Walter Reed National Military Medical Center Research Articles

Geospatial Assessment to Improve Time to Treatment (GAITT)

IntroductionGeographic information systems (GIS) can optimize trauma systems by identifying ways to reduce time to treatment. Using GIS, this study analyzed a system in Maryland served by Johns Hopkins Suburban Hospital and the University of Maryland Capital Region Medical Center. It was hypothesized that including Walter Reed National Military Medical Center (WRNMMC) in the Maryland trauma system in an access simulation would provide increased timely access for a portion of the local population. Materials and methodsUsing ArcGIS Online, catchment areas with and without WRNMMC were built. Catchment areas captured Johns Hopkins Suburban Hospital, University of Maryland Capital Region Medical Center, and WRNMMC at 5-, 10-, 15-, 20-, 25-, 30-, 45-, and 60-min. Various time conditions were simulated (12 am, 8 am, 12 pm, and 5 pm) on a weekday and weekend day. Data was enriched with 19 variables addressing population size, socioeconomic status, and diversity. ResultsAll catchment areas benefited on at least one time-day simulation, but the largest increases in mean population coverage were in the 0-5 (10.5%), 5-10 (12.3%), and 10-15 min (5.7%) catchment areas. These areas benefited regardless of time-day simulation. The lowest increase in mean population coverage was seen in the 20-25-min catchment area (0.1%). Subgroup analysis revealed that all socioeconomic status and diversity groups gained coverage. ConclusionsThis study suggests that incorporating WRNMMC into the Maryland trauma system might yield increased population coverage for timely trauma access. If incorporated, WRNMMC may provide nonstop or flexible coverage, possibly in different traffic scenarios or while civilian centers are on diversion status.

Updating the Military Unique Curriculum for a Ready Medical Force.

Previous conflicts have demonstrated the impact of physician readiness on early battlefield mortality rates. To prepare for the lethal nature of today's threat environment and the rapid speed with which conflict develops, our medical force needs to sustain a high level of readiness in order to be ready to "fight tonight." Previous approaches that have relied on on-the-job training, just-in-time predeployment training, or follow-on courses after residency are unlikely to satisfy these readiness requirements. Sustaining the successes in battlefield care achieved in Iraq and Afghanistan requires the introduction of effective combat casualty care earlier and more often in physician training. This needs assessment seeks to better understand the requirements, challenges, and opportunities to include the Military Unique Curriculum (MUC) during graduate medical education. This needs assessment used a multifaceted methodology. First, a literature review was performed to assess how Military Unique Curricula have evolved since their initial conception in 1988. Next, to determine their current state, a needs-based assessment survey was designed for trainees and program directors (PDs), each consisting of 18 questions with a mixture of multiple choice, ranking, Likert scale, and free-text questions. Cognitive interviewing and expert review were employed to refine the survey before distribution. The Housestaff Survey was administered using an online format and deployed to Internal Medicine trainees at the Walter Reed National Military Medical Center (WRNMMC). The Program Director Survey was sent to all Army and Navy Internal Medicine Program Directors. This project was deemed to not meet the definition of research in accordance with 32 Code of Federal Regulation 219.102 and Department of Defense Instruction 3216.02 and was therefore registered with the WRNMMC Quality Management Division. Out of 64 Walter Reed Internal Medicine trainees who received the survey, 32 responses were received. Seven of nine PDs completed their survey. Only 12.5% of trainees felt significantly confident that they would be adequately prepared for a combat deployment upon graduation from residency with the current curriculum. Similarly, only 14.29% of PDs felt that no additional training was needed. A majority of trainees were not satisfied with the amount of training being received on any MUC topic. When incorporating additional training on MUC topics, respondents largely agreed that simulation and small group exercises were the most effective modalities to employ, with greater than 50% of both trainees and PDs rating these as most or second most preferred among seven options. Additionally, there was a consensus that training should be integrated into the existing curriculum/rotations as much as possible. Current Military Unique Curricula do not meet the expected requirements of future battlefields. Several solutions to incorporate more robust military unique training without creating any significant additional time burdens for trainees do exist. Despite the limitation of these results being limited to a single institution, this needs assessment provides a starting point for improvement to help ensure that we limit the impact of any "peacetime effect."

Humanitarian Mission at Home: Walter Reed National Military Medical Center's Experience in Operation Allies Refuge and Operation Allies Welcome.

Military medicine has a long history of humanitarian efforts globally, including responses to natural disasters and as planned medical civil action projects. However, ending two decades of war in Afghanistan, Walter Reed National Military Medical Center (WRNMMC) was tasked to receive up to 63 injured patients with less than 96-hour notice on August 27, 2021. As part of Operation Allies Refuge and transition to Operation Allies Welcome, this article highlights the complicated cross-organizational and multidisciplinary response at WRNMMC where ultimately 277 Afghan patients and nonmedical attendants received medical care and other requirements for resettlement. Lessons learned from coordinating the complex short suspense medical, cultural, and logistic efforts are noted as considerations and practical recommendations for future missions.

0088 Remote clinical research operations during COVID-19: Lessons learned and recommendations

Abstract Introduction As a result of the global COVID-19 pandemic, there have been significant challenges conducting clinical sleep research. Participant recruitment has been a particular challenge due to federal safety guidelines and institutional directives. The purpose of this project is to describe the adaptation of an in-person study protocol (of sleep problems among military service members and their families) to an entirely remote approach. Methods Prior to COVID-19, planned research methods included in-person recruitment, enrollment, and study support; approved by the Institutional Review Board (IRB) of Walter Reed National Military Medical Center (WRNMMC), Fort Belvoir Community Hospital (FBCH), and the University of Maryland, Baltimore (UMB). As COVID-19 restrictions increased, the research team adapted to a fully remote approach (via phone/email) and developed a “research call center” to replace in-clinic recruitment/enrollment. Detailed operating procedures were standardized, including shipping study materials (wearable device) via FedEx. Following enrollment, participants completed multiple assessments, sleep diaries 2x/day over 10 days, and a post-monitoring satisfaction survey. Results Thirty-five participants between the ages of 18-75 years (M= 46 years, SD= 15.8) were successfully recruited from the Internal Medicine clinic and Sleep Disorders Center at WRNMMC. Following data collection, the research team debriefed and developed recommendations to execute a successful remote study protocol. Three key operational domains were identified: research team, remote procedures, and data management. Recommendations included 1) prioritizing consistent communication, mutual support, and personal wellbeing among the research team, 2) advancing recruitment by establishing and refining preferred recruitment pathways, and 3) providing critical attention to remote data management—allocating responsibilities to regulate the evolving changes of multiple data sources. In addition, partnering closely with IRB personnel was invaluable to refine procedures and maintain regulatory compliance. Conclusion Despite challenges associated with the on-going pandemic, researchers can conduct high-quality clinical research by transitioning to a fully remote study approach. These recommendations can help guide investigative teams to transition from in-person protocols to remote approaches, thus advancing the perpetuation of research activities through a pandemic. Support (If Any) This research was supported by an investigator-initiated research award from the Department of Defense (via the Medical Technology Enterprise Consortium) to the University of Maryland, Baltimore (PI: EMW).

0381 High levels of patient engagement with a novel sleep telehealth platform in the US military

Abstract Introduction Despite very high prevalence and documented adverse consequences of insufficient and disturbed sleep in the US military, there are well-recognized barriers limiting access to evidence-based sleep interventions within the military health system (MHS). Chief among these is an insufficient number of trained sleep specialists and sleep centers. As part of a larger implementation effort, the purpose of this pilot study was to evaluate patient engagement with a novel sleep telehealth platform at a busy military treatment facility. Methods The sleep telehealth platform consists of an online web portal for patients and providers, a secure mobile app, and integrated wearable sensors using an off the shelf commercial solution (COTS; in this study, Fitbit). The purposes of this platform are to 1) help primary care managers (PCMs) assess sleep complaints, 2) empower patients and PCMs to make evidence-based sleep treatment decisions, 3) deliver evidence-based behavioral sleep treatments via mobile devices, and 4) connect patients with sleep specialists in virtual or physical sleep centers. Participants were recruited from the Internal Medicine clinic and the Sleep Disorders Center at Walter Reed National Military Medical Center (WRNMMC). Inclusion criteria included ages of 18-75 years and self or provider referral for sleep problems, including insufficient sleep duration. In addition to wearing the COTS sleep tracker, participants completed a baseline assessment and 2x/daily diaries for ten days, and a brief satisfaction survey. Results Participants included 35 patients (57% female, mean age=44.7 years). One hundred percent of participants wore the COTS sleep tracker and completed the post-monitoring assessment. Satisfaction survey results indicated that 96.7% of participants found completing the 10-day continuous sleep monitoring assessments to be “easy” or “very easy,” and 96.7% of those who completed the monitoring expressed a preference for app-based sleep treatment either alone or in conjunction with virtual or in person care. Finally, participants offered suggestions to optimize the app and platform for pending clinical implementation. Conclusion Results of this pilot study demonstrate high levels of patient engagement with the sleep telehealth platform. Given the large number of patients seeking treatment and the shortage of trained specialist providers, sleep telehealth is a promising pathway to increase access to evidence-based care. Support (If Any) This research was supported by an investigator-initiated research award from the Department of Defense (via the Medical Technology Enterprise Consortium) to the University of Maryland, Baltimore (PI: EMW).

PD16-12 AGE AND RACE SPECIFIC GENE SIGNATURE: AN INDEPENDENT PREDICTOR OF PROSTATE CANCER IN RACIALLY DIVERSE MILITARY COHORT OF AFRICAN AND CAUCASIAN AMERICAN PATIENTS

You have accessJournal of UrologyCME1 May 2022PD16-12 AGE AND RACE SPECIFIC GENE SIGNATURE: AN INDEPENDENT PREDICTOR OF PROSTATE CANCER IN RACIALLY DIVERSE MILITARY COHORT OF AFRICAN AND CAUCASIAN AMERICAN PATIENTS Shashwat Sharad, Darryl Nousome, Gregory Chesnut, and Hua Li Shashwat SharadShashwat Sharad More articles by this author , Darryl NousomeDarryl Nousome More articles by this author , Gregory ChesnutGregory Chesnut More articles by this author , and Hua LiHua Li More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002548.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Age and Racial disparities in prostate cancer (PCa) is a serious challenge and the PCa mortality rates are nearly three times higher in African American (AA) men younger than age 65 than White Caucasian American (CA) men. Young age prostate cancer is more likely to be an aggressive cancer commonly seen in AA population. The objective of this study is to examine the age and racial disparities associated gene signatures for disease progression, patient stratification and targeted therapeutic options. METHODS: Specimens collected from radical prostatectomy patients (41 CA and 20 AA) who provided written consent under protocols (#393738, #GT90CM/385525 and #908925) approved by the Institutional Review Boards of the Walter Reed National Military Medical Center (WRNMMC) and the Uniformed Services University of the Health Sciences (USUHS). We used a cohort of non-familial PCa patients of AA and CA origin. Total RNA was extracted from tumor, and adjacent normal epithelium of formalin-fixed-paraffin-embedded (FFPE) specimens by Laser capture microdissection (LCM). Differential gene expression in tumor versus normal tissues between young and old AA and CA patients were analyzed by NanoString using a customized CodeSet of 151 probes sets. The panel was designed to detect 135 target transcripts, which were compiled from 34 genes implicated in or associated with prostate cancer progression, 27 prostate cancer specific gene fusions, 25 cancer associated genes, five genes encoding the ETS-family of transcription factors and genes over-expressed (27) or under-expressed (17) in PCa compared to matched benign epithelium. In addition, five prostate stroma or epithelium specific genes were selected as control and 11 housekeeping genes were included for biological normalization. RESULTS: The differentially expressed genes related to tumor-normal differences between the old (66–73 yrs) and young (42–58 yrs) AA and CA prostate cancer patients with Gleason (3+3 and 3+4) were identified. After controlling for false discovery rates, we identified a panel of nine genes (ANXA2, C-MYC, VEGFR1, ERG, NPY, PSMA/FOLH1, TWIST1, MAOA, MYCN) uniquely associated with the age and race. The tumor vs. normal ratios of ANXA2 and c-MYC expression in prostate tumors of old and young patients were found to be significant. We found a clear association of VEGFR1 gene expression with CA young and c-MYC gene with AA young PCa. Our study highlights the potential of using FFPE tissue as a source for the analysis of prognostic biomarkers for PCa. CONCLUSIONS: An unmet challenge in PCa is the identification of biomarkers for early detection of aggressive disease. Effective biomarkers with high specificity will provide early treatment options for high-risk patients. Using Age and Race as the endpoint, we identified ANXA2, c-MYC and VEGFR1 as age and race associated PCa gene which needs to be further validated in the lager cohort. Our findings clearly highlight distinct racial and age-related differences and addresses the clinical utility of available genetic tests across old and young AA and CA men. Source of Funding: This study was supported by CPDR, USUHS, HU0001-10-2-0002 © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e273 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shashwat Sharad More articles by this author Darryl Nousome More articles by this author Gregory Chesnut More articles by this author Hua Li More articles by this author Expand All Advertisement PDF DownloadLoading ...

Post-COVID-19 Multisystem Inflammatory Syndrome in Children and Adults: What Happens After Discharge?

IntroductionClassification criteria and practice guidelines for inpatient management of multisystem inflammatory syndrome (MIS) exist, but reports on outpatient management and clinical outcomes are lacking. Here we describe the management and clinical outcomes of four children and four adults with MIS seen at Walter Reed National Military Medical Center (WRNMMC) from diagnosis to six months follow-up.MethodsThis retrospective, case-series describes the initial presentation and management of MIS in four children and four adults seen at WRNMMC from March 2020 to September 2021. Data on each patient was collected from the time of exposure to the SARS-CoV-2 virus to six months post-diagnosis with MIS. Extracted data includes: demographics, comorbidities, initial MIS presentation, inpatient treatment, outpatient treatment, and clinical outcomes.ResultsA total of 62.5% of patients presented in shock. All pediatric patients received IVIG, methylprednisolone, and anakinra; no adult received this combination. Steroids and immunomodulatory medications were discontinued in 1-2 months outpatient. Three children and two adults had full symptomatic resolution. One child and two adults had persistent deconditioning at six months follow-up. One adult had persistent dyspnea.ConclusionsMIS appears to be monophasic with no recurrences at six months follow-up in our patients who only required 1-2 months of glucocorticoid or immunomodulatory medications. The better outcomes in children raise the question of how much of this difference can be attributed to early combination therapy versus physiologic differences in children and adults.

145. SARS-CoV-2 (COVID-19) Testing Experience within a Military Treatment Facility

BackgroundThe Walter Reed National Military Medical Center (WRNMMC) established a consolidated COVID-19 screening area (CSA) beginning in March 2020 to provide beneficiary and staff testing via a drive-through site. Testing was available to all patients and WRNMMC staff regardless of beneficiary status. Presented is a descriptive analysis of our testing operations and positivity rates within a closed medical system from March 2020 to April 2021.MethodsFor quality and process improvement, we compiled daily testing logs from March 2020 to April 2021 from the CSA. These logs included patient demographics, reason for testing, test result, testing platform, and occupational status at the hospital. We determined positivity rates in various subgroups – asymptomatic, symptomatic, pre-operative, in order to track testing use and access. Additionally, we compared the overall positivity rate to the surrounding civilian community by pulling data from the Maryland Department of Health’s COVID database.ResultsOver the course of nearly 14 months of testing availability, 34,694 beneficiaries were screened with 41,582 individual tests. After May 2020, the monthly overall positivity rate varied from 1.99% to 11.92%, peaking in December 2020 (with high rates in November 2020, 7.52% and January 2021, 9.53%), correlating with or exceeding elevated positivity rates in Montgomery County (November 2020: 4.91%; December 2020: 6.48%; January 2021: 6.51%). When examining only symptomatic individuals, the positivity rate is notably much higher, with monthly rates varying from 6.40% to 21.10%, with a similar peak in December 2020. After full implementation of pre-operative screening for procedures with aerosolization potential in June 2020, the range of positivity rates was 0.28%-1.66%. Since vaccination for COVID-19 became widely available beginning in Feb 2021, the preoperative positivity rate has remained below 0.85%.ConclusionOur institutional experience is unique in its ability to offer universal access to COVID-19 testing for beneficiaries and staff of the DoD under direction of the ID service. Our process serves as a model for public and occupational health response, and may guide lab resource and real-time staffing management in support of COVID-19 diagnostics at a medical center.Disclosures All Authors: No reported disclosures

86. Making the APPropriate Choice: Utilization of a Smartphone Application to Optimize Antimicrobial Decisions Among Internal Medicine Trainees

BackgroundUse of an application (App) to shape antimicrobial stewardship (AS) practice is largely unknown. Walter Reed National Military Medical Center (WRNNMC) is a tertiary military academic medical center where 2020 AS guidelines transitioned to a mobile App platform. This project aimed to determine barriers to AS and the impact of an App combined with educational sessions (ES) on Internal Medicine (IM) trainee prescribing practices for common Infectious Diseases (ID) syndromes.MethodsAfter an orientation, participants completed a pre-intervention survey. Once weekly ES reinforcing App content was implemented over 12 weeks after which a post-intervention survey was completed. Each weekly session covered a specific ID syndrome. Survey data was analyzed using SPSS Version 27 with paired t-test. ResultsAmongst 81 IM trainees, 59 (73%) completed both pre- and post-intervention surveys, of whom 39% were PGY1, 31% PGY2, and 27% PGY3. Common AS barriers included lack of knowledge, deference to seniority, established habits, and time needed to make an informed decision. The App and ES improved performance of an antimicrobial timeout (78%), IV to PO switch (61%), therapy de-escalation (56%), and antibiogram knowledge (68%) with 90% of trainees reporting increased access. Weekly ES led to 75% reporting it had at least a moderate impact on learning. Across all ID syndromes, each PGY year reported increased confidence in management post-intervention (P< 0.001) but PGY1s in particular saw the largest gain in confidence with antibiogram, febrile neutropenia, and hospital/ventilator acquired pneumonia categories. Usage of the App increased from 42% to 90% after the intervention, and 95% modified their prescribing practice based on the App. The most common barrier to App usage was forgetting to use the App. ConclusionUtilization of an App combined with ES improved multiple domains of AS practice among IM trainees leading to a modification in antimicrobial prescribing practice in the vast majority of participants. PGY1 trainees in particular may see a large benefit which supports implementation of AS training early in the academic year. This model can be used to build a sustainable AS trainee curriculum augmenting the learning and management of common ID syndromes. Disclosures All Authors: No reported disclosures

97. Pharmacist Driven Antimicrobial Stewardship Interventions on the Management of Urinary Tract Infections in the Emergency Department at a Tertiary Military Treatment Facility

BackgroundWith the Joint Commission standards targeting ambulatory settings serving as a catalyst, we designed a quality improvement (QI) project was designed to evaluate the existing management and prescribing patterns for urinary tract infections (UTI) in the Walter Reed National Military Medical Center (WRNMMC) Emergency Department (ED) in order to identify targets for ASP intervention. MethodsThis was a Pharmacist-driven, prospective, QI project conducted over a 3-month period. The clinical presentations and microbiological data of uncomplicated cystitis and pyelonephritis cases managed in the ED were reviewed. Within 24-72 hours of ED discharge, recommendations were relayed to both patients and ED staff. Diagnostic criteria and management concordant with established clinical guidelines were assessed. Inclusion criteria included age ≥ 18, admission status, urine culture and antibiotics for UTI or pyelonephritis.ResultsA daily urinalysis (UA) report identified 1781 ED encounters of which 117 cases met inclusion criteria. Nitrofurantoin was most prescribed empirically at 39.3% followed by a cephalosporin (23.1%) or a fluoroquinolone (19.7%), accounting for 32% of inappropriate empiric antibiotic selection. Cases were identified with inappropriate duration of therapy (22.2%), dosage (9.4%), and drug-bug mismatch (9.4%). Nearly 38% of cases required intervention to discontinue (32.5%) or initiate new antibiotics (3.4%). Diagnostic concordance was defined as having positive urinary symptoms, clinically significant UA and positive urine culture. This was only observed in 37.6% of all cases, of which only 43.2% were treated with a guideline concordant empiric regimen, dosage and duration of therapy. Although not included in the final analysis, it was noted 916 urine culture results were ordered where 70% were not associated with genitourinary complaints or sepsis.ConclusionDespite guidelines for UTI management, considerable practice discordance was found in the ED. Multiple Pharmacist targeted interventions were identified. Prioritized areas for ED provider education include first-line therapy, treatment duration, and diagnostic stewardship. This QI project has potential for optimizing prescribing practices in Military Health System ambulatory settings. Disclosures All Authors: No reported disclosures

NCOG-38. PREDICTORS OF COGNITIVE PERFORMANCE IN PATIENTS WITH PRIMARY BRAIN TUMORS: AN ANALYSIS OF BRAIN FITNESS CENTER (BFC) AT WALTER REED NATIONAL MILITARY MEDICAL CENTER

Abstract INTRODUCTION Although developed initially for patients with traumatic brain injury (TBI), cognitive rehabilitation training (CRT) has expanded its use to include patients suffering from a variety of neurocognitive disorders including neurologic malignancies. The Brain Fitness Center (BFC) at Walter Reed National Military Medical Center (WRNMMC) is a cognitive rehabilitation clinic that offers computer-based cognitive training programs as an adjunctive rehabilitation resource for a diverse patient population with cognitive complaints. METHODS Using a retrospective analysis of data from the BFC at WRNMMC, our study analyzed forty patients with primary brain tumors who had completed both symptom self-report questionnaires and cognitive assessments at the BFC. Self-report questionnaires included the neurobehavioral symptom inventory (NSI) and headache symptom inventory (HIT-6) while cognitive assessments were done using the Automated Neuropsychological Assessment Metrics (ANAM). Our study examined the relationship between subjective cognitive complaints, headache severity, neuropsychiatric symptoms and objective cognitive performance before and after initial CRT. The influence of high vs low grade tumors was also evaluated. RESULTS Our analysis demonstrated that increased number of affective symptoms, particularly self-reported irritability, were the strongest predictors of baseline, objective cognitive performance (r= -.377, p=0.008). Patient self-reported forgetfulness, but not overall subjective cognitive complaints, was also negatively correlated with objective cognitive performance (r= - 0.353, p= 0.020). A mean difference in objective cognitive performance between high grade and low grade tumors was also found (p=0.003). CONCLUSIONS Our results point to potential patient-level factors which could predict benefit from CRT including self-reported irritability, self-reported forgetfulness, and tumor grade. Further prospective studies will help to examine the true benefit of sustained CRT, and the subset of patients with CNS neoplasms most likely to benefit from this training.

Renovating Healthcare Facility Maintenance Planning: A Case Study From Walter Reed National Military Medical Center (WRNMMC).

This article documents the development and implementation of a new approach for health facilities construction and maintenance planning, the use of a Facilities and Clinical Coordination (FCC) Council, at Walter Reed National Military Medical Center (WRNMMC). WRNMMC is preparing for the largest and most complex renovation project in recent Department of Defense history. There is sparse documentation demonstrating stepwise frameworks for the implementation of effective and efficient health facilities maintenance management tools and techniques. This study discusses the development and evaluation of the FCC Council. Clarity to the literature sources guiding the development of the FCC Council is provided, followed by the survey approach undertaken to assess Council efficacy based on participants' perceptions. Data are analyzed using descriptive and inferential statistics. Our study suggests routine cross-functional synchronous FCC Council meetings improve perceptions of safety and communication, encourage teamwork, and are more productive when conducted using synchronous rather than asynchronous communication. Clinician participants strongly supported the face-to-face meeting approach and considered such meetings more effective as they are perceived to maintain staff and patient safety as a constant organizational focus. The FCC's perceived effectiveness toward improving healthcare facilities maintenance planning centers on engaged leadership, the inclusion of diverse subject matter experts, and structured group facilitation. Our results inform health facilities planners of the value the FCC Council brings to an organization by helping to develop organizational buy-in for major facilities renovation projects.

Naloxone Education: Patient Perspectives

Disclaimer: "The views expressed in this abstract are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. Naloxone is recommended as a risk mitigating strategy to reduce the incidence of death associated with opioid overdoses. Walter Reed National Military Medical Center (WRNMMC) developed and implemented the first Pharmacist-led naloxone prescription initiative within the Department of Defense. Research question: were WRNMMC pharmacists providing patients with accurate naloxone education? A survey was performed to determine the information being provided to patients. The military Health Population database was accessed to generate a list of 100 patients who recently received naloxone. A team member contacted the 100 patients and administered a survey. Results showed that 87.7% of the responders indicated they received pharmacy education. 52.6% of those receiving education received both verbal and written education, 33% received verbal education only, and 14% received written education only. 93% of those who received education had someone available to administer the naloxone in case of an emergency. 96.5% of those receiving education responders still had their naloxone and knew where their naloxone was kept. As the first DoD pharmacist led naloxone dispensing pharmacy, pharmacists identified patients within our patient population at high-risk for an opioid overdose and acted as a catalyst for increasing naloxone prescriptions and percent of prescriptions written by pharmacists. The results of the survey demonstrate that the majority of our patients were educated about naloxone, however, some slight adjustments in the workflow need to be made to make certain all our patients are being educated. Disclaimer: "The views expressed in this abstract are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. Naloxone is recommended as a risk mitigating strategy to reduce the incidence of death associated with opioid overdoses. Walter Reed National Military Medical Center (WRNMMC) developed and implemented the first Pharmacist-led naloxone prescription initiative within the Department of Defense. Research question: were WRNMMC pharmacists providing patients with accurate naloxone education? A survey was performed to determine the information being provided to patients. The military Health Population database was accessed to generate a list of 100 patients who recently received naloxone. A team member contacted the 100 patients and administered a survey. Results showed that 87.7% of the responders indicated they received pharmacy education. 52.6% of those receiving education received both verbal and written education, 33% received verbal education only, and 14% received written education only. 93% of those who received education had someone available to administer the naloxone in case of an emergency. 96.5% of those receiving education responders still had their naloxone and knew where their naloxone was kept. As the first DoD pharmacist led naloxone dispensing pharmacy, pharmacists identified patients within our patient population at high-risk for an opioid overdose and acted as a catalyst for increasing naloxone prescriptions and percent of prescriptions written by pharmacists. The results of the survey demonstrate that the majority of our patients were educated about naloxone, however, some slight adjustments in the workflow need to be made to make certain all our patients are being educated.

Efficacy of an Interdisciplinary Intensive Outpatient Program in Treating Combat-Related Traumatic Brain Injury and Psychological Health Conditions.

Background: Since 2000, over 413,000 US service members (SM) experienced at least one traumatic brain injury (TBI), and 40% of those with in-theater TBIs later screened positive for comorbid psychological health (PH) conditions, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many SMs with these persistent symptoms fail to achieve a recovery that results in a desirable quality of life or return to full duty. Limited information exists though to guide treatment for SMs with a history of mild TBI (mTBI) and comorbid PH conditions. This report presents the methods and outcomes of an interdisciplinary intensive outpatient program (IOP) in the treatment of SMs with combat-related mTBI and PH comorbidities. The IOP combines conventional rehabilitation therapies and integrative medicine techniques with the goal of reducing morbidity in multiple neurological and behavioral health domains and enhancing military readiness.Methods: SMs (n = 1,456) with residual symptoms from mTBI and comorbid PH conditions were treated in a 4-week IOP at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC). The IOP uses an interdisciplinary, holistic, and patient-centric rehabilitative care model. Interdisciplinary teams provide a diagnostic workup of neurological, psychiatric, and existential injuries, and from these assessments, individualized care plans are developed. Treatment response was assessed using the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist—Military Version (PCL-M), Satisfaction With Life Scale (SWLS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), and Headache Impact Test-6 (HIT-6) and administered at admission, discharge, and at 1, 3, and 6 months post-discharge.Findings: Following treatment in the IOP, the symptomatic patients had statistically significant and clinically meaningful improvements across all outcome measures. The largest effect size was seen with GAD-7 (r = 0.59), followed by PHQ-8 (r = 0.56), NSI (r = 0.55), PCL-M (r = 0.52), ESS (r = 0.50), SWLS (r = 0.49), and HIT-6 (r = 0.42). In cross-sectional follow ups, the significant improvements were sustained at 1, 3, and 6 months post-discharge.Interpretation: This report demonstrates that an interdisciplinary IOP achieves significant and sustainable symptom recovery in SMs with combat-related mTBI and comorbid PH conditions and supports the further study of this model of care in complex medical conditions.

Association between traumatic brain injuries and ketamine infusion side effects following combat injury

IntroductionKetamine is a vital component for acute pain management in emergency trauma care for both civilian and military hospitals. This preliminary analysis examined whether combat-injured US service members sustaining traumatic...

COVID-19 Airway Management Isolation Chamber.

ObjectiveDuring the coronavirus pandemic (COVID-19), health care workers are innovating patient care and safety measures. Unfortunately, many of these are not properly tested for efficacy. The objective of this study was to determine the efficacy of the novel COVID-19 Airway Management Isolation Chamber (CAMIC) to contain and evacuate particulate.Study DesignMulti-institutional proof-of-concept study.SettingTwo academic institutions: Walter Reed National Military Medical Center (WRNMMC) and Madigan Army Medical Center (MAMC).Subjects and MethodsSmoke, saline nebulizer, and simulated working port models were developed to assess the efficacy of the CAMIC to contain and remove ultrafine particles. Particulate counts were collected at set time intervals inside and outside the system.ResultsWith the CAMIC on, smoke particulate counts inside the chamber significantly decreased over time: r(18) = −0.88, P < .001, WRNMMC; r(18) = −0.91, P < .001, MAMC. Similarly, saline nebulizer particulate counts inside the chamber significantly decreased over time: r(23) = −0.82, P < .001, WRNMMC; r(23) = −0.70, P < .001, MAMC. In the working port model, particulate counts inside the chamber significantly decreased over time: r(23) = −0.95, P < .001, WRNMMC; r(23) = −0.85, P < .001, MAMC. No significant leak was detected in the smoke, saline nebulizer, or working port model when the CAMIC was turned on.ConclusionsThe CAMIC system appears to provide a barrier that actively removes particles from within the chamber and limits egress. Further studies are necessary to determine clinical applicability. The CAMIC may serve as an adjunct to improve health care worker safety and patient outcomes.

Abstract B075: Defining germline mutations of DNA damage repair genes in African American prostate cancer patients

Abstract Background: DNA damage repair genes (DDRGs) play a critical role in protecting genome integrity and have been implicated in several cancer types. In the context of prostate cancer (CaP) emerging data provide potential role of this pathway in aggressive disease. It has also been recently demonstrated that PARP inhibitors can extend overall survival in metastatic patients with DDRG mutations. However, the association and therapeutic stratification based on inherited mutations of DDRGs remains to be defined in African American (AA) CaP patients. Our objective was to assess the frequency and association with disease aggressiveness of all known DDRGs in blood derived genomic DNAs of AA and Caucasian American (CA) CaP patients archived at the DOD Center for Prostate Disease Research and assess how this information can refine patient stratification for specific targeted therapeutic options. Method: Germline mutations in all DDRGs was evaluated by whole genome sequence (WGS) analysis of archived blood DNA samples from 600 CaP patients (300 AA and 300 CA) who underwent primary treatment at Walter Reed National Military Medical Center (WRNMMC) over the past 20 years. These patients had equal access Department of Defense healthcare system with up to 20 years of follow-up time. Following quality control steps to assess DNA quantity by Qubit assay and DNA quality by Bioanalyzer assay, DNA samples were used to generate PCR-free libraries for WGS using the NovaSeq (Illumina) platform. Out of the 600 libraries we generated, 14 dropped out, achieving a success rate of 97.6%. The successful libraries had an excellent quality based on DNA library metrics (yield and fragment length). Whole genome sequencing depth of the samples exceeded 37x on average and about 4 million SNPs were identified in the samples. Patient genotypes were projected onto principal components from reference populations. Sample ancestries were predicted by using the “Peddy” program, which uses a machine learning model trained on individuals of diverse ancestries from the 1000 Genomes Project reference panel. Due to mismatched ancestry, 33 samples were excluded from further analyses. An additional 17 samples were excluded due to higher than minimal noise level based on analyses using “ContEst” tool from Broad GATK package and Illumina noise percent values. Results: Interrogation of an inclusive DDRG set of 180 genes predicted to have non-silent effects on the protein sequence (e.g. missense, nonsense, frameshift) for germline mutations in this cohort revealed several known and novel mutations. The analysis has not been finalized yet. Mutation data will be assessed for association with the extensive available clinical and pathological data, including disease progression (metastasis), family history and African ancestry. Novel mutations, anticipated especially in the understudied AA context, will be analyzed for functional impact. Citation Format: Kevin Babcock, Xijun Zhang, Matthew Wilkerson, Clifton L. Dalgard, Shyh-Han Tan, Lakshmi Ravindranath, Yongmei Chen, Jennifer Cullen, Shiv Srivastava, Inger L. Rosner, Gyorgy Petrovics. Defining germline mutations of DNA damage repair genes in African American prostate cancer patients [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B075.

The Use of Telepain for Chronic Pain in the U.S. Armed Forces: Patient Experience from Walter Reed National Military Medical Center.

Chronic pain affects over 100 million American adults. The prevalence of chronic pain is even higher among U.S. military personnel. Approximately 44% of active duty military experience pain upon returning from deployment compared with 26% of the general public who experience chronic pain. The high prevalence of chronic pain within the Military Health System is compounded by limited access to chronic pain specialists, specifically with regard to patients at remote military treatment facilities (MTFs). Thus, when compared to personnel at tertiary care MTFs, they often have decreased access to care and experience increased time away from their mission to receive care. Since 2009, Walter Reed National Military Medical Center (WRNMMC) has been using telemedicine to extend chronic pain consults to remote MTFs within the National Capital Region (NCR). The goal of this study was to determine if patients referred to the WRNMMC Telepain Program reported improvements in subjective measures associated with accessing care. To accomplish this, we surveyed a convenience sample of patients using the service to determine if participation: (1) improved pain, (2) improved quality of life, (3) decreased travel time, (4) improved access to care, and (5) decreased time away from work. An official on behalf of the Institutional Review Board at WRNMMC determined this research to be not human subject research. Over a 13-month period, surveys were administered at the conclusion of all initial Telepain Consults. The survey consisted of an eight question, 5-point balanced Likert scale survey with 1 (strongly disagree) being the most negative and 5 (strongly agree) being most positive. The questions were designed to gauge impact on patient's perceived access to care, quality of life, overall patient satisfaction, and privacy concerns. The percentages of answers, including strongly agree or agree for positive toned questions and strongly disagree and disagree for negatively toned questions, were calculated and presented in a clustered bar graph. A total of 66 Telepain surveys were collected over 13months with an overall positive reception. Respondents agreed or strongly agreed that Telepain increased access to care (98.5%) and decreased travel time (96.9%). When asked if they would recommend a Telepain visit to others, 93.9% of indicated strongly agree or agree. When asked about overall satisfaction, 83.3% of patients answered completely satisfied or very satisfied. The majority of pain specialists within the Military Health System are located at major military medical centers, the most of which are distant from surrounding MTFs. Prior to the development of the WRNMMC Telepain service, personnel at remote MTFs had to endure extended time away from their mission to receive care. The majority of patients that participated in the NCR Telepain program reported a positively perceived impact on pain, access to care, quality of life, transportation burden, and time away from work. In conclusion, The NCR Telepain team of providers have worked together to successfully establish a viable Telepain program at WRNMMC, one that will continue to be further improved and successful in the future.

A Novel Intervention Platform for Service Members With Subjective Cognitive Complaints: Implementation, Patient Participation, and Satisfaction.

Program overview of a novel cognitive training platform at Walter Reed National Military Medical Center (WRNMMC) for service members with subjective cognitive complaints: analysis of patient participation, satisfaction with the program, and perceived areas of improvement. Retrospective review of 1,030 participants from November 2008 through May 2017. Data were obtained within an approved protocol (WRNMMC-EDO-2017-0004/# 876230). The program has shown growth in numbers of referrals, types of patient populations served, and patient visits. Patients report satisfaction with the program and endorse improvements in cognitive functions. This program model may benefit other military facilities looking to provide and assess novel therapeutic approaches.

Advanced Modeling to Predict Pneumonia in Combat Trauma Patients.

Tools to assist clinicians in predicting pneumonia could lead to a significant decline in morbidity. Therefore, we sought to develop a model in combat trauma patients for identifying those at highest risk of pneumonia. This was a retrospective study of 73 primarily blast-injured casualties with combat extremity wounds. Binary classification models for pneumonia prediction were developed with measurements of injury severity from the Abbreviated Injury Scale (AIS), transfusion blood products received before arrival at Walter Reed National Military Medical Center (WRNMMC), and serum protein levels. Predictive models were generated with leave-one-out-cross-validation using the variable selection method of backward elimination (BE) and the machine learning algorithms of random forests (RF) and logistic regression (LR). BE was attempted with two predictor sets: (1) all variables and (2) serum proteins alone. Incidence of pneumonia was 12% (n = 9). Different variable sets were produced by BE when considering all variables and just serum proteins alone. BE selected the variables ISS, AIS chest, and cryoprecipitate within the first 24h following injury for the first predictor set 1 and FGF-basic, IL-2R, and IL-6 for predictor set 2. Using both variable sets, a RF was generated with AUCs of 0.95 and 0.87-both higher than LR algorithms. Advanced modeling allowed for the identification of clinical and biomarker data predictive of pneumonia in a cohort of predominantly blast-injured combat trauma patients. The generalizability of the models developed here will require an external validation dataset.