Characteristics of Active Duty Service Members Referred to the Navy’s Weight-Management Program

ABSTRACT Introduction Rates of overweight and obesity have increased in the military, particularly in the U.S. Navy. While the Navy has implemented weight-management programs like ShipShape, findings on the effectiveness of these programs are mixed. Further knowledge on the characteristics of service members (SMs) who participate in these programs may help inform course curricula and improve outcomes. This study aimed to (1) examine characteristics of SMs referred to the Navy’s ShipShape program at a large military treatment facility, (2) compare these characteristics among SMs who did and did not enroll in a randomized clinical trial of ShipShape (ShipShape study participants), and (3) compare demographic and health characteristics of ShipShape study participants to that of a random and similarly sized sample of Navy SMs who responded to the 2015 DoD Health-Related Behaviors Survey (HRBS). Materials and Methods Data from active duty Navy SMs referred to the ShipShape program at a large military treatment facility were evaluated (n = 225). A subset of these SMs enrolled in the ShipShape study (n = 187). Among enrolled SMs, data from 147 who completed all measures were compared to that of HRBS respondents. Univariate ANOVA and chi-square analyses were used to examine (1) demographic and motivational differences between SMs who did and did not enroll in the ShipShape study and (2) differences in demographics and medical and mental health conditions between ShipShape study participants and Navy HRBS respondents. Results The majority of SMs referred to ShipShape were female with an average age of 28.3 years. Compared to SMs who did not enroll in the ShipShape study (n = 38), ShipShape study participants were more likely to be female, less likely to be Hispanic, and had higher motivation and emotional eating scores. Compared to Navy HRBS respondents (n = 164), ShipShape study participants (n = 147) were younger, more likely to be female, non-Hispanic, enlisted, and obese. Further, ShipShape study participants reported significantly fewer medical health conditions but higher rates of probable depression, anxiety, and PTSD and were more likely to report receiving current mental health treatment than HRBS respondents. Conclusion Overweight or obese SMs seeking weight loss in the ShipShape study were relatively young, female, non-Hispanic, motivated, but with greater emotional eating. ShipShape study participants endorsed few medical health conditions but had higher rates of probable mental health conditions compared to the HRBS sample. These findings suggest that SMs referred to Navy weight-management programs are likely experiencing comorbid mental health conditions which may interfere with the effectiveness of their weight loss efforts. The descriptive nature of this study and the focus on Navy SMs in only one ShipShape program may decrease the generalizability of our findings to participants at other locations. Nonetheless, these findings demonstrate the potential need for Navy weight-management programs that incorporate mental health treatment and address the specific needs of female and diverse SMs. A more comprehensive curriculum could improve the results of weight-management efforts, increase SM quality of life and fitness and thereby operational readiness.

Evaluating the Efficacy of a Screening Protocol for Severe Acute Respiratory Syndrome Coronavirus 2 Virus in Asymptomatic Preoperative/Preprocedural Patients at a Military Hospital

ABSTRACT Introduction Facing the COVID-19 pandemic, many hospitals implemented severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening protocols before aerosol-generating procedures (AGPs) in an effort to protect patients and health care workers. Given the limited prior evidence on the effectiveness of such protocols, we report the process improvement experience at a military treatment facility. Materials and Methods We evaluated the outcomes of patients undergoing AGPs from March to September 2020, divided into three cohorts: a preprotocol (PP) cohort who did not receive screening, an early testing (ET) cohort representing the early months of the screening protocol, and a late testing (LT) cohort managed under adaptive modifications to the screening protocol. We recorded identifiable post-procedure COVID-19 diagnoses. The study was approved as a process improvement protocol and was determined not to meet criteria for human subject research through an institutional approval process. Results Across the three cohorts, 4520 procedures were performed: 422 PP, 1297 ET, and 2801 LT. Among 4098 procedures in the ET and LT cohorts, 12 asymptomatic patients tested positive for SARS-CoV-2 (0.29% positivity rate). One left the health system before completing the procedure and another proceeded urgently under COVID precautions, while 10 were rescheduled and completed at a later date; 7 were cleared using a test-based strategy, while 3 were cleared using a time-based strategy. Of 445 patients who had SARS-CoV-2 tests performed within 30 days following their procedures, three patients with negative preoperative tests had a positive test within 30 days, all in the LT cohort but had evidence of acquiring the infection after the procedure or had a false-positive test. Conclusions Our strategy of preprocedural SARS-CoV-2 testing successfully identified asymptomatic infected patients before surgery. Care was delayed for most of these patients without apparent detriment. Adaptation to a time-based strategy for clearance might reduce such delays, but other considerations may still influence how soon procedures should be completed after a positive test.

A Descriptive Analysis of Supermassive Transfusion Recipients Among US and Coalition Forces During Combat Operations in Afghanistan and Iraq

ABSTRACT Introduction Hemorrhage is the leading cause of potentially preventable death on the battlefield. Resuscitation with blood products is essential to restore circulating volume, repay the oxygen debt, and prevent coagulopathy. Massive transfusion (MT) occurs frequently after major trauma; a subset of casualties requires a supermassive transfusion (SMT), and thus, mobilization of additional resources remains unclear. Materials and Methods This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry. In this analysis, we isolated U.S. and Coalition casualties that received at least 1 unit of packed red blood cells (PRBCs) or whole blood (WB). Given a lack of consensus on the definition of SMT recipients, we included those patients receiving the top quartile of PRBC and WB administered within the first 24 hours following arrival to a military treatment facility. Results We identified 25,897 adult casualties from January 1, 2007 to March 17, 2020. Within this dataset, 2,608 (9.0%) met inclusion for this analysis. The median number of total products administered within the first 24 hours was 8 units of PRBC or WB. The upper quartile was 18 units (n = 666). Compared to all other blood product recipients, patients in the SMT cohort had a higher median injury severity score (27 vs 18, P < 0.001), were most frequently injured by explosives (84.9% vs 68.6%, P < 0.001), had a higher mean emergency department (ED) pulse (128 vs 111, P < 0.001), a lower mean systolic blood pressure (122 vs 132 mm Hg, P < 0.001), and a higher mean international normalized ratio (1.68 vs 1.38, P < 0.001). SMT patients experienced lower survival to hospital discharge (85.8% vs 93.3%, P < 0.001). Conclusions Compared to all other PRBC and WB recipients, SMT patients experienced more injury by explosives, severe injury patterns, ED vital sign derangements, and mortality. These findings may help identify those casualties who may require earlier aggressive resuscitation. However, more data is needed to define this population early in their clinical course for early identification to facilitate rapid resource mobilization. Identifying casualties who are likely to die within 24 hours compared to those who are likely to survive, may assist in determining a threshold for a SMT.

COVID-19 Vaccine Distribution: Bolstering the Air Force Immunizations Model

ABSTRACT From its emergence and declaration as a worldwide pandemic, coronavirus disease-2019 (COVID-19) has been associated with significant medical and logistical challenges. Initial obstacles ranged from the need to develop testing platforms to the determination of effective treatments to decrease the significant morbidity and mortality associated with the disease. Due to significant scientific breakthroughs, the most recent pressing challenge has been the distribution of vaccines against severe acute respiratory syndrome coronavirus 2 to prevent the spread of the infection across the world. Historically, the U.S. Military has been involved in immunizations delivery to prevent disease among its troops. This experience has led to the establishment of programs designed to distribute safe vaccinations to service members and beneficiaries. It is upon this infrastructure that the Air Force (AF) medical community was thrust to devise and execute COVID-19 vaccine delivery implementation across all military treatment facilities. In the AF, specialty trained allergist and immunologists provide the technical expertise for the establishment and execution of the AF immunizations program. These medical professionals have the proficiency, knowledge, and experience to run efficient mass immunization events in order to provide vaccines in a safe and rapid environment. Despite this, significant challenges attributable to the variable and novel nature of COVID-19 vaccine logistical requirements have led to unanswered questions and debate that needed resolution before and during the launch of this program. Here we describe the process for establishing a mass vaccination program for COVID-19 vaccine delivery and our experience-based problem solving approach at a large AF military treatment facility.

Bamlanivimab Use in a Military Treatment Facility

ABSTRACT Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), was first identified in 2019 in Wuhan, China, and has rapidly spread across the world. As of April 2021, SARS-CoV-2 has infected more than 140,000,000 and caused more than 3,000,000 deaths globally. In November 2020, the monoclonal antibody bamlanivimab was approved by the FDA for non-hospitalized patients with SARS-CoV-2 (COVID-19) who possessed risk factors for progression to severe COVID-19. This provided a treatment option that may help prevent hospitalization. Methods Patients who regularly received ambulatory care at a military treatment facility and who were diagnosed with mild-to-moderate COVID-19 and possessed risk factors for progression to severe COVID-19 were treated with a single, intravenous infusion (700 mg) of the virus-neutralizing monoclonal antibody bamlanivimab. The primary outcome was improvement of self-reported symptoms within 24 to 72 hours of receiving the infusion. The secondary outcome was prevention of disease progression requiring emergency department (ED) utilization or hospitalization related to COVID-19 within 30 days of infusion. Bamlanivimab was administered in accordance with the FDA’s approval and Defense Health Agency’s guidance, including follow-up within 72 hours of administration. Institutional Review Board (IRB) approval was obtained. Results Of the COVID-19 patients who were given the option of a bamlanivimab infusion, 40 accepted and 6 did not (40/46, 86.9%). Thirty-six of 40 patients in the treatment group were contacted within 72 hours. ED/hospitalization information was available for all 46 patients. In the treatment group, 94.4% (34/36) reported global improvement. Three of 40 (7.5%) patients in the treatment group required inpatient admission, and 2 of 40 patients (5%) required ED evaluation within 30 days of infusion. Therefore, 5 of 40 (12.5%) patients required evaluation shortly after infusion, while 2 of 6 (33.3%) patients who declined treatment required hospital evaluation or admission related to COVID-19 within 30 days of infusion (P = .15). Conclusions Global improvement of symptoms within 24 to 72 hours of infusion was reported by 94.4% of patients receiving bamlanivimab; however, statistical significance could not be determined due to the small sample size and lack of placebo group due to study design. Furthermore, ED visits and hospital admissions were analyzed, but with only six patients in the comparison group, the relative risk was not statistically significant and could not be precisely estimated. In the future, this study can be replicated with both larger control/treatment arms to validate the initial results of this small, retrospective, cohort study.

Preventing Surgical and Postpartum Hemorrhage in an Active Duty Patient With an Undiagnosed Coagulopathy at a Military Treatment Facility

ABSTRACT Factor VII (FVII) deficiency is a hereditary bleeding disorder that significantly increases the risk of hemorrhage during the intrapartum and postpartum periods as well as during surgery. Management often requires careful pre- and post-operative planning, a multi-disciplinary approach, and management at a tertiary center. Most cases in the literature utilized recombinant FVII for treatment. We present a case of a young active duty female who had an undiagnosed FVII deficiency that became apparent during her expedited delivery for fetal distress. Our patient was admitted for delivery while undergoing a work up for an abnormal coagulation panel. Given high suspicion for FVII deficiency, anticipated hemorrhage, and need for cesarean delivery, she was treated with blood products containing FVII. Two days after delivery her diagnosis was confirmed. Available literature discusses the management of known FVII deficiency in pregnancy; however, to the best of our knowledge, there are no cases of an unknown bleeding diathesis incidentally identified just before delivery and later diagnosed as FVII deficiency. This case highlights the appropriate management of an unknown coagulopathy, the significant challenges associated, and the incorporation of a multi-disciplinary team critical to reducing significant maternal morbidity.

Characteristics, Treatment, and Outcomes of Patients With Severe or Life-threatening COVID-19 at a Military Treatment Facility—A Descriptive Cohort Study

ABSTRACT Introduction The treatment of severe and life-threatening COVID-19 is a rapidly evolving practice. The purpose of our study was to describe the characteristics and outcomes of patients with severe or life-threatening COVID-19 who present to a Military Treatment Facility (MTF) with an emphasis on addressing institutional adaptations to rapidly changing medical evidence. Materials and Methods A single-center retrospective study conducted on a prospectively maintained cohort. The MTF is a 52-bed hospital within an urban setting. Patients were included in the cohort if they had laboratory-confirmed severe or life-threatening COVID-19 with positive SARS-CoV-2 reverse transcription polymerase chain reaction. Severe disease was defined as dyspnea, respiratory frequency ≥30/min, blood oxygen saturation ≤93% on ambient air, partial pressure of arterial oxygen to fraction of inspired oxygen ratio <300, or lung infiltrates involving >50% of lung fields within 24-48 hours. Life-threatening COVID-19 was defined as respiratory failure, septic shock, or multiple organ dysfunction. The cohort included patients admitted from June 1 through November 13. Data were collected retrospectively via chart review by a resident physician. Results In total, our MTF saw 14 cases of severe or life-threatening COVID-19 from June 1 to November 13. Patients had a median age of 70.5 years, with 7% being active duty personnel, 21% dependents, and 71% retired military members. The median time to dexamethasone, remdesivir, and convalescent plasma administration was 4.7, 6.3, and 11.2 hours, respectively. The 28-day in-hospital mortality was 0%. Conclusions Patients who present to an MTF with severe or life-threatening COVID-19 are largely retirees, with only a small fraction comprising active duty personnel. The institution of order sets and early consultation can help facilitate prompt patient care for COVID-19.