Resident Trainee Access and Barriers to Routine Health Services in the Military Health System.

OBJECTIVE: Resident physician wellness has been a highly contentious topic in graduate medical education over the past 2 decades. Physicians, including residents and attending physicians, are more likely than other professionals to work through illness and delay necessary healthcare screening appointments. Potential reasons for underutilization of health care include-unpredictable work hours, limited time, concerns about confidentiality, poor support from training programs, and apprehension about the impact on their peers. The goal of this study was to evaluate access to health care amongst resident physicians within a large military training facility. DESIGN: This is an observational study using Department of Defense approved software to distribute an anonymous ten question survey on routine health care practices of residents. The survey was distributed to a total of 240 active-duty military resident physicians at a large tertiary military medical center. RESULTS: One hundred seventy-eight residents completed the survey with a 74% response rate. Residents from 15 specialty areas responded. Compared to male counterparts', female residents were more likely to miss routine scheduled health care appointments to include, behavioral health appointments (54.2% vs 28%, p < 0.01). Female residents were more likely to report that attitudes toward missing clinical duties for health care appointments impacted their decision to start or add to their family more than male coresidents (32.3% vs 18.3%, p = 0.03). Surgical residents are also more likely to miss routine screening appointments or scheduled follow ups than residents in nonsurgical training programs; (84.0-88% compared to 52.4%-62.8%) respectively. CONCLUSIONS: Resident health and wellness have long been an issue, with resident physical and mental health being negatively impacted during residency. Our study notes that residents in the military system also face barriers accessing routine health care. Female surgical residents being the demographic most significantly impacted. Our survey highlights cultural attitudes in military graduate medical education regarding the prioritization of personal health, and the negative impact that can have on residents' utilization of care. Our survey also raises concerns particularly amongst female surgical residents, that these attitudes may impact career advancement, as well as influence their decision to start or add to their families.

Identification of Potentially Preventable Traumatic Injury Among Military Working Dogs Deployed During the Global War on Terror.

BACKGROUND: Prevention of deployment-related injury is critical for readiness of US military working dogs (MWDs). This study evaluated deployment-related injuries to determine if they were potentially preventable and identify possible abatement strategies. METHODS: Data were collected on 195 MWD injury events that occurred between 11 September 2001 and 31 December 2018. Injuries were reviewed by a panel of veterinarians and categorized into groups based on panel consensus. The panel also established which interventions could have been effective for mitigating injuries. Multipurpose canine (MPC) and conventional MWD injury event characteristics were compared to identify meaningful differences. RESULTS: Of the 195 injuries, 101 (52%) were classified as preventable or potentially preventable. Most (72%) of the potentially preventable injuries occurred in conventional MWDs, with penetrating injuries (64%) being the most common type of trauma. For the preventable/potentially preventable injuries, the most common preventative intervention identified was handler training (53%) followed by protective equipment (46%). There were differences between MPCs and conventional MWDs for injury prevention category, type of trauma, mechanism of injury, and preventative intervention (all p < .001). CONCLUSION: The application of a preventable review process to MWD populations may be beneficial in identifying potentially preventable injuries and preventative intervention strategies.

Comparison of assessment of coagulation in healthy dogs by the TEG 6s and TEG 5000 viscoelastic analyzers.

The TEG 6s (Haemonetics) point-of-care viscoelastic analyzer is portable, compact, simple to use, and has the potential for rapid viscoelastic analysis that can guide the treatment of veterinary patients at the site of care. Although approved for use in people, the TEG 6s has yet to be evaluated for hemostatic analysis in veterinary medicine. Citrated whole blood (CWB) was collected from 27 healthy dogs. An aliquot of CWB from each dog was diluted by 33% with an isotonic crystalloid, representing an in vitro model of hemodilution. Unaltered and diluted CWB samples were analyzed using 2 TEG 6s and 6 TEG 5000 (Haemonetics) analyzers. The 6 TEG 5000 analyzers ran duplicate analyses of either unaltered or diluted samples using 1 of 3 reagents (Haemonetics): Kaolin TEG, RapidTEG, or TEG Functional Fibrinogen. Duplicate TEG 5000 analyses were averaged and compared with a single TEG 6s analysis. Lin concordance correlation coefficient and Bland-Altman plots were used to evaluate agreement of reaction time, kinetic time, alpha angle, maximum amplitude (MA), and G value (G) for samples activated with Kaolin TEG, and agreement of MA for samples activated with RapidTEG between the 2 machines. Overall, agreement between the TEG 6s and TEG 5000 analyzers was poor. Viscoelastic measurements by the TEG 6s and TEG 5000 in healthy dogs were not all interchangeable. Agreement was satisfactory only for MA and G measurements of diluted blood samples activated with Kaolin TEG, and MA measurements for both unaltered and diluted blood samples activated with RapidTEG.

Comparison of trauma sustained by civilian dogs and deployed military working dogs.

OBJECTIVE: To compare the prevalence of types of trauma, mechanisms of injury, and outcomes among military working dogs (MWDs), operational canines (OpK9s), and civilian dogs (CDs) that sustained traumatic injury. DESIGN: Retrospective descriptive analysis. ANIMALS: One hundred and ninety-three cases of MWD trauma, 26,099 cases of CD trauma, 35 cases of OpK9 trauma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Medical records of MWDs that incurred trauma while deployed to the Middle East were identified, and information was extracted from these records. The resultant database was compared to CD and OpK9s in the American College of Veterinary Emergency and Critical Care (ACVECC) Veterinary Committee on Trauma registry. All 3 groups showed similar trends with regard to type of trauma: penetrating injuries occurred most frequently, followed by blunt injuries for CDs and OpK9s. An equal proportion of blunt and blunt and penetrating traumas were observed in MWDs. Only MWDs sustained trauma from explosions, which accounted for 22.3% of injuries in this group. Animal bite/scratch/quilling and motor vehicle accidents (MVAs) were significantly more prevalent among CDs than MWDs (P < 0.01), whereas injuries from gunshot wounds (GSW) or a knife/sharp object were more common among MWDs compared to CDs (P < 0.01). No statistical differences in survival were observed between CDs and MWDs after excluding civilian dogs euthanized due to financial limitations. CONCLUSIONS: MWDs, OpK9s, and CDs experience differences in injury type, mechanism, and outcome. Regardless, MWDs and CDs have good prognosis for survival to discharge after trauma.

Treatment of Corneal Infections Utilizing an Ocular Wound Chamber.

Purpose: To demonstrate that the ocular wound chamber (OWC) can be used for the treatment of bacterial keratitis (BK). Methods: A blepharotomy was performed on anesthetized, hairless guinea pigs to induce exposure keratopathy 72 hours before corneal wound creation and Pseudomonas aeruginosa inoculation. Twenty-four hours postinoculation, eyes were treated with an OWC filled with 500 µL 0.5% moxifloxacin hydrochloride ophthalmic solution (OWC), 10 µL 0.5% moxifloxacin hydrochloride drops (DROPS) four times daily, or not treated (NT). White light, fluorescein, and spectral domain optical coherence tomography (SD-OCT) images; ocular and periocular tissues samples for colony-forming units (CFU) quantification; and plasma samples were collected at 24 and 72 hours posttreatment. Results: White light, fluorescein, and SD-OCT imaging suggests OWC-treated eyes are qualitatively healthier than those in DROPS or NT groups. At 24 hours, the median number of CFUs (interquartile range) measured was 0 (0-8750), 150,000 (106,750-181,250), and 8750 (2525-16,000) CFU/mL for OWC, NT, and DROPS, respectively. While 100% of NT and DROPS animals remained infected at 24 hours, only 25% of OWC-treated animals showed infection. Skin samples at 24 hours showed infection percentages of 50%, 75%, and 0% in DROPS, NT, and OWC groups, respectively. OWC-treated animals had higher moxifloxacin plasma concentrations at 24 and 72 hours than those treated with drops. Conclusions: OWC use resulted in a more rapid decrease of CFUs when compared to DROPS or NT groups and was associated with qualitatively healthier ocular and periocular tissue. Translational Relevance: The OWC could be used clinically to continuously and rapidly deliver antimicrobials to infected ocular and periocular tissues, effectively lowering bacterial bioburdens and mitigating long-term complications.

The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq.

BACKGROUND: Reducing time from injury to care can optimize trauma patient outcomes. A previous study of prehospital transport of US military casualties during the Afghanistan conflict demonstrated the importance of time and treatment capability for combat casualty survival. METHODS: A retrospective descriptive analysis was conducted to analyze battlefield data collected on US military combat casualties during the Iraq conflict from March 19, 2003, to August 31, 2010. All casualties were analyzed by mortality outcome (killed in action, died of wounds, case fatality rate) and compared with Afghanistan conflict. Detailed data for those who underwent prehospital transport were analyzed for effects of transport time, injury severity, and blood transfusion on survival. RESULTS: For the total population, percent killed in action (16.6% vs. 11.1%), percent died of wounds (5.9% vs. 4.3%), and case fatality rate (10.0 vs. 8.6) were higher for Iraq versus Afghanistan (p < 0.001). Among 1,692 casualties (mean New Injury Severity Score, 22.5; mortality, 17.6%) with detailed data, the injury mechanism included 77.7% from explosions and 22.1% from gunshot wounds. For prehospital transport, 67.6% of casualties were transported within 60 minutes, and 32.4% of casualties were transported in greater than 60 minutes. Although 97.0% of deaths occurred in critical casualties (New Injury Severity Score, 25-75), 52.7% of critical casualties survived. Critical casualties were transported more rapidly (p < 0.01) and more frequently within 60 minutes (p < 0.01) than other casualties. Critical casualties had lower mortality when blood was received (p < 0.01). Among critical casualties, blood transfusion was associated with survival irrespective of transport time within or greater than 60 minutes (p < 0.01). CONCLUSION: Although data were limited, early blood transfusion was associated with battlefield survival in Iraq as it was in Afghanistan. LEVEL OF EVIDENCE: Performance improvement and epidemiological, level IV.

Quantifying and Adjusting for Disease Misclassification Due to Loss to Follow-Up in Historical Cohort Mortality Studies.

The purpose of this analysis was to quantify and adjust for disease misclassification from loss to follow-up in a historical cohort mortality study of workers where exposure was categorized as a multi-level variable. Disease classification parameters were defined using 2008 mortality data for the New Zealand population and the proportions of known deaths observed for the cohort. The probability distributions for each classification parameter were constructed to account for potential differences in mortality due to exposure status, gender, and ethnicity. Probabilistic uncertainty analysis (bias analysis), which uses Monte Carlo techniques, was then used to sample each parameter distribution 50,000 times, calculating adjusted odds ratios (ORDM-LTF) that compared the mortality of workers with the highest cumulative exposure to those that were considered never-exposed. The geometric mean ORDM-LTF ranged between 1.65 (certainty interval (CI): 0.50-3.88) and 3.33 (CI: 1.21-10.48), and the geometric mean of the disease-misclassification error factor (εDM-LTF), which is the ratio of the observed odds ratio to the adjusted odds ratio, had a range of 0.91 (CI: 0.29-2.52) to 1.85 (CI: 0.78-6.07). Only when workers in the highest exposure category were more likely than those never-exposed to be misclassified as non-cases did the ORDM-LTF frequency distributions shift further away from the null. The application of uncertainty analysis to historical cohort mortality studies with multi-level exposures can provide valuable insight into the magnitude and direction of study error resulting from losses to follow-up.

Mortality and cancer incidence in ammonium perfluorooctanoate production workers.

OBJECTIVE: To evaluate mortality and cancer incidence in a cohort of ammonium perfluorooctanoate (APFO) exposed workers. METHODS: We linked a combined cohort (n=9027) of employees from APFO and non-APFO production facilities in Minnesota to the National Death Index and to cancer registries of Minnesota and Wisconsin. Industrial hygiene data and expert evaluation were used to create a task-based job exposure matrix to estimate APFO exposure. Standardised mortality ratios were estimated using Minnesota population rates. HRs and 95% CIs for time-dependent cumulative APFO exposure were estimated with an extended Cox model. A priori outcomes of interest included cancers of the liver, pancreas, testes, kidney, prostate and breast, and mortality from cardiovascular, cerebrovascular and chronic renal diseases. RESULTS: Mortality rates in the APFO-exposed cohort were at or below the expected, compared with Minnesota. The HR for dying from the cancer and non-cancer outcomes of interest did not show an association with APFO exposure. Similarly, there was little evidence that the incident cancers were associated with APFO exposure. Compared to the non-exposed population, modestly elevated, but quite imprecise HRs were observed in the higher-exposure quartiles for bladder cancer (HR=1.66, 95% CI 0.86 to 3.18) and pancreatic cancer (HR=1.36, 95% CI 0.59 to 3.11). No association was observed between APFO exposure and kidney, prostate or breast cancers. CONCLUSIONS: This analysis did not support an association between occupational APFO exposure and the evaluated health endpoints, however, the study had limited power to evaluate some conditions of interest.

Brain cancer in workers employed at a specialty chemical research facility.

ABSTRACT This study evaluated unique exposures and their relationship to brain cancer mortality in employees of a specialty chemical research facility. Following an exposure assessment that concerned compounds distinct to this facility, the authors conducted a cohort mortality study of 5,284 workers to assess mortality in reference to the general population and a nested case-control study to evaluate brain cancer risk associated with specific jobs and unique chemical exposures. Four hundred eighty-six deaths, including 14 brain cancer deaths, were identified. Overall mortality was lower than expected. Brain cancer mortality was elevated (standardized mortality ratio [SMR] = 2.02, 95% confidence interval [CI] = 1.11-3.40). Exposures to 5 specific chemical categories were assessed. Exploration of work history and the specific chemical exposures did not explain the brain cancer cases. No clear occupational etiology was identified.

Malignant pleural mesothelioma in US automotive mechanics: reported vs expected number of cases from 1975 to 2007.

Until the 1980s, chrysotile asbestos was a component of automotive brakes manufactured in the US. The current OSHA Bulletin (2006) for brake repair cites a single study (Lemen, 2004) which concluded that the number of mesothelioma cases reported in the literature in "end-product users of friction materials" indicated an asbestos-related risk for auto mechanics. However, Lemen (2004) did not compare the reported number of cases to an "expected" value, even though pleural mesothelioma occurs in the general population in the absence of asbestos exposure. We compare the number of malignant pleural mesothelioma (MPM) cases reported in the US literature among auto mechanics between 1975-2007 to an expected value derived from estimated numbers of current and former auto mechanics. A total of 106 cases categorized as mesothelioma or malignant neoplasm of the pleura were found in the literature. Using background incidence rates for MPM of two and three cases per million individuals per year, we estimated that a range of 278-515 cases of non-asbestos-related MPM, respectively, would have occurred in current or former auto mechanics from 1975-2007. Our findings are consistent with the numerous epidemiology studies that have found no increased risk of MPM in auto mechanics.

PCB concentrations in shrimp from major import markets and the United States.

Currently, environmental studies describing levels of polychlorinated biphenyls (PCBs) in imported shrimp are limited, particularly studies of aquaculture shrimp. In the present study, we measured concentrations of the 209 PCB congeners in 84 uncooked, warm-water shrimp samples from the United States and 14 other countries in three continents. Total PCB and dioxin-like PCB (DL-PCB) levels were not significantly different between wild-caught and farm-raised shrimp, and the distribution of total PCB levels did not vary considerably by country of origin although significant differences were observed in some cases. Regional trends in both total PCB and DL-PCB concentrations were observed, with the highest concentrations measured in shrimp from North America followed by Asia and then South America. The lower chlorinated homologues (i.e., mono-, di-, and tri-PCBs) generally comprised a greater fraction of the total levels measured in farm-raised shrimp and shrimp from Asia and South America whereas higher chlorinated homologues (i.e., hepta-, octa-, nona-, and deca-PCBs) contributed more to levels in wild-caught shrimp and shrimp from North America. Estimated daily intake of PCBs associated with shrimp consumption ranged from 2 pg/kg/d (shrimp from South America) to 15 pg/kg/d (shrimp from North America). Results from the present study were comparable to other studies conducted recently and demonstrate that exposure to PCBs from consumption of farm-raised and wild-caught shrimp imported from different regions are not likely to pose any health risks.

Geographic region of residence and blood lead levels in US children: results of the National Health and Nutrition Examination Survey.

PURPOSE: This study investigated the association between geographic region and blood lead levels (BLLs) in US children, as well as trends in this relationship, using data from the National Health and Nutrition Examination Survey (NHANES). METHODS: SAS® and SUDAAN® software programs were utilized to develop linear regression models adjusted for several factors associated with BLLs. RESULTS: The largest decline in BLLs was observed in Northeastern children, while the percentage of children with elevated blood lead levels decreased the most for the West and Northeast. Lead levels of Northeastern children were still higher than those of children living in the West. However, levels were not different among children residing in the Northeast, Midwest, and South, and the blood lead concentrations were less than 5 µg/dL for all but one subgroup of children and less than 2 µg/dL for >70% of the subgroups. More importantly, the effects of different risk factors for higher blood lead levels varied by region even after adjusting for all other covariates. CONCLUSIONS: The results of this study not only provide relevant and current blood lead levels for US children that can be used as reference values to evaluate biomonitoring data, but can also be used to help direct prevention and surveillance strategies to reduce lead in the environment of at-risk children.

Levels of polychlorinated dibenzo-p-dioxins, dibenzofurans, and biphenyls in southern Mississippi catfish and estimation of potential health risks.

Fish consumption has been classified as one of the primary pathways of exposure to polychlorinated dibenzo-p-dioxins, dibenzofurans (PCDD/Fs) and biphenyls (PCBs). In this study, we evaluated tissue levels of the 17 laterally substituted PCDD/Fs, 12 dioxin-like PCBs, and 97 non-dioxin-like PCBs in a number of wild-caught and farm-raised catfish collected throughout southern Mississippi. Total lipid-adjusted TEQ and non-dioxin-like PCB concentrations in wild-caught catfish fillets were significantly higher than concentrations in farm-raised fillet samples. The percent contribution of PCDDs, PCDFs, and dioxin-like PCBs to mean total TEQ varied between wild-caught and farm-raised samples as well as by collection site for wild-caught catfish. The non-dioxin-like PCBs that contributed the most to total PCB concentrations also differed between wild-caught and farm-raised samples. Regardless of whether samples were farm-raised or wild-caught, estimated cancer risks associated with consumption of these catfish were less than 27.0E-06. Overall, results of this study indicate that levels of dioxin-like compounds and PCBs in Mississippi catfish are similar to those measured in more recent studies in the US and that levels of these compounds appear to be decreasing in this food source.

Assessment of polybrominated diphenyl ether exposures and health risks associated with consumption of southern Mississippi catfish.

Despite the growing public interest in polybrominated diphenyl ethers (PBDEs), there are relatively few studies in the published literature which characterize and quantify human intake of these compounds. In this study, PBDE concentrations were measured in southern Mississippi catfish to determine background levels, daily intake, and risk associated with the consumption of these chemicals from a primary food source for residents in this region of the United States. A total of 33 wild catfish samples were collected from five sites, and 28 farm-raised catfish samples were purchased, all of which were from locations in southern Mississippi. All samples were analyzed for 43 PBDEs (mono- through deca-congeners) using high-resolution gas chromatography-mass spectrometry. Both PBDE concentrations (sigmaPBDE ranged from 0.3 to 23.3 ng/g wet weight) and congener profiles varied by fish type and location; however, BDE congeners 47, 99, 100, 153, and 154 were the dominant contributors in all samples. The estimated daily intake of PBDEs associated with consumption of the catfish ranged from 0.03 to 1.80 ng/kg-day. Evaluation of the cancer risk for BDE 209 and the noncancer hazard for BDE congeners 47, 99, 153, and 209 indicated that health risks/hazards due to fish consumption in adults are substantially lower than risk levels generally considered to be at the U.S. EPA minimum concern level.

Addendum to: Evaluation of PCDD/F and dioxin-like PCB serum concentration data from the 2001-2002 National Health and Nutrition Examination Survey of the United States population.

In 2007, we published a paper in the Journal of Exposure Science and Environmental Epidemiology describing PCDD/F and dioxin-like PCB serum concentration data collected for the 2001-2002 National Health and Nutrition Examination Survey. Since publication of this paper, several of the 1998 World Health Organization Toxic Equivalency Factors (TEFs), which were used to calculate the summary statistics we presented, have been changed. In this addendum, we publish new reference statistics using the WHO(2006) TEFs in addition to assessing the effect of these new TEFs on total TEQ concentrations for the general US population. We also examined the effect of the limits of detection (LODs) on the calculated TEQ summary statistics for the top seven contributing congeners and completed a missing data analysis to determine whether our estimates were biased by excluding individuals without complete congener profiles. Similar to our previous results, 2, 3, 7, 8-TCDD; 1, 2, 3, 7, 8-PeCDD; 1, 2, 3, 6, 7, 8-HxCDD; 2, 3, 4, 7, 8-PeCDF; and PCB 126 contributed the most to total TEQ. However, both PCB 156 and 157 were no longer significant contributors, instead being displaced by 1, 2, 3, 4, 7, 8-HxCDF, and PCB 169. In general, the decrease in TEFs for the mono-ortho-substituted PCBs decreased their contribution to total TEQ appreciably, causing TEQ(17-9) to approximately equal TEQ(17-3). The effect of LODs for five of the top seven contributing congeners was negligible; however, the LODs for 2, 3, 7, 8-TCDD and 1, 2, 3, 7, 8-PeCDD were noticeably higher and may impact TEQ estimates primarily for individuals aged 20-29 years. Results from the missing data analysis provide compelling evidence that the summary statistics we reported previously, as well as those described here, were not greatly influenced due to censoring data.