Naval Medical Center Research Articles

Effectiveness of the Ophthalmological Training Component of the STOMP (Simulation Training for Operational Medical Providers) Curriculum.

Introduction: Simulation has been used in medicine to train clinicians to manage a variety of clinical scenarios. A key adaptation of the use of simulation in military healthcare occurred in 2015 with the development of the STOMP (Simulation Training for Operational Medical Providers) curriculum, a specific curriculum designed for the intern (PGY-1) trained physicians being sent into the military to practice primary care. Despite showing the curriculum’s influence on self-perceived comfort scores, no study has determined whether simulation is an effective means of improving general medical officer (GMO) physicians’ skills compared to other traditional styles of education. Specifically, this study sought to determine whether simulation-based education (SBE) of ophthalmologic skills improves GMO physicians’ clinical performance, as compared to traditional didactic-based instruction.Methods: The study, conducted at Naval Medical Center Portsmouth, included GMO physicians who were enrolled in the 2019 STOMP class. Following a brief overview of the study, GMO physicians who elected to participate in the study were randomized to either SBE or lecture-based training for three commonly used ophthalmological procedures: slit lamp exam, tonometry, and corneal foreign body removal. After completing the simulation and lecture-based education training sessions, participants' procedural performance was evaluated utilizing a locally developed performance checklist, and completion time for each of the three procedures was recorded. Data were analyzed using the t-test and Mann-Whitney test. A significance level of 0.05 was considered to be statistically significant.Results: Of the 50 consented participants, 46 completed the study. The mean overall completion scores for the performance checklists were significantly higher for the SBE group (n=26) compared to the lecture group (n=20) [80% (95% CI 78-82%) vs 41% (95% CI 35-47%), respectively]. Time to completion of the individual tasks was also significantly shorter for the SBE group compared to the lecture group (with mean differences ranging from 27 to 126 seconds, all p<.05).Conclusions: Simulation-based training appeared to be more effective at teaching three ophthalmological procedures (slit lamp exam, tonometry, and corneal foreign body removal) to GMO physicians compared to didactic-based instruction alone.

Learning Curve for Robotic-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection.

Introduction: Robotic retroperitoneal lymph node dissection (R-RPLND) is a challenging procedure. We hypothesized that surgical times and operative complications would decrease as surgeons became more facile with R-RPLND. Materials and Methods: We retrospectively reviewed 121 consecutive R-RPLNDs performed at Naval Medical Center San Diego and Mayo Clinic Arizona by 4 fellowship trained robotic surgeons between 2008 and 2018. Linear regression was used to analyze independent predictors of setup time, operative time, and lymph node counts. Logistic regression was used to analyze open conversions, overall complications, and high-grade complications. Variables included as independent predictors were: sequential case number, surgeon, clinical stage, chemotherapy status, RPLND template, and body mass index. Univariate and multivariate analyses were conducted. Statistical significance was established at α = 0.05. Results: There was no change in setup time with case number (p = 0.317), but differences were noted between surgeons. Operative times decreased with increasing case number (p < 0.001) but were negatively affected by clinical stage III testis cancer (p = 0.029) and history of chemotherapy exposure (p = 0.050). Surgical times are predicted to decrease by 1 hour after 44 cases. Lymph node counts were dependent only on the surgeon. No factors were predictive of open conversions. Fewer overall complications occurred as experience was gained (p = 0.001), but high-grade complications could not be predicted. Conclusions: Consistent with the learning curves shown for other technologically advanced surgical techniques, experience appears to improve surgical times and lower complication rates for R-RPLND.

The Advanced Modular Manikin Open Source Platform forHealthcare Simulation.

Current thinking in healthcare education stipulates a holistic approach with a focus on patient management, bringing together technical skills, decision-making, and team performance. In parallel, training opportunities with actual patients have diminished, and the number of different interventions to master has increased. Training on simulators has become broadly accepted; however, requirements for such training devices have outpaced the development of new simulators. The Department of Defense (DoD) targeted this gap with a development challenge. This article introduces the Advanced Modular Manikin (AMM) platform and describes the path followed to address the challenge. Under Contract # W81XWH-14-C-0101, our interdisciplinary team of healthcare providers, educators, engineers, and scientists, together with partners in industry and the government collaborated to establish a set of comprehensive requirements and develop an overarching system architecture and specifications to meet healthcare simulation needs. In order to instantiate the architecture and investigate usability of the platform, a demonstration modular manikin was created that incorporated physical and digital peripherals. The system architecture and corresponding data models have been completed and published as open source. A developer's tool kit has been created, including instructional materials and required hardware and software for interested parties to develop AMM-compatible modules. A reference manikin was created based on the platform specifications and successfully supported a usability study that was performed by the American College of Surgeons, Education Division at the Naval Medical Center San Diego. The formal release of a functional modular, interoperable open-source healthcare simulation platform is complete. Next steps involve a strategy for maintaining the open standards and verification of AMM-compatibility for modules. Increasing awareness of this powerful tool and prioritization of module-development to address the wide range of healthcare education needs could lead to a renaissance in military and civilian healthcare simulation-based training.

Telementorship in Underway Naval Operations: Leveraging Operational Virtual Health for Tactical Combat Casualty Care.

Virtual health (VH) may enhance mentorship to remote first responders. We evaluated the feasibility of synchronous bidirectional VH to mentor life-saving procedures performed by deployed novice providers. Video teleconferencing (VTC) was established between the USNS Mercy (T-AH 19) underway in the Pacific Ocean to Naval Medical Center San Diego using surgeon teleconsultation. The adult simulated clinical vignette included injuries following a shipboard explosion with subsequent fire. The pediatric simulated vignette included injuries that resulted from an improvised explosive device (IED) blast. Using VTC, augmented reality (AR) goggles, and airway simulation equipment, corpsmen (HMs) received visual cues to perform advanced life-saving procedures. In adult scenarios, 100% of novice hospital HMs performed tasks on first attempt (n = 12). Mean time for tourniquet placement was 46 seconds (standard deviation [SD], 19 seconds); needle thoracostomy, 70 seconds (SD, 67 seconds); tube thoracostomy, 313 seconds (SD, 152 seconds); and cricothyroidotomy, 274 seconds (SD, 82 seconds). In pediatric scenarios, 100% of novice HMs performed tasks on first attempt (n = 5). Mean time for tube thoracostomy completion was 532 seconds (SD, 109 seconds). VH can enhance the training and delivery of trauma care during prolonged field care in resource-limited settings.

Red-Green Tactical Lighting Is Preferred for Suturing Wounds in a Simulated Night Environment.

Delivering medical care in nighttime conditions is challenging, as 25% of Special Operations medical Operators have reported that problems with lighting contributed to poor casualty outcomes. Red light is often used in nighttime operations but makes blood detection difficult and diminishes depth perception and visual acuity. Red-green combination lighting may be superior for differentiating blood from tissue and other fluids but had not been tested versus red-only or green-only lighting for combat-related medical procedures, such as wound suturing. Dark-adapted medical resident physicians (N = 24) sutured 6cm long, 3cm deep, full-thickness lacerations in deceased swine under red-only, green-only, and red-green lighting provided by a tactical flashlight using a randomized within-subjects design. Time to suture completion, suture quality, user ratings, and user preference data were contrasted at p < .05. This study was approved by Naval Medical Center Portsmouth IRB. Suture completion time and suture quality were similar across all lighting conditions. Participants rated red-green lighting as significantly easier for identifying blood, identifying instruments, and performing suturing (p < .01). Red-green lighting was preferred by 83% of participants compared to 8% each for red-only and green-only (p < .001). Pending further study under tactical conditions, red-green lighting is tentatively recommended for treating battlefield wounds in low-light environments.

A Preliminary Investigation on the Effects of Atenolol for Treating Symptoms of Anxiety.

Anxiety disorders are among the most commonly diagnosed of psychiatric disorders. Many symptoms of posttraumatic stress disorder are also anxiety-related. Traditional medications used to treat these disorders, such as antidepressants and benzodiazepines, are often ineffective, not well-tolerated, and can be habit forming. An alternative agent is, therefore, needed. Beta-blockers are one class of medication with potential to treat anxiety-related disorders; however, current evidence remains limited and requires further characterization. To this end, this retrospective study aims to present a novel preliminary report on the use of the beta-blocker, atenolol, to potentially treat anxiety-related disorders. Ninety-two patients were identified from outpatient military mental health clinics in Okinawa, Japan, who had received atenolol for mental health-related symptoms. Primary measures collected were the rates of patient-reported (1) general beneficial/positive effect of atenolol, (2) adverse effects from atenolol, and (3) preference of atenolol to propranolol. Data were collected from patients who were given binary response options to report their perceived experiences for each primary measure. This study was approved by the Naval Medical Center San Diego Institutional Review Board. The results showed 86% of patients reporting a positive effect and continuing to take atenolol, including 87% with a diagnosis of posttraumatic stress disorder, 100% with diagnosis of other specified trauma- and stressor-related disorder, and 81% diagnosed with anxiety disorders. In total, 90% of patients denied adverse effects or found the adverse effects tolerable. Additionally, 100% of patients who had previously taken propranolol for anxiety reported that they preferred atenolol. The present preliminary observational data suggests that atenolol may be well-tolerated and effective among persons with anxiety disorders. These data also suggest that atenolol may be more effective and better tolerated than propranolol, which is the most commonly prescribed beta-blocker for these conditions; however, more rigorously controlled empirical studies are needed to further substantiate this claim. Despite an overwhelmingly high rate of positive reports from patients' self-evaluations of atenolol treatment for anxiety-related disorders, this early investigation was not placebo-controlled nor double-blinded, and formal outcome measures were not assessed due to a lack of availability. More detailed examinations are needed to further determine whether atenolol is a viable alternative or augmenting agent to propranolol, benzodiazepines, and antidepressants for anxiety disorders and trauma-related disorders.

Variaciones de la frecuencia cardíaca, temperatura corporal y presión arterial en pacientes sometidos a cirugía de implantes dentales

Objective: Determine the variations of heart rate, blood pressure and temperature in patients with dental implant surgery. Methods: Series of clinical cases that included 26 patients from 20 to 60 years of age assisted at the Naval Medical Center “Cirujano Mayor Santiago Tavara” (Lima, Peru). The temperature, heart rate and blood pressure were recorded 5 minutes before implant surgery, 5 minutes after local anesthesia and 5 minutes after surgery. To make the measurements, a digital thermometer and a digital wrist monitor were used. Results: The body temperature during the preoperative period was 36.9 ± 0.3 ° C while in the intra and postoperative period it was 36.7 ± 0.07 °C (p >0.05). The heart rate increased during the intraoperative period (80.3 ± 8 beats/min) and was restored in the postoperative period (72.5 ± 7.4 beats/min) (p <0.05). The mean arterial pressure in the intraoperative on average was 100.14 ± 6.35 mmHg while in the postoperative period it was 93.97 ± 7.57 mmHg (p <0.05). Conclusion: The main variations were found from the intraoperative to the postoperative moment in terms of heart rate, mean, systolic and diastolic blood pressure; being relevant parameters for clinical consideration.

Incidence and Impact of Swimming-Induced Pulmonary Edema on Navy SEAL Candidates

Respiratory complications such as swimming-induced pulmonary edema (SIPE) are a common feature of United States Navy Special Warfare (NSW) training. This study was designed to evaluate the incidence and clinical features of SIPE seen in this population. A prospective, observational review of all NSW candidates over a 15-month period was designed. Baseline height, weight, and ECG data were obtained. Candidates with respiratory issues were evaluated with a two-view chest radiograph and ECG while symptomatic and were closely followed up. The chest radiograph and clinical data were then independently reviewed. A total of 2,117 NSW candidates participated in training during the study period, with 106 cases of SIPE identified (5.0%). Ten additional cases of SIPE were repeat episodes in candidates already diagnosed. Forty-four cases of pneumonia were identified (no repeat cases). The majority had cough (90.4%), frothy-pink sputum (35.6%), and hemoptysis (23.7%). Overall, 80.1%of candidates had an oxygen saturation≥ 90%. Physical examination findings were variable: crackles (50%), wheezing (36%), and rhonchi (19%). Several had more than one feature; 23%presented with a normal examination. Radiologic findings in patients with SIPE most commonly revealed an interstitial pattern with perifissural thickening, larger average azygos vein diameter, larger average heart size, and normal lung height. ECG findings were not significantly different from baseline. Height and weight were not significantly different between the groups. Lower water temperatures were suggestive of increased SIPE incidence, but this was not a statistically significant trend. The burden of SIPE in NSW training was greater than anticipated. Clinical symptoms and physical examination assisted by imaging were able to differentiate SIPE from pneumonia. ECG was not a useful diagnostic or screening tool, and height and weight did not affect risk of SIPE. Institutional Review Board registration at Naval Medical Center, San Diego, California; Registration No.: NMCSD.2017.0020.

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.

329 Clinical Utility of Coronary Computed Tomographic Angiography in the Emergency Department at Naval Medical Center Portsmouth

329 Clinical Utility of Coronary Computed Tomographic Angiography in the Emergency Department at Naval Medical Center Portsmouth

Editorial introductions

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Joseph AquilinaJoseph AquilinaJoseph Aquilina, FRCOG, MFFP, is a consultant obstetrician and gynaecologist at Barts Health NHS Trust based St. Bartholomew's and the Royal London Hospitals, UK, and Honorary Senior Lecturer in Obstetrics and Gynaecology at Queen Mary University of London, UK. He is the Lead Clinician for Fetal Medicine Clinical Academic Group and runs a one-stop menstrual disorders clinic at St Bartholomew's Hospital. Mr Aquilina obtained his primary medical degree in Malta and then moved to the UK for his basic postgraduate training in Bristol, and in London at King's College and Greenwich Hospitals, UK. He subsequently undertook research and subspecialty training in feto-maternal medicine/gynaecological ultrasound as a lecturer at St.Bartholomew's and Royal London Medical School, Queen Mary Westfield College, based at Homerton Hospital, UK. He is recognised as a preceptor for training in gynaecological scanning by the Royal College of Obstetricians and Gynaecologists, UK. His special interests include polycystic ovarian syndrome, prediction of pre-eclampsia and the application of ultrasound in the diagnosis and management of benign gynaecological conditions. Ruben AlveroRuben AlveroDr Ruben Alvero is Professor of Obstetrics and Gynecology at Stanford Medical School, USA, and is the Division Director of Reproductive Endocrinology and Infertility at the Lucille Packard Children's Hospital, USA. He is Board Certified in obstetrics and gynecology, and in reproductive endocrinology and infertility. He is a fellow of the American College of Obstetrics and Gynecology and the American College of Surgeons. Following undergraduate training at Harvard College, USA (BA, Economics, 1980), Dr Alvero received his medical degree from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, USA, in 1986. He completed his residency in Obstetrics and Gynecology at Walter Reed Army Medical Center, USA (1990), and a fellowship in Reproductive Endocrinology and Infertility at the National Institutes of Health, USA (NIH, 1995). Dr Alvero was the Division Director for Infertility Services at the National Naval Medical Center, Bethesda, USA, and Walter Reed Army Medical Center and faculty in the NIH-sponsored fellowship in Reproductive Endocrinology and Infertility. Dr Alvero remained a reserve Colonel in the US Army Medical Corps until 2012, and during 27 years in the Army was mobilized several times for missions around the world, including service in Iraq, Kuwait, Mongolia, Germany and various locations in the United States. Dr Alvero was Professor of Obstetrics and Gynecology and Vice Chair for Education at the University of Colorado Health Sciences Center, USA, and the Director of the Assisted Reproductive Technologies, and founding member of the Center for Surgical Innovation. Dr Alvero was Residency Program Director in Obstetrics and Gynecology at the University of Colorado, USA. He was subsequently Division and Fellowship Director at Brown University, USA. The Council in Residency Education in Obstetrics and Gynecology awarded him its National Faculty Award for Excellence three times. He has been NIH-funded, most recently as part of the Reproductive Medicine Network. Dr Alvero is currently the Vice President of the Society for Reproductive Endocrinology, the national organization of fertility specialists and will take over as President in October 2020. Dr Alvero's clinical interests include IVF, polycystic ovary syndrome, endometriosis and robotic surgery. Dr Alvero's research interests include non-invasive evaluation of embryo quality, cost-effectiveness analysis, and the role of critical thinking in medical education. A fluent Spanish-speaker, Dr Alvero is also dedicated to improving the health of the Latinx community.

An In-House Protocol for Fabrication of Patient-Specific Implants to Correct Genial Asymmetry

Facial disharmony as a result of genial malformation or malposition is a correctable condition with a mandibular osteotomy with subsequent repositioning and fixation. Surgical accuracy with osteotomy design and hardware placement in the correct position is paramount to achieve the appropriate surgical outcome and resultant facial balance. These cases highlight a unique protocol developed at Naval Medical Center San Diego to use computer-aided surgical simulation (CASS) to customize patient-specific osteotomy guides and titanium plates for corrective chin surgery. Cross sectional imaging was used to generate virtual stereolithic models of the patient’s facial skeleton. An osteotomy was then virtually performed to divide the patient’s lower jaw. A surgical guide was then designed to index the osteotomy in its precise location. Incorporated into the surgical guide were the fixation holes for a titanium implant. The titanium plate was designed in a similar fashion to align with the predetermined points of fixation and anatomically approximate the chin in its virtually planned position. The virtual files (STL) were then sent to 3D Medical Applications Center at Walter Reed National Military Medical Center for printing. The surgeries were performed in the main operating room with accurate replication of the computer assisted surgical simulation and excellent clinical outcomes to follow. Post-surgical accuracy was evaluated by comparing postoperative CT imaging with the predetermined surgical simulation. The mean difference in of the final chin position was < 1mm in the vertical and horizontal planes. These results reinforced clinical replication of the CASS with a level of accuracy less easily obtained through more traditional methods. Although the presurgical planning required time investment for virtual planning and design, intraoperative surgical time was reduced. Additionally, by managing the computer-assisted design in institution, a tremendous reduction in cost was realized. Surgical correction of facial imbalance requires the utmost intraoperative precision to optimize patient outcomes. Virtual surgical planning with guided osteotomies and patient-specific implants offers an avenue to enhance surgical predictability in the operating room. Further, guided surgery streamlines operating time and efficiency by effectively negating the need for intraoperative measurements or repositioning guides. This unique protocol nearly eliminates the significant financial burden often associated with such procedures, making it far more applicable globally.

Relación entre trastornos neurocognitivos,Diabetes Mellitus Tipo 2 y otros factores en adultos mayores del Centro Médico Naval del Perú, entre los años 2010 a 2015

Diabetes Mellitus (DM) se caracteriza fisiopatologicamente por alteraciones metabolicas tales como hiperglucemia cronica debida a un defecto en la secrecion de insulina, en la accion de esta o a una combinacion de ambos factores. Los trastornos neurocognitivos o trastornos mentales organicos presentan tres categorias: delirium, trastorno neurocognitivo menor (para referirse a deterioro cognitivo leve) y trastorno neurocognitivo mayor, este ultimo mejor conocido como demencia. Varios estudios epidemiologicos sobre trastornos neurocognitivos y DM han mostrado algunas caracteristicas comunes a ambas patologias. Objetivo: Determinar la relaci6n entre DM y trastornos neurocognitivos en la poblacion adulta mayor. Material y Metodos: Estudio retrospectivo con analisis secundario de bases de datos procedentes de investigaciones realizadas entre los años 2010 y 2015 en una poblacion de 1896 adultos mayores, atendidos en el Servicio de Geriatria del Centro Medico Naval, el principal establecimiento hospitalario de la Marina de Guerra del Peru. Resultados: Se encontro una frecuencia mayor de pacientes del sexo masculino (58,4%), el grupo etario mas frecuente de 71-80 años (46,4%) y una frecuencia de DM del 16,86%. En el analisis bivariado, un 30,67% de participantes con trastorno neurocognitivo tenian antecedente de Diabetes, con diferencias estadisticamente significativas. Una similar asociacion estadistica fue evidente en cuanto a variables como edad, sexo, educacion, apoyo social, polifarmacia, sedentarismo y promedio de hemoglobina glicosilada (7.03). Conclusiones: Se documento una relaci6n entre Diabetes Mellitus y deterioro cognitivo. Sexo masculino parece constituir un factor protector de trastornos neurocognitivos. La hiperglucemia estaria relacionada con estos ultimos y la hemoglobina glicosilada puede ser un test determinante en la valoracion del adulto mayor diabetico con problemas cognitivos.

A Text Messaging Initiative to Improve the Well Child HEDIS Metric in a General Pediatrics Clinic

Background: In 2016, the Naval Medical Center San Diego General Pediatrics Clinic was not compliant ( < 75th percentile benchmark) with national a HEDIS goal for well child visits, which specifies a minimum of 6 well child encounters in the first 15 months of life. Goal: Our specific process improvement aim was to improve patient compliance with scheduled well child visits such that we would achieve the HEDIS 90th percentile benchmark …

Implementing Evidence-Based Practice Facilitators: A Case Series.

In 2017, the TriService Nursing Research Program completed a strategic planning session, which identified key barriers to implementing evidence-based practice (EBP) within the U.S. Military Health System (MHS) including a focus on readiness training and deployments, frequent staff moves for military members, and relatively junior nurses in clinical roles. To facilitate EBP at individual military treatment facilities (MTFs), an EPB Facilitator role was developed using an evidence-based model and based on validated EBP competencies. This new role was implemented at four MTFs in 2018: Naval Medical Center Portsmouth, 59th Medical Wing at Joint Base San Antonio Lackland, Naval Medical Center San Diego, and David Grant USAF Medical Center at Travis Air Force Base. This case series provides a description of the initial implementation of this role. Common enablers and challenges were identified from the experiences at all four sites. These included the importance of incorporating efforts into existing organizational efforts and infrastructure; the value of nurse leaders inviting EBP facilitators to participate and engage in scheduled meetings and committees; the significance of engaging with existing quality, process improvement, and training initiatives; and the benefit of collaborating with advanced practice nurses within the organization. The common challenges for all EBP facilitators were the frequent staff turnover at all levels and a lack of standardization to review and approve EBP initiatives, which makes it difficult to navigate the complete process of project implementation and collaboration across sites. Another challenge has been the difficulty to measure the impact of this role at the MTF and MHS levels. As EBP efforts continue and the program matures, it is anticipated that the outcomes from the individually completed projects, to include decreases in safety events, fiscal savings, and other improvements in organizational metrics, can be compiled to demonstrate the collective impact of these roles within the MHS.

Adapting group interpersonal psychotherapy (IPT-G) for treating depression among military spouses at Naval Medical Center Portsmouth (NMCP): Formative qualitative phase

Introduction: Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq have resulted in the deployment of nearly 2,000,000 troops, of which nearly 60% were married, and nearly half had dependent children. While great attention is being paid to the mental health of returning Veterans, we cannot neglect the mental health of this substantial population of military family members. Studies have found that spouses exhibit similar rates of mental health problems as soldiers returning from combat. Whereas rates of anxiety have been shown to drop significantly post-deployment, depression in military spouses appears to persist following deployment. Although a number of psychosocial interventions tailored to military families have been developed, to the knowledge of the authors, no evidence-based interventions have been adapted to specifically target clinical depression in military spouses. Methods: This case study is part of a larger pilot study that sought to adapt, test, and evaluate Group Interpersonal Therapy (IPT-G), an evidence-based treatment for depression, for depressed military spouses. A formative qualitative assessment is crucial to the intervention’s long-term effectiveness, dissemination, and sustainability. This study aimed to understand military spouses’ unique mental health needs and their experience with mental health services. Three focus groups were conducted – two groups of military spouses and a group of mental health care providers – and transcripts were generated using verbatim note-taking. Five independent coders then coded the transcripts for themes that emerged as most salient using an inductive thematic analysis approach. Results: The results identified were clustered under three main themes: (1) psychosocial stressors for depressed military spouses; (2) barriers to mental health care for military spouses; and (3) proposed services. Discussion: When implementing an intervention for a specific population, optimization of its fit to the needs, priorities, and help-seeking patterns of the population should take place to ensure that it is meaningful, ecologically valid, and sensitive to context and culture. Our analysis showed that the military culture presents unique psychosocial stressors, barriers, demands, and needs to mental health provision that should be accounted for in the adaptation of evidence-based mental health intervention. The interpersonal nature of many of the challenges faced by military spouses lend themselves readily to the problem areas that are treatment targets of IPT, therefore increasing the patients’ potential for engagement and sense of compatibility with the treatment.

Improving Access to HPV Vaccination for Inpatient Postpartum Women at Naval Medical Center San Diego [19M

INTRODUCTION: Human Papillomavirus (HPV) is the most common sexually transmitted infection in the US and is thought to be the etiologic agent in 99.7% of cervical cancers 1, 2. Despite this, in 2016, only 51.4% of adolescents ages 13-17 have completed the full HPV vaccination series. Vaccination rates at Naval Medical Center San Diego mirror national trends. In our postpartum care, ensuring inpatient vaccination of for diseases (i.e. MMR, Tdap, VZV) is well established, however HPV vaccination was not available on the ward. We sought to develop and evaluate a process improvement program aimed at improving HPV vaccination rates by incorporating screening and administration into an established inpatient postpartum vaccination program. METHODS: Women ages 9 to 45 were evaluated for eligibility and offered the nine valent HPV vaccine as inpatients on the postpartum ward. An IRB exempt retrospective chart review pre- and post- intervention was conducted to determine vaccination status and rates of vaccination. The results were stratification based on active duty status and age. RESULTS: For all patients prior to intervention, the vaccination rate was 6.4% in the postpartum period when the vaccine was only available in the outpatient clinic. After implementation, the overall vaccination rate rose to 33.3% for postpartum patients (RR 5.2, CI 2.54-10.75, P&lt;.0001). Women 26 years of age or younger were 11.2 times more likely to receive vaccination post-intervention (RR 11.2, CI 2.64-47.29, p=0.001). CONCLUSION: An inpatient postpartum HPV vaccination program is associated with increased rates of vaccination.

Health Characteristics of the Madeira Riverine Population.

The Amazon River Basin is the largest and the most complex fluvial system in the world. The Brazilian government provides dental and medical care to the riverine populations in this region in part through medical assistance missions, conducted by four hospital ships. The Brazilian Navy invited U.S. Navy medical personnel to join the February 2019 mission aboard Navio de Assistência Hospitalar (NAsH) Carlos Chagas to provide care along the Madeira River. In the course of providing primary care services, demographic, health, and dental data of the Madeira Riverine population were collected. Descriptive statistics were used to generate average health and dental data. Chi-square tests were used to compare population prevalence data. Linear regression was used to evaluate dental caries per patient with proximity to nearest large population center and village population. This project was approved by Naval Medical Center Portsmouth Institutional Review Board. The Madeira Riverine population has similar dental health to Brazilians living in urban centers. Their prevalence of hypertension and diabetes compared favorably with the U.S. averages (17.7% vs. 34.3% [P<0.001] and 3% vs. 9.4% [P<0.001], respectively). Based on the most prevalent ICD-10 code diagnoses, future missions can expect high volumes of patients with intestinal parasites, hypertension, common skin infections, women's health concerns, and musculoskeletal complaints. This study adds to the limited health data currently available on Brazilian Riverine populations. It demonstrates the effectiveness of the Hospital Assistance missions in providing dental care and documents some unique aspects of Riverine health that warrant further study.

Human Papilloma Virus Vaccination Compliance in a Military Aviation Training Community

Human Papilloma Virus (HPV) vaccination compliance as reported by the CDC in 2011 falls short of a national goal to have 80% of adolescents vaccine-complete by 2020. The Naval Aviation Schools Command, Pensacola, Florida offers a single point of contact for military aviation trainees offering near-complete capture of an HPV vaccine target population. The purpose of this study is to identify baseline HPV vaccination rates among military aviation trainees and whether or not the provision of educational materials at the start of aviation training would increase future HPV vaccination compliance. Approval to conduct this study was obtained from the Institutional Review Board of Naval Medical Center Portsmouth, Virginia. Our population of interest consisted of US Navy and Marine Corps student naval aviators, student naval flight officers (officers), and student enlisted air crew (enlisted) reporting for aviation related duty. A convenience sampling of officer and enlisted student classes checking in for training was performed over a period of 6months. The first 3months of students were assigned as the intervention group and the remaining 3months of students were assigned to the control group. This study was conducted in two parts: (1) an anonymous survey captured cross-sectional data of self-reported HPV vaccine use, and (2) prospective analysis of service members' HPV vaccine rates before and after educational intervention as documented within the military's electronic health record system, Armed Forces Health Longitudinal Technology Application (AHLTA). AHLTA immunization status was evaluated for 1,164 personnel; 114 (9.8%) were excluded for missing basic vaccination information. Of the remaining 1,050, another 199 (19%) members were excluded as already vaccine complete (evidenced by three shots documented) prior to entry into the study. Within the 199 service members with documented baseline HPV vaccination completion, 197/199 (99%) were officers and 2/199 (0.1%) were enlisted. A total of 851 personnel were included for prospective analysis. Person-time of 100 person years was used and the vaccination rate translates to 16.62/100 person years (95% CI 11.29, 23.59) within intervention vs. 2.96/100 person years (95% CI 0.80, 7.58) within control groups and are significantly different (P=0.0001). Comparing intervention and control groups, rate ratios=5.61 (95% CI 2.14, 18.64) and rate differences=13.66 (95% CI 7.13, 20.19). Among intervention group survey responders who previously reported nonvaccine use, 50.5% reported a change in opinion about obtaining the vaccination, with a higher proportion of enlisted members reporting a change in opinion (62.8% vs. 39.7%, P=0.0053). Electronic health records immunizations review noted a baseline vaccine completion rate of 19%. Our study showed a health inequity between enlisted and officers, with officers having 99% of the documented baseline completion rates per AHLTA data. Our prospective analysis noted statistically significant rate differences of 13.66% and rate ratios of 5.61 between intervention and control groups. This analysis of AHLTA data combined with survey response of 50.5% indicating a change in opinion about HPV vaccine use among those who had not yet started vaccine series suggests targeted education would be a low-cost intervention to improve HPV vaccine use rates.

Use of Lean Six Sigma to Improve Access to Care in a Surgical Subspecialty Clinic.

At the Naval Medical Center San Diego urology clinic, patients reported waiting for greater than 1month for an initial consult. A Lean Six Sigma approach was used to improve access to care (ATC) and decrease variation in access by improving scheduling. A Define-Measure-Analyze-Improve-Control approach was used. Delay to new patient visits was identified as the focus of intervention. The scheduling template was changed from a fixed stream to a modified wave based on simulation software analysis of appointment cycle times. Appointment length was adjusted based on cycle time analysis, and two rooms per clinician were used instead of one. The ratio of initial consults relative to established follow-ups and procedures was adjusted upward to better balance with the historic demand. Statistically significant improvement was seen in ATC and compliance with the Defense Health Agency (DHA) standard that new consults be seen within 28days. Average days for a new consult to be seen were reduced by 7.2days in the pediatric urology clinic (P<0.0001) and 6.4days in the adult urology clinic (P<0.0001). Compliance with the Defense Health Agency 28-day ATC standard increased from a baseline of 69.2% to 88.9% and 61.7% to 84.4%, respectively, in the pediatric and adult clinics (P<0.001 for both). Patient satisfaction was maintained at or above the goal threshold throughout the project. An Lean Six Sigma model was used to improve timeliness of care for our patients, improving the overall quality of their healthcare experience. Simulation software can be used to model the clinic throughput and test alternative scheduling templates. ATC was significantly improved and patient satisfaction was maintained at or above goal thresholds.