Effect of Serial Pregnancies on Physical Fitness.

INTRODUCTION: Pregnancy has a profound impact on physical fitness, and delivery does not allow for rapid return to peak performance levels as physiologic changes can persist for greater than 1 year postpartum. Multiple studies across all military services have documented decrements in physical performance with pregnancy among women. The purpose of this study was to determine the impact of serial pregnancies on physical fitness and body composition in a cohort of Army women. We hypothesized that a second pregnancy would be associated with increasing decrements in physical fitness in active duty soldiers beyond that seen following a first delivery. MATERIALS AND METHODS: This retrospective cohort study screened all active duty soldiers who had delivered a singleton pregnancy of ≥32 weeks gestation between January 1, 2011 and March 31, 2017 at a single military medical center. This roster of eligible women was used to extract Army Physical Fitness Test (APFT) and height/weight data from the U.S. Army Digital Training Management System. Soldiers who delivered their first 2 pregnancies over this period were included. Select antepartum, intrapartum, and postpartum data were collected from the electronic medical record. The primary outcome variables were raw scores for push-ups, sit-ups, and run events as well as weight measures across the 2 pregnancies. The secondary outcomes were the failure rates on both the APFT events and body mass index measurements. Data were analyzed using paired t-tests to compare the means of APFT scores across the 2 pregnancies. The subjects served as their own controls. This study was approved by Regional Health Command-Pacific. RESULTS: A total of 2,103 active duty soldiers delivered singleton pregnancies at Tripler Army Medical Center between January 2011 and March 2017. Among these, 16 women delivered both their first- and second-term pregnancies and had APFT data available for analysis. Average age at time of first and second delivery was 26.1 and 28.1 years, respectively. Mean time separating the first postpartum APFT from the delivery was 8.8 months for the first pregnancy and 7.3 months following the second.A significant decrease in mean sit-up score was found comparing APFT-1 with APFT-2 (72.1 vs 65.7, P = .043) and comparing APFT-1 to APFT-3 (72.1 vs 60.9, P = .002). A significant increase in mean run time was found comparing APFT-1 to APFT-3 (16.9 minutes vs 17.9 minutes, P = .010) and APFT-2 to APFT-3 (17.5 minutes vs 17.9 minutes, P = .027). Comparing APFT-1 to APFT-3 showed a significant decrease in sit-up raw scores (P = .002), run times (P = .010), and total APFT scores (P = .01). Overall, the data show a trend of decreasing performance in all APFT events across the 3 APFTs and a trend toward higher failure rates. This cohort of soldiers did not experience weight gain following the pregnancies. CONCLUSIONS: The present study is the first to analyze the association of serial pregnancies on physical fitness utilizing a validated physical fitness test, and the results suggest that a second pregnancy is associated with progressive worsening of performance. This study is limited by the small sample size, and future studies could further elucidate the degree to which serial pregnancies affect physical fitness.

Seasonality and Climatic Factors Associated With Human Rhinovirus/Enterovirus Nasopharyngeal Sample Positivity on Oahu, Hawai'i, 2016-2019.

INTRODUCTION: Globally, human rhinoviruses/enteroviruses (HRVs/ENTs), indistinguishable on many widely available molecular platforms, are among the leading causes of the common cold. Geographic and climatic factors impact the peak activity of these viruses. In temperate climates, the peak activity of HRV occurs during autumn and spring whereas that of ENT occurs during autumn and summer. Both viruses are thought to peak during the rainy season in tropical climates like Hawai'i; however, data remain limited. We describe HRV/ENT seasonality and evaluate the climatic factors associated with peak activity among respiratory viral samples processed on Oahu, Hawai'i. MATERIALS AND METHODS: We conducted a retrospective analysis of all respiratory specimens submitted to Tripler Army Medical Center for multiplex polymerase chain reaction testing between May 2016 and May 2019. Among HRV/ENT-positive samples, we recorded the month and year of positivity. Summative monthly positive detection was calculated with peak months above the mean. Associations between temperature, precipitation levels, relative humidity, and wind speed by week and the number of positive samples for HRV/ENT were evaluated using Poisson regression. This analysis was conducted via IRB exempt protocol number 19R18. RESULTS: During our study period, there were 7,143 nasopharyngeal respiratory samples sent for multiplex polymerase chain reaction testing, with 1,572 positive for HRV/ENT (22%). Nineteen percent of respiratory samples positive for HRV/ENT were additionally positive for one or more respiratory pathogens. The majority of HRV/ENT-positive samples arose from children < 5 years of age (n = 959, 61%). Peak months were February, March, May, August, November, and December. After controlling for lagged count and year, average wind speed was the only climatic factor significantly associated with HRV/ENT sample positivity. CONCLUSIONS: The peak monthly activity of HRV/ENT was similar to temperate climates with the exception of peak activity in February. Unlike other tropical climates, lower wind speed was associated with increased weekly HRV/ENT positivity and should be further explored as a transmission factor. Our study contributes to understanding the annual variability of HRV/ENT activity in tropical environments, which can inform clinician expectations regarding respiratory viral symptomatology in this region.

Outcomes of LGBTQ culturally sensitive training among civilian and military healthcare personnel.

BACKGROUND: Lesbian, gay, bisexual, transgender, or queer (LGBTQ) military servicemembers are at higher risk of developing health problems compared to heterosexual peers. To improve outcomes and address negative attitudes, previous literature has recommended education of healthcare personnel. The purpose of our study was to evaluate the knowledge and skill outcomes of an LGBTQ cultural sensitivity training program. METHODS: We used a pretest/posttest design. Participants completed the Ally Identity Measure (AIM) to assess three subscales: knowledge and skills, openness and support, and oppression awareness. Participants included both military and civilian healthcare personnel from multiple disciplines. Descriptive statistics and pairwise analyses were used. RESULTS: A total of 101 participants answered both pretest and posttest. Across all AIM subscales, posttest scores demonstrated statistically significant (P < 0.001) increases from mean pretest scores. Completion rates for the pretest and posttest were 99% and 93%, respectively. The majority of participants were female (75%) and non-Hispanic (87%), composed of Caucasians (39%) and Asians (33%). Over one-third (39%) of participants were aged 30-39. Fifty percent were active-duty military and more than half (58%) of all participants did not have prior training in LGBTQ patient care. Statistically significant differences were found between the pretest and posttest scores for the knowledge and skills subscale (M = 2.64-3.70). The most significant increases were observed in Item 12 and Item 15 (M = 2.72-3.70) regarding awareness of theories and skill development to provide proper support, respectively. CONCLUSION: These significant findings contribute to the currently limited research exploring LGBTQ cultural sensitivity training in both civilian and military settings. To our knowledge, this is the first time a cultural sensitivity training of this depth has been provided to active-duty servicemembers. Further research and development of similar educational programs integrating interactive participation can potentially aid in the delivery of improved care and military readiness for all servicemembers.

Using Reminder Letters to Improve Adherence to Routine Hemoglobin A1C Testing in Adults with Diabetes.

The American Diabetes Association (ADA) recommends hemoglobin A1C (A1C) goals of < 7% for most non-pregnant adults and < 8% for adult patients with extensive or life-limiting comorbidities. A1C testing is indicated every 3-months for patients not meeting goals to assess glycemic control, adjust medications, suggest lifestyle changes, and offer counseling. However, many patients do not adhere to routine testing. A clinic-wide quality improvement (QI) pilot project was implemented using mailed reminder letters to improve patient adherence to routine A1C testing in patients with hemoglobin A1C . 8%. Sixty-eight patients were identified for this letter intervention. Of these, 14 patients (20%) were historically adherent to 3-month interval testing, 31 patients (46%) were historically non-adherent, and 23 (34%) had historical A1C test intervals of less than 3-months because of provider orders. The primary outcome was improvement in A1C testing adherence rates of those who were previously non-adherent. There was a 58% increase overall and a 103% increase in testing rates among women. Statistical significance was not observed at the P = .05 level. However, improvement in adherence rates among women reached the P = .10 significance level. Mailed reminder letters may be useful in improving adherence to routine A1C testing in patients with diabetes. Further study of this intervention in larger groups is needed to provide timely data for the management of diabetes care.

Behavioral Health Screening in Military Cystic Fibrosis Centers: A Survey.

INTRODUCTION: Cystic fibrosis (CF) is the most common life-threatening genetic illness in the United States. People with CF as well as their caregivers are up to three times more likely to report experiencing symptoms of depression and anxiety than those without CF. In 2016, the Cystic Fibrosis Foundation and the European Cystic Fibrosis Society came together to form the International Committee on Mental Health in CF and released guidelines outlining behavioral health (BH) screening recommendations for patients with CF and at least one primary caregiver. This study sought to characterize the role of BH care in routine CF treatment within the DoD health care system and identify potential opportunities for improvement. The resultant brief report is intended to elucidate and present identified areas of improvement as well as to inform further research projects in this field. MATERIALS AND METHODS: A representative sample of program leaders (8 of 12; five program directors and three nurse coordinators) from all six affiliate CF centers in the DoD completed a 23-item web-based survey. This study sought to identify the following: (1) What tools are DoD affiliate CF centers using to screen patients with CF and their caregiver(s) for psychological distress and how often does screening take place? (2) What is the composition of the DoD's CF BH teams by specialty and to what degree are BH personnel available to support the needs of CF patients? (3) How comfortable are program directors and nurse coordinators in screening patients with CF and their caregiver(s) for indicators of psychological distress? (4) How familiar are CF BH teams with the use of the U.S. Military's Behavioral Health Data Portal (BHDP)? This descriptive study was approved by the Human Use Committee at the Tripler Army Medical Center. RESULTS: The results of this study indicated that 80% of the DoD affiliate CF centers are screening patients with CF who are 12 years and older and at least one caregiver at least annually for depression and anxiety with the Patient Health Questionnaire depression module and generalized anxiety disorder screening tool, respectively. Reported screening tools for suicidality were not standardized across centers. All respondents indicated that there is a designated social worker in their CF clinic team. Three-quarters of respondents reported that their social worker is physically present in CF clinics 75%-100% of the time. Other types of BH team members varied by clinic. Program directors and nurse coordinators on average indicated feeling "somewhat comfortable" in screening patients with CF for depression, anxiety, and suicidality. Eighty percent of program directors reported being "not so comfortable" in screening caregivers for depression, anxiety, and suicidality, with nurse coordinators on average reporting feeling "somewhat comfortable." Eighty percent of affiliate CF centers indicated that they are unaware of, are not utilizing, or do not have access to the BHDP to screen and record BH data for patients with CF or their caregiver(s). CONCLUSIONS: This study characterized routine CF BH care at DoD affiliate CF centers. Areas for improvement include the standardized use of screening tools for suicidality, increased provider comfort with screening, and streamlined recording and tracking of this data using the BHDP. Limitations of this study include inherent self-report bias, specifically social desirability bias. Steps toward suggested improvements and further utilization of the BHDP may improve BH care for patients with CF and their caregiver(s) in addition to facilitating future research.

Pre-Pregnancy Physical Fitness, Body Mass Index and Gestational Weight Gain as Risk Factors for Cesarean Delivery: A Study of Active Duty Women.

INTRODUCTION: The World Health Organization considers the optimal rate of delivery by Cesarean among healthy nulliparous women to be <15%. In 2020, the rate of primary Cesarean delivery (CD) in the US among nulliparous women with singleton, vertex pregnancies was 26%. An enhanced understanding of factors associated with women undergoing CD may assist in reducing this rate. One potential factor is the level of physical fitness in women before pregnancy. Active duty (AD) soldiers provide a cohort of women who begin pregnancy while actively pursuing physical fitness. The research team sought to assess the effects of pre-pregnancy physical fitness of AD soldiers as measured by the Army Physical Fitness Test (APFT) on the incidence of CD in AD women, in addition to examining known demographic and pregnancy risk factors in this cohort. MATERIALS AND METHODS: We conducted a retrospective study of healthy AD nulliparous women who delivered their singleton pregnancy of >32 weeks at a tertiary medical center between 2011 and 2016. Soldiers undergoing non-labored CD were excluded. Demographics, pre-pregnancy APFT results, antepartum and labor and delivery data were collected from the Digital Training Management System, the outpatient, and inpatient medical records respectively. Weight gain in pregnancy was assessed using the Institute of Medicine Guidelines for pregnancy. Fisher's exact tests and chi-squared tests assessed associations between categorical outcomes, and unpaired t-tests assessed differences in APFT scores between women who underwent CD vs. vaginal delivery. Multivariable logistic regression analysis was used to assess for independent risk factors among all collected variables. The protocol was approved by the Regional Health Command-Pacific Institutional Review Board. RESULTS: Five-hundred-and-twenty-three women delivering singleton pregnancies between 2011 and 2016 were reviewed for this study. Three-hundred ninety women met inclusion criteria: 316 in the vaginal delivery cohort, and 74 in the CD cohort, with a CD rate of 19%. Twenty non-labored CDs were excluded. Neither total APFT performance nor performance on the individual push-up, sit-up or run events in the 15 months prior to pregnancy was associated with mode of delivery. Excessive gestational weight gain (EWG) and neonatal birth weight were the only two factors independently associated with an increased rate of cesarean delivery. Women who had excessive gestational weight gain, were twice as likely to undergo CD as those who had adequate or insufficient weight gain (24% vs. 12%, p = 0.004). Soldiers delivering a neonate ≥4,000 g were 2.8 times as likely to undergo CD as those delivering a neonate <4,000 g (47% vs. 17%, p < 0.001). Age, race, and rank, a surrogate marker for socioeconomic status, were not associated with mode of delivery. CONCLUSION: Pre-pregnancy fitness levels as measured by the APFT among healthy physically active nulliparous AD women showed no association with the incidence of labored CD. EWG is one modifiable factor which potentially increases the risk for CD in this cohort and has been documented as a risk factor in a recent metanalysis (RR-1.3). Counseling on appropriate weight gain in pregnancy may be the most effective way to reduce the rate of CD among this population of healthy and physically active women.

Effect of SARs-CoV-2 pandemic on infection prevention behaviors and bacterial burden of high touch surfaces in a medical/surgical setting.

This study aimed to determine the longitudinal efficacy of ultraviolet germicidal disinfection (UV-C) in a non-terminal disinfection context. Moreover, factors influencing enhanced infection prevention behaviors during the SARS-CoV-2 pandemic were evaluated. Sixty nursing staff from three medical/surgical wards in a large military hospital were recruited for a survey and microbiological sampling of high-touch surfaces (stethoscope, personal electronic device, common access card, and hospital ID badge) and portable medical equipment (wheelchairs and mobile commodes). Surveys included hand hygiene estimates, frequency/method of cleaning items of interest, perception of UV-C, and factors influencing the use of enhanced disinfection tools. Surveys and microbiological samples were performed prior to and after the installation of a rapid, automated ultraviolet disinfection enclosure for staff use. Both time points preceded the SARS-CoV-2 pandemic in the United States. A final survey/sampling time point was carried out eight months after the declaration of the COVID-19 pandemic. Participants' hand hygiene frequency did not increase throughout the study, with > 80% reporting a minimum of 4 hand hygiene events per patient hour. The cleaning frequency of high-touch surfaces (non-clinical) but not portable medical equipment increased after installation of a UV-C disinfection tool and was sustained eight months into the COVID-19 pandemic. While a modest decrease in bacterial burden was observed after UV-C intervention, a more significant reduction was observed across all surfaces during pandemic time sampling, though no detectable decrease in pathogenic contamination was observed at either time point. Motivators of UV-C use included fear of SARS-CoV-2 contamination and transmission, ease of device use, and access to rapid, automated disinfection tools while deterrents reported included technical concerns, lack of time, and preference for other disinfection methods. Automated, rapid-cycle UV-C disinfection can be efficacious for high-touch surfaces not currently governed by infection prevention and control guidelines. The introduction of enhanced disinfection tools like UV-C can enhance the overall cleaning frequency and is correlated with mild decreases in bacterial burden of high-touch surfaces, this is enhanced during periods of heightened infection threat. Evidence from this study offers insights into the factors which prompt healthcare workers to internalize/dismiss enhanced infection prevention procedures.

Prospective Results of the Modified Glide Path Technique for Improved Syndesmotic Reduction During Ankle Fracture Fixation.

BACKGROUND: Malreduction after syndesmotic stabilization occurs in as many as 52% of cases and has been shown to detrimentally affect clinical outcomes. We propose that the modified Glide Path technique reduces the occurrence of syndesmotic malreduction. METHODS: This study is a prospective series comparing 16 patients reduced with the modified Glide Path technique with a retrospectively reviewed series of 25 patients reduced with a traditional technique using fluoroscopy and a clamp. The modified Glide Path technique consists of manual reduction of the fibula and placement of a Kirschner wire through the fibula and tibia along the transmalleolar axis. The syndesmosis can then be reduced along the glide path created by the Kirschner wire to prevent posterior or anterior malreduction. Computed tomographic scans of the repaired and contralateral ankles were obtained postoperatively to assess reduction. RESULTS: We found a statistically significant decrease of syndesmotic malreductions using the modified Glide Path technique when compared with technique that did not use a glide path. In our study, 2 of 16 patients (12.5%) had syndesmotic malreductions using the modified Glide Path technique, compared with 11 of 25 patients (44%) with syndesmotic malreductions in the historical cohort. CONCLUSION: The modified Glide Path technique is a simple method for ankle syndesmotic reduction. The technique has lower rates of malreduction compared with historical methods and may be useful for most operative syndesmotic injuries. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Aerodigestive clinic reduces emergency department and primary care utilization and increases access to ancillary and specialty care.

OBJECTIVE: The study aimed to evaluate the effect of the aerodigestive clinic (ADC) on healthcare utilization. STUDY DESIGN: Retrospective quality improvement project; before and after. SETTING: The ADC at Tripler Army Medical Center (TAMC) in Honolulu, HI. METHODS: We retrospectively analyzed the electronic medical records of children ≤17 years old seen in the ADC at TAMC between April 2015 and June 2019. The number of emergency department (ED), primary care (PC), specialty care (SC), ancillary care (AC), and teleconsult (TC) encounters were tallied before and after one year of the initial intake visit. RESULTS: A total of 261 children were included during the study period. Comparing visits before aerodigestive evaluation to after aerodigestive evaluation, the total number of visits before and after were similar with significant changes in the distribution of encounters. The total number of ED (-38%) and PC (-40%) visits decreased significantly (p < 0.001 for both). The total number of other visits were found to have non-significant increases. PC visits accounted for nearly one-third (31%) of all visits prior to the initial ADC visit, but only 19% of visits after. PC visits decreased for all age groups. ED visits decreased by nearly half (-48.1%) for ages 1-17, but there was no change for <1-year olds. CONCLUSION: There is a statistically significant reduction in the number of emergency department and primary care visits for patients seen in a multidisciplinary ADC. The distribution of visits differed strongly among age groups. These findings emphasize the positive impact that the multidisciplinary clinic has on healthcare utilization for pediatric aerodigestive patients.

Persons tested for SAR-CoV-2 at a military treatment facility in Hawaii.

Health inequalities based on race are well-documented, and the COVID-19 pandemic is no exception. Despite the advances in modern medicine, access to health care remains a primary determinant of health outcomes, especially for communities of color. African-Americans and other minorities are disproportionately at risk for infection with COVID-19, but this problem extends beyond access alone. This study sought to identify trends in race-based disparities in COVID-19 in the setting of universal access to care. Tripler Army Medical Center (TAMC) is a Department of Defense Military Treatment Facility (DoD-MTF) that provides full access to healthcare to active duty military members, beneficiaries, and veterans. We evaluated the characteristics of individuals diagnosed with SARS-CoV-2 infection at TAMC in a retrospective, case-controlled (1:1) study. Most patients (69%) had received a COVID-19 test within 3 days of symptom onset. Multivariable logistic regression analyses were used to identify factors associated with testing positive and to estimate adjusted odds ratios. African-American patients and patients who identified as "Other" ethnicities were two times more likely to test positive for SARS-CoV-2 relative to Caucasian patients. Other factors associated with testing positive include: younger age, male gender, previous positive test, presenting with >3 symptoms, close contact with a COVID-19 positive patient, and being a member of the US Navy. African-Americans and patients who identify as "Other" ethnicities had disproportionately higher rates of positivity of COVID-19. Although other factors contribute to increased test positivity across all patient populations, access to care does not appear to itself explain this discrepancy with COVID-19.

Increasing Faculty Participation and Mentorship in Quality Improvement with an Experiential Four-Hour Workshop.

BACKGROUND: Graduate medical education programs lack enough faculty trained in quality improvement (QI). A major barrier to increasing the number of faculty competent in QI is insufficient time to engage in training. Research is missing on the effectiveness of short faculty development workshops to teach academic faculty QI principles and promote participation and mentorship in QI projects. OBJECTIVE: The authors assessed the ability of a four-hour experiential QI workshop to increase faculty proficiency in QI principles, enhance faculty involvement in QI, and improve resident mentorship in QI. METHODS: From 2016 to 2017, the authors conducted seven QI faculty development workshops at a large academic medical center with 12 ACGME training programs. We evaluated the workshop using pre- and post-workshop surveys, as well as six- and twelve-month follow up surveys. RESULTS: Sixty-five faculty participated in seven workshops over 13 months. All participants completed pre- and post-workshop surveys, while 38% (n = 25) responded to the six- and twelve-month follow up surveys. Overall, the workshop significantly increased confidence to lead and mentor residents on a QI project (25% pre vs. 72% post, p < .001), increased ability to teach QI (8% pre vs. 36% post, p < .001), increased participation in planning and decision making on a QI team (32% pre vs. 50% post, p = .002), and increased the mean number of QI projects implemented (.45 pre vs. 1.24 post; p < .05). CONCLUSION: A four-hour QI workshop is a quick and effective training method to develop academic faculty to teach and mentor residents in QI. The principles taught increased perceived knowledge, confidence in mentorship, and participation in QI.

Updated Review of the Pacific Asynchronous Telehealth System's Impact on Military Pediatric Teleconsultations.

Introduction: The Pacific Asynchronous TeleHealth (PATH) system is an asynchronous provider-to-provider teleconsultation platform utilized by military medical facilities throughout the Western Pacific Region. This study focused on PATH utilization for pediatric cases and its impact on patient transfers and cost avoidance. Methods: This retrospective analysis reviewed PATH cases from March 2017 to February 2020 for patients aged 0-17 years. We reviewed the referring users' responses to survey questions related to the impact of PATH consultation on patient travel for in-person subspecialty care and the need for local referral. Data for cost avoidance were estimated using per diem rates and airline flight costs for Fiscal Year 2020. Results: A total of 2,448 pediatric consultations were submitted from 29 military medical facilities. Pediatric Pulmonology (n = 557, 24.5%), Pediatric Cardiology (n = 446, 19.6%), and Pediatric Neurology (n = 236, 10.37%) had the highest percentage of pediatric teleconsults. Approximately 42% of referring users completed the survey questions. Among survey respondents, 710 (69.4%) indicated that unnecessary patient transfers were prevented, equating to a cost savings of ∼$3.3 million. Conclusions: We observed robust utilization of the PATH system by pediatric providers in the Military Health System that ultimately resulted in substantial cost avoidance. This asynchronous telemedicine platform is a vital asset in locations with limited access or travel restriction to medical specialists, such as during pandemics.

Respiratory Viral Pathogens Among U.S. Military Personnel at a Medical Treatment Facility in Hawaii From 2014 to 2019.

INTRODUCTION: Acute respiratory diseases account for a substantial number of outpatient visits and hospitalizations among U.S. military personnel, significantly affecting mission readiness and military operations. We conducted a retrospective analysis of respiratory viral pathogen (RVP) samples collected from U.S. military personnel stationed in Hawaii and tested at Tripler Army Medical Center from January 2014 to May 2019 in order to describe the etiology, distribution, and seasonality of RVP exposure in a military population. MATERIALS AND METHODS: Samples were analyzed by viral culture or multiplex PCR. Distribution of respiratory viruses over time was analyzed as well as subject demographic and encounter data. Presenting signs and symptoms were evaluated with each RVP. RESULTS: A total of 2,576 military personnel were tested, of which 726 (28.2%) were positive for one or more RVP. Among positive tests, the three most common viral pathogens detected were influenza A (43.0%), rhinovirus (24.5%), and parainfluenza (7.6%). Symptoms were generally mild and most frequently included cough, fever, and body aches. CONCLUSION: Our study evaluated respiratory virus prevalence, seasonality, and association with clinical symptoms for military personnel in an urban tropical setting in Oahu, HI, over a 5-year period. We show that viral prevalence and seasonality in Hawaii are distinct from those of the CONUS. Results contribute to the broader understanding of seasonality, clinical manifestation, and demographics of RVP among active duty military personnel stationed in Hawaii.

Limited impact of an ultraviolet disinfection intervention on hygienic behaviors of nursing staff in a military hospital.

Ultraviolet disinfection (UV-C), though effective, has not been thoroughly evaluated at the level of the clinical end user. We assessed behavioral outcomes related to environmental hygiene among 60 nursing staff in a medical-surgical section after introduction of a UV-C tool aimed at disinfecting 4 high-touch surfaces, and we noted limited changes.

Correlation of stress radiographs to injuries associated with lateral ankle instability.

BACKGROUND: Stress radiographs have demonstrated superior efficacy in the evaluation of ankle instability. AIM: To determine if there is a degree of instability evidenced by stress radiographs that is associated with pathology concomitant with ankle ligamentous instability. METHODS: A retrospective review of 87 consecutive patients aged 18-74 who had stress radiographs performed at a single institution between 2014 and 2020 was performed. These manual radiographic stress views were then correlated with magnetic resonance imaging and operative findings. RESULTS: A statistically significant association was determined for the mean and median stress radiographic values and the presence of peroneal pathology (P = 0.008 for tendonitis and P = 0.020 for peroneal tendon tears). A significant inverse relationship was found between the presence of an osteochondral defect and increasing degrees of instability (P = 0.043). CONCLUSION: Although valuable in the clinical evaluation of ankle instability, stress radiographs are not an independent predictor of conditions associated with ankle instability.

Implementing total-dose ferumoxytol in lieu of split-dose ferumoxytol.

BACKGROUND: Ferumoxytol is Food and Drug Administration-approved as two 510 mg infusions. Retrospective and prospective reviews have established that a single 1020 mg infusion is as efficacious and safe as two 510 mg infusions. OBJECTIVES: To transition our preferred intravenous iron infusion practice from two 510 mg infusions to a single 1020 mg ferumoxytol infusion. PRACTICE DESCRIPTION: This is a prospective process improvement study conducted at Tripler Army Medical Center, a large academic medical center. PRACTICE INNOVATION: We set up an evidence-based project to transition and monitor our preferred iron treatment of ferumoxytol from 2 doses to 1 dose. EVALUATION METHODS: We collected efficacy and safety data for 188 unique patients receiving 228 infusions, of which 62 were single 1020 mg doses, and 166 were two 510 mg doses. RESULTS: Comparing the 1020 mg dose in 62 patients with 166 patients treated with two 510 mg infusions, we found no increase in the rate of infusion reactions (4.8 % vs. 4.8 %) and comparable improvement in ferritin and hemoglobin (144 ng/mL vs. 140 ng/mL; P value = 0.874, and 1.8 g/dL vs. 1.9 g/dL; P value = 0.721, respectively). CONCLUSION: Thus, we were able to successfully transition to total-dose ferumoxytol for iron-deficient anemia, effectively reducing patient treatment visits without any difference in safety or efficacy. Ferumoxytol 1020 mg infused intravenously over 30 minutes in 250 mL normal saline single dose is a viable, safe, and effective treatment for iron-deficiency anemia.

The effect of pregnancy and the duration of postpartum convalescence on the physical fitness of healthy women: A cohort study of active duty servicewomen receiving 6 weeks versus 12 weeks convalescence.

INTRODUCTION: Pregnancy profoundly affects cardiovascular and musculoskeletal performance requiring up to 12 months for recovery in healthy individuals. OBJECTIVE: To assess the effects of extending postpartum convalescence from 6 to 12 weeks on the physical fitness of Active Duty (AD) soldiers as measured by the Army Physical Fitness Test (APFT) and Body Mass Index (BMI). METHODS: We conducted a retrospective study of AD soldiers who delivered their singleton pregnancy of ≥ 32weeks gestation at a tertiary medical center. Pre- and post-pregnancy APFT results as well as demographic, pregnancy, and postpartum data were collected. Changes in APFT raw scores, body composition measures, and failure rates across the 6-week and 12-week convalescent cohorts were assessed. Multivariable regressions were utilized to associate risk factors with failure. RESULTS: Four hundred sixty women met inclusion criteria; N = 358 in the 6 week cohort and N = 102 in the 12 week cohort. Demographic variables were similar between the cohorts. APFT failure rates across pregnancy increased more than 3-fold in both groups, but no significant differences were found between groups in the decrement of performance or weight gain. With the combined cohort, multivariable regression analysis showed failure on the postpartum APFT to be independently associated with failure on the pre-pregnancy APFT (OR = 16.92, 95% CI 4.96-57.77), failure on pre-pregnancy BMI (OR = 8.44, 95% CI 2.23-31.92), elevated BMI at 6-8 weeks postpartum (OR = 4.02, 95% CI 1.42-11.35) and not breastfeeding at 2 months (OR = 3.23, 95% CI 1.48-7.02). Within 36 months of delivery date, 75% of women had achieved pre-pregnancy levels of fitness. CONCLUSION: An additional 6 weeks of convalescence did not adversely affect physical performance or BMI measures in AD Army women following pregnancy. Modifiable factors such as pre- and post-pregnancy conditioning and weight, weight gain in pregnancy and always breastfeeding were found to be significant in recovery of physical fitness postpartum.

The prevalence of M. tuberculosis among acid fast bacilli cultures from military health system and veterans affairs beneficiaries in Hawaii and the Pacific Islands from 2002 to 2019.

The prevalence of tuberculosis among military health system (MHS) and Veterans Affairs (VA) beneficiaries in Hawaii and the Pacific Islands has not been previously reported. Our analysis evaluates the prevalence of M. tuberculosis (MTB) among acid fast bacilli culture(s) (AFB) tested at Tripler Army Medical Center (TAMC) on Oahu, HI and describes demographic factors associated with positive samples. We analyzed 9,768 AFBs from 4,129 individuals with AFB specimens processed at TAMC from January 2002 to November 2019: of those who were tested 3,178 were MHS beneficiaries and 951 were VA beneficiaries. There were a total of 40 individuals with MTB-positive cultures over the period of study: 31 MHS beneficiaries and 9 VA beneficiaries. Of the MTB-positive specimens, 93% were from pulmonary samples while the remainder were from lymph node aspirates (5%) and peritoneal samples (2%). Cumulative incidence rates of MTB-isolation were 1.8 per 100,000 MHS beneficiaries and 1.2 per 100,000 VA beneficiaries, both of which were lower than reported incidence rates in Hawaii, the U.S.-affiliated Pacific Islands and the United States for the study period. MHS beneficiaries of Asian-Pacific Islander race or ethnicity had nearly 20 times higher odds of positive AFB than white MHS beneficiaries (OR = 19.56, 95% CI 5.52, 69.29, p = < 0.001). This study demonstrated a higher odds of MTB-positivity associated with Asian-Pacific Islander race or ethnicity and low incidence rates of TB among MHS and VA beneficiaries in Hawaii and the Pacific Islands when compared with the civilian population.

Prevalence and Epidemiology of Mycoplasma genitalium in a Pacific-Region Military Population.

BACKGROUND: Mycoplasma genitalium is an important emerging sexually transmitted pathogen commonly causing urethritis in men, cervicitis, and pelvic inflammatory disease in women with potential of infertility. Accumulating evidence identifies the prevalence of M. genitalium similar to long recognized pathogens, Chlamydia trachomatis and Neisseria gonorrhoeae. The purpose of this study was to establish the prevalence and epidemiology of M. genitalium in a mid-Pacific military population. METHODS: A prospective analysis was conducted from routine specimens collected as standard of care for sexually transmitted infection (STI) testing at Tripler Army Medical Center on Oahu, HI. The prevalence of M. genitalium was determined using the Aptima M. genitalium assay, a transcription-mediated amplification test. A multivariate analysis was performed to assess the associations for this infection with other STIs and demographic factors. RESULTS: A total of 1876 specimens were tested in a 6-month period including 6 sample types from 1158 females and 718 males. Subject ages ranged from 18 to 76 years, with a median of 24 years (interquartile range, 21-29 years). The prevalence of M. genitalium was 8.8% overall (n = 165), 7.1% in females and 11.6% in males. Coinfection with M. genitalium occurred with another sexually-transmitted pathogen in 43 patients (18.3%), with C. trachomatis as the most common organism (n = 38). CONCLUSIONS: These data contribute to the evidence base for M. genitalium and STI screening in an active-duty military.

A Longitudinal Evaluation of the Bacterial Pathogens Colonizing Chronic Non-Healing Wound Sites at a United States Military Treatment Facility in the Pacific Region.

PURPOSE: The biology of chronic wounds is complex and many factors act concurrently to impede healing progress. In this study, the dynamics of microflora changes and their antibiotic susceptibility patterns were evaluated longitudinally over 30 days using data from 28 patients with a total of 47 chronic lower extremity wounds. MATERIALS AND METHODS: In this study, colonized wound isolates were characterized using cultural, biochemical, and VITEK 2 methods. Antibiotic susceptibility patterns of the wound isolates were analyzed using various phenotypic assays. Furthermore, antimicrobial resistance patterns and the presence of mutations were evaluated by a genotypic assay, whole-genome sequencing (WGS). RESULTS: Staphylococcus aureus and Pseudomonas aeruginosa were found to be the most common strains at early time points, while members of Enterobacteriaceae were prevalent at later stages of infection. Antimicrobial resistance testing and whole-genome sequencing revealed that the molecular and phenotypic characteristics of the identified wound pathogens remained relatively stable throughout the study period. It was also noted that Enterobacter and Klebsiella species may serve as reservoirs for quinolone resistance in the Pacific region. CONCLUSION: Our observations showed that wounds were colonized with diverse bacteria and interestingly their numbers and/or types were changed over the course of infection. The rapid genetic changes that accompanied the first 4 weeks after presentation did not directly contribute to the development of antibiotic resistance. In addition, standard wound care procedures did not appear to select for resistant bacterial strains. Future efforts should focus on defining those genetic changes associated with the wound colonizing microorganisms that occur beyond 4 weeks.