Walter Reed National Military Medical Research Articles

Is Greener Better? Quantifying the Impact of a Nature Walk on Stress Reduction Using HRV and Saliva Cortisol Biomarkers

The physiological impact of walking in nature was quantified via continuous heart rate variability (HRV), pre- and post-walk saliva cortisol measures, and self-reported mood and mindfulness scores for N = 17 participants who walked “The Green Road” at Walter Reed National Military Medical Center in Bethesda, Maryland. For N = 15 of the participants, HRV analysis revealed two main groups: group one individuals had a 104% increase (mean) in the root mean square standard deviation (RMSSD) and a 47% increase (mean) in the standard deviation of NN values (SDNN), indicating an overall reduction in physiological stress from walking the Green Road, and group two individuals had a decrease (mean) of 42% and 31% in these respective HRV metrics, signaling an increase in physiological stresses. Post-walk self-reported scores for vigor and mood disturbance were more robust for the Green Road than for a comparable urban road corridor and showed that a higher HRV during the walk was associated with improved overall mood. Saliva cortisol was lower after taking a walk for all participants, and it showed that walking the Green Road elicited a significantly larger reduction in cortisol of 53%, on average, when compared with 37% of walking along an urban road. It was also observed that the order in which individuals walked the Green Road and urban road also impacted their cortisol responses, with those walking the urban road before the Green Road showing a substantial reduction in cortisol, suggesting a possible attenuation effect of walking the Green Road first. These findings provide quantitative data demonstrating the stress-reducing effects of being in nature, thus supporting the health benefit value of providing access to nature more broadly in many settings.

Dupilumab use in patients with hypereosinophilic syndromes: a multicenter case series and review of the literature

BackgroundHypereosinophilic syndromes (HES) are defined as hypereosinophilia with eosinophil-related clinical manifestations, some of which overlap in presentation with asthma, atopic dermatitis, eosinophilic esophagitis, and/or chronic rhinosinusitis with nasal polyps (CRSwNP). Dupilumab is approved to treat these conditions but can induce a transient rise in the absolute eosinophil count (AEC) and rare eosinophil-related complications. ObjectiveTo determine whether eosinophil-related complications of dupilumab are increased in HES. MethodsRetrospective chart review of patients with HES treated with dupilumab enrolled on an IRB-approved research protocol at the National Institutes of Health (NCT00001406) or receiving care at Walter Reed National Military Medical Center. Clinical response and treatment-emergent adverse events were recorded. Serum mediators were assessed in a subset of patients before and after dupilumab using stored samples. ResultsAmong the 28 patients (15 male, 13 female; median age 41.5), the most common prescribing indication for dupilumab was CRSwNP (n=11). Twenty-three patients (82%) showed significant clinical improvement on dupilumab. Hypereosinophilia (AEC >1.5x109/L) recurred or worsened in 9/20 patients on dupilumab monotherapy. Moreover, 4/20 (20%) patients developed an eosinophil-related complication with dupilumab discontinuation and/or addition of eosinophil-lowering therapy. None of the 8 patients who received dupilumab while in hematologic remission on an eosinophil-lowering biologic developed hypereosinophilia or an eosinophil-related complication. Serum IgE and eotaxin levels decreased on dupilumab therapy. ConclusionThese data suggest that dupilumab is effective in treating residual symptoms in HES patients but that the incidence of eosinophil-related complications is increased. Concomitant eosinophil-lowering therapy may reduce the risk of eosinophil-related complications during dupilumab therapy in patients with HES.

Individual heart failure patient variability in nocturnal hypoxia and arrhythmias.

Traditional heart failure research often uses daytime population parameter estimates to assess hypoxia and arrhythmias. This approach might not accurately represent heart failure patients as nighttime cardiac behaviors offer crucial insights into their health, especially regarding oxygen levels and heart rhythms. We conducted a prospective study on nocturnal oxygen saturation and heart rate in home-dwelling heart failure patients over 6 nights. Patients were recruited from the Walter Reed National Military Medical Center heart failure clinic. Criteria included a clinical diagnosis of heart failure, a New York Heart Association (NYHA) classification of I to III, ages between 21 to 90, cognitive intactness, capability to use the wearable device, and willingness to use the device for 6 consecutive nights. Average oxygen saturation was 92% with individual readings ranging from 40% to 100%. The mean heart rate was 72 beats per minute (bpm), but individual rates ranged from 18 bpm to a high of 296 bpm. A significant drop in oxygen levels and sleep arrhythmias were consistently observed among participants. Heart failure patients demonstrate notable and variable desaturations and arrhythmias across multiple nights. A single-night sleep study or a 24-hour heart rate monitor may not comprehensively depict patients' oxygenation and heart rate irregularities. Our research highlights wearable devices' potency in medical research for capturing essential nocturnal data. In only 6 nights, we gleaned invaluable clinical insights for optimizing patient care. This study is pioneering, being the first to intensively examine nighttime oxygen levels and heart rates in home-based heart failure patients.

Molecular Surveillance of Multidrug-Resistant Bacteria among Refugees from Afghanistan in 2 US Military Hospitals during Operation Allies Refuge, 2021.

In 2021, two US military hospitals, Landstuhl Regional Medical Center in Landstuhl, Germany, and Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland, USA, observed a high prevalence of multidrug-resistant bacteria among refugees evacuated from Afghanistan during Operation Allies Refuge. Multidrug-resistant isolates collected from 80 patients carried an array of antimicrobial resistance genes, including carbapenemases (blaNDM-1, blaNDM-5, and blaOXA-23) and 16S methyltransferases (rmtC and rmtF). Considering the rising transmission of antimicrobial resistance and unprecedented population displacement globally, these data are a reminder of the need for robust infection control measures and surveillance.

Empowering Pediatricians With Direct Penicillin Challenges: A Promising Delabeling Strategy.

Current literature supports a multidisciplinary approach to penicillin allergy delabeling. Our study aims to review the success rate of penicillin challenges performed at Walter Reed National Military Medical Center Allergy Clinic and assess the reaction rate associated with a direct oral challenge in low-risk patients. We conducted a retrospective review of the outcomes of pediatric penicillin challenges at the Walter Reed National Military Medical Center Allergy and Immunology clinic from June 2019 to May 2023. A total of 74 challenges were included in this study. Patients were initially screened to assess the date of reaction, nature of reaction, if the reaction was life-threatening, and if the patient was hospitalized or sought emergency medical care for the reported reaction. After completion of the screening questionnaire, a direct graded challenge was performed (without skin testing) if a patient's history was deemed low risk. Patients with a recent reaction or a history of multiple drug allergies were more likely to be directed to skin prick testing and intra-dermal testing with Pre-pen and Penicillin-G prior to challenge. All patients passed all challenges. Thus, there was a 100% pass rate for both direct challenges and skin test with oral challenges. Given the low rate of adverse events in this study, expansion of penicillin delabeling in the primary care setting should be considered in patients deemed to be at low risk. It is important for allergists to empower and educate their peers and push forward a movement to create a multidisciplinary approach to penicillin delabeling.

Comparison of Four Body Composition Methods: Circumference Measurements, Eight-Point Bioelectrical Impedance Analysis up to 500 and 1000 kHz to Dual-Energy X-Ray Absorptiometry to Measure Body Fat Percentage

ABSTRACT Introduction A comparison of body composition assessments using military circumferences to bioelectrical impedance analysis (BIA) and the reference standard dual-energy X-ray absorptiometry (DEXA) can gauge effectiveness of assessments. High-frequency (500 KHz) direct segmental multifrequency bioelectrical impedance analysis (DSM-BIA) accurately calculates total water mass and body fat% (BF%), but it is unknown whether higher frequencies (1,000 KHz) increase measurement accuracy. The purpose was to compare DSM-BIA 500, DSM-BIA 1000, the DoD Circumference Method (CM), and the reference-standard DEXA. Materials and Methods Design: Cross sectional, observational study. Participants/Setting: A total of 62 participants from the military healthcare system (n = 25 males, 38.8 ± 11.4 years, n = 37 females 43.7 ± 15.95 years) were measured in an outpatient clinic setting. Statistical Analysis: BF% was estimated via DEXA, DSM-BIA 500, DSM-BIA 1000, and CM to identify the relationship between methods using Pearson correlation, intraclass correlation coefficients (ICCs), and Bland-Altman plots. The study was approved by the IRB from Walter Reed National Military Medical Center at Bethesda and Concordia University Chicago. Results Circumference Method BF% was moderately correlated with DSM-BIA 500 (males r = 0.63, ICC = 0.76; females r = 0.77, ICC = 0.85), DSM-BIA 1000 (males r = 0.59, ICC = 0.74; females r = 0.77, ICC = 0.85), and DEXA (males r = 0.62, ICC = 0.62; females r = 0.73, ICC = 0.82). DSM-BIA 500 BF% was strongly correlated with DSM-BIA 1000 (males r = 0.99, ICC = 0.99; females r = 0.99, ICC = 0.99) and DEXA (males r = 0.93, ICC = 0.94; females r = 0.89, ICC = 0.89). Lastly, DSM-BIA 1000 BF% was also strongly correlated with DEXA (males r = 0.93, ICC = 0.94; females r = 0.84, ICC = 0.90) (P for each reported r < 0.01). Bland-Altman analysis confirmed an overall mean bias of −1.72% CM vs. DEXA in females, indicating the tendency of CM to underestimate BF% compared to DEXA limits of agreement from −14.24 to 10.8. There was an upward slope of the linear relationship between the bias and mean of the measures (Beta = 0.34, P = 0.01). In the full cohort, there was an overall mean bias of 1.14% of CM vs. DSM BIA 1000, with CM tending to overestimate BF% compared to DSM BIA 1000 with limits of agreement −11.13 to 13.41%. There is an upward slope line of the linear relationship between the bias and the mean of the measures (Beta = 0.17, P = .03). Conclusion This study found that CM BF% was moderately correlated with DSM-BIA 500 kHz, DSM-BIA 1,000 kHz BIA, and DEXA. Both DSM-BIA 500 and DSM-BIA 1,000 kHz strongly correlated well with DEXA implying that there was no further increase in correlation with increased frequency. Additionally, there was proportional bias in BF% in the female group between CM and DEXA and in the total group between CM and DSM BIA 1000.

The Association of Mental Health Symptoms to Post-Traumatic Nightmares Among Treatment Seeking Active Duty Service Members.

Posttraumatic nightmares (PTNs) are common among service members with a history of combat or mission-related trauma and are associated with decreased well-being. Unfortunately, beyond establishing an association between mental health symptoms and PTNs, the existing literature fails to provide a more comprehensive understanding of factors associated with PTNs. The effectiveness of current recommended treatments is frequently debated, with the literature varying in levels of support. Treatment of PTN is complicated, given their association with a number of mental health difficulties including posttraumatic stress disorder (PTSD), anxiety, and depression. The present study sought to better delineate the association of these difficulties with PTNs, in an effort to inform and improve treatments for the nation's service members. This study utilized de-identified data collected during standard procedures for an interdisciplinary intensive outpatient program for service members with a history of traumatic brain injury and/or psychological health conditions (N = 1,550). Study analyses were performed under a Walter Reed National Military Medical Center institutional review board-approved protocol. Three cross-sectional forward likelihood ratio logistic regressions predicting the presence of PTNs were conducted while controlling for the alpha-blocker prazosin, as it is recommended for the treatment of PTSD-associated nightmares. Separate models were created for posttraumatic stress symptoms (PTSS), depression, and anxiety because of multicollinearity concerns. Additional variables considered for inclusion were psychological symptoms (e.g., suicide ideation, postconcussive symptoms), satisfaction with life, sleep (e.g., pain that disrupts sleep, early awakenings, sleepiness), demographics (e.g., sex, race/ethnicity, marital status, age), and military characteristics (e.g., rank, branch, special operator status, time in service). PTSS (odds ratio [OR]: 1.13), anxiety (OR: 1.19), and depression (OR: 1.19) were associated with increased odds of PTNs when controlling for prazosin. Each of the final models accounted for a significant amount of variance in the presence/absence of PTN. The included variables differed across models. The PTSS model included pain that disrupted sleep, postconcussive symptoms, special operator status, and early awakenings. The anxiety model included postconcussive symptoms, pain that disrupted sleep, special operator status, and prazosin use. The depression model included postconcussive symptoms, pain that disrupted sleep, special operator status, difficulty falling asleep within 30 min, and prazosin use. Although most variables were associated with an increased odds of PTNs, postconcussive symptoms in the PTSS model and special operator status in all 3 models were associated with decreased odds of PTNs. These findings are illustrated in Tables2 to 4. Findings support the association of PTSS, anxiety, and depression to PTNs, and, importantly, suggest that other factors may be equally or more important in understanding PTNs. Notably, increased odds of PTNs were observed among patients with pain that disrupts their sleep. The cross-sectional nature of the study allows examination of these co-occurring symptoms as they would present in the clinic, potentially informing assessment and treatment strategies; however, it precludes consideration of temporal relationships. Results highlight the importance of considering comorbid symptoms and relevant military characteristics to gain a more complete understanding of PTNs. Future research utilizing longitudinal methods are needed to inform the temporal/causal aspects of these relationships.

A Mixed-Methods Study to Evaluate Family Planning Desires and Barriers to Building Families Among Gay, Bisexual, and Lesbian Cisgender Military Service Members.

Barriers to seeking infertility care for lesbian, gay, bisexual, transgender, intersex, queer/questioning, and asexual (LGBTIQA+) individuals are well documented in the literature. However, little is known about military LGBTIQA+ service members seeking infertility care within the Military Health System. Approximately 6.1% of active duty U.S. service members across all branches identify as LGBTIQA+, which underscores the need for a deeper understanding of the needs of this community to support and retain service members. We therefore sought to describe the lived experiences of lesbian and gay cisgender service members in building their families in order to understand their family-building desires and potential barriers to seeking infertility care. We developed a survey to investigate the impact of military service on family planning. After Institutional Review Board approval, we distributed the survey throughout Walter Reed National Military Medical Center's obstetrics and gynecology clinic and posted the survey on multiple open and closed social media pages for LGBTIQA+ service members. We reported descriptive statistics of our survey and compared binary variables using the Fisher exact test. Following completion of this survey, participants could self-select to participate in semi-structured interviews. Sixty-eight respondents completed our survey and self-identified as either cis-male (n = 28) or cis-female (n = 40). Most respondents (67.9% cis-males, 92.5% cis-females) plan to build their families during their military commitment; however, approximately half (50.0% cis-male, 42.5% cis-female) reported a lack of support in this endeavor. Many respondents were unaware of resources that would assist in the pursuit of donor egg, donor sperm, or surrogacy (78.6% cis-males, 50.0% cis-females). Thirty-six participants elected to complete a follow-up interview. After coding the interviews, 5 themes emerged: (1) barriers to initiating care; (2) institutional barriers within the military; (3) political barriers; (4) knowledge sharing; and (5) implicit and explicit bias. Our results suggest significant barriers to LGBTIQA+ service members seeking infertility care. Overall, LGBTIQA+ service members did not feel supported by the military in building their families. Although the military has expanded access to infertility services, efforts to raise awareness and build support for LGBTIQA+ service members are warranted.

Discharge Opioid Dose Indirectly Associated With Functional Outcomes 2 Weeks After Shoulder and Knee Arthroscopy in a US Military Sample.

Postsurgical opioid utilization may be directly and indirectly associated with a range of patient-related and surgery-related factors, above and beyond pain intensity. However, most studies examine postsurgical opioid utilization without accounting for the multitude of co-occurring relationships among predictors. Therefore, this study aimed to identify factors associated with opioid utilization in the first 2 weeks after arthroscopic surgery and examine the relationship between discharge opioid prescription doses and acute postsurgical outcomes. In this prospective longitudinal observational study, 110 participants undergoing shoulder or knee arthroscopies from August 2016 to August 2018 at Walter Reed National Military Medical Center completed self-report measures before and at 14 days postoperatively. The association between opioid utilization and both patient-level and surgery-related factors was modeled using structural equation model path analysis. Participants who were prescribed more opioids took more opioids, which was associated with worse physical function and sleep problems at day 14, as indicated by the significant indirect effects of discharge opioid dose on day 14 outcomes. Additional patient-level and surgery-related factors were also significantly related to opioid utilization dose and day 14 outcomes. Most participants had opioid medications leftover at day 14. Excess opioid prescribing was common, did not result in improved pain alleviation, and was associated with poorer physical function and sleep 14 days after surgery. As such, higher prescribed opioid doses could reduce subacute functioning after surgery, without benefit in reducing pain. Future patient-centered studies to tailor opioid postsurgical prescribing are needed.

Evaluating WIC Engagement andFood Insecurity Among Active Duty Military Families.

Nearly a quarter of active duty service members identified as food insecure in a 2022 Department of Defense report. Food insecurity impacts military readiness, retention, and recruitment. The Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal food supplementation program that can mitigate food insecurity for service members with children less than 5 years of age. To date, there is a lack of standardized screening for WIC eligibility or enrollment for service members and their families. This project sought to evaluate WIC awareness and enrollment as well as the prevalence of food insecurity at Walter Reed National Military Medical Center. A 26-question survey was developed to assess WIC awareness, source of WIC information, food insecurity, and nutritional insecurity. Our team developed and utilized a novel WIC screening algorithm to rapidly screen families for WIC eligibility. These tools were administered to families presenting for care at the Walter Reed National Military Medical Center pediatrics and obstetric outpatient clinics during the month of July 2022. This study was approved by the institutional review board at Walter Reed. A total of 108 (25%) of the 432 surveyed participants were eligible for WIC, with odds of WIC eligibility increasing for lower-ranking and younger service members. Of the 432 participants, 354 (81.9%) were aware of WIC. Enlisted service members were more likely than officers to know about WIC (P = 0.03), and of the 354 participants aware of WIC, a higher proportion of enlisted rank respondents learned about WIC from a military source (P = 0.01). Among the 108 participants eligible for WIC, only 38 (35.2%) reported being enrolled in WIC. Among WIC-eligible respondents who knew about WIC, being enrolled in the WIC program was not associated with rank, branch of service, sponsor gender, or sponsor age. Despite proven efficacy, WIC remains an underutilized resource for eligible military families. Our results show that a standardized screening approach at Walter Reed National Military Medical Center increased identification of WIC-eligible active duty service members by 180%, with approximately $150,000 a year in increased food supplementation benefits. Military healthcare and readiness leaders should embrace efforts to increase knowledge of, referral to, and enrollment in WIC to increase family health, well-being, and military family readiness.

Patient Engagement and Provider Effectiveness of a Novel Sleep Telehealth Platform and Remote Monitoring Assessment in the US Military: Pilot Study Providing Evidence-Based Sleep Treatment Recommendations.

Sleep problems are common and costly in the US military. Yet, within the military health system, there is a gross shortage of trained specialist providers to address sleep problems. As a result, demand for sleep medicine care far exceeds the available supply. Telehealth including telemedicine, mobile health, and wearables represents promising approaches to increase access to high-quality and cost-effective care. The purpose of this study was to evaluate patient engagement and provider perceived effectiveness of a novel sleep telehealth platform and remote monitoring assessment in the US military. The platform includes a desktop web portal, native mobile app, and integrated wearable sensors (ie, a commercial off-the-shelf sleep tracker [Fitbit]). The goal of the remote monitoring assessment was to provide evidence-based sleep treatment recommendations to patients and providers. Patients with sleep problems were recruited from the Internal Medicine clinic at Walter Reed National Military Medical Center. Patients completed intensive remote monitoring assessments over 10 days (including a baseline intake questionnaire, daily sleep diaries, and 2 daily symptom surveys), and wore a Fitbit sleep tracker. Following the remote monitoring period, patients received assessment results and personalized sleep education in the mobile app. In parallel, providers received a provisional patient assessment report in an editable electronic document format. Patient engagement was assessed via behavioral adherence metrics that were determined a priori. Patients also completed a brief survey regarding ease of completion. Provider effectiveness was assessed via an anonymous survey. In total, 35 patients with sleep problems participated in the study. There were no dropouts. Results indicated a high level of engagement with the sleep telehealth platform, with all participants having completed the baseline remote assessment, reviewed their personalized sleep assessment report, and completed the satisfaction survey. Patients completed 95.1% of sleep diaries and 95.3% of symptom surveys over 10 days. Patients reported high levels of satisfaction with most aspects of the remote monitoring assessment. In total, 24 primary care providers also participated and completed the anonymous survey. The results indicate high levels of perceived effectiveness and identified important potential benefits from adopting a sleep telehealth approach throughout the US military health care system. Military patients with sleep problems and military primary care providers demonstrated high levels of engagement and satisfaction with a novel sleep telehealth platform and remote monitoring assessment. Sleep telehealth approaches represent a potential pathway to increase access to evidence-based sleep medicine care in the US military. Further evaluation is warranted.

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

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

Improving Pre-exposure Prophylaxis Counseling at a Military Women's Health Care Clinic to Champion CDC and Defense Health Agency Recommendations.

The CDC updated their guidelines in 2021 to recommend all doctors speak about pre-exposure prophylaxis (PrEP) against human immunodeficiency virus infection with all sexually active patients. In addition, there is a demonstrated need for physicians to counsel patients on PrEP to achieve military readiness. Results from the 2018 Health Related Behaviors Survey indicate 21.8% of U.S. service members were at high risk for human immunodeficiency virus. This improvement project aimed to assess deficiencies in providers' knowledge before and after an educational intervention and describe policies clinics can adopt to adhere to CDC recommendations. A pre-intervention survey was distributed to providers at the Walter Reed National Military Medical Center Gynecologic Surgery and Obstetrics clinic. Based on results, an educational lecture and standardized intake form were developed. Following the intervention, a post-survey was distributed to providers. A chart review was performed to determine whether PrEP counseling increased following the intervention. Forty-seven gynecologic providers were sent a pre- and post-intervention survey. Thirty-seven individuals completed the pre-intervention survey (response rate 78.72%), whereas 18 people completed the post-intervention survey (response rate 38.30%). Descriptive analysis suggested comfort counseling on PrEP, comfort with Defense Health Agency guidance on PrEP, and knowledge of PrEP all increased. In terms of the chart review, 81 charts were reviewed pre- and post-intervention. Although we failed to meet our target counseling rate of 70%, the number of patients who were counseled on or prescribed PrEP following our intervention was statistically significant (P = .013). This improvement project increased provider knowledge and comfort with PrEP, but only marginally affected behavior changes among providers. This failure may be related to the specific clinic in which the study was implemented. Further research is needed to facilitate routine counseling of PrEP among military women's health care providers.

Pediatric Obesity Prevalence inthe U.S. Military Health System, Fiscal Years 2012-2018.

Obesity prevalence in Military Health System (MHS) children has been reported through fiscal year (FY) 2012 as consistently lower than in the general population. Our study reports military pediatric overweight, obesity, and severe obesity prevalence through FY2018. We compared FY2018 prevalence to a sample of the general population using National Health and National Health and Nutrition Examination Survey (NHANES) 2017-2018 data. The MHS Data Repository was queried for all children aged 2-17 years seen at any military treatment facility between FY2012 and FY2018. We calculated overweight and obesity (classes 1, 2, and 3) prevalence for each FY and performed subgroup analysis for sex, age, and sponsor rank. We also compared FY2018 to NHANES 2017-2018 data. This study was approved by the Walter Reed National Military Medical Center Institutional Review Board. The prevalence of overweight and obesity was stable from FY2012 (14.4% and 11.3%, respectively) to FY2018 (14.1% and 10.7%). Rates of classes 2 and 3 obesity combined were also stable at around 2.5% of all children. In FY2018, obesity prevalence was greater in assigned males, increased with age, and was highest in 16-17-year-olds (odds ratio: 2.75) and children with an enlisted military sponsor (odds ratio: 1.78). Compared to NHANES, MHS children had lower rates of obesity (10.7% versus 19.3%) with a smaller proportion of severe obesity (24% versus 32%). The prevalence of pediatric overweight and obesity in the MHS was stable over time. Disparities were observed between age and sponsor rank groups. When compared to the general population, overall obesity prevalence was lower in younger military children. Further research is needed to explore disparities and to identify optimal strategies to mitigate the increase in obesity prevalence with age.

The SOAP Feedback Training Program.

Accessible and efficient opportunities for health professional faculty to hone feedback skills are limited. In addition, feedback models to apply to the objective structured clinical examination (OSCE) setting are lacking. Annually, paediatric interns from Children's National Hospital and Walter Reed National Military Medical Center participate in an OSCE, which includes faculty observation and immediate feedback to trainees. In 2018, we incorporated the subjective, objective, assessment, plan (SOAP) Feedback Training Program during 20 min of the pre-OSCE faculty orientation. The SOAP Feedback Training Program introduced the SOAP feedback model (subjective, objective, assessment, plan), facilitated practice in pairs and distributed a cognitive aid referencing the model. We evaluated the quality of faculty feedback exchanges during the 2018 OSCE via retrospective video review using the Direct Observation of Clinical Skills Feedback Scale (DOCS-FBS). We compared the results to the 2015 initial evaluation and used focus groups to understand how and why faculty feedback changed. Comparison of the initial evaluation to the post-SOAP Feedback Training Program intervention data using a Wilcoxon signed rank test showed statistically significant improvement in six of eight feedback items on the DOCS-FBS. Causal coding of focus group transcripts revealed that the SOAP Feedback Training Program evoked affective responses, reinforced prior practice in feedback delivery, improved feedback organisation and increased feedback delivery preparation. The SOAP Feedback Training Program is an effective intervention to teach the SOAP feedback model and improve faculty feedback quality in an OSCE setting. It is efficient and low resource, facilitating its potential use in settings beyond the OSCE.

Characterization of initial ankle-foot prosthesis prescription patterns in U.S. Service members following unilateral transtibial amputation.

The purpose of this study was to explore relationships between patient-specific characteristics and initial ankle-foot prosthesis prescription patterns among U.S. Service members with unilateral transtibial limb loss. A retrospective review of health records identified 174 individuals with unilateral transtibial limb loss who received care at Walter Reed National Military Medical Center between 2001 and 2019. We examined patient-specific factors such as demographics, participant duty status at injury and amputation, amputation etiology, and timing between injury, amputation, and initial prescription. The type of first prescribed ankle-foot prosthesis was categorized as energy storing and return - nonarticulating, energy storing and return - articulating, or computer controlled. Sex, amputation etiology, time from injury to initial prescription, and time from amputation to initial prescription differed by type of initial ankle-foot prosthesis prescription. Service members with shorter intervals between injury-initial prescription and amputation-initial prescription, and those injured by combat blast, were more likely to receive a non-articulating device. Incorporating sex, time from injury-initial prescription, time from amputation-initial prescription, and amputation etiology as predictors of prosthesis type, we were able to correctly classify 72% of all first prostheses prescribed. Patient-specific characteristics such as sex, the time between injury-initial prescription, time from amputation-initial prescription and amputation etiology are essential characteristics that influence initial ankle-foot prosthesis prescription patterns in U.S. Service members.

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.

Transition to Tenecteplase From t-PA for Acute Ischemic Stroke at Walter Reed National Military Medical Center

Transition to Tenecteplase From t-PA for Acute Ischemic Stroke at Walter Reed National Military Medical Center

Abstract B054: Inherited mutations of DNA damage repair genes in a racially diverse cohort of men with prostate cancer

Abstract Introduction: DNA damage repair genes (DDRGs) play an important role in genomic stability and mutations in DDRGs contribute to clinically significant prostate cancer (PCa). However, the association of germline mutations in DDRGs with PCa progression and therapeutic stratification remain to be defined in African American (AA) men. Our objective was to genomically profile all known DDRGs and provide ancestry specific findings, focusing on PCa patients with African ancestry. Methods: Germline mutations in all DDRGs (N=276) was evaluated by whole genome sequence (WGS) analysis of archived blood DNA samples from 600 PCa patients (300 AA and 300 CA) who underwent primary treatment at Walter Reed National Military Medical Center. The WGS mean coverage exceeded 37x. Principal Component Analysis using the Peddy program was conducted, and ancestry prediction was based on a machine learning approach using 1000G as reference. Variant frequencies in CPDR PCa patients were compared to variant frequencies available from the Exome Aggregation Consortium (ExAC) controls with no PCa. Data analysis approaches included single variant association, gene-based total frequency test and clinico-pathological associations for germline mutations. All statistical tests were two-sided, and FDR adjusted. FDR &amp;lt; 0.05 was set as significance threshold. Results: Comprehensive analysis of 276 DDRGs revealed that germline mutation (Pathogenic/Likely Pathogenic; P/LP) carrier rate was 23.5%, which is three times higher than reported before in both AA and CA men, due to our unbiased WGS approach. We found that only 13 of the 46 DDRGs identified with P/LP mutations were common to AA and CA men, demonstrating clear disparity along ancestry lines. Importantly, RAD family genes (RAD54L, RAD54B, RAD51), which are potentially targetable, as well as PMS2 and BRCA1, were among the most frequently mutated DDRGs in AA, but not in CA men. Germline mutations in RAD51 and PMS2 were enriched in AA cohort as compared to CA men (P 0.01 and 0.03 respectively), while germline mutations in FANCA were significantly enriched in CA cohort (P &amp;lt; 0.01). Pathway analysis showed that the HR pathway (with 15 mutations) was associated with faster disease progression to biochemical recurrence (BCR) (P &amp;lt;0.05), while the NHEJ pathway (with three mutations) was found to be marginally associated with metastasis (p &amp;lt;0.05). Additionally, we found that germline mutations in DDRGs was associated with shorter time to BCR (P &amp;lt;0.05) in AA patients, but not in CA men. Conclusion: Our findings highlight distinct DDRG germline mutation profile across AA and CA prostate cancer men. This may help refine patient stratification for specific targeted therapeutic options especially for under-studied AA men. Future replication studies in an independent patient cohort are warranted to validate our findings. Citation Format: Indu Kohaar, Xijun Zhang, Gregory Chesnut, Clifton Dalgard, Matthew D. Wilkerson, Gyorgy Petrovics. Inherited mutations of DNA damage repair genes in a racially diverse cohort of men with prostate cancer [abstract]. In: Proceedings of the AACR Special Conference: Advances in Prostate Cancer Research; 2023 Mar 15-18; Denver, Colorado. Philadelphia (PA): AACR; Cancer Res 2023;83(11 Suppl):Abstract nr B054.

Is There a Role for Adjuvant Therapy in Patients with Large Juvenile Nasopharyngeal Angiofibromas?

The LaryngoscopeEarly View Triological Society Best Practice Is There a Role for Adjuvant Therapy in Patients with Large Juvenile Nasopharyngeal Angiofibromas? Charles A. Riley MD, Corresponding Author Charles A. Riley MD [email protected] orcid.org/0000-0002-1993-7018 Department of Otolaryngology—Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA Send correspondence to Charles A. Riley, MD, Department of Otolaryngology—Head and Neck Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA. Email: [email protected]Search for more papers by this authorDavid A. Gudis MD, David A. Gudis MD orcid.org/0000-0002-1938-9349 Department of Otolaryngology – Head and Neck Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York City, New York, USASearch for more papers by this author Charles A. Riley MD, Corresponding Author Charles A. Riley MD [email protected] orcid.org/0000-0002-1993-7018 Department of Otolaryngology—Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA Send correspondence to Charles A. Riley, MD, Department of Otolaryngology—Head and Neck Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA. Email: [email protected]Search for more papers by this authorDavid A. Gudis MD, David A. Gudis MD orcid.org/0000-0002-1938-9349 Department of Otolaryngology – Head and Neck Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York City, New York, USASearch for more papers by this author First published: 30 May 2023 https://doi.org/10.1002/lary.30797 Editor's Note: This Manuscript was accepted for publication on May 18, 2023 The authors have no other funding, or financial relationships to disclose. The authors whose names are listed above certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions, or policies of Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DoD), the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. BIBLIOGRAPHY 1McAfee WJ, Morris CG, Amdur RJ, Werning JW, Mendenhall WM. Definitive radiotherapy for juvenile nasopahryngeal angiofibroma. Am J Clin Oncol. 2006; 29(2): 168- 170. 2Mallick S, Benson R, Bhasker S, Mohanti BK. Long-term treatment outcomes of juvenile nasopharyngeal angiofibroma treated with radiotherapy. Acta Otorhinolaryngol Ital. 2015; 35(2): 75- 79. 3Amdur RJ, Yeung AR, Fitzgerald BM, Mancuso AA, Werning JW, Mendenhal WM. Radiotherapy for juvenile nasopharyngeal angiofibroma. Pract Radiot Oncol. 2011; 1(4): 271- 278. 4Thakar A, Gupta G, Bhalla AS, et al. Adjuvant therapy with flutamide for presurgical volume reduction in JNA. Head Neck. 2011; 33(12): 1747- 1753. 5Labra A, Chavolla-Magana R, Lopez-Ugalde A, Alanis-Calderon J, Huerta-Delgado A. Flutamide as a preoperative treatment in juvenile angiofibroma (JA) with intracranial invasion: report of 7 cases. Otolaryngol Head Neck Surg. 2004; 130(4): 466- 469. Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation