Vasovagal Electrophysiology on 12-Lead ECG After Venipuncture.

Vasovagal syncope is the most common form of syncope seen in young and otherwise healthy active duty service members. Although self-limiting, syncopal events often produce a significant drain of medical resources because of their sudden and often dramatic presentation, which can be associated with traumatic injuries secondary to loss in postural tone. Malignant differential pathologies associated with syncopal presentation need to be ruled out, which in turn further diminishes resources, especially in a deployed environment that is often in austere, remote locations with a lack of readily available medical supplies. We present a case of vasovagal syncope experienced by a 20-year-old sailor shortly after venipuncture and the 12-lead electrocardiogram captured shortly after presentation. This case highlights the unique electrophysiology during a vasovagal episode and the impact a relatively benign condition has on medical operations in the operational setting.

Optimizing Scarce Resource Allocation During COVID-19: Rapid Creation of a Regional Health-Care Coalition and Triage Teams in San Diego County, California.

Successful management of an event where health-care needs exceed regional health-care capacity requires coordinated strategies for scarce resource allocation. Publications for rapid development, training, and coordination of regional hospital triage teams to manage the allocation of scarce resources during coronavirus disease 2019 (COVID-19) are lacking. Over a period of 3 weeks, over 100 clinicians, ethicists, leaders, and public health authorities convened virtually to achieve consensus on how best to save the most lives possible and share resources. This is referred to as population-based crisis management. The rapid regionalization of 22 acute care hospitals across 4500 square miles in the midst of a pandemic with a shifting regulatory landscape was challenging, but overcome by mutual trust, transparency, and confidence in the public health authority. Because many cities are facing COVID-19 surges, we share a process for successful rapid formation of health-care care coalitions, Crisis Standard of Care, and training of Triage Teams. Incorporation of continuous process improvement and methods for communication is essential for successful implementation. Use of our regional health-care coalition communications, incident command system, and the crisis care committee helped mitigate crisis care in the San Diego and Imperial County region as COVID-19 cases surged and scarce resource collaborative decisions were required.

Effects of Obstructive Sleep Apnea and CPAP on Cognitive Function.

PURPOSE OF REVIEW: Obstructive sleep apnea (OSA) is characterized by repetitive episodes of complete or partial upper airway obstruction during sleep. Studies indicate that OSA is an independent risk factor for cognitive decline in older patients. The purpose of this paper is to critically review the recent literature on the cognitive effects of untreated OSA and the benefits of treatment across cognitive domains. RECENT FINDINGS: OSA's greatest impact appears to be on attention, vigilance, and information processing speed. Furthermore, the presence of OSA seems to have a significant impact on development and progression of mild cognitive impairment (MCI). Impact of OSA treatment, particularly with CPAP, appears to mitigate and slow the rate of cognitive decline and may reduce the risk of dementia. Larger properly controlled studies, of a prospective nature, are required to further elucidate the degree of treatment effect. More studies are needed on other treatments for OSA such as oral mandibular devices and hypoglossal nerve stimulation.

Enhancing behavioral sleep care with digital technology: study protocol for a hybrid type 3 implementation-effectiveness randomized trial.

BACKGROUND: Insomnia affects almost one in four military service members and veterans. The first-line recommended treatment for insomnia is cognitive-behavioral therapy for insomnia (CBTI). CBTI is typically delivered in-person or online over one-to-four sessions (brief versions) or five-to-eight sessions (standard versions) by a licensed doctoral or masters-level clinician with extensive training in behavioral sleep medicine. Despite its effectiveness, CBTI has limited scalability. Three main factors inhibit access to and delivery of CBTI including restricted availability of clinical expertise; rigid, resource-intensive treatment formats; and limited capacities for just-in-time monitoring and treatment personalization. Digital technologies offer a unique opportunity to overcome these challenges by providing scalable, personalized, resource-sensitive, adaptive, and cost-effective approaches for evidence-based insomnia treatment. METHODS: This is a hybrid type 3 implementation-effectiveness randomized trial using a scalable evidence-based digital health software platform, NOCTEM™'s Clinician-Operated Assistive Sleep Technology (COAST™). COAST includes a clinician portal and a patient app, and it utilizes algorithms that facilitate detection of sleep disordered patterns, support clinical decision-making, and personalize sleep interventions. The first aim is to compare three clinician- and system-centered implementation strategies on the reach, adoption, and sustainability of the COAST digital platform by offering (1) COAST only, (2) COAST plus external facilitation (EF: assistance and consultation to providers by NOCTEM's sleep experts), or (3) COAST plus EF and internal facilitation (EF/IF: assistance/consultation to providers by NOCTEM's sleep experts and local champions). The second aim is to quantify improvements in insomnia among patients who receive behavioral sleep care via the COAST platform. We hypothesize that reach, adoption, and sustainability and the magnitude of improvements in insomnia will be superior in the EF and EF/IF groups relative to the COAST-only group. DISCUSSION: Digital health technologies and machine learning-assisted clinical decision support tools have substantial potential for scaling access to insomnia treatment. This can augment the scalability and cost-effectiveness of CBTI without compromising patient outcomes. Engaging providers, stakeholders, patients, and decision-makers is key in identifying strategies to support the deployment of digital health technologies that can promote quality care and result in clinically meaningful sleep improvements, positive systemic change, and enhanced readiness and health among service members. TRIAL REGISTRATION: ClinicalTrials.gov NCT04366284 . Registered on 28 April 2020.

Triage of Scarce Critical Care Resources in COVID-19 An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians.

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

The relationship between military occupation and diagnosed insomnia following combat deployment.

STUDY OBJECTIVES: Our objective was to investigate the relationship between military occupation and diagnosed insomnia following combat deployment. METHODS: This retrospective cohort study was conducted using existing electronic military databases. Eligible participants were military personnel with a deployment to Iraq, Afghanistan, or Kuwait between 2005 and 2009. A total of 66,869 U.S. Navy and U.S. Marine Corps service members constituted the study sample and were categorized by military occupation. Military medical databases were used to abstract information on insomnia diagnoses and prescription medications. RESULTS: The overall prevalence of diagnosed insomnia was 3.4%. In multivariable logistic regression, personnel in law enforcement (odds ratio = 1.62; 95% confidence interval, 1.28-2.04), motor transport (odds ratio = 1.38; 95% confidence interval, 1.14-1.66), and health care occupations (odds ratio = 2.24; 95% confidence interval, 1.85-2.71) had significantly higher odds of an insomnia diagnosis following deployment than did those in infantry occupations. These results remained unchanged after excluding those who reported posttraumatic stress disorder symptoms. Nonbenzodiazepine sedative/hypnotics were prescribed for 44.2% of those with insomnia, and prescription patterns differed by occupation. CONCLUSIONS: These results suggest that military occupation may play a primary role in the onset and management of insomnia. The findings provide a rationale for targeting individuals in insomnia-susceptible occupations with better methods to prevent and/or minimize sleep issues during and after combat deployment.

Effect of Obstructive Sleep Apnea on Neurocognitive Performance.

This article reviews the effects of obstructive sleep apnea on neurocognitive performance, proposed mechanisms of cognitive impairment, and the effects of continuous positive airway pressure on performance. Obstructive sleep apnea can affect several domains of neurocognitive performance to include attention and vigilance, memory and learning, psychomotor function, emotional regulation, and executive function. Proposed mechanisms include intermittent hypoxemia, sleep deprivation and fragmentation, hypercapnia, and disruption of the hypothalamic-pituitary-adrenal-axis. Continuous positive airway pressure can improve cognitive defects associated with obstructive sleep apnea. More data are needed to determine whether other therapies improve cognitive function.

Lung Cancer Screening at a Military Treatment Facility: A Retrospective Review.

INTRODUCTION: Lung cancer is the leading cause of cancer death among men and women, accounting for more fatalities than colon, breast, and prostate cancers combined. Smoking causes about 85% of all lung cancers in the United States and is the single greatest risk factor. In 2013, the US Preventive Services Task Force (USPSTF) published initial guidelines for low-dose computed tomography lung cancer screening (LCS) among patients 55-80 years old, with a 30-pack-year history, who are current smokers or who quit within the previous 15 years. Smoking prevalence is higher among military personnel compared to the civilian population, demonstrating a need for vigilant screening. MATERIALS AND METHODS: A retrospective review of Naval Medical Center San Diego's (NMCSD) LCS data was conducted to examine screening numbers, lung cancer rates, and initial analysis of screening results. Patients were referred for screening if they met the USPSTF criteria. Between September 2013 and September 2018, 962 patients underwent LCS. A total of 1758 examinations were performed, including follow-up and annual surveillance examinations. The American College of Radiology's Lung CT Screening Reporting and Data System (Lung-RADS) was used to classify lung nodules' risk for malignancy. RESULTS: On this initial analysis, 42 enrolled patients received the diagnosis of lung cancer detected by screening. The initial calculated lung cancer rate is 4.4% (42/962) over the 5-year reporting period. The lung cancer rate among those patients with a Lung-RADS score of 3 or 4 was 31% (42/135). Thirty-seven patients were classified as having non-small cell lung cancer (NSCLC), while five were classified as having small cell lung cancer. Of the 37 NSCLC patients, 76% (28/37) were diagnosed at stage I and II, 11% (4/37) were diagnosed at stage III, and 13% (5/37) were diagnosed at stage IV. The total number of years a person smoked was a significant risk factor (P = 0.004), but not pack-years a person smoked (P = 0.052). CONCLUSIONS: These preliminary results demonstrate the success of a Military Treatment Facility (MTF)-based LCS Program in the detection of early stage lung cancer. Earlier stage detection may result in better health outcomes for affected patients. In the population studied, duration of smoking proved to be more significant than pack-years in predicting lung cancer risk. These results validate the newly dedicated resources and continued efforts to strengthen the LCS program at NMCSD and across MTFs.

Augmenting Critical Care Capacity in a Disaster.

A health care facility must develop a comprehensive disaster plan that has a provision for critical care services. Mass critical care requires surge capacity: augmentation of critical care services during a disaster. Surge capacity involves staff, supplies, space, and structure. Measures to increase critical care staff include recalling essential personnel, using noncritical care staff, and emergency credentialing of volunteers. Having an adequate supply chain and a cache of critical care supplies is essential. Virtual critical care or tele-critical care can augment critical care capacity by assisting with patient monitoring, specialized consultation, and in pandemics reduces staff exposure.

Disasters Resulting from Radiologic and Nuclear Events.

Radiation accidents are rare, but can produce large numbers of casualties with predictable patterns of injury. Casualties may suffer from a wide range of radiation exposures. Triage based on presence or absence of conventional injuries and an accurate assessment of radiation dose based on event history, symptoms, and laboratory testing, is critical. Treatment of acute radiation syndrome is supportive: including fluids, antibiotics, blood products, colony-stimulating factors, and stem cell or bone marrow transplantation. Care of radiation-injured patients with conventional trauma or burns needs to be modified to account for adverse effects of radiation on wound healing and susceptibility to infections.

Effects of Insomnia and Depression on CPAP Adherence in a Military Population.

Initial self-reported depression and insomnia prior to the diagnosis and treatment of obstructive sleep apnea with continuous positive airway pressure therapy did not reliably predict short- and long-term adherence in a sample of active-duty military and veteran patients.

Comparative meta-analysis of prazosin and imagery rehearsal therapy for nightmare frequency, sleep quality, and posttraumatic stress.

STUDY OBJECTIVE: In this meta-analysis, we compare the short-term efficacy of prazosin vs. IRT on nightmares, sleep quality, and posttraumatic stress symptoms (PTSS). METHODS: Reference databases were searched for randomized controlled trials using IRT or prazosin for nightmares, sleep disturbance, and/or PTSS. Effect sizes were calculated by subtracting the mean posttest score in the control group from the mean posttest score in the treatment group, and dividing the result by the pooled standard deviation of both groups. Mixed effects models were performed to evaluate effects of treatment characteristics, as well as sample characteristics (veteran vs. civilian) on treatment efficacy. RESULTS: Four studies used prazosin, 10 used IRT alone or in combination with another psychological treatment, and 1 included a group receiving prazosin and another group receiving IRT. Overall effect sizes of both treatments were of moderate magnitude for nightmare frequency, sleep quality, and PTSS (p < 0.01). Effect size was not significantly different with type of treatment (psychological vs. pharmacological) on nightmare frequency (p = 0.79), sleep quality (p = 0.65), or PTSS, (p = 0.52). IRT combined with CBT for insomnia showed more improvement in sleep quality compared to prazosin (p = 0.03), IRT alone (p = 0.03), or IRT combined with another psychological intervention, (p < 0.01). CONCLUSION: Although IRT interventions and prazosin yield comparable acute effects for the treatment of nightmares, adding CBT for insomnia to IRT seems to enhance treatment outcomes pertaining to sleep quality and PTSS. More randomized clinical trials with long-term follow-up are warranted. COMMENTARY: A commentary on this article appears in this issue on page 9.

Medication effects on sleep and breathing.

Sleep respiration is regulated by circadian, endocrine, mechanical and chemical factors, and characterized by diminished ventilatory drive and changes in Pao2 and Paco2 thresholds. Hypoxemia and hypercapnia are more pronounced during rapid eye movement. Breathing is influenced by sleep stage and airway muscle tone. Patient factors include medical comorbidities and body habitus. Medications partially improve obstructive sleep apnea and stabilize periodic breathing at altitude. Potential adverse consequences of medications include precipitation or worsening of disorders. Risk factors for adverse medication effects include aging, medical disorders, and use of multiple medications that affect respiration.

Plasmapheresis in the management of severe hypertriglyceridemia.

Plasmapheresis can benefit a variety of critically ill patients. A woman with diabetic ketoacidosis and severe hypertriglyceridemia was treated with plasmapheresis when conventional treatments did not markedly reduce her triglyceridemia. The patient was admitted to a medical intensive care unit because of diabetic ketoacidosis with severe lipemia. The lipemia-associated interference in laboratory studies made treatment of electrolyte abnormalities extremely difficult. The hypertriglyceridemia was initially treated with insulin, antilipidemic medications, and heparin, but the levels of triglycerides remained elevated, delaying results of needed laboratory studies for hours. After plasmapheresis, the serum level of triglycerides decreased by 77% in less than 24 hours. Severe lipemia interferes with photometric laboratory studies, yielding an underestimation of serum levels of electrolytes. Plasmapheresis is safe, rapid, and effective for emergent management of severe hypertriglyceridemia in critically ill patients. The impact of the procedure on critical care nursing is growing as nurses become involved in the treatment and follow-up care of patients who have plasmapheresis.

Chronic obstructive pulmonary disease and vascular disease delay timeliness of early stage lung cancer resectional surgery.

INTRODUCTION: Lung cancer remains the leading cause of cancer death in the United States and worldwide. Timeliness to diagnosis and referral for resectional surgery is key to successful management for early stage disease. METHODS: We investigated the contribution of medical co-morbidities in the timeliness to resectional surgery for non-small cell lung cancer (NSCLC). A retrospective record review of NSCLC surgery cases at Naval Medical Center San Diego (NMCSD) from 2004 to 2009 from the tumor registry was conducted. RESULTS: More than 75% of NSCLC patients exhibited at least one co-morbidity. Of the 84 patients, 26% of patients had diabetes, patients with different vascular co-morbidities accounted for 39%, whereas 33% of subjects had COPD. Patients with sleep apnea or liver disease each accounted for 6%. Vascular disease co-morbidity and COPD in NSCLC patients significantly delayed time from initial cardiothoracic surgery evaluation to thoracotomy (p = 0.01-0.02 and p < 0.05 respectively). CONCLUSION: Although significances of different co-morbities in the development NSCLC cannot be extrapolated, theses data show that COPD and vascular diseases are significant risk factors that delay surgical treatment of early stage lung cancer.

The immune response and its therapeutic modulation in bronchiectasis.

Bronchiectasis (BC) is a chronic pulmonary disease with tremendous morbidity and significant mortality. As pathogen infection has been advocated as a triggering insult in the development of BC, a central role for the immune response in this process seems obvious. Inflammatory cells are present in both the airways as well as the lung parenchyma, and multiple mediators of immune cells including proteases and cytokines or their humoral products are increased locally or in the periphery. Interestingly, a defect in the immune system or suppression of immune response during conditions such as immunodeficiency may well predispose one to the devastating effects of BC. Thus, the outcome of an active immune response as detrimental or protective in the pathogenesis of BC may be dependent on the state of the patient's immunity, the severity of infection, and the magnitude of immune response. Here we reassess the function of the innate and acquired immunity in BC, the major sites of immune response, and the nature of the bioactive mediators. Furthermore, the potential link(s) between an ongoing immune response and structural alterations accompanying the disease and the success of therapies that can modulate the nature and extent of immune response in BC are elaborated upon.

Population characterization, histological evaluation, and timeliness of care of surgical nonsmall cell lung cancer patients in a military academic medical center.

UNLABELLED: Lung cancer remains a major medical impediment in which early diagnosis and timely treatment are key factors in its management. This study evaluated nonsmall cell lung cancer (NSCLC) patients in a large military medical center to determine the timeliness to diagnosis and curative surgery in comparison with published guidelines. A retrospective record review of tumor registry NSCLC surgery cases at Navy Medical Center San Diego (NMCSD) from 2004 to 2009 was conducted. Of the 84 patients, 49% were women, the median age was 63, 58% were Caucasian, and 71% represented ex- or active smokers. A significant number of women were Asian (30%) and nonsmokers (77%). The predominant histology was adenocarcinoma (86%) with positron emission tomography-computed tomography (PET-CT) nonavid (57%). Median time for pulmonologist evaluation was 8 days, median time for PET-CT was 13 days, median time for cardiothoracic surgery evaluation to thoracotomy was 25 days, and median time from pulmonologist evaluation to thoractomy was 59 days. CONCLUSIONS: Except for the pulmonary specialist referral time (8 vs. 7 days), timeliness of diagnosis and curative surgery for NSCLC patients at NMCSD was within international guideline recommendations. Additional proposals have been made to improve the evaluation and treatment of lung cancer patients.

Recognizing asthma mimics and asthma complications.

Asthma is a chronic inflammatory disorder of the airways characterized by airflow obstruction, bronchial hyperreactivity, and underlying inflammation. Two common reasons asthmatics fail standard therapy are incorrect diagnosis and failure to recognize underlying contributing factors. A correct diagnosis of asthma is of great importance to military practitioners since misdiagnosis or uncontrolled asthma affects an individual's operational readiness or determines whether one can receive a medical waiver to enlist in military service. This article presents four cases of patients with dyspnea that have conditions which mimic asthma or complicate asthma management: vocal cord dysfunction misdiagnosed as asthma, respiratory bronchiolitis interstitial lung disease mistaken as asthma, difficult-to-control asthma because of bronchiectasis and allergic bronchopulmonary aspergillosis, and difficult and fatal asthma. Asthma is contrasted to other respiratory disorders, and an outlined approach to asthma diagnosis and management is presented using the Global Initiative for Asthma guidelines.

Predominant cartilaginous hamartoma: an unusual variant of chondromatous hamartoma.

Chondromatous hamartomas are the most common benign lung tumors and the third most common pulmonary nodule. Histologically, they are characteristically composed of hyaline cartilage mixed with fibromyxoid stroma and adipose tissue surrounded by epithelial cells. We report the case of a healthy, 60-year-old woman with an incidentally discovered chondromatous hamartoma that was thorascopically excised. Her pulmonary hamartoma was predominantly cartilaginous, which only occurs in 1% of hamartomas.

A case of severe exercise-induced rhabdomyolysis associated with a weight-loss dietary supplement.

In response to questions about the safety of ephedra-based dietary products, ephedra-free products are now available. Many contain synephrine, a sympathomimetic amine with structural similarities to ephedra. We present a 22-year-old, previously healthy, African American male with sickle cell trait who developed rhabdomyolysis after ingestion of a synephrine-containing dietary supplement. The patient developed fatigue, dehydration, and myalgias while exercising. He developed severe rhabdomyolysis, with a peak creatine phosphokinase level of 2.8 million U/L, complicated by pulmonary edema, acute renal failure, disseminated intravascular coagulation, and bilateral compartment syndromes in his lower extremities. He required prolonged hospitalization for hemodialysis, multiple wound debridements, hyperbaric oxygen therapy, and physical therapy. He has permanent sensory and motor neurological deficits in his distal lower extremities. Military physicians should routinely inquire about the use of dietary supplements, educate patients about the potential adverse reactions associated with these agents, and encourage healthy diets and exercise for weight loss.