Military Medical Treatment Facilities Research Articles

Convergent and Discriminant Validity of the Blast Exposure Threshold Survey in United States Military Service Members and Veterans.

The Blast Exposure Threshold Survey (BETS) is a recently developed and promising new self-report measure of lifetime blast exposure (LBE). However, there are no studies that have examined the psychometric properties of the BETS, which currently limits its clinical utility. The purpose of this study was to examine the convergent and discriminant validity of the BETS by comparing the BETS Generalized Blast Exposure Value (GBEV) to six variables hypothesized to be associated with LBE (i.e., single-item LBE, combat exposure, years in the military, number of combat deployments, and military occupation specialty [MOS]) and three variables hypothesized not to be associated with LBE (i.e., age at the time of injury, estimated pre-morbid Full-Scale Intelligence Quotient [FSIQ], and resilience). Participants were 202 United States service members and veterans prospectively enrolled from three military medical treatment facilities (68.7%) and via community recruitment initiatives (31.3%). Participants completed the BETS, Combat Exposure Scale (CES), Deployment Risk and Resiliency Inventory-2 Combat Experiences (DRRI-2 CE), Traumatic Brain Injury-Quality of Life Resilience scale, and a brief structured interview. For some analyses, participants were classified into two blast risk MOS groups: high (n = 89) and low (n = 94). The BETS GBEV was not significantly correlated with all three non-blast related variables (rs = 0.01 to rs = -0.12). In contrast, GBEV was significantly (p < 0.001) associated with all blast-related variables; single-item LBE (rs = 0.76), CES (rs = 0.58), number of combat deployments (rs = 0.53), DRRI-2 CE (rs = 0.48), and high blast risk MOS (r = 0.36, medium effect size). However, a stronger relationship was found between the blast-related variables and three modified GBEV scores when excluding some small weapons categories; single-item LBE (rs = 0.80-0.82), CES (rs = 0.64-0.67), number of combat deployments (rs = 0.56), DRRI-2 CE (rs = 0.51-0.53), and high blast risk MOS (r = 0.42-0.49, medium-large effect size). This is the first study to examine the psychometric properties of the BETS. Overall, these results offer support for the convergent and discriminant validity of the BETS. In order to ensure that the BETS can be confidently used as a valid and reliable measure of LBE, more research is needed to further examine the psychometric properties of the test, particularly with regard to the establishment of test-retest reliability.

Perioperative Pressure Injury Prevention Program ina Military Medical Treatment Facility: A Quality Improvement Project.

The incidence of perioperative pressure injuries (PPIs) at a military medical treatment facility (MTF) increased from three PPI events in 2018 to five PPI events in the first half of 2019. The purpose of this quality improvement initiative was to determine whether an evidence-based PPI prevention program introduced during the second half of 2019 reduced pressure injuries compared to the previous 1.5 years that followed the standard of care for perioperative patient positioning. We used a multidisciplinary quality improvement PPI prevention approach that included education, Scott Triggers® patient risk assessment, application of a five-layer silicone dressing to at-risk surgical position sites, and feedback via multidisciplinary postoperative rounding. There was an observed decrease in the rate of PPIs from 0.62 to 0.00 per 1,000 patient surgeries during the 26-month period that this protocol was implemented. This project was conducted at a major MTF using a multidisciplinary PPI prevention approach that may be of value in reducing PPIs in other settings. This approach seems worthy of further investigation and may be applicable to other military MTFs and in deployed settings.

Changes in Surgical Volume in Military Medical Treatment Facilities and Military Surgeon Clinical Combat Readiness During the COVID-19 Pandemic.

Mini-abstract In this retrospective study, we evaluated changes in measures of surgeon clinical combat readiness within the military health system during the COVID-19 pandemic. We found a 36% reduction in surgical knowledge and skills as compared to pre-COVID. Sizable reductions were encountered for surgery for colectomy (-50%) and aneurysm repair (-61%).

Finding the bleeding edge: 24-hour mortality by unit of blood product transfused in combat casualties from 2002-2020.

Transfusion studies in civilian trauma patients have tried to identify a general futility threshold. We hypothesized that in combat settings there is no general threshold where blood product transfusion becomes unbeneficial to survival in hemorrhaging patients. We sought to assess the relationship between the number of units of blood products transfused and 24-hour mortality in combat casualties. A retrospective analysis of the Department of Defense Trauma Registry supplemented with data from the Armed Forces Medical Examiner. Combat casualties who received at least one unit of blood product at US military medical treatment facilities (MTFs) in combat settings (2002-2020) were included. The main intervention was the total units of any blood product transfused, which was measured from the point of injury until 24 hours after admission from the first deployed MTF. The primary outcome was discharge status (alive, dead) at 24 hours from time of injury. Of 11,746 patients included, the median age was 24 years, and most patients were male (94.2%) with penetrating injury (84.7%). The median injury severity score was 17 and 783 (6.7%) patients died by 24 hours. Median units of blood products transfused was 8. Most blood products transfused were red blood cells (50.2%), followed by plasma (41.1%), platelets (5.5%), and whole blood (3.2%). Among the 10 patients who received the most units of blood product (164 units to 290 units), 7 survived to 24 hours. The maximum amount of total blood products transfused to a patient who survived was 276 units. Of the 58 patients who received over 100 units of blood product, 20.7% died by 24 hours. While civilian trauma studies suggest the possibility of futility with ultra-massive transfusion, we report that the majority (79.3%) of combat casualties who received transfusions greater than 100 units survived to 24 hours. These results do not support a threshold for futility of blood product transfusion. Further analysis as to predictors for mortality will help in situations of blood product and resource constraints. Prognostic and Epidemiological; Level IV.

Elevated Serum Tau and UCHL-1 Concentrations Within 12 Months of Injury Predict Neurobehavioral Functioning 2 or More Years Following Traumatic Brain Injury: A Longitudinal Study.

Blood-based biomarkers have received considerable attention for their diagnostic and prognostic value in the acute and postacute period following traumatic brain injury (TBI). The purpose of this study was to examine whether blood-based biomarker concentrations within the first 12 months of TBI can predict neurobehavioral outcome in the chronic phase of the recovery trajectory. Inpatient and outpatient wards from 3 military medical treatment facilities. A total of 161 service members and veterans classified into 3 groups: ( a ) uncomplicated mild TBI (MTBI; n = 37), ( b ) complicated mild, moderate, severe, penetrating TBI combined (STBI; n = 46), and ( c ) controls (CTRL; n = 78). Prospective longitudinal. Participants completed 6 scales from the Traumatic Brain Injury Quality of Life (ie, Anger, Anxiety, Depression, Fatigue, Headaches, and Cognitive Concerns) within 12 months (baseline) and at 2 or more years (follow-up) post-injury. Serum concentrations of tau, neurofilament light, glial fibrillary acidic protein, and UCHL-1 at baseline were measured using SIMOA. Baseline tau was associated with worse anger, anxiety, and depression in the STBI group at follow-up ( R2 = 0.101-0.127), and worse anxiety in the MTBI group ( R2 = 0.210). Baseline ubiquitin carboxyl-terminal hydrolase L1 (UCHL-1) was associated with worse anxiety and depression at follow-up in both the MTBI and STBI groups ( R2 Δ = 0.143-0.207), and worse cognitive concerns in the MTBI group ( R2 Δ = 0.223). A blood-based panel including these biomarkers could be a useful tool for identifying individuals at risk of poor outcome following TBI.

1056. Correlates of Omicron SARS-CoV-2 viral load: diagnostic and clinical implications

Abstract Background Omicron SARS-CoV-2 infections are associated with less frequent olfactory sensory loss and a predominance of pharyngitis symptoms compared to prior variants, with proposed diagnostic implications. We examined whether such symptomology predicts a higher RNA abundance in the oropharynx. We further investigated how age, symptom-day, vaccination history and clinical severity correlate with viral load to inform clinical prognostication and transmission modeling. Methods The EPICC study is a longitudinal cohort of COVID-19 cases enrolled through U.S military medical treatment facilities. Demographic and clinical characteristics were measured with interviews and surveys. Nasopharyngeal (NP), oropharyngeal (OP) and nasal swabs (NS) were collected for SARS-CoV-2 qPCR and sequence genotyping. Multivariable linear regression models were fit to estimate the effect of anatomical site on SARS-CoV-2 RNA abundance (a proxy for viral load), adjusting for sampling time, vaccine history and host age. Results We analyzed 77 sequence-confirmed Omicron cases; no BA.2 cases were detected. The median age was 38.8 years. 81.8% were vaccinated and 15.6% cases were hospitalized. 80.0%, 21.8%, and 65.5% reported nasal congestion, loss of smell or taste, and sore throat, respectively. The median RNA abundance was lowest in OP swabs (p &amp;lt; 0.001) (Fig 1). Linear regression confirmed that OP sampling was associated with lower viral load (p &amp;lt; 0.001). We further noted that greater age and symptom-day were independent correlates of viral load (Table 1). By bivariate analysis there was a trend toward lower RNA abundance in vaccinated subjects (p = 0.35). RNA abundance (at any site) was substantially higher in hospitalized (10634 N2 genome equivalents [GE]/reaction) versus outpatient cases (1419 N1 GE/reaction) but this was not statistically significant (p = 0.26). Fig 1.RNA abundance by upper respiratory swab anatomical location of collection (n = 142 swabs from n = 77 subjects) Conclusion We noted prevalent sore throat symptoms and infrequent sensory loss in Omicron cases. Despite this, viral load was highest in NP/NS collected swabs as has been noted in prior variants. We note an age correlation with RNA abundance, and provide a viral load decay rate which may be useful for transmission modeling. Vaccination and clinical severity may also correlate with Omicron viral load, as noted with prior SARS-CoV-2 variants. Disclosures Simon Pollett, MBBS, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Julia S. Rozman, n/a, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response David Tribble, MD, DrPH, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Mark P. Simons, PhD, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Timothy Burgess, MD, MPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response.

1102. The Host Response to SARS-CoV-2 Infection Differs by Age

Abstract Background Infection with SARS-CoV-2 and the resulting host immune response has been primarily characterized in middle and older aged populations due to a higher incidence of symptoms in these age groups. Due to reduced severity of disease, children were poorly studied and assumed to be less frequently infected compared to older age groups. We measured the viral load and adaptive immune response across the age-spectrum to define the age-dependent viral and host responses. Methods From March 2020-March 2022, we enrolled individuals across the age spectrum who presented to U.S. military medical treatment facilities with COVID-19-like symptoms. In this longitudinal cohort study, demographic and clinical data were collected in addition to nasopharyngeal swabs and peripheral blood. Magnitude of viral RNA was measured by quantitative PCR (qPCR) from nasopharyngeal samples and SARS-CoV-2-specific IgG antibodies were measured from blood with multiplex microsphere immunoassays. Results 4,768 SARS-CoV-2 positive participants were enrolled, among whom 42, 64, 89, 380, 948 and 245 individuals were in age brackets 0-4y, 5-11y, 12-17y, 18-44, 45-64y, and &amp;gt;65y, respectively. Viral load as measured by qPCR was determined to be similar across age groups within the first week post symptom onset. The magnitude of the IgG antibody response against the spike protein was also compared across age groups at early and convalescent time points and was higher in those over the age of 65 years. Conclusion Early viral load during acute infection did not correlate with age in individuals who experienced COVID-19. These findings diverge from other respiratory viruses, such as respiratory syncytial virus and influenza where children tend to have higher viral loads. In contrast, the magnitude of the antibody response against the spike protein correlated with older age at acute and convalescent time points. Together our data suggest that the host response against SAR-CoV-2 differs with age and is not associated with the acute viral load. Defining age-dependent immunity against SARS-CoV-2 has the potential to identify key immunologic responses that can be used to optimize treatment and vaccine strategies. Disclosures Julia S. Rozman, n/a, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Ryan C. Maves, MD, AiCuris: Grant/Research Support|Sound Pharmaceuticals: Grant/Research Support|Trauma Insights, LLC: Advisor/Consultant Mark P. Simons, PhD, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response David Tribble, MD, DrPH, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Timothy Burgess, MD, MPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Simon Pollett, MBBS, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response.

A Comparison of Direct Care at Military Medical Treatment Facilities With Purchased Care in Plastic Surgery Operative Volume

A Comparison of Direct Care at Military Medical Treatment Facilities With Purchased Care in Plastic Surgery Operative Volume

Analysis of 983 civilian blast and ballistic casualties and the generation of a template of injury burden: An observational study.

SummaryBackgroundTerrorism and armed conflict cause blast and ballistic casualties that are unusual in civilian practice. The immediate surgical response to mass casualty events, with civilians injured by these mechanisms, has not been systematically characterised. Standardising an approach to reacting to these events is challenging but is essential to optimise preparation for them. We aimed to quantify and assesses the surgical response to blast and ballistic injuries managed in a world-class trauma unit paradigm.MethodsThis was an observational study conducted at the UK-led military Medical Treatment Facility, Camp Bastion, Afghanistan from original theatre log-book entries between Nov 5, 2009, and Sept 21, 2014; a total of 10,891 consecutive surgical cases prospectively gathered by surgical teams were catalogued. Patients with combatant status/wearing body-armour to various degrees including interpreters were excluded from the study. Civilian casualties that underwent primary trauma surgery for blast and ballistic injuries were included (n=983). Surgical activity was analysed as a rate per 100 casualties, and patients were grouped according to adult vs. paediatric and ballistic vs. blast injury mechanisms to aid comparison.FindingsThe three most common surgical procedures for civilian blast injuries were debridement, amputation, and laparotomy. For civilian ballistic injuries, these were debridement, laparotomy and vascular procedures. Blast injuries generated more amputations in both adults and children compared to ballistic injuries. Blast injuries generated more removal of fragmentation material compared to ballistics injuries amongst adult casualties. Ballistic injuries lead to more chest drain insertions in adults. As a rate per 100 casualties, adults injured by blast underwent significantly more debridement (63·5); temporary skeletal stabilisation (13·2) and vascular procedures (12·8) compared to children (43·4, z=4·026, p=0·00007; 5·7, z=2·230, p=0·022; 4·9, z=2·468, p=0·014). Adults injured by ballistics underwent significantly more debridement (63·4); chest drain (12·3) and temporary skeletal fixation procedures (11·4) compared to children (50·0, z=2·058, p=0.040, p<0·05; 2·9, z=2·283, p=0.0230; 2·9, z=2·131, p=0.034 respectively). By comparison, children injured by ballistics underwent significantly more removal of fragmentation and ballistic materials (20·6) when compared to adults (7·7, z=−3·234; p=0.001).InterpretationThis is the first evidence-based, template of the immediate response required to manage civilians injured by blast and ballistic mechanisms. The template presented can be applied to similar conflict zones and to prepare for terror attacks on urban populations.FundingThe work was supported in part by a grant to LM from School of Medicine, University of St Andrews.

Prescription medication use of United States military service members by therapeutic classification.

Background: This cross-sectional study investigated the prevalence of, and factors associated with, filled prescription medications (FPMs) among United States (US) service members (SMs). Methods: A stratified random sample of active duty SMs from the Air Force, Army, Marine Corps, and Navy was obtained from military workforce records. Participants (n = 26,680) completed a questionnaire on demographics, physical characteristics, and lifestyle factors and approved access to their FPM for the previous 6 months. FPMs were obtained from the military Pharmacy Data Transaction Service that included all prescription medications dispensed at military medical treatment facilities, abroad, at retail pharmacies in the US, and/or through mail-order programs. Results: About two-thirds (65%) of SMs had ≥1 FPM in the 6 months surveillance period. Central nervous system (CNS) agents had the highest prevalence (41%), followed by anti-infective agents (20%), eye/ear/nose/throat preparations (20%), gastrointestinal drugs (18%), autonomic drugs (17%), skin and mucous membrane agents (13%), antihistamine drugs (12%), respiratory tract agents (12%) and cardiovascular drugs (9%). Among CNS agents, overall prevalence of dispensed non-steroidal anti-inflammatory drug (NSAIDs) was 30%. The odds of any FPM was independently associated with female gender, older age, higher body mass index, former tobacco use (smoking and smokeless tobacco), lower alcohol consumption, and was highest among Army, lowest among Marine Corps personnel. Conclusion: In this sample of SMs, dispensing of prescription medication was high, especially NSAIDs, but dispensing of cardiovascular drugs was much lower compared to the general US population, likely because of the younger age and higher level of physical activity of SMs.

Geospatial Analysis of Access to Emergency Cesarean Delivery for Military and Civilian Populations in the US

Many women in the US, particularly those living in rural areas, have limited access to obstetric care. Military-civilian partnership could improve access to obstetric care and benefit military personnel, their civilian dependents, and the civilian population as a whole. To identify medical facilities within military and civilian geographic areas that present opportunities for military-civilian partnership in obstetric care and to assess whether civilian use of military medical treatment facilities (MTFs) could improve access to emergency cesarean delivery care in the US. This geospatial epidemiological population-based cross-sectional study was conducted from November 2020 to March 2021. ArcGIS Pro software, version 2.7 (Esri), was used to assess population coverage for TRICARE (military insurance) beneficiaries and civilian populations and to estimate 30-minute travel time to 2392 total military and civilian medical facilities that were capable of providing emergency cesarean delivery care in the continental US. Data on health insurance coverage for TRICARE beneficiaries and their civilian dependents per county were obtained from the American Community Survey tables available through ArcGIS Pro software. Demographic characteristics of the general population were obtained from the 2020 key demographic indicators published by Esri. Race and ethnicity were not examined because the data used for this study were aggregated and did not include further categorization by race or ethnicity. Population coverage rates (measured in percentages) within 30-minute catchment areas, defined as areas that were within a 30-minute travel time to a medical facility capable of providing emergency cesarean delivery care. A total of 29 MTFs and 2363 civilian hospitals capable of providing emergency cesarean delivery were identified across the contiguous US. Overall, an estimated 167 759 762 women (3 640 000 TRICARE beneficiaries and 164 119 762 civilians) were included in these service areas. The analysis identified 17 of 29 MTFs (58.6%) capable of providing emergency cesarean delivery care that were located within 30-minute catchment areas. Of those, 3 MTFs were the only facilities capable of providing emergency cesarean delivery care within a 30-minute travel time in those regions, and 14 additional MTFs had catchment areas partially overlapping with civilian hospitals that also covered areas without alternative access to emergency cesarean delivery. Expanded use of these 14 MTFs could enhance access to emergency cesarean delivery care not otherwise covered by current civilian hospitals. In this study, 58.6% of MTFs capable of providing emergency cesarean delivery care were located in areas with the potential to improve access to obstetric care within a 30-minute travel time. Maintenance of MTFs in these important access regions could be prioritized in the context of restructuring MTFs. This prioritization has the potential to improve access to emergency cesarean delivery care for underserved civilian populations in the US, particularly among those living in rural areas.

Examining the initial prescription leading to long-term opioid use at a military medical treatment facility.

Chronic pain is common in the military, and over a quarter of active-duty military members have received a prescription for opioids. This study reviewed the initial opioid prescription among those who became future long-term users at an Air Force base in the United States and reports the characteristics of the provider and patient. Our single-center retrospective study evaluated initial opioid prescriptions leading to long-term use within the military's electronic medical record at a large military medical treatment facility including active-duty patients and veterans. Of the 3,701 charts reviewed, 348 patients met the inclusion criteria for the long-term opioid use. Older patient groups received a higher initial amount of opioids than younger groups (p = 0.007). Primary care outpatient clinics started 43 percent of initial long-term opioid users, while surgical specialties contributed to 34 percent of the sample. In our study, 35.9 percent of the long-term opioid users were given their first opioid prescription within 30 days of an operation. Veterans or those separated from the military were less likely to have a behavioral disorder than active duty or family members. Our sample mirrored the civilian population in terms of age, gender, and most common pain diagnosis. We found that older patients initially received a higher dispensed amount compared to our younger patients. There was a concerning trend for surgical patients to develop into chronic opioid users.

Patient Experience and Hospital Environment Measures at Military Treatment Facilities.

SUMMARY Goal: We examined the relationship of nine hospital environment measures (room cleanliness, room quietness, food temperature, food variety, mattress comfort, room temperature, room privacy, hospital signage, adequate parking) to two patient outcome measures (likelihood of recommending hospital, overall satisfaction with hospital) by type of services received (medical, obstetric, surgical) at all military medical treatment facilities globally. Our aim was to understand the impact of various hospital environment measures on the patient experience. Methods: We analyzed six logistic regression models, one for each patient satisfaction measure and each service line (medical, obstetric, surgical). The patient characteristic variables were gender, patient age group, and beneficiary category (active duty, active duty family member, retiree, retiree dependents). Results are based on 20,534 completed surveys representing inpatient care delivered October 2019 to March 2020. Data are from the Military Health System TRICARE Inpatient Satisfaction Survey, which is based on the Hospital Consumer Assessment of Healthcare Providers and Systems survey with additional Department of Defense questions. Principal Findings: Across all models, nearly all hospital environment measures were found to be significantly related to patient satisfaction outcomes, aside from food variety in two models and room privacy and temperature in one model. The strongest environment impact factor was room cleanliness for both outcomes with odds ratios ranging from 2.1 to 2.7, p &lt; .01 in all cases. The order of impact for the other eight environment factors varied across service lines with some playing dominant roles dependent on the type of care being received. Significant odds ratios (p &lt; .05) ranged from 1.3 to 2.0 for room quietness, 1.5 to 1.9 for hospital signage, 1.3 to 1.5 for both food variety and food temperature, 1.3 to 1.8 for mattress comfort, 1.3 to 1.6 for room temperature, and 1.3 to 1.8 for adequate parking. Hospital environment measures represented a breadth of the patient experience and were significantly related to a patient’s overall satisfaction and likelihood to recommend military inpatient facilities. Applications to Practice: Healthcare leaders continuously focus on improving the overall patient experience. Fostering a positive experience includes many factors such as provider and nurse interactions and communications with patients. Moreover, the hospital environment should not be overlooked as also having an impact on patient satisfaction, and hospital leaders—both military and civilian—should continue to emphasize hospital amenities as well.

461. Classical Antigen Presenting Cell Activation Correlates with T Cell Immunity and COVID-19 Severity

BackgroundThe initial response of immune cells against respiratory viruses often determines the severity and duration of disease. The early trajectory of the immune response during infection with SARS-CoV-2 remains poorly understood. Dysregulation of innate immune factors that facilitate viral clearance and the adaptive response, such as type I interferons, have been implicated in severe COVID-19. However, collection of biological samples during the first seven days post-symptom onset has posed a logistical challenge, limiting our knowledge surrounding the immune responses that drive protection versus immunopathology.MethodsFrom March 2020, Military Health System beneficiaries presenting with a positive SARS-CoV-2 test, a COVID-19 like illness, or a high-risk SARS-CoV-2 exposure at nine military medical treatment facilities across the United States were eligible for enrollment in our longitudinal cohort study, which included collection of respiratory sample, sera, plasma, and peripheral blood mononuclear cells (PBMCs). Twenty-five SARS-CoV-2 infected study participants provided samples with in the first seven days of symptom onset, fifteen of whom were hospitalized with COVID-19. We employed multiparameter spectral flow cytometry to comprehensively analyze the early trajectory of the innate and adaptive immune responses.ResultsWe discovered that early activation of critical antigen presenting cell subsets was impaired upon comparing inpatients with outpatients, correlating with decreased antigen-experienced T cell responses. Specifically, we noted reduced expression of key costimulatory molecules, CD80 and CD86, on conventional dendritic cells that are required for viral antigen-specific T cell priming. Reduction in CD38, a marker of activation was also observed on inpatient dendritic cell subsets.ConclusionReduced antigen presenting cell activation and expression of ligands that facilitate T cell engagement may impede the efficient clearance of SARS-CoV-2, coinciding with more severe disease in our cohort. Further analysis of the functional activation of early innate immune responses triggered by SARS-CoV-2 may unveil new immune biomarkers and therapeutic targets to predict and prevent severe disease associated with inadequate T cell immunity.Disclosures Simon Pollett, MBBS, Astra Zeneca (Other Financial or Material Support, HJF, in support of USU IDCRP, funded under a CRADA to augment the conduct of an unrelated Phase III COVID-19 vaccine trial sponsored by AstraZeneca as part of USG response (unrelated work))

Analysis of Surgical Volume in Military Medical Treatment Facilities and Clinical Combat Readiness of US Military Surgeons

Low surgical volume in the US Military Health System (MHS) has been identified as a challenge to military surgeon readiness. The Uniformed Services University of Health Sciences, in partnership with the American College of Surgeons, developed the Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program that includes a tool for quantifying the clinical readiness value of surgeon workload, known as the KSA metric. To describe changes in US military general surgeon procedural volume and readiness using the KSA metric. This cohort study analyzed general surgery workload performed across the MHS, including military and civilian facilities, between fiscal year 2015 and 2019 and the calculated KSA metric value. The surgeon-level readiness among military general surgeons was calculated based on the KSA metric readiness threshold. Data were obtained from TRICARE, the US Department of Defense health insurance product. The main outcomes were general surgery procedural volumes and the KSA metric point value of those procedures across the MHS as well as the number of military general surgeons meeting the KSA metric readiness threshold. Aggregate facility and regional market-level claims data were used to calculate the procedural volumes and KSA metric readiness value of those procedures. Annual adjusted KSA metric points earned were used to determine the number of individual US military general surgeons meeting the readiness threshold. The number of general surgery procedures generating KSAs in military hospitals decreased 25.6%, from 128 377 in 2015 to 95 461 in 2019, with a 19.1% decrease in the number of general surgeon KSA points (from 7 155 563 to 5 790 001). From 2015 to 2019, there was a 3.2% increase in both the number of procedures (from 419 980 to 433 495) and KSA points (from 21 071 033 to 21 748 984) in civilian care settings. The proportion of military general surgeons meeting the KSA metric readiness threshold decreased from 16.7% (n = 97) in 2015 to 10.1% (n = 68) in 2019. This study noted that the number of KSA metric points and procedural volume in military hospitals has been decreasing since 2015, whereas both measures have increased in civilian facilities. The findings suggest that loss of surgical workload has resulted in further decreases in military surgeon readiness and may require substantial changes in patient care flow in the MHS to reverse the change.

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

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. 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. 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. 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.

Objective Dual-Task Turning Measures for Return-to-Duty Assessment After Mild Traumatic Brain Injury: The ReTURN Study Protocol

Determining readiness for duty after mild traumatic brain injury (mTBI) is essential for the safety of service members and their unit. Currently, these decisions are primarily based on self-reported symptoms, objective measures that assess a single system, or standardized physical or cognitive tests that may be insensitive or lack ecological validity for warrior tasks. While significant technological advancements have been made in a variety of assessments of these individual systems, assessments of isolated tasks are neither diagnostically accurate nor representative of the demands imposed by daily life and military activities. Emerging evidence suggests that complex tasks, such as dual-task paradigms or turning, have utility in probing functional deficits after mTBI. Objective measures from turning tasks in single- or dual-task conditions, therefore, may be highly valuable for clinical assessments and return-to-duty decisions after mTBI. The goals of this study are to assess the diagnostic accuracy, predictive capacity, and responsiveness to rehabilitation of objective, dual-task turning measures within an mTBI population. These goals will be accomplished over two phases. Phase 1 will enroll civilians at three sites and active-duty service members at one site to examine the diagnostic accuracy and predictive capacity of dual-task turning outcomes. Phase 1 participants will complete a series of turning tasks while wearing inertial sensors and a battery of clinical questionnaires, neurocognitive testing, and standard clinical assessments of function. Phase 2 will enroll active-duty service members referred for rehabilitation from two military medical treatment facilities to investigate the responsiveness to rehabilitation of objective dual-task turning measures. Phase 2 participants will complete two assessments of turning while wearing inertial sensors: a baseline assessment prior to the first rehabilitation session and a post-rehabilitation assessment after the physical therapist determines the participant has completed his/her rehabilitation course. A variable selection procedure will then be implemented to determine the best task and outcome measure for return-to-duty decisions based on diagnostic accuracy, predictive capacity, and responsiveness to rehabilitation. Overall, the results of this study will provide guidance and potential new tools for clinical decisions in individuals with mTBI.Clinical Trial Registration: clinicaltrials.gov, Identifier NCT03892291.

620. Real-World Insights on HIV Treatment Decision-Making in Federal and Public Healthcare Settings

BackgroundEvidence-based guidelines and novel antiretroviral therapies (ART) for people living with HIV (PLHIV) are quickly evolving. Understanding the practice patterns, gaps, and needs of healthcare professionals (HCPs) who care for PLHIV in specific settings, such as those in the federal and public healthcare sector, can inform education and improvement strategies.MethodsSurveys were administered before and after a series of 1.5 hour continuing education programs (n=20) on HIV treatment conducted live in various US cities between April 2019 and March 2020. These programs were designed for HCPs in federal and public healthcare systems, such as the Veterans Affairs Medical Centers, Military Medical Treatment Facilities, and Federally Qualified Health Centers.ResultsSurvey respondents (n=655) were mostly physicians (35%) or nurse practitioners/physician assistants (25%) practicing in federal healthcare settings (Table 1). Respondents reported a mean patient volume of 1,893 (±240) PLHIV monthly.Before and after the education, only 34% and 61% of HCPs, respectively, correctly identified recommended first-line ART for most PLHIV. Only 19% and 38% of HCPs reported high levels of confidence in selecting ART for rapid ART initiation before and after the education.A case-based survey item showed that 35% (pre-education) and 45% (post-education) of HCPs would recommend switching a virologically suppressed patient over age 50 with comorbidities from a boosted protease inhibitor-based regimen to an integrase inhibitor-based regimen. Only 13% and 33% of HCPs reported high confidence in switching ART for older patients with comorbidities before and after the education, respectively.The biggest challenges identified by HCPs were related to ART selection and patient management (Table 1). After the education, HCPs reported needs and intention to improve their team-based processes to: 1) facilitate rapid ART initiation; 2) optimize ART for patients with comorbidities; 3) optimize treatment for patients with virologic failure. ConclusionThis educational program improved knowledge and competency in evidence-based HIV treatment and supported team-based action planning. The findings also inform persistent challenges and needs among HCPs in federal settings.Disclosures Chad J. Zawitz, MD, Gilead Sciences (Speaker’s Bureau)ViiV (Advisor or Review Panel member) Tamar Sapir, PhD, Gilead Sciences, Inc. (Other Financial or Material Support, Independent medical education grant)ViiV Healthcare (Other Financial or Material Support, Independent medical education grant)

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.

Posttraumatic Stress Disorder is a Stronger Predictor of Long-Term Neurobehavioral Outcomes Than Traumatic Brain Injury Severity.

Concurrent posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) is common in military populations. The purpose of this study was to examine long-term neurobehavioral outcomes in service members and veterans (SMVs) with versus without PTSD symptoms following TBI of all severities. Participants were 536 SMVs prospectively enrolled from three military medical treatment facilities who were recruited into three experimental groups: TBI, injured controls (IC), and noninjured controls (NIC). Participants completed the PTSD Checklist, Neurobehavioral Symptom Inventory, and the TBI-Quality of Life (TBI-QOL) and were divided into six subgroups based on the three experimental categories, two PTSD categories (i.e., present vs. absent), and two broad TBI severity categories (unMTBI, which included uncomplicated mild TBI; and smcTBI, which included severe TBI, moderate TBI, and complicated mild TBI): (a) NIC/PTSD-absent, (b) IC/PTSD-absent, (c) unMTBI/PTSD-absent, (d) unMTBI/PTSD-present, (e) smcTBI/PTSD-absent, and (f) smcTBI/PTSD-present. There were significant main effects across the six groups for all TBI-QOL measures, ps < .001. Select pairwise comparisons revealed significantly lower scores, p < .001, on all TBI-QOL measures in the PTSD-present groups when compared to the PTSD-absent groups within the same TBI severity classification, ds = 0.90-2.11. In contrast, when controlling for PTSD, there were no significant differences among the TBI severity groups for any TBI-QOL measures. These results provide support for the strong influence of PTSD but not TBI severity on neurobehavioral outcomes following TBI. Concurrent PTSD and TBI of all severities should be considered a risk factor for poor long-term neurobehavioral outcomes that require ongoing monitoring.