All healthcare leaders will inevitably face patient death and dealing with loss. While leaders have different preparation for this, many lack comfort and confidence navigating death, whether it be of a patient, family member, or colleague. Learning how to support others in dealing with death is a fundamental leadership skill.
{"title":"Leadership Lessons From the Field: Leading Others to Cope With Death.","authors":"Jamie Geringer, S. Durning","doi":"10.1093/milmed/usac128","DOIUrl":"https://doi.org/10.1093/milmed/usac128","url":null,"abstract":"All healthcare leaders will inevitably face patient death and dealing with loss. While leaders have different preparation for this, many lack comfort and confidence navigating death, whether it be of a patient, family member, or colleague. Learning how to support others in dealing with death is a fundamental leadership skill.","PeriodicalId":86137,"journal":{"name":"Military surgeon","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42273478","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ret Carlos J Rodriguez, A. Ganesan, Faraz Shaikh, M. L. Carson, William P. Bradley, T. Warkentien, D. Tribble
INTRODUCTION During Operation Enduring Freedom in Afghanistan, an outbreak of combat-related invasive fungal wound infections (IFIs) emerged among casualties with dismounted blast trauma and became a priority issue for the Military Health System. METHODS In 2011, the Trauma Infectious Disease Outcomes Study (TIDOS) team led the Department of Defense IFI outbreak investigation to describe characteristics of IFIs among combat casualties and provide recommendations related to management of the disease. To support the outbreak investigation, existing IFI definitions and classifications utilized for immunocompromised patients were modified for use in epidemiologic research in a trauma population. Following the conclusion of the outbreak investigation, multiple retrospective analyses using a population of 77 IFI patients (injured during June 2009 to August 2011) were conducted to evaluate IFI epidemiology, wound microbiology, and diagnostics to support refinement of Joint Trauma System (JTS) clinical practice guidelines. Following cessation of combat operations in Afghanistan, the TIDOS database was comprehensively reviewed to identify patients with laboratory evidence of a fungal infection and refine the IFI classification scheme to incorporate timing of laboratory fungal evidence and include categories that denote a high or low level of suspicion for IFI. The refined IFI classification scheme was utilized in a large-scale epidemiologic assessment of casualties injured over a 5.5-year period. RESULTS Among 720 combat casualties admitted to participating hospitals (2009-2014) who had histopathology and/or wound cultures collected, 94 (13%) met criteria for an IFI and 61 (8%) were classified as high suspicion of IFI. Risk factors for development of combat-related IFIs include sustaining a dismounted blast injury, experiencing a traumatic transfemoral amputation, and requiring resuscitation with large-volume (>20 units) blood transfusions. Moreover, TIDOS analyses demonstrated the adverse impact of IFIs on wound healing, particularly with order Mucorales. A polymerase chain reaction (PCR)-based assay to identify filamentous fungi and support earlier IFI diagnosis was also assessed using archived formalin-fixed, paraffin-embedded tissue specimens. Although the PCR-based assay had high specificity (99%), there was low sensitivity (63%); however, sensitivity improved to 83% in tissues collected from sites with angioinvasion. Data obtained from the initial IFI outbreak investigation (37 IFI patients) and subsequent TIDOS analyses (77 IFI patients) supported development and refinement of a JTS clinical practice guideline for the management of IFIs in war wounds. Furthermore, a local clinical practice guideline to screen for early tissue-based evidence of IFIs among blast casualties at the Landstuhl Regional Medical Center was critically evaluated through a TIDOS investigation, providing additional clinical practice support. Through a collaboration with th
{"title":"Combat-Related Invasive Fungal Wound Infections.","authors":"Ret Carlos J Rodriguez, A. Ganesan, Faraz Shaikh, M. L. Carson, William P. Bradley, T. Warkentien, D. Tribble","doi":"10.1093/milmed/usab074","DOIUrl":"https://doi.org/10.1093/milmed/usab074","url":null,"abstract":"INTRODUCTION\u0000During Operation Enduring Freedom in Afghanistan, an outbreak of combat-related invasive fungal wound infections (IFIs) emerged among casualties with dismounted blast trauma and became a priority issue for the Military Health System.\u0000\u0000\u0000METHODS\u0000In 2011, the Trauma Infectious Disease Outcomes Study (TIDOS) team led the Department of Defense IFI outbreak investigation to describe characteristics of IFIs among combat casualties and provide recommendations related to management of the disease. To support the outbreak investigation, existing IFI definitions and classifications utilized for immunocompromised patients were modified for use in epidemiologic research in a trauma population. Following the conclusion of the outbreak investigation, multiple retrospective analyses using a population of 77 IFI patients (injured during June 2009 to August 2011) were conducted to evaluate IFI epidemiology, wound microbiology, and diagnostics to support refinement of Joint Trauma System (JTS) clinical practice guidelines. Following cessation of combat operations in Afghanistan, the TIDOS database was comprehensively reviewed to identify patients with laboratory evidence of a fungal infection and refine the IFI classification scheme to incorporate timing of laboratory fungal evidence and include categories that denote a high or low level of suspicion for IFI. The refined IFI classification scheme was utilized in a large-scale epidemiologic assessment of casualties injured over a 5.5-year period.\u0000\u0000\u0000RESULTS\u0000Among 720 combat casualties admitted to participating hospitals (2009-2014) who had histopathology and/or wound cultures collected, 94 (13%) met criteria for an IFI and 61 (8%) were classified as high suspicion of IFI. Risk factors for development of combat-related IFIs include sustaining a dismounted blast injury, experiencing a traumatic transfemoral amputation, and requiring resuscitation with large-volume (>20 units) blood transfusions. Moreover, TIDOS analyses demonstrated the adverse impact of IFIs on wound healing, particularly with order Mucorales. A polymerase chain reaction (PCR)-based assay to identify filamentous fungi and support earlier IFI diagnosis was also assessed using archived formalin-fixed, paraffin-embedded tissue specimens. Although the PCR-based assay had high specificity (99%), there was low sensitivity (63%); however, sensitivity improved to 83% in tissues collected from sites with angioinvasion. Data obtained from the initial IFI outbreak investigation (37 IFI patients) and subsequent TIDOS analyses (77 IFI patients) supported development and refinement of a JTS clinical practice guideline for the management of IFIs in war wounds. Furthermore, a local clinical practice guideline to screen for early tissue-based evidence of IFIs among blast casualties at the Landstuhl Regional Medical Center was critically evaluated through a TIDOS investigation, providing additional clinical practice support. Through a collaboration with th","PeriodicalId":86137,"journal":{"name":"Military surgeon","volume":"187 Supplement_2 1","pages":"34-41"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43000535","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
D. Tribble, M. Spott, Stacey A Shackleford, J. Gurney, Bg Clinton K Murray
BACKGROUND The Joint Trauma System (JTS) is a DoD Center of Excellence for Military Health System trauma care delivery and the DoD's reference body for trauma care in accordance with National Defense Authorization Act for Fiscal Year 2017. Through the JTS, evidence-based clinical practice guidelines (CPGs) have been developed and subsequently refined to standardize and improve combat casualty care. Data are amassed through a single, centralized DoD Trauma Registry to support process improvement measures with specialty modules established as the registry evolved. Herein, we review the implementation of the JTS DoD Trauma Registry specialty Infectious Disease Module and the development of infection-related CPGs and summarize published findings on the subsequent impact of the Infectious Disease Module on combat casualty care clinical practice and guidelines. METHODS The DoD Trauma Registry Infectious Disease Module was developed in collaboration with the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious Disease Outcomes Study (TIDOS). Infection-related information (e.g., syndromes, antibiotic management, and microbiology) were collected from military personnel wounded during deployment June 1, 2009 through December 31, 2014 and medevac'd to Landstuhl Regional Medical Center in Germany before transitioning to participating military hospitals in the USA. RESULTS To support process improvements and reduce variation in practice patterns, data collected through the Infectious Disease Module have been utilized in TIDOS analyses focused on assessing compliance with post-trauma antibiotic prophylaxis recommendations detailed in JTS CPGs. Analyses examined compliance over three time periods: 6 months, one-year, and 5 years. The five-year analysis demonstrated significantly improved adherence to recommendations following the dissemination of the 2011 JTS CPG, particularly with open fractures (34% compliance compared to 73% in 2013-2014). Due to conflicting recommendations regarding use of expanded Gram-negative coverage with open fractures, infectious outcomes among patients with open fractures who received cefazolin or expanded Gram-negative coverage (cefazolin plus fluoroquinolones and/or aminoglycosides) were also examined in a TIDOS analysis. The lack of a difference in the proportion of osteomyelitis (8% in both groups) and the significantly greater recovery of Gram-negative organisms resistant to aminoglycosides or fluoroquinolones among patients who received expanded Gram-negative coverage supported JTS recommendations regarding the use of cefazolin with open fractures. Following recognition of the outbreak of invasive fungal wound infections (IFIs) among blast casualties injured in Afghanistan, the ID Module was refined to capture data (e.g., fungal culture and histopathology findings, wound necrosis, and antifungal management) needed for the TIDOS team to lead the DoD outbreak investigation. These data captured through the In
{"title":"Department of Defense Trauma Registry Infectious Disease Module Impact on Clinical Practice.","authors":"D. Tribble, M. Spott, Stacey A Shackleford, J. Gurney, Bg Clinton K Murray","doi":"10.1093/milmed/usac050","DOIUrl":"https://doi.org/10.1093/milmed/usac050","url":null,"abstract":"BACKGROUND\u0000The Joint Trauma System (JTS) is a DoD Center of Excellence for Military Health System trauma care delivery and the DoD's reference body for trauma care in accordance with National Defense Authorization Act for Fiscal Year 2017. Through the JTS, evidence-based clinical practice guidelines (CPGs) have been developed and subsequently refined to standardize and improve combat casualty care. Data are amassed through a single, centralized DoD Trauma Registry to support process improvement measures with specialty modules established as the registry evolved. Herein, we review the implementation of the JTS DoD Trauma Registry specialty Infectious Disease Module and the development of infection-related CPGs and summarize published findings on the subsequent impact of the Infectious Disease Module on combat casualty care clinical practice and guidelines.\u0000\u0000\u0000METHODS\u0000The DoD Trauma Registry Infectious Disease Module was developed in collaboration with the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious Disease Outcomes Study (TIDOS). Infection-related information (e.g., syndromes, antibiotic management, and microbiology) were collected from military personnel wounded during deployment June 1, 2009 through December 31, 2014 and medevac'd to Landstuhl Regional Medical Center in Germany before transitioning to participating military hospitals in the USA.\u0000\u0000\u0000RESULTS\u0000To support process improvements and reduce variation in practice patterns, data collected through the Infectious Disease Module have been utilized in TIDOS analyses focused on assessing compliance with post-trauma antibiotic prophylaxis recommendations detailed in JTS CPGs. Analyses examined compliance over three time periods: 6 months, one-year, and 5 years. The five-year analysis demonstrated significantly improved adherence to recommendations following the dissemination of the 2011 JTS CPG, particularly with open fractures (34% compliance compared to 73% in 2013-2014). Due to conflicting recommendations regarding use of expanded Gram-negative coverage with open fractures, infectious outcomes among patients with open fractures who received cefazolin or expanded Gram-negative coverage (cefazolin plus fluoroquinolones and/or aminoglycosides) were also examined in a TIDOS analysis. The lack of a difference in the proportion of osteomyelitis (8% in both groups) and the significantly greater recovery of Gram-negative organisms resistant to aminoglycosides or fluoroquinolones among patients who received expanded Gram-negative coverage supported JTS recommendations regarding the use of cefazolin with open fractures. Following recognition of the outbreak of invasive fungal wound infections (IFIs) among blast casualties injured in Afghanistan, the ID Module was refined to capture data (e.g., fungal culture and histopathology findings, wound necrosis, and antifungal management) needed for the TIDOS team to lead the DoD outbreak investigation. These data captured through the In","PeriodicalId":86137,"journal":{"name":"Military surgeon","volume":"187 Supplement_2 1","pages":"7-16"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44546875","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
K. Mende, K. Akers, Stuart D. Tyner, J. Bennett, M. Simons, D. Blyth, Ping Li, L. Stewart, D. Tribble
INTRODUCTION During the wars in Iraq and Afghanistan, increased incidence of multidrug-resistant (MDR) organisms, as well as polymicrobial wounds and infections, complicated the management of combat trauma-related infections. Multidrug resistance and wound microbiology are a research focus of the Trauma Infectious Disease Outcomes Study (TIDOS), an Infectious Disease Clinical Research Program, Uniformed Services University, research protocol. To conduct comprehensive microbiological research with the goal of improving the understanding of the complicated etiology of wound infections, the TIDOS MDR and Virulent Organisms Trauma Infections Initiative (MDR/VO Initiative) was established as a collaborative effort with the Brooke Army Medical Center, Naval Medical Research Center, U.S. Army Institute of Surgical Research, and Walter Reed Army Institute of Research. We provide a review of the TIDOS MDR/VO Initiative and summarize published findings. METHODS Antagonism and biofilm formation of commonly isolated wound bacteria (e.g., ESKAPE pathogens-Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.), antimicrobial susceptibility patterns, and clinical outcomes are being examined. Isolates collected from admission surveillance swabs, as part of infection control policy, and clinical infection workups were retained in the TIDOS Microbiological Repository and associated clinical data in the TIDOS database. RESULTS Over the TIDOS study period (June 2009 to December 2014), more than 8,300 colonizing and infecting isolates were collected from military personnel injured with nearly one-third of isolates classified as MDR. At admission to participating U.S. military hospitals, 12% of wounded warriors were colonized with MDR Gram-negative bacilli. Furthermore, 27% of 913 combat casualties with ≥1 infection during their trauma hospitalization had MDR Gram-negative bacterial infections. Among 335 confirmed combat-related extremity wound infections (2009-2012), 61% were polymicrobial and comprised various combinations of Gram-negative and Gram-positive bacteria, yeast, fungi, and anaerobes. Escherichia coli was the most common Gram-negative bacilli isolated from clinical workups, as well as the most common colonizing MDR secondary to extended-spectrum β-lactamase resistance. Assessment of 479 E. coli isolates collected from wounded warriors found 188 pulsed-field types (PFTs) from colonizing isolates and 54 PFTs from infecting isolates without significant overlap across combat theaters, military hospitals, and study years. A minority of patients with colonizing E. coli isolates developed subsequent infections with the same E. coli strain. Enterococcus spp. were most commonly isolated from polymicrobial wound infections (53% of 204 polymicrobial cultures). Patients with Enterococcus infections were severely injured with a high proportion of lower extremity amputations and ge
在伊拉克和阿富汗战争期间，耐多药(MDR)微生物以及多微生物伤口和感染的发病率增加，使战斗创伤相关感染的管理复杂化。多药耐药和伤口微生物学是创伤传染病结果研究(TIDOS)的研究重点，这是军警大学传染病临床研究项目，研究方案。为了开展全面的微生物学研究，以提高对伤口感染复杂病因的理解，TIDOS MDR和有毒生物创伤感染倡议(MDR/VO倡议)是与布鲁克陆军医学中心、海军医学研究中心、美国陆军外科研究所和沃尔特里德陆军研究所共同努力建立的。我们提供了TIDOS MDR/VO倡议的回顾，并总结了已发表的研究结果。方法对ESKAPE病原菌(如粪肠球菌、金黄色葡萄球菌、肺炎克雷伯菌、鲍曼不动杆菌、铜绿假单胞菌和肠杆菌)的拮抗作用和生物膜形成、抗菌药物敏感性模式和临床结果进行研究。作为感染控制政策的一部分，从入院监测拭子中收集的分离株和临床感染检查保存在TIDOS微生物库中，并将相关临床数据保存在TIDOS数据库中。结果在2009年6月至2014年12月的TIDOS研究期间，从受伤的军事人员中收集了8300多株定植和感染分离株，其中近三分之一的分离株被归类为MDR。在美国参与的军事医院入院时，12%的受伤战士被MDR革兰氏阴性杆菌定植。此外，在创伤住院期间感染≥1次的913名战斗伤亡者中，27%为耐多药革兰氏阴性细菌感染。在335例确诊的战斗相关肢体伤口感染(2009-2012年)中，61%为多微生物感染，包括革兰氏阴性菌和革兰氏阳性菌、酵母菌、真菌和厌氧菌的各种组合。大肠杆菌是临床检出的最常见的革兰氏阴性杆菌，也是继发于广谱β-内酰胺酶耐药的最常见定植耐多药。对从受伤战士身上收集的479株大肠杆菌进行了评估，发现定植分离株中有188种脉冲场型(PFTs)，感染分离株中有54种脉冲场型(PFTs)，在战区、军队医院和研究年份之间没有明显的重叠。少数有定植大肠杆菌分离株的患者随后发生了相同大肠杆菌菌株的感染。肠球菌最常见于多微生物伤口感染(204例多微生物培养中有53%)。肠球菌感染的患者损伤严重，下肢截肢和泌尿生殖系统损伤的比例很高。大约65%的多微生物肠球菌感染分离出其他ESKAPE微生物。由于生物膜被认为是伤口延迟愈合的原因，因此对细菌持续恢复的伤口感染(同一生物分离株相隔≥14天)和非复发性细菌分离株进行了评估。生物膜的产生与复发性细菌分离显著相关(97% vs. 59%与非复发性分离;p < 0.001);然而，需要进一步的分析来证实生物膜的形成是持续伤口感染的预测因子。结论:TIDOS MDR/VO倡议提供了与战斗相关伤口感染相关的主要微生物威胁的全面和详细数据，以进一步了解伤口病因，并可能确定传染病对策，这可能导致战斗伤员护理的改善。
{"title":"Multidrug-Resistant and Virulent Organisms Trauma Infections: Trauma Infectious Disease Outcomes Study Initiative.","authors":"K. Mende, K. Akers, Stuart D. Tyner, J. Bennett, M. Simons, D. Blyth, Ping Li, L. Stewart, D. Tribble","doi":"10.1093/milmed/usab131","DOIUrl":"https://doi.org/10.1093/milmed/usab131","url":null,"abstract":"INTRODUCTION\u0000During the wars in Iraq and Afghanistan, increased incidence of multidrug-resistant (MDR) organisms, as well as polymicrobial wounds and infections, complicated the management of combat trauma-related infections. Multidrug resistance and wound microbiology are a research focus of the Trauma Infectious Disease Outcomes Study (TIDOS), an Infectious Disease Clinical Research Program, Uniformed Services University, research protocol. To conduct comprehensive microbiological research with the goal of improving the understanding of the complicated etiology of wound infections, the TIDOS MDR and Virulent Organisms Trauma Infections Initiative (MDR/VO Initiative) was established as a collaborative effort with the Brooke Army Medical Center, Naval Medical Research Center, U.S. Army Institute of Surgical Research, and Walter Reed Army Institute of Research. We provide a review of the TIDOS MDR/VO Initiative and summarize published findings.\u0000\u0000\u0000METHODS\u0000Antagonism and biofilm formation of commonly isolated wound bacteria (e.g., ESKAPE pathogens-Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.), antimicrobial susceptibility patterns, and clinical outcomes are being examined. Isolates collected from admission surveillance swabs, as part of infection control policy, and clinical infection workups were retained in the TIDOS Microbiological Repository and associated clinical data in the TIDOS database.\u0000\u0000\u0000RESULTS\u0000Over the TIDOS study period (June 2009 to December 2014), more than 8,300 colonizing and infecting isolates were collected from military personnel injured with nearly one-third of isolates classified as MDR. At admission to participating U.S. military hospitals, 12% of wounded warriors were colonized with MDR Gram-negative bacilli. Furthermore, 27% of 913 combat casualties with ≥1 infection during their trauma hospitalization had MDR Gram-negative bacterial infections. Among 335 confirmed combat-related extremity wound infections (2009-2012), 61% were polymicrobial and comprised various combinations of Gram-negative and Gram-positive bacteria, yeast, fungi, and anaerobes. Escherichia coli was the most common Gram-negative bacilli isolated from clinical workups, as well as the most common colonizing MDR secondary to extended-spectrum β-lactamase resistance. Assessment of 479 E. coli isolates collected from wounded warriors found 188 pulsed-field types (PFTs) from colonizing isolates and 54 PFTs from infecting isolates without significant overlap across combat theaters, military hospitals, and study years. A minority of patients with colonizing E. coli isolates developed subsequent infections with the same E. coli strain. Enterococcus spp. were most commonly isolated from polymicrobial wound infections (53% of 204 polymicrobial cultures). Patients with Enterococcus infections were severely injured with a high proportion of lower extremity amputations and ge","PeriodicalId":86137,"journal":{"name":"Military surgeon","volume":"187 Supplement_2 1","pages":"42-51"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42547599","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jay McDonald, S. Liang, Ping Li, L. Stewart, D. Tribble
BACKGROUND In the aftermath of wars, there is a surge in the number of wounded service members who leave active duty and become eligible for healthcare through the Department of Veterans Affairs (VA). Collaborations between the Department of Defense (DoD) and VA are crucial to capture comprehensive data and further understand the long-term impact of battlefield trauma. We provide a summary of the development, methodology, and status of an effective collaboration between the Infectious Disease Clinical Research Program and the St. Louis VA Health Care System with the multicenter, observational Trauma Infectious Disease Outcomes Study (TIDOS), which examines the short- and long-term outcomes of deployment-related trauma. METHODS As part of TIDOS, wounded service members who transitioned to participating military hospitals in the United States (2009-2014) were given the opportunity to enroll in a prospective follow-up cohort study to continue to capture infection-related data after their hospital discharge. Enrollees in the TIDOS cohort who left military service and received health care through the VA also had the option of consenting to have relevant VA medical records abstracted and included with the study data. Infections considered to be complications resulting from the initial trauma were examined. RESULTS Among 1,336 TIDOS enrollees, 1,221 (91%) registered and received health care through the VA with 633 (47%) consenting to follow-up using VA records and comprising the TIDOS-VA cohort. Of the first 337 TIDOS-VA cohort enrollees, 38% were diagnosed with a new trauma-related infection following hospital discharge (median: 88 days; interquartile range: 18-351 days). Approximately 71% of the infections were identified through DoD sources (medical records and follow-up) and 29% were identified through VA electronic medical records, demonstrating the utility of DoD-VA collaborations. The TIDOS DoD-VA collaboration has also been utilized to assess intermediate and long-term consequences of specific injury patterns. Among 89 TIDOS-VA cohort enrollees with genitourinary trauma, 36% reported sexual dysfunction, 21% developed at least one urinary tract infection, 14% had urinary retention/incontinence, and 8% had urethral stricture. The rate of urinary tract infections was 0.05/patient-year during DoD follow-up time and 0.07/patient-year during VA follow-up time. CONCLUSIONS Wider capture of infection-related outcome data through the DoD-VA collaboration provided a clearer picture of the long-term infection burden resulting from deployment-related trauma. Planned analyses include assessment of osteomyelitis among combat casualties with amputations and/or open fractures, evaluation of mental health and social factors related to injury patterns, and examination of health care utilization and cost in relation to infectious disease burdens.
{"title":"DoD-VA Trauma Infection Research Collaboration.","authors":"Jay McDonald, S. Liang, Ping Li, L. Stewart, D. Tribble","doi":"10.1093/milmed/usab482","DOIUrl":"https://doi.org/10.1093/milmed/usab482","url":null,"abstract":"BACKGROUND\u0000In the aftermath of wars, there is a surge in the number of wounded service members who leave active duty and become eligible for healthcare through the Department of Veterans Affairs (VA). Collaborations between the Department of Defense (DoD) and VA are crucial to capture comprehensive data and further understand the long-term impact of battlefield trauma. We provide a summary of the development, methodology, and status of an effective collaboration between the Infectious Disease Clinical Research Program and the St. Louis VA Health Care System with the multicenter, observational Trauma Infectious Disease Outcomes Study (TIDOS), which examines the short- and long-term outcomes of deployment-related trauma.\u0000\u0000\u0000METHODS\u0000As part of TIDOS, wounded service members who transitioned to participating military hospitals in the United States (2009-2014) were given the opportunity to enroll in a prospective follow-up cohort study to continue to capture infection-related data after their hospital discharge. Enrollees in the TIDOS cohort who left military service and received health care through the VA also had the option of consenting to have relevant VA medical records abstracted and included with the study data. Infections considered to be complications resulting from the initial trauma were examined.\u0000\u0000\u0000RESULTS\u0000Among 1,336 TIDOS enrollees, 1,221 (91%) registered and received health care through the VA with 633 (47%) consenting to follow-up using VA records and comprising the TIDOS-VA cohort. Of the first 337 TIDOS-VA cohort enrollees, 38% were diagnosed with a new trauma-related infection following hospital discharge (median: 88 days; interquartile range: 18-351 days). Approximately 71% of the infections were identified through DoD sources (medical records and follow-up) and 29% were identified through VA electronic medical records, demonstrating the utility of DoD-VA collaborations. The TIDOS DoD-VA collaboration has also been utilized to assess intermediate and long-term consequences of specific injury patterns. Among 89 TIDOS-VA cohort enrollees with genitourinary trauma, 36% reported sexual dysfunction, 21% developed at least one urinary tract infection, 14% had urinary retention/incontinence, and 8% had urethral stricture. The rate of urinary tract infections was 0.05/patient-year during DoD follow-up time and 0.07/patient-year during VA follow-up time.\u0000\u0000\u0000CONCLUSIONS\u0000Wider capture of infection-related outcome data through the DoD-VA collaboration provided a clearer picture of the long-term infection burden resulting from deployment-related trauma. Planned analyses include assessment of osteomyelitis among combat casualties with amputations and/or open fractures, evaluation of mental health and social factors related to injury patterns, and examination of health care utilization and cost in relation to infectious disease burdens.","PeriodicalId":86137,"journal":{"name":"Military surgeon","volume":"187 Supplement_2 1","pages":"17-24"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43970530","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Joseph L. Petfield, Louis R. Lewandowski, L. Stewart, C. Murray, D. Tribble
INTRODUCTION Extremity trauma is the most common battlefield injury, resulting in a high frequency of combat-related extremity wound infections (CEWIs). As these infections are associated with substantial morbidity and may impact wounded warriors long after initial hospitalization, CEWIs have been a focus of the Infectious Disease Clinical Research Program (IDCRP). Herein, we review findings of CEWI research conducted through the IDCRP and discuss future and ongoing analyses. METHODS Military personnel with deployment-related trauma sustained between 2009 and 2014 were examined in retrospective analyses through the observational Trauma Infectious Disease Outcomes Study (TIDOS). Characteristics of wounded warriors with ≥1 open extremity wound were assessed, focusing on injury patterns and infection risk factors. Through a separate trauma-associated osteomyelitis study, military personnel with combat-related open fractures of the long bones (tibia, femur, and upper extremity) sustained between 2003 and 2009 were examined to identify osteomyelitis risk factors. RESULTS Among 1,271 wounded warriors with ≥1 open extremity wound, 16% were diagnosed with a CEWI. When assessed by their most severe extremity injury (i.e., amputation, open fracture, or open soft-tissue wound), patients with amputations had the highest proportion of infections (47% of 212 patients with traumatic amputations). Factors related to injury pattern, mechanism, and severity were independent predictors of CEWIs during initial hospitalization. Having a non-extremity infection at least 4 days before CEWI diagnosis was associated with reduced likelihood of CEWI development. After hospital discharge, 28% of patients with extremity trauma had a new or recurrent CEWI during follow-up. Risk factors for the development of CEWIs during follow-up included injury pattern, having either a CEWI or other infection during initial hospitalization, and receipt of antipseudomonal penicillin for ≥7 days. A reduced likelihood for CEWIs during follow-up was associated with a hospitalization duration of 15-30 days. Under the retrospective osteomyelitis risk factor analysis, patients developing osteomyelitis had higher open fracture severity based on Gustilo-Anderson (GA) and the Orthopaedic Trauma Association classification schemes and more frequent traumatic amputations compared to open fracture patients without osteomyelitis. Recurrence of osteomyelitis was also common (28% of patients with open tibia fractures had a recurrent episode). Although osteomyelitis risk factors differed between the tibia, femur, and upper extremity groups, sustaining an amputation, use of antibiotic beads, and being injured in the earlier years of the study (before significant practice pattern changes) were consistent predictors. Other risk factors included GA fracture severity ≥IIIb, blast injuries, foreign body at fracture site (with/without orthopedic implant), moderate/severe muscle damage and/or necrosis, and moder
{"title":"IDCRP Combat-Related Extremity Wound Infection Research.","authors":"Joseph L. Petfield, Louis R. Lewandowski, L. Stewart, C. Murray, D. Tribble","doi":"10.1093/milmed/usab065","DOIUrl":"https://doi.org/10.1093/milmed/usab065","url":null,"abstract":"INTRODUCTION\u0000Extremity trauma is the most common battlefield injury, resulting in a high frequency of combat-related extremity wound infections (CEWIs). As these infections are associated with substantial morbidity and may impact wounded warriors long after initial hospitalization, CEWIs have been a focus of the Infectious Disease Clinical Research Program (IDCRP). Herein, we review findings of CEWI research conducted through the IDCRP and discuss future and ongoing analyses.\u0000\u0000\u0000METHODS\u0000Military personnel with deployment-related trauma sustained between 2009 and 2014 were examined in retrospective analyses through the observational Trauma Infectious Disease Outcomes Study (TIDOS). Characteristics of wounded warriors with ≥1 open extremity wound were assessed, focusing on injury patterns and infection risk factors. Through a separate trauma-associated osteomyelitis study, military personnel with combat-related open fractures of the long bones (tibia, femur, and upper extremity) sustained between 2003 and 2009 were examined to identify osteomyelitis risk factors.\u0000\u0000\u0000RESULTS\u0000Among 1,271 wounded warriors with ≥1 open extremity wound, 16% were diagnosed with a CEWI. When assessed by their most severe extremity injury (i.e., amputation, open fracture, or open soft-tissue wound), patients with amputations had the highest proportion of infections (47% of 212 patients with traumatic amputations). Factors related to injury pattern, mechanism, and severity were independent predictors of CEWIs during initial hospitalization. Having a non-extremity infection at least 4 days before CEWI diagnosis was associated with reduced likelihood of CEWI development. After hospital discharge, 28% of patients with extremity trauma had a new or recurrent CEWI during follow-up. Risk factors for the development of CEWIs during follow-up included injury pattern, having either a CEWI or other infection during initial hospitalization, and receipt of antipseudomonal penicillin for ≥7 days. A reduced likelihood for CEWIs during follow-up was associated with a hospitalization duration of 15-30 days. Under the retrospective osteomyelitis risk factor analysis, patients developing osteomyelitis had higher open fracture severity based on Gustilo-Anderson (GA) and the Orthopaedic Trauma Association classification schemes and more frequent traumatic amputations compared to open fracture patients without osteomyelitis. Recurrence of osteomyelitis was also common (28% of patients with open tibia fractures had a recurrent episode). Although osteomyelitis risk factors differed between the tibia, femur, and upper extremity groups, sustaining an amputation, use of antibiotic beads, and being injured in the earlier years of the study (before significant practice pattern changes) were consistent predictors. Other risk factors included GA fracture severity ≥IIIb, blast injuries, foreign body at fracture site (with/without orthopedic implant), moderate/severe muscle damage and/or necrosis, and moder","PeriodicalId":86137,"journal":{"name":"Military surgeon","volume":"187 Supplement_2 1","pages":"25-33"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45319063","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Joining the military and entering a career in medicine are both intensely personal decisions. Individually, becoming a physician or a naval officer requires people to join a profession, represented by the oaths of each group. Both require hard work, demanding schedules, and dedication. Those entering into the Medical Corps will combine these roles. To optimize finding a fulfilling career, students interested in joining the medical corps should identify mentors, which helps them create the career path they want and aids in their self-reflection to discover their motivations and expectations, finally "Semper Gumby." My own path fulfilled my desire to serve and passion for medicine but more importantly afforded me the opportunity to pursue fellowship, gain expertise in academic medicine, and construct a network of mentors, colleagues, and friends around the globe.
{"title":"Joining the Navy to Become a Physician: Nothing Typical About It.","authors":"Daphne P Morrison Ponce","doi":"10.1093/milmed/usac121","DOIUrl":"https://doi.org/10.1093/milmed/usac121","url":null,"abstract":"Joining the military and entering a career in medicine are both intensely personal decisions. Individually, becoming a physician or a naval officer requires people to join a profession, represented by the oaths of each group. Both require hard work, demanding schedules, and dedication. Those entering into the Medical Corps will combine these roles. To optimize finding a fulfilling career, students interested in joining the medical corps should identify mentors, which helps them create the career path they want and aids in their self-reflection to discover their motivations and expectations, finally \"Semper Gumby.\" My own path fulfilled my desire to serve and passion for medicine but more importantly afforded me the opportunity to pursue fellowship, gain expertise in academic medicine, and construct a network of mentors, colleagues, and friends around the globe.","PeriodicalId":86137,"journal":{"name":"Military surgeon","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48776819","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
INTRODUCTION The decision to enter the Navy as a physician is a major career choice. However, there are no published studies that address the typical Navy physician's experience in the Health Professions Scholarship Program (HPSP) and Uniformed Services University of the Health Sciences (USUHS) programs. The purpose of this qualitative study is to describe the typical Navy physician's experience in the HPSP and USUHS programs. MATERIALS AND METHODS An anonymous online survey containing 47 questions was distributed to 63 Navy HPSP and USUHS physicians who started internships from 2008 to 2015. Participants were chosen by using purposeful, criterion, and snowball sampling methods with whom the author had a professional relationship during his military experience. The survey data were plotted in Excel spreadsheets and graphs according to six sub-research questions. Mean, SD, Likert scale 1-5, and grouping of free text responses were recorded. RESULTS A total of 54 out of 63 Navy physicians (85.7%) responded to the survey. Navy physicians got their first-choice residency selection of 67.3% of the time, 34.6% went straight through residency without interruptions, 44.2% answered definitely or probably that military match changed their residency selection compared to them applying for civilian residency, and 46.2% answered definitely or probably that it was more difficult to get into military versus civilian residency. Participants answered definitely or probably that military experience puts them ahead of civilians in terms of leadership (82.7%), prior medical experience (46.2%), and applying for civilian residency (76.2%). Common positive themes of free-text answers included having financial stability, unique life experiences, and serving their country. Common negative themes included lack of career control, lack of knowledge regarding HPSP/USUHS programs, and delay in residency and career. CONCLUSIONS The principal findings in this study are that most Navy physicians favored paid medical school/financial support, working overseas and in unique operational climates, having unique life experiences, leadership skills, and prior military experience put them ahead of their civilian colleagues, thought the Navy experience was worth it, and would join again if given the opportunity. However, most Navy physicians had a lack of career control due to needs of the Navy, lack of knowledge regarding residency selection, operational billets, and active duty service obligation, had more difficulty getting into a military residency of their choice versus civilians, and had interrupted residency training/training delays. The Navy would possibly benefit from a nationwide HPSP/USUHS physician mentorship program and an educational seminar to increase medical student applicant knowledge, which may improve recruiting and retention.
{"title":"Joining the Navy to Become a Physician: The Typical Experience.","authors":"Eric Goodrich","doi":"10.1093/milmed/usac117","DOIUrl":"https://doi.org/10.1093/milmed/usac117","url":null,"abstract":"INTRODUCTION\u0000The decision to enter the Navy as a physician is a major career choice. However, there are no published studies that address the typical Navy physician's experience in the Health Professions Scholarship Program (HPSP) and Uniformed Services University of the Health Sciences (USUHS) programs. The purpose of this qualitative study is to describe the typical Navy physician's experience in the HPSP and USUHS programs.\u0000\u0000\u0000MATERIALS AND METHODS\u0000An anonymous online survey containing 47 questions was distributed to 63 Navy HPSP and USUHS physicians who started internships from 2008 to 2015. Participants were chosen by using purposeful, criterion, and snowball sampling methods with whom the author had a professional relationship during his military experience. The survey data were plotted in Excel spreadsheets and graphs according to six sub-research questions. Mean, SD, Likert scale 1-5, and grouping of free text responses were recorded.\u0000\u0000\u0000RESULTS\u0000A total of 54 out of 63 Navy physicians (85.7%) responded to the survey. Navy physicians got their first-choice residency selection of 67.3% of the time, 34.6% went straight through residency without interruptions, 44.2% answered definitely or probably that military match changed their residency selection compared to them applying for civilian residency, and 46.2% answered definitely or probably that it was more difficult to get into military versus civilian residency. Participants answered definitely or probably that military experience puts them ahead of civilians in terms of leadership (82.7%), prior medical experience (46.2%), and applying for civilian residency (76.2%). Common positive themes of free-text answers included having financial stability, unique life experiences, and serving their country. Common negative themes included lack of career control, lack of knowledge regarding HPSP/USUHS programs, and delay in residency and career.\u0000\u0000\u0000CONCLUSIONS\u0000The principal findings in this study are that most Navy physicians favored paid medical school/financial support, working overseas and in unique operational climates, having unique life experiences, leadership skills, and prior military experience put them ahead of their civilian colleagues, thought the Navy experience was worth it, and would join again if given the opportunity. However, most Navy physicians had a lack of career control due to needs of the Navy, lack of knowledge regarding residency selection, operational billets, and active duty service obligation, had more difficulty getting into a military residency of their choice versus civilians, and had interrupted residency training/training delays. The Navy would possibly benefit from a nationwide HPSP/USUHS physician mentorship program and an educational seminar to increase medical student applicant knowledge, which may improve recruiting and retention.","PeriodicalId":86137,"journal":{"name":"Military surgeon","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47554140","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Artemisinin and its derivatives have potential antidiabetic effects. There is no evaluation of reported studies in the literature on the treatment of diabetic nephropathy (DN), one of the commonest diabetic microangiopathies, with artemisinins. Here, we aimed to evaluate preclinical evidence for the efficacy and possible mechanisms of artemisinins in reducing diabetic renal injury.
Methods: We conducted an electronic literature search in fourteen databases from their inception to November 2021. All animal studies assessing the efficacy and safety of artemisinins in DN were included, regardless of publication or language. Overall, 178 articles were screened according to predefined inclusion and exclusion criteria. Finally, 18 eligible articles were included in this systematic review. The SYstematic Review Center for Laboratory animal Experimentation (SYRCLE) risk-of-bias tool was used to assess the risk of bias in the included studies. The primary outcomes were kidney function, proteinuria, and renal pathology. Secondary endpoints included changes in fasting plasma glucose (FPG) levels, body weight, and relevant mechanisms.
Results: Of the 18 included articles involving 418 animal models of DN, 1, 2, 6, and 9 used dihydroartemisinin, artemether, artesunate, and artemisinin, respectively. Overall, artemisinins reduced indicators of renal function, including blood urea nitrogen (P < 0.00001), serum creatinine (P < 0.00001), and kidney index (P = 0.0001) compared with control group treatment. Measurements of proteinuria (P < 0.00001), microalbuminuria (P < 0.05), and protein excretion (P = 0.0002) suggested that treatment with artemisinins reduced protein loss in animals with DN. Artemisinins may lower blood glucose levels (P = 0.01), but there is a risk of weight gain (P < 0.00001). Possible mechanisms of action of artemisinins include delaying renal fibrosis, reducing oxidative stress, and exerting antiapoptotic and anti-inflammatory effects.
Conclusion: Available evidence suggests that artemisinins may be protective against renal injury secondary to diabetes in preclinical studies; however, high-quality and long-term trials are needed to reliably determine the balance of benefits and harms.
{"title":"Protective Effect and Possible Mechanisms of Artemisinin and Its Derivatives for Diabetic Nephropathy: A Systematic Review and Meta-Analysis in Animal Models.","authors":"Haoyue Feng, Tingchao Wu, Qi Zhou, Hui Li, Tianyi Liu, Xitao Ma, Rensong Yue","doi":"10.1155/2022/5401760","DOIUrl":"10.1155/2022/5401760","url":null,"abstract":"<p><strong>Background: </strong>Artemisinin and its derivatives have potential antidiabetic effects. There is no evaluation of reported studies in the literature on the treatment of diabetic nephropathy (DN), one of the commonest diabetic microangiopathies, with artemisinins. Here, we aimed to evaluate preclinical evidence for the efficacy and possible mechanisms of artemisinins in reducing diabetic renal injury.</p><p><strong>Methods: </strong>We conducted an electronic literature search in fourteen databases from their inception to November 2021. All animal studies assessing the efficacy and safety of artemisinins in DN were included, regardless of publication or language. Overall, 178 articles were screened according to predefined inclusion and exclusion criteria. Finally, 18 eligible articles were included in this systematic review. The SYstematic Review Center for Laboratory animal Experimentation (SYRCLE) risk-of-bias tool was used to assess the risk of bias in the included studies. The primary outcomes were kidney function, proteinuria, and renal pathology. Secondary endpoints included changes in fasting plasma glucose (FPG) levels, body weight, and relevant mechanisms.</p><p><strong>Results: </strong>Of the 18 included articles involving 418 animal models of DN, 1, 2, 6, and 9 used dihydroartemisinin, artemether, artesunate, and artemisinin, respectively. Overall, artemisinins reduced indicators of renal function, including blood urea nitrogen (<i>P</i> < 0.00001), serum creatinine (<i>P</i> < 0.00001), and kidney index (<i>P</i> = 0.0001) compared with control group treatment. Measurements of proteinuria (<i>P</i> < 0.00001), microalbuminuria (<i>P</i> < 0.05), and protein excretion (<i>P</i> = 0.0002) suggested that treatment with artemisinins reduced protein loss in animals with DN. Artemisinins may lower blood glucose levels (<i>P</i> = 0.01), but there is a risk of weight gain (<i>P</i> < 0.00001). Possible mechanisms of action of artemisinins include delaying renal fibrosis, reducing oxidative stress, and exerting antiapoptotic and anti-inflammatory effects.</p><p><strong>Conclusion: </strong>Available evidence suggests that artemisinins may be protective against renal injury secondary to diabetes in preclinical studies; however, high-quality and long-term trials are needed to reliably determine the balance of benefits and harms.</p>","PeriodicalId":86137,"journal":{"name":"Military surgeon","volume":"126 1","pages":"5401760"},"PeriodicalIF":0.0,"publicationDate":"2022-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9073547/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82890336","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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