time on ECMO vs. shortest tertile, p=0.0001); transport was not significantly associated with infection (OR 2.1, p=0.06).Nosocomial infection rate by site of ECMO cannulation ConclusionThis study did not find a significant difference in nosocomial infection rate or recovery of MDROs between transported and non-transported patients on ECMO, regardless of transport modality. This study suggests that transportation is not the primary driver of nosocomial infections in this cohort.Disclosures All Authors: No reported disclosures

1542. Provider Uptake of Extragenital Screening for Gonorrhea and Chlamydia in Active Duty Air Force Members with Incident HIV Diagnosis

BackgroundThe prevalence of Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) is much higher at extragenital anatomic sites among men who have sex with men (MSM) with HIV infection. National guidelines recommend that all MSM with HIV infection undergo screening for extragenital sexually transmitted infections (EG-STIs), however uptake is low in many primary care settings. We evaluated EG-STI screening by primary care providers (PCPs) for US Air Force (USAF) members with incident HIV infection.MethodsAll USAF members newly diagnosed with HIV infection who received initial HIV specialty care with Infectious Disease (ID) providers at Brooke Army Medical Center from 2016-2018 (n=98) were included. A retrospective chart review was conducted to evaluate STI screening performed by PCPs within 1 week of HIV diagnosis compared to screening at entry into ID care. Demographic, clinical, laboratory and behavioral risk data were collected. STI screening included GC/CT EG-STIs, urethral GC/CT, syphilis, and hepatitis B and C.ResultsPatients were predominantly male (97.9%) with a median age of 26 (IQR 23, 32) years at HIV diagnosis (Table 1). A previous history of STIs was reported in 53 (54.1%) patients and the majority of males self-identified as MSM (66.3%) or bisexual (22.5%). The median time from HIV diagnosis to ID evaluation was 26 days (IQR 9, 33). PCPs performed any STI screening in 61 (62.2%) patients (Table 2). EG-STI screening was conducted in 3 (3.1%) patients overall and in (3.4%) MSM/bisexuals. A total of 31 (31.6%) patients had missed STIs; the majority due to EG-STIs of the rectum (71%) and pharynx (21.9%). All EG-STIs would have been missed by urethral GC/CT screening alone.Table 1 Table 2 ConclusionEG-STI screening uptake was low among PCPs evaluating USAF members with incident HIV infection. Underutilization of EG-STI screening can result in missed infections and forward transmission of GC/CT. Barriers to low uptake need to be explored. Continued education and training of PCPs may be necessary to improve uptake of EG-STI screening.Disclosures All Authors: No reported disclosures

104. Evaluation of a 2-Step Testing Algorithm for Clostridioides difficile Infection

BackgroundA 2-step testing strategy for diagnosis of Clostridioides difficile infection (CDI) is recommended to limit over-diagnosis when clinical criteria requirements for stool sample submission cannot be enforced. Real-world evaluations of this strategy are limited.MethodsThe Antimicrobial Stewardship Program at Brooke Army Medical Center, San Antonio, TX, implemented a 2-step CDI algorithm: polymerase chain reaction (PCR) testing followed by toxin enzyme immunoassay (EIA). The goal was to improve diagnosis of CDI and reduce unnecessary antibiotic use. Patients with PCR+ tests from August 2018 to September 2019 were included. Charts were reviewed for demographics, laboratory data, treatment, and outcomes. Cases were grouped based on concordant (PCR+/EIA+) or discordant (PCR+/EIA-) results. To determine factors contributing to treatment decisions, an analysis of discordant cases were compared by treatment status. Groups were compared by Chi-squared, Fisher’s exact, or Mann-Whitney U tests.ResultsA total of 216 PCR+ tests from 215 patients were recorded. Of these, 155 (71.8%) were discordant. Demographics, laboratory data, and risk factors for CDI were similar between groups (Table 1; p >0.05 for all). Compared to discordant cases, concordant cases were more frequently hospitalized (59% vs 43.9%; p=0.05), had a higher median daily stool count (5 [4–7] vs 4 [2–6], p=0.03), met criteria for severe CDI (33.3% vs 18.7%; p=0.05), received treatment (95.1% vs 66.5%; p< 0.01) and were readmitted in 30 days with CDI (8.3% vs 1.3%; p=0.02). Among discordant cases, median daily stool count was higher in treated vs untreated cases (4 [3–7] vs 3 [1–5], p=0.02). Otherwise, there was no difference in variables according to treatment status (Table 2; p >0.05 for all). Discordant cases with infectious disease (ID) or gastroenterology (GI) consultation had a high rate of treatment (73.9% and 61.1%, respectively).Table 1. Characteristics and outcomes of patients with concordant and discordant tests. Table 2. Characteristics and outcomes of treated and untreated patients with discordant tests. ConclusionImplementation of 2-step strategy reduced antibiotic treatment by nearly 30%. However, the majority of discordant cases were deemed clinically significant and received treatment by providers, including ID or GI specialists. Further studies are needed to determine the unmeasured factors that guide treatment decisions in discordant cases.Disclosures All Authors: No reported disclosures

Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team.

The use of extracorporeal membrane oxygenation (ECMO) for the care of critically ill adult patients has increased over the past decade. It has been utilized in more austere locations, to include combat wounded. The U.S. military established the Acute Lung Rescue Team in 2005 to transport and care for patients unable to be managed by standard medical evacuation resources. In 2012, the U.S. military expanded upon this capacity, establishing an ECMO program at Brooke Army Medical Center. To maintain currency, the program treats both military and civilian patients. We conducted a single-center retrospective review of all patients transported by the sole U.S. military ECMO program from September 2012 to December 2019. We analyzed basic demographic data, ECMO indication, transport distance range, survival to decannulation and discharge, and programmatic growth. The U.S. military ECMO team conducted 110 ECMO transports. Of these, 88 patients (80%) were transported to our facility and 81 (73.6%) were cannulated for ECMO by our team prior to transport. The primary indication for ECMO was respiratory failure (76%). The range of transport distance was 6.5 to 8,451miles (median air transport distance=1,328miles, median ground transport distance=16miles). In patients who were cannulated remotely, survival to decannulation was 76% and survival to discharge was 73.3%. Utilization of the U.S. military ECMO team has increased exponentially since January 2017. With an increased tempo of transport operations and distance of critical care transport, survival to decannulation and discharge rates exceed national benchmarks as described in ELSO published data. The ability to cannulate patients in remote locations and provide critical care transport to a military medical treatment facility has allowed the U.S. military to maintain readiness of a critical medical asset.

Maternity Leave Length Impact on Breastfeeding and Postpartum Depression.

In January 2016, the U.S. Department of Defense increased the duration of paid maternity leave for active duty service members from 6weeks to 12weeks. Our study aims to determine the impact of maternity leave length on breastfeeding duration and postpartum depression rates in active duty service members. An institutional review board-approved survey of 9 questions was given to patients at the Brooke Army Medical Center Obstetrics and Gynecology Clinic. Patients were offered voluntary participation if they had delivered a baby while on active duty in the preceding 20years. The survey included questions about length of maternity leave, duration of breastfeeding, age at delivery, route of delivery, and whether the patient suffered from postpartum depression. A total of 214 surveys were collected. Fisher exact test was used to compare rates of breastfeeding and postpartum depression between the 2 groups. A total of 87% of service members initiated breastfeeding. Among women who had 6weeks versus 12weeks of maternity leave, 51.64% versus 56.96% breastfed up to 6months, p=0.45.The overall rate of postpartum depression was 13.5%. Among women who had 6weeks versus 12weeks of maternity leave, 16.1% versus 9.5% reported postpartum depression, p=0.11. The ideal maternity leave duration is unknown. With recent changes to the Department of Defense maternity leave policy, we aimed to evaluate the effect this had on breastfeeding and postpartum depression rates. No statistically significant difference was seen when we compared rates of breastfeeding in women who had 6weeks versus 12weeks of maternity leave. Further research is required to determine the ideal maternity leave duration and best practices to promote breastfeeding.When looking at postpartum depression, our study shows that postpartum depression was noted in 16% of patients who took 6weeks versus 9% of those who took 12weeks of maternity leave. No statistically significant difference was seen; however, this was likely because of the small sample size. Only 29 out of 214 women suffered from depression regardless of length of maternity leave. More research is needed to determine if maternity leave length does indeed impact postpartum depression rates.

Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study.

Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. A retrospective cohort study. Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. Not applicable. Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Poor Soldier Medical Readiness In The Year Following Return To Unrestricted Duty After Musculoskeletal Injury

Not all Soldiers cleared for full unrestricted duty are without injury just because they do not seek medical attention. Using medical care-seeking as proxy for medical readiness & deployability has limitations. Efficient injury detection & long-term management can improve if surveillance begins before patients make decisions to seek care. PURPOSE: 1) determine proportion of Soldiers reporting new or recurring injuries for which they did not seek medical care, & 2) report perceived ability to perform full military duty when injured & not seeking care. METHODS: This was a secondary analysis of a cohort of Soldiers (n=469) recently cleared to return to full duty (RTFD) without limitations. Monthly adaptive text messages queried about any new or recurrent injuries for 1 yr after clearance to RTFD after spine or lower extremity injury. Presence of MSK pain, care-seeking behavior, & perceived ability to perform military duties were assessed. RESULTS: 424 soldiers had at least 1 response over the 1-yr follow-up & a mean response rate of 45.5% (at least 5 months). 315 participants reported injury-related MSK pain at least once. Of those, 276 (87.6%) reported not seeking care during at least 1 pain episode. When care was not sought, 89 (32.2%) reported it affecting their ability to perform military duties. On at least one occasion, 127 individuals believed they would not pass an annual fitness test due to pain, deconditioning, or fear of injury. CONCLUSIONS: Soldiers do not always seek care for MSK injuries, & thus, many are not confident in their ability to complete military duties. Early indicators & improved surveillance strategies could identify problematic injuries before they reach a threshold of needing to seek care. Equally important is the ability to predict which individuals can self-manage without adversely affecting ability to perform military duties. This research was supported by the Department of Defense Military Operational Medicine Research Program under program number (W81XWH-13-MOMJPC5-IPPEHA). 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 U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, the Department of Defense, or the U.S.Government.

Multidrug-Resistant Organisms from Ophthalmic Cultures: Antibiotic Resistance and Visual Acuity.

There is a growing trend of multidrug-resistant organisms (MDRO). The goal of this study was to characterize MDRO at a single center from ophthalmic cultures to better understand how treatments were tailored and to assess effect on visual acuity. The MDRO data were collected by the Multidrug-Resistant Organism Repository and Surveillance Network from the Brooke Army Medical Center clinical laboratory. Both patient- and isolate-specific data were collected and qualitatively analyzed. Primary outcome measures were organism and type of resistance, anatomic location of isolate, initial and final antibiotic choice, and visual acuity. Thirty-one bacterial culture samples were analyzed from 29 patients. Twenty-two (72%) were Gram-positive and all were methicillin-resistant Staphylococcus aureus (MRSA). Nine (29%) were Gram-negative and of these five were Pseudomonas spp. Fourteen (45%) isolates were cultured from the cornea, nine (29%) from the lid, four (13%) from the conjunctiva, and four (13%) from other locations. The majority (66.6%) required adjustment of initial antibiotics following ocular culture results. Sixteen adult patients had recorded initial and final visual acuities. Fifteen of those 16 patients had stable or improved visual acuities following treatment of the infection, but five patients had a final visual acuity less than 20/200. This study demonstrated a high frequency of corneal MDRO infections and specifically MRSA and Pseudomonas spp. isolates. Antibiotic treatments frequently required adjustment. Further prospective study of visual outcomes from ophthalmic MDRO cultures is needed.

Procedural Volume Within Military Treatment Facilities-Implications for a Ready Medical Force.

Consistent procedural volume is important for emergency physicians (EPs) to maintain opportunities for critical lifesaving skills. While non-EP literature demonstrates improved patient outcomes with higher volumes, few studies examine the optimal number of repetitions needed to maintain procedural competency in EP populations. The largely young, healthy active duty population that constitutes the majority of patients in military treatment facilities (MTFs) decreases the likelihood to utilize emergent procedures. Despite this likelihood, EPs are expected to maintain proficiency and readiness to perform critical procedures in deployed settings. A retrospective analysis of de-identified data obtained through the Military Health System Mart was performed for procedural codes involving surgical airway, central venous access, and intubation. Data were sought for 2014-2016 calendar years from seven Army hospitals under the Southwest Region Medical Command. Procedural numbers were obtained for both overall volume and those performed per 1,000 encounters. Additionally, we analyzed for volume differences with the highest volume MTF (Brooke Army Medical Center [BAMC]) removed from the data set. A total of 1,450 procedures were performed among the MTFs analyzed, including 973 intubations, 473 central venous catheter placements, and 4 surgical airways. MTFs averaged 69.5 intubations and 38.8 venous catheters placed each year, but decreased to 28.1 intubations and 13.0 venous catheters placed annually when BAMC was removed from the data set (a 59.6 and 61.6% decrease, respectively). Monthly averages of 40.5 intubations and 19.7 central venous catheterizations per month among all included MTFs decreased to 14.0 and 6.5 when BAMC was removed. All surgical airways were performed at BAMC. Procedural frequency per 1,000 encounters was highest at BAMC, although ordinal differences were noted in the remaining six MTFs compared with overall procedural volumes. This retrospective analysis demonstrates a significant variation in procedural volumes across MTFs, illustrating disproportionate opportunities for procedural skill maintenance among Army EPs. Low procedural volume threatens the maintenance of critical EP skills. These numbers could also suggest low skills for other providers (such as physician assistants), further illustrating decreased skill readiness throughout the force. Further research is needed to examine procedural volumes per individual EP, as well as those performed by other providers to evaluate for overall procedural readiness across the military force.

Are Exercise and Physical Therapy Common Forms of Conservative Management in the Year Before Lumbar Spine Surgery?

ObjectiveTo quantify and compare utilization of opioids, exercise therapy, and physical therapy in the year before spine surgery. DesignA retrospective cohort of surgical and claims data. SettingBeneficiaries of the Military Health System seen at Brooke Army Medical Center ParticipantsPatients (N=411) undergoing surgery between January 1, 2014, and December 31, 2015, identified retrospectively through the Surgical Scheduling System (S3) based on procedure type (fusion, laminectomy, arthroplasty, vertebroplasty, and diskectomy). InterventionsElective lumbar spine surgery. Main Outcome MeasuresHealth care utilization variables present during the full 12 months before surgery, which included physical therapy services and visits for exercise therapy or manual therapy procedures and opioid prescriptions. ResultsThe mean age of participants was 44.8±11.7 years and 32.4% were female. In the year before surgery, 143 (34.8%) patients had a physical therapy plan of care, 140 (34.1%) had at least 1 visit that included exercise therapy, and only 60 (14.6%) had a minimum of 6 exercise therapy visits. However, 347 (84.4%) patients received at least 1 opioid prescription fill (mean of 6.1 unique fills). ConclusionsBefore elective lumbar spine surgery, opioid prescriptions were common but physical therapy services and exercise therapy utilization occurred infrequently.

Impact of Structured Insulin Order Sets on Inpatient Hypoglycemia and Glycemic Control

Objective: In hospitalized patients, glycemic excursions outside recommended glycemic targets have been associated with increased morbidity and mortality. Despite recommendations to avoid use of correctional insulin alone for managing hyperglycemia, this approach remains common. We performed a quality improvement project aimed at both reducing hypoglycemic events and promoting increased use of basal insulin by updating our insulin order sets to reflect clinical practice guideline recommendations. Methods: Brooke Army Medical Center correctional insulin order sets were modified to reflect higher treatment thresholds and targets, and a basal insulin order was added with a recommended weight-based starting dose. Pre- and postintervention analyses were performed. Patients were included if they were prescribed subcutaneous insulin during their hospital stay. The following outcomes were measured: (1) glucose levels, and (2) prescriptions for basal insulin. Results: A significant reduction in hypoglycemia events was noted following the intervention (glucose <70 mg/dL: 9.2% pre-intervention vs. 8.8% postintervention; glucose <55 mg/dL: 4.2% pre-intervention vs. 2.2% postintervention). When excluding patients that were ordered correctional insulin alone but did not receive a dose, an increase in basal insulin use was seen (50% pre-intervention vs. 61% postintervention). Rates and severity of hyperglycemia (glucose >180 mg/dL) remained unchanged. Conclusion: The alteration in insulin order set parameters resulted in a significant reduction in hypoglycemia without significant increases in hyperglycemia. Although basal insulin use increased, optimal dosing recommendations were not often utilized. Further interventions are necessary to reduce hyperglycemia. Abbreviations: CPOE = computerized provider order entry; EMR = electronic medical record; HbA1c = hemoglobin A1c; LOS = length of stay; QI = quality improvement; SSI = sliding scale insulin.

Claudin‐1 responsiveness through modulation of the inflammatory status in the Caco‐2 model epithelium.

The use of hydrocortisone in association with indomethacin is a known risk factor for spontaneous intestinal perforation (SIP) in extremely low birthweight infants. While hypoxia, inflammation, and hydrocortisone have been found to independently alter both tight junction functionality and formation, the concomitant effects of inflammation, hydrocortisone, and indomethacin have yet to be well defined. Through the use of the Caco‐2‐BBe cell line as an in vitro model of the intestinal epithelial barrier, we tested the effects of the pro‐inflammatory agents TNF and IFNγ and the anti‐inflammatory agents indomethacin and hydrocortisone on barrier integrity and tight junction protein expression. Confocal imaging and cellular ATP analysis after 24 and 48 hours of exposure to the inflammatory agents both showed no significant changes in cellular proliferation or ATP synthesis, respectively. Western blot analysis found that claudin‐1 protein expression and localization is affected by inflammatory cytokines. Live cell confocal imaging of eGFP‐claudin‐1 Caco‐2 cells found that addition of pro‐inflammatory agents or the addition of anti‐inflammatory agents resulted in rapid dynamic junctional reorganization. When both the pro‐ and anti‐inflammatory agents were added, this pattern of reorganization was also seen. However, the concomitant effects of the combined pro‐ and anti‐inflammatory agents resulted in a profound inability to recapitulate its original claudin‐1 configuration. The lack of an effect on cellular proliferation and ATP synthesis paired with the alterations in claudin‐1 protein levels and localization suggests that claudin‐1 may be a potential target in better understanding the progression of spontaneous intestinal perforation.Competing Interest StatementAll authors have indicated they have no potential conflicts of interest to disclose. 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 U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Air Force and Army, Department of Defense or the U.S. Government.Support or Funding InformationTrinity University Biology Department

A Mixed Methods Analysis of Acute Upper Extremity Pain as Measured by the Patient Reported Outcomes Measurement Information System

AbstractIntroductionChronic pain affects U.S. service member’s (SMs) more disproportionately than individuals in the general public. SMs have unique cultural pressures to ignore or deny acute pain; therefore, the beliefs and behaviors of this group may cause them to self-report their acute pain in a specific manner. This study evaluated the strength of the relationship of the patient reported outcomes measurement information system (PROMIS) upper extremity computer adaptive test (CAT) and assessed U.S. active duty SMs experience of acute pain and function compared to the quick disabilities of the arm, shoulder, and hand (QuickDASH). In addition, the PROMIS pain interference CAT, PROMIS pain behavior CAT, and PROMIS anxiety CAT were correlated to the PROMIS upper extremity CAT and QuickDASH questionnaires.Materials and MethodsThis mixed methods, sequential, explanatory study included a convenience sample of 26 participants from two occupational therapy clinics. Participants were administered five self-report questionnaires at initial evaluation and at follow up (30–90 day). At follow up, 12 participants completed a semi-structured interview. Categorical variables were summarized using percentages and analyzed using a chi-square goodness of fit test. A Pearson correlation coefficient was used to analyze the linear relationship between the QuickDASH and specified PROMIS questionnaires. This study was approved by the Institutional Review Board at Brooke Army Medical Center, reference number C.2017.173d.ResultsThe initial and follow up scores from the self-report questionnaires demonstrated a good to excellent correlation between the PROMIS upper extremity CAT and the QuickDASH (r = –0.65; r = –0.81; p &amp;lt; 0.001). Qualitative data were gathered during a semi-structured interview of 12 participants after the follow up and were analyzed using thematic analysis. Three themes emerged from qualitative analysis of data: (1) impact of military culture, (2) psychosocial effects of acute pain, and (3) therapist contributions to disability awareness.ConclusionsThis study demonstrates several cultural and psychosocial influences concerning the experience of SMs with acute UE disability and pain, which were not previously reported for this population.

A randomized trial comparing the Tennant Biomodulator to transcutaneous electrical nerve stimulation and traditional Chinese acupuncture for the treatment of chronic pain in military service members

BackgroundThe present investigation tested the efficacy of the Tennant Biomodulator, a novel pain management intervention that uses biofeedback-modulated electrical stimulation, to reduce chronic pain and its psychosocial sequelae in a sample of current and former military service members. The Tennant Biomodulator used on its most basic setting was compared to two commonly used, non-pharmacological pain treatments—traditional Chinese acupuncture and transcutaneous electrical nerve stimulation (TENS)—in a comparative efficacy, randomized, open-label trial.MethodsParticipants included 100 active duty and retired service men and women with chronic pain undergoing treatment at the Brooke Army Medical Center in Texas, USA, randomly assigned to receive six, weekly sessions of either Tennant Biomodulator treatment, traditional Chinese acupuncture, or TENS, in addition to usual care. Recruitment was conducted between May 2010 to September 2013. Outcome measures were collected at intake, before and after each treatment session, and at a 1-month follow-up. Intent-to-treat analyses were used throughout, with mixed models used to investigate main effects of group, time, and group × time interactions with consideration given to quadratic effects. Outcomes measured included ratings of chronic pain, pain-related functional disability, and symptoms of post-traumatic stress disorder (PTSD) and depression.ResultsOn average, regardless of their treatment group, participants exhibited a 16% reduction in pain measured by the Brooke Army Medical Center’s Clinic Pain Log [F(1, 335) = 55.7, P < 0.0001] and an 11% reduction in pain-related disability measured by the Million Visual Analog Scale [MVAS: F(1, 84) = 28.3, P < 0.0001] from baseline to the end of treatment, but no one treatment performed better than the other, and the reductions in pain and pain-related disability were largely lost by 1-month follow-up. Symptoms of PTSD and depression did not change significantly as a function of time or group.ConclusionsFindings build on previous work suggesting that traditional Chinese acupuncture and TENS can reduce pain and its functional sequelae without risks associated with pharmacological pain management. The Tennant Biomodulator used on its most basic setting performs as well as these other interventions. Based on the present findings, large, randomized controlled trials on the Tennant Biomodulator are indicated. Future work should test this device using its full range of settings for pain-related psychological health.Trial registrationClincialtrials.gov (NCT01752010); registered December 14, 2012.

PRACTITIONER APPLICATION: Patient Engagement Functionalities in U.S. Hospitals: Is Early Adoption Associated With Financial Performance?

chief information officer, Brooke Army Medical Center, San Antonio, Texas The author declares no conflicts of interest.