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Cybulski DJ, Matthews Z, Kieffer JW, Casey TM, Osuna AB, Kasper K, Frankel DN, Aden J, Yun HC, Marcus JE. Impact of SARS-CoV-2 Arrival Surveillance Screening by Nucleic Acid Amplification Versus Rapid Antigen Detection on Subsequent COVID-19 Infections in Military Trainees. Clin Infect Dis 2024; 78:65-69. [PMID: 37610361 DOI: 10.1093/cid/ciad466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND For persons entering congregate settings, optimal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) arrival surveillance screening method, nucleic acid amplification test (NAAT) versus rapid antigen detection test (RADT), is debated. To aid this, we sought to determine the risk of secondary symptomatic coronavirus disease 19 (COVID-19) among military trainees with negative arrival NAAT or RADT screening. METHODS Individuals who arrived for US Air Force basic military training from 1 January-31 August 2021 were placed into training groups and screened for SARS-CoV-2 via NAAT or RADT. Secondary symptomatic COVID-19 cases within 2 weeks of training were then measured. A case cluster was defined as ≥5 individual symptomatic COVID-19 cases. RESULTS 406 (1.6%) of 24 601 trainees screened positive upon arrival. The rate of positive screen was greater for those tested with NAAT versus RADT (2.5% vs 0.4%; RR: 5.4; 95% CI: 4.0-7.3; P < .001). The proportion of training groups with ≥1 positive individual screen was greater in groups screened via NAAT (57.5% vs 10.8%; RR: 5.31; 95% CI: 3.65-7.72; P < .001). However, NAAT versus RADT screening was not associated with a difference in number of training groups to develop a secondary symptomatic case (20.3% vs 22.5%; RR: .9; 95% CI: .66-1.23; P = .53) or case cluster of COVID-19 (4% vs 6.6%; RR: .61; 95% CI: .3-1.22; P = .16). CONCLUSIONS NAAT versus RADT arrival surveillance screening method impacted individual transmission of COVID-19 but had no effect on number of training groups developing a secondary symptomatic case or case cluster. This study provides consideration for RADT arrival screening in congregate settings.
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Affiliation(s)
- Daniel J Cybulski
- Infectious Diseases Section, Department of Medicine, Brooke Army Medical Center, JBSA-Fort Sam, Houston, Texas, USA
| | - Zachary Matthews
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - John W Kieffer
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- Trainee Health Surveillance, JBSA-Lackland, San Antonio, Texas, USA
| | - Theresa M Casey
- Trainee Health Surveillance, JBSA-Lackland, San Antonio, Texas, USA
| | - Angela B Osuna
- Trainee Health Surveillance, JBSA-Lackland, San Antonio, Texas, USA
| | - Korey Kasper
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- Trainee Health, JBSA-Lackland, San Antonio, Texas, USA
| | - Dianne N Frankel
- Headquarters U.S. Africa Command, Kelley Barracks, Stuttgart, Germany
| | - James Aden
- Biostatistics, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, Texas, USA
| | - Heather C Yun
- Infectious Diseases Section, Department of Medicine, Brooke Army Medical Center, JBSA-Fort Sam, Houston, Texas, USA
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Joseph E Marcus
- Infectious Diseases Section, Department of Medicine, Brooke Army Medical Center, JBSA-Fort Sam, Houston, Texas, USA
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
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Kwon S, Casleton BG, Rivera GZ, Gella MM, Winkler EL, Kieffer JW, Osuna AB, Casey TM, Yun HC, Marcus JE. Infectious etiologies among post-donation deferrals in a military blood donation center. Transfusion 2023; 63:2265-2272. [PMID: 37850496 DOI: 10.1111/trf.17584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/19/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND The burden of transfusion-transmitted infections among blood recipients remains low due to extensive pre- and post-donation screening. However, the military has the unique challenge of providing blood in austere environments with limited testing capabilities. This study evaluates the infectious etiologies of deferred blood donors at a large military blood donation center. METHODS All blood donors at the Armed Service Blood Bank Center, San Antonio, between 2017 and 2022 with positive post-donation screening for hepatitis C (HCV), hepatitis B (HBV), human immunodeficiency virus (HIV), human T-lymphotropic virus (HTLV-I/II), Zika (2018-2021), West Nile virus, Trypanosoma cruzi, Treponema pallidum, or Babesia microti (2020-2022) were evaluated. Donors were deferred based on Food and Drug Administration (FDA) guidance. RESULTS Two-hundred and thirteen (213) donors met FDA criteria for deferral. T. pallidum (n = 45, 50.3 per 100,000), HCV (n = 34, 38.0 per 100,000), and HBV (n = 19, 21.2 per 100,000) were the most common pathogens among those with both positive screening and confirmatory testing. The majority of HIV (95%), Chagas (78%), HTLV-I/II (50%) deferrals were due to indeterminate confirmatory tests following initial positive screens. The majority of deferrals for HBV were for a second occurrence of a positive screen despite negative confirmatory testing. CONCLUSION The rates of post-donation deferral for transfusion-transmissible infections were low in this military cohort. Our findings suggest that donor testing in deployed service members should focus on HBV, HCV, and T. pallidum and highlight the need for better diagnostics for HIV, Chagas, and HTLV-I/II.
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Affiliation(s)
- Somin Kwon
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Brian G Casleton
- Armed Services Blood Bank Center-San Antonio, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
| | - Glorimar Z Rivera
- Armed Services Blood Bank Center-San Antonio, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
| | - Melita M Gella
- Armed Services Blood Bank Center-San Antonio, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
- Department of Veterans Affairs, Audie Murphy VA Hospital, San Antonio, Texas, USA
| | - Erin L Winkler
- Trainee Health Surveillance, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
| | - John W Kieffer
- Trainee Health Surveillance, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Angela B Osuna
- Trainee Health Surveillance, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
| | - Theresa M Casey
- Trainee Health Surveillance, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
| | - Heather C Yun
- Infectious Diseases Service, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Fort Sam Houston, Texas, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Joseph E Marcus
- Infectious Diseases Service, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Fort Sam Houston, Texas, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Webber BJ, Yun HC, Whitfield GP. Leisure-time physical activity and mortality from influenza and pneumonia: a cohort study of 577 909 US adults. Br J Sports Med 2023; 57:1231-1237. [PMID: 37192831 PMCID: PMC10579185 DOI: 10.1136/bjsports-2022-106644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE To examine the association of leisure-time physical activity with mortality from influenza and pneumonia. METHODS A nationally representative sample of US adults (aged ≥18 years) who participated in the National Health Interview Survey from 1998 to 2018 were followed for mortality through 2019. Participants were classified as meeting both physical activity guidelines if they reported ≥150 min/week of moderate-intensity equivalent aerobic physical activity and ≥2 episodes/week of muscle-strengthening activity. Participants were also classified into five volume-based categories of self-reported aerobic and muscle-strengthening activity. Influenza and pneumonia mortality was defined as having an underlying cause of death with an International Classification of Diseases, 10th Revision code of J09-J18 recorded in the National Death Index. Mortality risk was assessed using Cox proportional hazards, adjusting for sociodemographic and lifestyle factors, health conditions and influenza and pneumococcal vaccination status. Data were analysed in 2022. RESULTS Among 577 909 participants followed for a median of 9.23 years, 1516 influenza and pneumonia deaths were recorded. Compared with participants meeting neither guideline, those meeting both guidelines had 48% lower adjusted risk of influenza and pneumonia mortality. Relative to no aerobic activity, 10-149, 150-300, 301-600 and >600 min/week were associated with lower risk (by 21%, 41%, 50% and 41%). Relative to <2 episodes/week of muscle-strengthening activity, 2 episodes/week was associated with 47% lower risk and ≥7 episodes/week with 41% higher risk. CONCLUSIONS Aerobic physical activity, even at quantities below the recommended level, may be associated with lower influenza and pneumonia mortality while muscle-strengthening activity demonstrated a J-shaped relationship.
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Affiliation(s)
- Bryant J Webber
- Division of Nutrition, Physical Activity and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Heather C Yun
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Geoffrey P Whitfield
- Division of Nutrition, Physical Activity and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Matthews ZK, Cybulski DJ, Frankel DN, Kieffer JW, Casey TM, Osuna AB, Yun HC, Marcus JE. Sensitivity of Symptom-Based Screening for COVID-19 in Active Duty Basic Trainees. Mil Med 2023:7165271. [PMID: 37192055 DOI: 10.1093/milmed/usad138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/04/2023] [Accepted: 04/20/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION Symptomatic Coronavirus Disease 2019 (COVID-19) screening has been a cornerstone of case identification during the pandemic. Despite the myriad of COVID-19 symptoms, symptom screens have primarily focused on symptoms of influenza-like illnesses such as fever, cough, and dyspnea. It is unknown how well these symptoms identify cases in a young, healthy military population. This study aims to evaluate the utility of symptom-based screening in identifying COVID-19 through three different COVID-19 waves. MATERIALS AND METHODS A convenience sample of 600 military trainees who arrived at Joint Base San Antonio-Lackland in 2021 and 2022 were included. Two hundred trainees with symptomatic COVID-19 before the emergence of the Delta variant (February-April 2021), when Delta variant was predominant (June-August 2021), and when Omicron was the predominant variant (January 2022) had their presenting symptoms compared. At each time point, the sensitivity of a screen for influenza-like illness symptoms was calculated. RESULTS Of the 600 symptomatic active duty service members who tested positive for COVID-19, the most common symptoms were sore throat (n = 385, 64%), headache (n = 334, 56%), and cough (n = 314, 52%). Although sore throat was the most prominent symptom during Delta (n = 140, 70%) and Omicron (n = 153, 77%), headache was the most common before Delta (n = 93, 47%). There were significant differences in symptoms by vaccination status; for example, ageusia was more common in patients who were not completely vaccinated (3% vs. 0%, P = .01). Overall, screening for fever, cough, or dyspnea had a 65% sensitivity with its lowest sensitivity in the pre-Delta cases (54%) and highest sensitivity in Omicron cases (78%). CONCLUSIONS In this descriptive cross-sectional study evaluating symptomatic military members with COVID-19, symptom prevalence varied based on predominant circulating COVID-19 variant as well as patients' vaccination status. As screening strategies evolve with the pandemic, changing symptom prevalence should be considered.
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Affiliation(s)
- Zachary K Matthews
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Daniel J Cybulski
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Division of Infectious Diseases, Department of Medicine, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX 78234, USA
| | | | - John W Kieffer
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Trainee Health Surveillance, 559 THLS, JBSA-Lackland, TX 78236, USA
| | - Theresa M Casey
- Trainee Health Surveillance, 559 THLS, JBSA-Lackland, TX 78236, USA
| | - Angela B Osuna
- Trainee Health Surveillance, 559 THLS, JBSA-Lackland, TX 78236, USA
| | - Heather C Yun
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Division of Infectious Diseases, Department of Medicine, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX 78234, USA
| | - Joseph E Marcus
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Division of Infectious Diseases, Department of Medicine, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX 78234, USA
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Marcus JE, Bennett WN, Frankel DN, Kieffer JW, Casey TM, Huston AE, Hintz CN, Keller AP, Smolka MT, Sikorski CS, Yun HC, Dolan MJ, Kiley JL. Response to a Serogroup B Meningococcal Disease Case Among Military Trainees. Open Forum Infect Dis 2022; 9:ofac162. [DOI: 10.1093/ofid/ofac162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/24/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
We describe the public health response to a military trainee who developed serogroup B meningococcal disease while sharing underwater breathing equipment. Despite high transmission risk, with rapid isolation and post-exposure prophylaxis administration, there were no secondary cases. This case supports carefully weighing serogroup B meningococcal vaccination in high risk settings.
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Affiliation(s)
- Joseph E Marcus
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - William N Bennett
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Dianne N Frankel
- Office of the Command Surgeon, Air Education and Training Command, Joint Base San Antonio-Randolph, Texas, USA
| | - John W Kieffer
- Trainee Health Surveillance, THLS, Joint Base San Antonio-Lackland, Texas, USA
| | - Theresa M Casey
- Trainee Health Surveillance, THLS, Joint Base San Antonio-Lackland, Texas, USA
| | - Amanda E Huston
- Public Health, AMDS, Joint Base San Antonio-Lackland, Texas, USA
| | - Courtney N Hintz
- Special Warfare Human Performance Support Group, Joint Base San Antonio-Lackland, Texas, USA
| | - Alexander P Keller
- Special Warfare Human Performance Support Group, Joint Base San Antonio-Lackland, Texas, USA
| | - Michael T Smolka
- Special Warfare Human Performance Support Group, Joint Base San Antonio-Lackland, Texas, USA
| | | | - Heather C Yun
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Matthew J Dolan
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - John L Kiley
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
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Tisdale MD, Tribble DR, Mitra I, Telu K, Kuo HC, Fraser JA, Liu J, Houpt ER, Riddle MS, Tilley DH, Kunz AN, Yun HC, Geist CC, Lalani T. TaqMan Array Card testing of participant-collected stool smears to determine the pathogen-specific epidemiology of travellers' diarrhoea†. J Travel Med 2022; 29:6365984. [PMID: 34494100 PMCID: PMC8763119 DOI: 10.1093/jtm/taab138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND We assessed the compliance with self-collection of stool smears on Whatman® FTA® Elute Card (FTA Card) and detection of travellers' diarrhoea (TD)-associated pathogens by using a quantitative Polymerase Chain Reaction (PCR) assay [customized TaqMan® array card (TAC)] in a prospective, observational cohort of travellers. METHODS Enrolled travellers documented symptoms on a travel diary and collected an FTA Card during a diarrhoeal episode, or at the end of travel if they remained asymptomatic. TAC testing was performed on FTA Cards from TD cases and 1:1 matched asymptomatic controls and 1:1 matched loose stool cases that did not meet TD criteria. Odds ratios were used to determine the association between detected pathogens and TD. RESULTS Of 2456 travellers, 484 (19.7%) completed an illness diary and met TD criteria, and 257 (53.1%) collected an FTA Card during the TD episode. FTA Cards were stored for a median of 2 years at room temperature (IQR: 1-4 years) before extraction and testing. The overall TAC detection rate in TD cases was 58.8% (95% CI: 52.5-64.8). Enterotoxigenic Escherichia coli was the most common pathogen in TD cases (26.8%), and 3.5% of samples were positive for norovirus. The odds of detecting TD-associated pathogens in 231 matched cases and asymptomatic controls were 5.4 (95% CI: 3.6-8.1) and 2.0 (95% CI: 1.1-3.7) in 121 matched TD and loose stool cases (P < 0.05). Enteroaggregative E. coli was the most common pathogen detected in asymptomatic controls and loose stool cases. Detection of diarrhoeagenic E. coli, Shigella/enteroinvasive E. coli and Campylobacter spp. was significantly associated with TD. CONCLUSION FTA Cards are a useful adjunct to traditional stool collection methods for evaluating the pathogen-specific epidemiology of TD in austere environments. Qualitative detection of pathogens was associated with TD. Measures to improve compliance and quality of FTA Card collection with decreased storage duration may further optimize detection.
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Affiliation(s)
- Michele D Tisdale
- To whom correspondence should be addressed. Infectious Disease & Travel Clinic, Building 3, 1st Floor, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.
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Hsu JL, Bonura EM, Blyth DM, Lindholm DA, Yun HC, Barsoumian AE. The Impact of Coronavirus Disease 2019 on Medical Trainee Career Decisions. Open Forum Infect Dis 2021; 8:ofab523. [PMID: 34805438 PMCID: PMC8600172 DOI: 10.1093/ofid/ofab523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/20/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jennifer L Hsu
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Erin M Bonura
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Dana M Blyth
- Infectious Disease Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - David A Lindholm
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Infectious Disease Service, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Heather C Yun
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Infectious Disease Service, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Alice E Barsoumian
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Infectious Disease Service, Brooke Army Medical Center, San Antonio, Texas, USA
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8
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Marcus JE, Frankel DN, Pawlak MT, Casey TM, Enriquez E, Yun HC. Effect of Arrival Quarantine on Subsequent COVID-19 Testing in a Cohort of Military Basic Trainees. Mil Med 2021; 186:984-987. [PMID: 34142709 DOI: 10.1093/milmed/usab247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/20/2021] [Accepted: 06/11/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Basic Military Training at Joint Base San Antonio-Lackland implemented several sequential non-pharmaceutical interventions in response to coronavirus disease-2019 (COVID-19). One measure, arrival quarantine, has not been studied as a modern military disease prevention strategy. This study aimed to determine the effect of a 14-day arrival quarantine on symptomatic COVID-19 testing. MATERIAL AND METHODS A retrospective cohort study compared symptomatic COVID-19 testing among all trainees who entered Basic Military Training between March 17, 2020, and April 17, 2020, before the implementation of universal arrival COVID-19 testing, during their first 2 weeks in arrival quarantine compared to the rest of their training. Furthermore, symptomatic COVID-19 testing in the last 5 weeks of training in those who completed arrival quarantine was compared to testing in the last 5 weeks for trainees who arrived between February 16, 2020, and March 16, 2020, and did not undergo arrival quarantine. Nominal variables were compared by chi-square test, and continuous variables were compared by Mann-Whitney U test. This study was approved as a public health surveillance project by the 59th Medical Wing Institutional Review Board. RESULTS Five thousand five hundred and seventy-six trainees started training between February 16, 2020, and April 17, 2020, with 2,573 trainees undergoing an arrival quarantine compared to 3,003 trainees who did not. Trainees who underwent arrival quarantine had higher rates of COVID-19 testing while in arrival quarantine (10.5 tests per 1,000 trainee-weeks vs. 2.3, P ≤ .001) and higher rates of concomitant influenza testing (74% vs. 38%, P = .001) compared to after they completed quarantine. Trainees that completed quarantine had less symptomatic COVID-19 testing after day 14 of training (2.3 tests per 1,000 trainee-weeks vs. 14.3, P ≤ .001) and influenza testing (38% vs. 74%, P = .001) compared to trainees that did not undergo arrival quarantine. CONCLUSION Arrival quarantine appears to be an effective non-pharmaceutical intervention associated with fewer symptomatic COVID-19 tests, especially after completion of quarantine.
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Affiliation(s)
- Joseph E Marcus
- Infectious Diseases Service, Department of Medicine, Brooke Army Medical Center, JBSA-Ft Sam Houston, TX 78234, USA
| | | | - Mary T Pawlak
- Trainee Health Surveillance, JBSA-Lackland, TX 78236, USA
| | | | - Erin Enriquez
- Trainee Health Surveillance, JBSA-Lackland, TX 78236, USA
| | - Heather C Yun
- Infectious Diseases Service, Department of Medicine, Brooke Army Medical Center, JBSA-Ft Sam Houston, TX 78234, USA
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9
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Buchek G, Mende K, Telu K, Kaiser S, Fraser J, Mitra I, Stam J, Lalani T, Tribble D, Yun HC. Travel-associated multidrug-resistant organism acquisition and risk factors among US military personnel. J Travel Med 2021; 28:6154715. [PMID: 33675647 PMCID: PMC8045176 DOI: 10.1093/jtm/taab028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND International travel is a risk factor for incident colonization with extended spectrum beta-lactamase (ESBL)-producing organisms. These and other multidrug-resistant (MDR) bacteria are major pathogens in combat casualties. We evaluated risk factors for colonization with MDR bacteria in US military personnel travelling internationally for official duty. METHODS TravMil is a prospective observational study enrolling subjects presenting to military travel clinics. We analysed surveys, antimicrobial use data, and pre- and post-travel perirectal swabs in military travellers to regions outside the continental USA, Canada, Western or Northern Europe, or New Zealand, presenting to one clinic from 12/2015 to 12/2017. Recovered Gram-negative isolates underwent identification and susceptibility testing (BD Phoenix). Characteristics of trip and traveller were analysed to determine risk factors for MDR organism colonization. RESULTS 110 trips were planned by 99 travellers (74% male, median age 38 years [IQR 31, 47.25]); 72 trips with returned pre- and post-travel swabs were completed by 64 travellers. Median duration was 21 days (IQR 12.75, 79.5). 17% travelled to Mexico/Caribbean/Central America, 15% to Asia, 57% to Africa and 10% to South America; 56% stayed in hotels and 50% in dormitories/barracks. Travellers used doxycycline (15%) for malaria prophylaxis, 11% took an antibiotic for travellers' diarrhoea (TD) treatment (fluoroquinolone 7%, azithromycin 4%). Incident MDR organism colonization occurred in 8 travellers (incidence density 3.5/1000 travel days; cumulative incidence 11% of trips [95% CI: 4-19%]), all ESBL-producing Escherichia coli. A higher incidence of ESBL-producing E. coli acquisition was associated with travel to Asia (36% vs 7%, P = 0.02) but not with travel to other regions, TD or use of antimicrobials. No relationship was seen between fluoroquinolone or doxycycline exposure and resistance to those antimicrobials. CONCLUSIONS Incident colonization with MDR organisms occurs at a lower rate in this military population compared with civilian travellers, with no identified modifiable risk factors, with highest incidence of ESBL acquisition observed after South Asia travel.
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Affiliation(s)
- Gregory Buchek
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Katrin Mende
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Kalyani Telu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Susan Kaiser
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Jamie Fraser
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Indrani Mitra
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Jason Stam
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - David Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Heather C Yun
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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10
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Marcus JE, Frankel DN, Pawlak MT, Casey TM, Cybulski RJ, Enriquez E, Okulicz JF, Yun HC. Risk Factors Associated With COVID-19 Transmission Among US Air Force Trainees in a Congregant Setting. JAMA Netw Open 2021; 4:e210202. [PMID: 33630090 PMCID: PMC7907953 DOI: 10.1001/jamanetworkopen.2021.0202] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IMPORTANCE Owing to concerns of coronavirus disease 2019 (COVID-19) outbreaks, many congregant settings are forced to close when cases are detected because there are few data on the risk of different markers of transmission within groups. OBJECTIVE To determine whether symptoms and laboratory results on the first day of COVID-19 diagnosis are associated with development of a case cluster in a congregant setting. DESIGN, SETTING, AND PARTICIPANTS This cohort study of trainees with COVID-19 from May 11 through August 24, 2020, was conducted at Joint Base San Antonio-Lackland, the primary site of entry for enlistment in the US Air Force. Symptoms and duration, known contacts, and cycle threshold for trainees diagnosed by reverse transcription-polymerase chain reaction were collected. A cycle threshold value represents the number of nucleic acid amplification cycles that occur before a specimen containing the target material generates a signal greater than the predetermined threshold that defines positivity. Cohorts with 5 or more individuals with COVID-19 infection were defined as clusters. Participants included 10 613 trainees divided into 263 parallel cohorts of 30 to 50 people arriving weekly for 7 weeks of training. EXPOSURES All trainees were quarantined for 14 days on arrival. Testing was performed on arrival, on day 14, and anytime during training when indicated. Protective measures included universal masking, physical distancing, and rapid isolation of trainees with COVID-19. MAIN OUTCOMES AND MEASURES Association between days of symptoms, specific symptoms, number of symptoms, or cycle threshold values of individuals diagnosed with COVID-19 via reverse transcription-polymerase chain reaction and subsequent transmission within cohorts. RESULTS In this cohort study of 10 613 US Air Force basic trainees in 263 cohorts, 403 trainees (3%) received a diagnosis of COVID-19 in 129 cohorts (49%). Among trainees with COVID-19 infection, 318 (79%) were men, and the median (interquartile range [IQR]) age was 20 (19-23) years; 204 (51%) were symptomatic, and 199 (49%) were asymptomatic. Median (IQR) cycle threshold values were lower in symptomatic trainees compared with asymptomatic trainees (21.2 [18.4-27.60] vs 34.8 [29.3-37.4]; P < .001). Cohorts with clusters of individuals with COVID-19 infection were predominantly men (204 cohorts [89%] vs 114 cohorts [64%]; P < .001), had more symptomatic trainees (146 cohorts [64%] vs 53 cohorts [30%]; P < .001), and had more median (IQR) symptoms per patient (3 [2-5] vs 1 [1-2]; P < .001) compared with cohorts without clusters. Within cohorts, subsequent development of clusters of 5 or more individuals with COVID-19 infection compared with those that did not develop clusters was associated with cohorts that had more symptomatic trainees (31 of 58 trainees [53%] vs 43 of 151 trainees [28%]; P = .001) and lower median (IQR) cycle threshold values (22.3 [18.4-27.3] vs 35.3 [26.5-37.8]; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study of US Air Force trainees living in a congregant setting during the COVID-19 pandemic, higher numbers of symptoms and lower cycle threshold values were associated with subsequent development of clusters of individuals with COVID-19 infection. These values may be useful if validated in future studies.
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Affiliation(s)
- Joseph E. Marcus
- Infectious Diseases Service, Brooke Army Medical Center, Joint Base San Antonio, Texas
| | - Dianne N. Frankel
- Trainee Health Surveillance, 559th Medical Group, Joint Base San Antonio–Lackland, Texas
| | - Mary T. Pawlak
- Trainee Health Surveillance, 559th Medical Group, Joint Base San Antonio–Lackland, Texas
| | - Theresa M. Casey
- Trainee Health Surveillance, 559th Medical Group, Joint Base San Antonio–Lackland, Texas
| | - Robert J. Cybulski
- Clinical Microbiology, Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, Joint Base San Antonio, Texas
| | - Erin Enriquez
- Trainee Health Surveillance, 559th Medical Group, Joint Base San Antonio–Lackland, Texas
| | - Jason F. Okulicz
- Infectious Diseases Service, Brooke Army Medical Center, Joint Base San Antonio, Texas
| | - Heather C. Yun
- Infectious Diseases Service, Brooke Army Medical Center, Joint Base San Antonio, Texas
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11
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Yun HC, Cable CT, Pizzimenti D, Desai SS, Muchmore EA, Vasilias J, Thomas C, Nasca TJ, Lieh-Lai MW. Internal Medicine 2035: Preparing the Future Generation of Internists. J Grad Med Educ 2020; 12:797-800. [PMID: 33391612 PMCID: PMC7771588 DOI: 10.4300/jgme-d-20-00794.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Heather C Yun
- Chair, Department of Medicine, Brooke Army Medical Center
| | - Christian T Cable
- Designated Institutional Official, Baylor Scott & White Health-Temple
| | - David Pizzimenti
- Associate Medical Officer of Acute Care, North Mississippi Health Systems
| | - Sima S Desai
- Residency Program Director and Professor of Medicine, Oregon Health & Science University
| | | | - Jerry Vasilias
- Executive Director, Review Committee for Internal Medicine, Accreditation Council for Graduate Medical Education (ACGME)
| | | | | | - Mary W Lieh-Lai
- Professor of Pediatrics, Wayne State University School of Medicine
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12
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Lago K, Telu K, Tribble D, Ganesan A, Kunz A, Geist C, Fraser J, Mitra I, Lalani T, Yun HC. Doxycycline Malaria Prophylaxis Impact on Risk of Travelers' Diarrhea among International Travelers. Am J Trop Med Hyg 2020; 103:1864-1870. [PMID: 32815505 PMCID: PMC7646764 DOI: 10.4269/ajtmh.20-0241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/11/2020] [Indexed: 12/21/2022] Open
Abstract
International travelers are frequently at risk for travelers' diarrhea (TD) and malaria. Doxycycline was one of the earliest antibiotics shown to have efficacy in TD prevention. With increasing resistance and recommendations against antibiotic chemoprophylaxis, doxycycline fell out of use. We evaluated TD incidence and risk factors in a prospective cohort of travelers, specifically in regard to malaria prophylaxis. Travelers' diarrhea was defined as ≥ 3 loose stools in 24 hours or two loose stools in 24 hours associated with other gastrointestinal symptoms. The Poisson regression model with robust error variance was used to estimate the RR of TD. Three thousand two hundred twenty-seven trips were enrolled: 62.1% of participants were male, with a median age of 39 years (interquartile range [IQR] 27,59) and a median travel duration of 19 days (IQR 12,49); 17.4% developed TD; 32% traveled to Africa, 40% to Asia, and 27% to the Caribbean and Latin America; and 20% took doxycycline for malaria chemoprophylaxis, 50% took other antimalarials, and 30% took none. Decreased RR of TD was associated with doxycycline (RR 0.62 [0.47-0.82], P < 0.01) and military travel (RR 0.57 [0.47-0.70], P < 0.01). Increased risk of TD was associated with female gender (RR 1.28 [1.09-1.50], P < 0.01), hotel accommodations (RR 1.30 [1.10-1.53], P < 0.01), travel to tropical South America (RR 1.34 [1.09-1.64], P < 0.01), and duration of travel (RR 1.00 [1.00-1.01], P < 0.01). The use of doxycycline for malaria prophylaxis is associated with lower TD risk, suggesting increasing bacterial enteropathogen susceptibility similar to previous observations. Doxycycline selection for antimalarial chemoprophylaxis may provide additional traveler benefit in infection prevention.
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Affiliation(s)
- Kathryn Lago
- Brooke Army Medical Center, Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kalyani Telu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - David Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Anjali Kunz
- Madigan Army Medical Center, Tacoma, Washington
| | - Charla Geist
- Landstuhl Regional Medical Center, Landstuhl, Germany
| | - Jamie Fraser
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Indrani Mitra
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
- Naval Medical Center, Portsmouth, Virginia
| | - Heather C. Yun
- Brooke Army Medical Center, Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - for the Infectious Disease Clinical Research Program TravMil Study Group
- Brooke Army Medical Center, Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
- Walter Reed National Military Medical Center, Bethesda, Maryland
- Madigan Army Medical Center, Tacoma, Washington
- Landstuhl Regional Medical Center, Landstuhl, Germany
- Naval Medical Center, Portsmouth, Virginia
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13
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Jacobson SL, Shutak DJ, Canuela RA, Maldonado EA, Yun HC. How to Prevent Harm When Performing Outpatient Procedures. J Perianesth Nurs 2020. [DOI: 10.1016/j.jopan.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Marcus JE, Frankel DN, Pawlak MT, Casey TM, Blackwell RS, Tran FV, Dolan MJ, Yun HC. COVID-19 Monitoring and Response Among U.S. Air Force Basic Military Trainees - Texas, March-April 2020. MMWR Morb Mortal Wkly Rep 2020; 69:685-688. [PMID: 32497031 PMCID: PMC7315849 DOI: 10.15585/mmwr.mm6922e2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has resulted in substantial morbidity and mortality since it was first described in December 2019 (1). Based on epidemiologic data showing spread in congregate settings (2-4), national, state, and local governments instituted significant restrictions on large gatherings to prevent transmission of disease in early March 2020. This and other nonpharmaceutical interventions (NPIs) have shown initial success in slowing the pandemic across the country (5). This report examines the first 7 weeks (March 1-April 18) of implementation of NPIs in Basic Military Training (BMT) at a U.S. Air Force base. In a population of 10,579 trainees, COVID-19 incidence was limited to five cases (47 per 100,000 persons), three of which were in persons who were contacts of the first patient. Transmission of symptomatic COVID-19 was successfully limited using strategies of quarantine, social distancing, early screening of trainees, rapid isolation of persons with suspected cases, and monitored reentry into training for trainees with positive test results after resolution of symptoms.
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15
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Barsoumian AE, Hartzell JD, Bonura EM, Ressner RA, Whitman TJ, Yun HC. Factors Influencing Selection of Infectious Diseases Training for Military Internal Medicine Residents. Clin Infect Dis 2019; 67:1582-1587. [PMID: 29912315 DOI: 10.1093/cid/ciy322] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/12/2018] [Indexed: 11/14/2022] Open
Abstract
Background Applications to infectious diseases fellowships have declined nationally; however, the military has not experienced this trend. In the past 6 years, 3 US military programs had 58 applicants for 52 positions. This study examines military resident perceptions to identify potential differences in factors influencing career choice, compared with published data from a nationwide cohort. Methods An existing survey tool was adapted to include questions unique to the training and practice of military medicine. Program directors from 11 military internal medicine residencies were asked to distribute survey links to their graduating residents from December 2016 to January 2017. Data were categorized by ID interest. Result The response rate was 51% (n = 68). Of respondents, 7% were ID applicants, 40% considered ID but reconsidered, and 53% were uninterested. Of those who considered ID, 73% changed their mind in their second and third postgraduate years and cited salary (22%), lack of procedures (18%), and training length (18%) as primary deterrents to choosing ID. Active learning styles were used more frequently by ID applicants to learn ID concepts than by those who considered or were uninterested in ID (P = .02). Conclusions Despite differences in the context of training and practice among military trainees compared with civilian colleagues, residents cited similar factors affecting career choice. Interest in global health was higher in this cohort. Salary continues to be identified as a deterrent to choosing ID. Differences between military and civilian residents' desire to pursue ID fellowship are likely explained by additional unmeasured factors deserving further study.
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Affiliation(s)
- Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX
| | - Joshua D Hartzell
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Erin M Bonura
- Division of Infectious Diseases, Oregon Health & Science University, Portland, MD
| | - Roseanne A Ressner
- Department of Infectious Diseases, Walter Reed National Military Medical Center, Bethesda, MD
| | - Timothy J Whitman
- Department of Infectious Diseases, Walter Reed National Military Medical Center, Bethesda, MD
| | - Heather C Yun
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX
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16
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Wood S, Telu K, Tribble D, Ganesan A, Kunz A, Fairchok M, Schnaubelt E, Johnson MD, Maves R, Fraser J, Mitra I, Lalani T, Yun HC, For The Infectious Disease Clinical Research Program TravMil Study Group. Influenza-Like Illness in Travelers to the Developing World. Am J Trop Med Hyg 2019; 99:1269-1274. [PMID: 30226131 DOI: 10.4269/ajtmh.17-0884] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Travelers to developing regions are at risk for development of influenza-like illness (ILI). Little is known of traveler and trip characteristics associated with the development of ILI. TravMil is a prospective observational study, enrolling subjects presenting to six military travel clinics or predeployment-screening sites. We analyzed pre- and post-travel surveys from travelers visiting regions outside of the continental United States, Western or Northern Europe, Canada, Australia, or New Zealand between January 2010 and March 2016. Influenza-like illness was defined as a self-reported fever associated with either sore throat or cough. Trip and traveler characteristics were analyzed to determine risk factors for the development of ILI. Two thousand nine hundred and thirty-two trips were recorded (55% male, median age 45 years, 69% white, 51% on vacation, median travel duration 17 days). The 2,337 trips included the number of self-reported influenza vaccinations in the preceding 5 years (median 5). Eleven percent of the trips were complicated by an ILI lasting a median of 5 days; 70% and 17% of these reported upper and lower respiratory tract infection, respectively, and 12% reported both. On multivariate analysis, increased risk of ILI was associated with female gender (odds ratio [OR]: 1.60 [confidence interval (CI): 1.25-2.05], P < 0.01), age (years) (OR: 1.01 [CI: 1.01-1.02], P < 0.01); and duration of travel (days) (OR: 1.01 [CI: 1.00-1.01], P < 0.01). Influenza-like illness is common in travelers, regardless of traveler characteristics, purpose of travel, destination, or season of year. Female gender, older age, and longer duration of travel were associated with an increased risk of ILI. Additional tools and strategies are needed to prevent ILI in international travelers.
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Affiliation(s)
- Stuart Wood
- San Antonio Military Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas
| | - Kalyani Telu
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - David Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Anuradha Ganesan
- Walter Reed National Military Medical Center, Bethesda, Maryland.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Anjali Kunz
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington
| | - Mary Fairchok
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Mark D Johnson
- Department of Defense HIV/AIDS Prevention Program, Naval Health Research Center, San Diego, California.,Naval Medical Center, San Diego, California
| | - Ryan Maves
- Naval Medical Center, San Diego, California
| | - Jamie Fraser
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Indrani Mitra
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Tahaniyat Lalani
- Naval Medical Center, Portsmouth, Virginia.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Heather C Yun
- San Antonio Military Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas.,Uniformed Services University of the Health Sciences, Department of Medicine, Bethesda, Maryland
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17
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Barsoumian AE, Hartzell JD, Bonura EM, Ressner RA, Whitman TJ, Yun HC. Military Internal Medicine Resident Decision to Apply to Fellowship and Extend Military Commitment. Mil Med 2019; 183:e299-e303. [PMID: 29420762 DOI: 10.1093/milmed/usx091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/07/2018] [Indexed: 11/12/2022] Open
Abstract
Introduction Nationally, the number of internal medicine physicians practicing in primary care has decreased amidst increasing interest in hospitalist medicine. Current priorities in the Military Health System include access to primary care and retention of trained personnel. Recently, we have conducted a study of military internal medicine residents' decision to enter infectious disease. As part of our larger effort, we saw an opportunity to characterize factors impacting decision making of internal medicine residents' desire to apply for subspecialty training and to extend active duty service obligations. Materials and Methods Questions were developed after discussion with various military graduate medical education and internal medicine leaders, underwent external review, and were added to a larger question set. The survey link was distributed electronically to all U.S. military affiliated residencies' graduating internal medicine residents in December 2016-January 2017. Data were analyzed by decision to apply to fellowship and decision to extend military obligation using Fisher's exact test or Pearon's chi-square test. Results Sixty-eight residents from 10 of 11 military residency programs responded, for a response rate of 51%. The majority (62%) applied to fellowship to start after residency completion. Reasons cited for applying to fellowship included wanting to become a specialist as soon as possible (74%), wishing to avoid being a general internist (57%), and because they are unable to practice as a hospitalist in the military (52%). Fellowship applicants were more likely to plan to extend their military obligation than non-applicants, as did those with longer duration of military commitments. No other factors, including Uniformed Services University attendance or participation in undergraduate military experiences, were found to impact plan to extend active duty service commitment. Conclusion The majority of graduating internal medicine residents apply for fellowship and report a desire to avoid being a general internist. Prospective fellows anticipate extending their active duty commitment, as do those with longer commitments.
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Affiliation(s)
- Alice E Barsoumian
- Department of Medicine, Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX
| | - Joshua D Hartzell
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
| | - Erin M Bonura
- Division of Infectious Diseases, Oregon Health & Science University, Mail Code L457, 3181 SW Sam Jackson Park Road, Portland, OR
| | - Roseanne A Ressner
- Department of Infectious Diseases, Walter Reed National Military Medical Center, 4494 North Palmer Road, Bethesda, MD
| | - Timothy J Whitman
- Department of Infectious Diseases, Walter Reed National Military Medical Center, 4494 North Palmer Road, Bethesda, MD
| | - Heather C Yun
- Department of Medicine, Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX
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18
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Barsoumian AE, Yun HC. Augmenting Fellow Education Through Spaced Multiple-Choice Questions. Mil Med 2019; 183:e122-e126. [PMID: 29401332 DOI: 10.1093/milmed/usx020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 10/20/2017] [Indexed: 11/13/2022] Open
Abstract
Background The San Antonio Uniformed Services Health Education Consortium Infectious Disease Fellowship program historically included a monthly short-answer and multiple-choice quiz. The intent was to ensure medical knowledge in relevant content areas that may not be addressed through clinical rotations, such as operationally relevant infectious disease. After completion, it was discussed in a small group with faculty. Over time, faculty noted increasing dissatisfaction with the activity. Spaced interval education is useful in retention of medical knowledge and skills by medical students and residents. Its use in infectious disease fellow education has not been described. To improve the quiz experience, we assessed the introduction of spaced education curriculum in our program. Materials and Methods A pre-intervention survey was distributed to assess the monthly quiz with Likert scale and open-ended questions. A multiple-choice question spaced education curriculum was created using the Qstream(R) platform in 2011. Faculty development on question writing was conducted. Two questions were delivered every 2 d. Incorrectly and correctly answered questions were repeated after 7 and 13 d, respectively. Questions needed to be answered correctly twice to be retired. Fellow satisfaction was assessed at semi-annual fellowship reviews over 5 yr and by a one-time repeat survey. Results Pre-intervention survey of six fellows indicated dissatisfaction with the time commitment of the monthly quiz (median Likert score of 2, mean 6.5 h to complete), neutral in perceived utility, but satisfaction with knowledge retention (Likert score 4). Eighteen fellows over 5 yr participated in the spaced education curriculum. Three quizzes with 20, 39, and 48 questions were designed. Seventeen percentage of questions addressed operationally relevant topics. Fifty-nine percentage of questions were answered correctly on first attempt, improving to 93% correct answer rate at the end of the analysis. Questions were attempted 2,999 times. Fellows consistently indicated that the platform was "highly enjoyed," "beneficial," a "fun format," and "completely satisfied." Fellows additionally commented that they desired more questions and considered the platform helpful in board preparation. Formal survey data post-intervention found that the fellows were satisfied with the new approach, found it to be useful in board preparation, overall educational value, and in-line with their personal learning style (median Likert score of 4 for all queries). Fellows were satisfied with time commitment, spending a mean of 47 min on the spaced education curriculum questions per month. Conclusions Introduction of a spaced education curriculum resulted in a sustained positive learner experience for >5 yr with demonstrated mastery of material. Spaced education learning is a viable addition to augment training experience, especially in areas of curricular gaps such as operational medicine. Correct answer data may also be useful to perform Accreditation Council for Graduate Medical Education-required objective assessment of knowledge.
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Affiliation(s)
- Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, San Antonio TX 78234
| | - Heather C Yun
- Infectious Disease Service, Department of Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, San Antonio TX 78234
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19
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Webber BJ, Kieffer JW, White BK, Hawksworth AW, Graf PCF, Yun HC. Chemoprophylaxis against group A streptococcus during military training. Prev Med 2019; 118:142-149. [PMID: 30393152 DOI: 10.1016/j.ypmed.2018.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 08/27/2018] [Accepted: 10/20/2018] [Indexed: 10/28/2022]
Abstract
Chemoprophylaxis with intramuscular benzathine penicillin G has been used widely by the U.S. military to prevent epidemics of group A streptococcus infections during basic training. The recent global shortage of benzathine penicillin prompted a detailed analysis of this issue in 2017 by military preventive medicine and infectious disease authorities in San Antonio, Texas, and San Diego, California, USA. This paper explores the history of group A streptococcus and chemoprophylaxis in the U.S. military training environment, current policy and practice, and challenges associated with widespread chemoprophylaxis. In light of the history presented, preventive medicine authorities at basic training centers should be extremely cautious about discontinuing benzathine penicillin chemoprophylaxis.
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Affiliation(s)
- Bryant J Webber
- Epidemiology Consult Service, U.S. Air Force School of Aerospace Medicine, 2510 Fifth Street, Bldg 840, Rm W318.23, Wright-Patterson Air Force Base, OH 45433, USA.
| | - John W Kieffer
- 559th Medical Group, Wilford Hall Ambulatory Surgical Center, 1440 McGuire Street, Bldg 7206, Joint Base San Antonio-Lackland, TX 78235, USA.
| | - Brian K White
- 559th Medical Group, Wilford Hall Ambulatory Surgical Center, 1440 McGuire Street, Bldg 7206, Joint Base San Antonio-Lackland, TX 78235, USA.
| | - Anthony W Hawksworth
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., 6720A Rockledge Drive, Bethesda, MD 20817, USA
| | - Paul C F Graf
- Operational Infectious Diseases Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106, USA.
| | - Heather C Yun
- Department of Infectious Diseases, San Antonio Military Medical Center, 3351 Roger Brooke Drive, MCHE-ZDM, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA.
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20
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Blyth DM, Barsoumian AE, Yun HC. Timing of Infectious Disease Clinical Rotation Is Associated With Infectious Disease Fellowship Application. Open Forum Infect Dis 2018; 5:ofy155. [PMID: 30087906 DOI: 10.1093/ofid/ofy155] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/30/2018] [Indexed: 11/13/2022] Open
Abstract
Background With declining interest in infectious disease (ID) noted among internal medicine (IM) residents, national attention has been directed at methods to recruit more prospective ID applicants. The factors driving the recent decline in ID fellowship applications have thus far only been evaluated in survey studies. Since 2008 at our institution, all IM interns were required to complete a 4-week inpatient ID rotation. We evaluated this rotation to determine if any experiential factors could be linked to future ID interest. Methods Categorical IM interns rotating on the mandatory ID rotation at our institution between July 1, 2008, and June 30, 2015, were included. Interns were grouped by eventual application to ID fellowship (IDA) and nonapplication (non-IDA). Consult numbers and types and characteristics of team members during the rotation were compared. Results Between July 2008 and June 2015, 143 IM interns met inclusion criteria. Ten (7%) were IDA. There was no difference in number of consults seen, intern, team member, faculty, or fellow characteristics among groups. However, 90% of IDA compared with 46% of non-IDA rotated during the first 6 months of internship (P = .01). Conclusions During a 7-year period, those interns randomly assigned to rotate on ID in the first 6 months of their intern year were more likely to become future ID applicants. This supports prior self-reported survey data that early exposure to the field may impact future career choice and suggests that incorporating ID early into the intern experience may increase recruitment.
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Affiliation(s)
- Dana M Blyth
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Houston, Texas
| | - Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Houston, Texas
| | - Heather C Yun
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Houston, Texas
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21
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Valiant WG, Lalani T, Yun HC, Kunz A, Burgess TH, Mattapallil JJ. Human Serum With High Neutralizing Antibody Titers Against Both Zika and Dengue Virus Shows Delayed In Vitro Antibody-Dependent Enhancement of Dengue Virus Infection. Open Forum Infect Dis 2018; 5:ofy151. [PMID: 30019003 DOI: 10.1093/ofid/ofy151] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/21/2018] [Indexed: 11/14/2022] Open
Abstract
Zika virus infection in a dengue virus-naïve subject was associated with the induction of high levels of cross-reactive binding antibodies. These responses were, however, largely non-neutralizing and displayed a capacity to enhance dengue infection in vitro at significantly low dilution (1:10). In contrast, a subject who had high levels of neutralizing antibodies against both dengue and Zika viruses enhanced infection at a dilution of 1:10 000. These results suggest that high levels of dengue cross-neutralizing antibodies could potentially prevent the enhancement of dengue infection in Zika virus-convalescent individuals.
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Affiliation(s)
- William G Valiant
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University, Rockville, Maryland.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland.,Division of Infectious Diseases, Naval Medical Center, Portsmouth, Virginia
| | - Heather C Yun
- San Antonio Military Medical Center, San Antonio, Texas
| | - Anjali Kunz
- Madigan Army Medical Center, Tacoma, Washington
| | - Timothy H Burgess
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University, Rockville, Maryland
| | - Joseph J Mattapallil
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland
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22
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McMains KC, Rodriguez RG, Peel J, Yun HC, True MW, Jones WS. Assessing Mentorship Experiences of Faculty at a Military Academic Center: Challenge and Opportunity. South Med J 2018; 111:262-267. [PMID: 29767217 DOI: 10.14423/smj.0000000000000799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Mentor relationships are a key component of professional development within academic medicine. To date, there are no investigations into the prevalence and effects of mentor relationships within military academic medicine. This quality improvement initiative aimed to establish the prevalence and effects of mentorship, including whether sex differences exist among faculty at a military academic center, the San Antonio Uniformed Services Health Education Consortium, and identify opportunities to improve faculty development efforts for mentorship to benefit faculty at this institution. METHODS A 17-item survey was developed using an iterative process. Using the SurveyMonkey platform, the survey was distributed to each faculty member within the 33 Accreditation Council for Graduate Medical Education-accredited programs. RESULTS A total of 104 responses (26%) were received from 393 total faculty members, including 48 Air Force, 45 Army, 3 Navy, and 8 Contractor/Government Service respondents. Thirty-four respondents were women (33%) and 70 were men (67%). Only 42% of faculty reported currently having a mentor. Thirty-nine respondents (38%; 44% men and 27% women) received formal mentorship at their first staff physician position after residency training. Mentorship helped respondents the most in the areas of clinical skills, understanding departmental/institutional culture, professionalism/officership, academic promotion/advancement, and clarification of priorities/goals. When asked whether more effective mentorship would affect their own decision to remain on active-duty military service, 14% responded "yes" and 28% responded "possibly." CONCLUSIONS Increased mentorship has the potential to positively affect career development in military academic military medicine. Results from this study affirm previous reports that effective mentorship potentially represents a powerful tool for faculty retention. Future study should include other military medical academic centers to assess the generalizability of these results across US military medicine.
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Affiliation(s)
- Kevin C McMains
- From the Uniformed Services University of the Health Sciences, Bethesda, Maryland, the San Antonio VA Health Care System, the University of Texas Health Science Center at San Antonio, and the San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - Rechell G Rodriguez
- From the Uniformed Services University of the Health Sciences, Bethesda, Maryland, the San Antonio VA Health Care System, the University of Texas Health Science Center at San Antonio, and the San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - Jennifer Peel
- From the Uniformed Services University of the Health Sciences, Bethesda, Maryland, the San Antonio VA Health Care System, the University of Texas Health Science Center at San Antonio, and the San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - Heather C Yun
- From the Uniformed Services University of the Health Sciences, Bethesda, Maryland, the San Antonio VA Health Care System, the University of Texas Health Science Center at San Antonio, and the San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - Mark W True
- From the Uniformed Services University of the Health Sciences, Bethesda, Maryland, the San Antonio VA Health Care System, the University of Texas Health Science Center at San Antonio, and the San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - Woodson S Jones
- From the Uniformed Services University of the Health Sciences, Bethesda, Maryland, the San Antonio VA Health Care System, the University of Texas Health Science Center at San Antonio, and the San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
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23
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Barsoumian AE, White BK, Yun HC. Teaching Antimicrobial Stewardship to Infectious Disease Fellows Through Simulated Interdisciplinary Scenarios. MedEdPORTAL 2018; 14:10693. [PMID: 30800893 PMCID: PMC6342414 DOI: 10.15766/mep_2374-8265.10693] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/21/2018] [Indexed: 06/01/2023]
Abstract
INTRODUCTION While several approaches have been described to teach antimicrobial stewardship (AS) practices, fewer have been aimed at infectious disease physicians. We developed a series of simulated AS meetings to train infectious disease fellows in the synthesis of AS interventions. METHODS Three simulated AS committee scenarios were developed. Background lectures were given 1 week prior to the simulation during which multidisciplinary roles were assigned. Precourse work included review of primary literature pertinent to the scenario. Simulations were conducted over 1.5 hours. Individual and team performances were evaluated. Pre- and postsurveys were collected from fellows and faculty members to assess the format. RESULTS Six infectious disease fellows participated in the series. Fellows demonstrated information synthesis and improvements in individual and team performance. Eighty-three percent of fellows before the simulation series and 100% postseries reported educating others on AS principles in the previous month. Fellows were satisfied with the series and requested more scenarios. Eight faculty members completed surveys. Thirty-eight percent of faculty before the series and 63% after completion reported that fellows viewed antimicrobial preauthorization as useful or necessary. Faculty supported the format, found it useful in evaluation of learners, and perceived that fellows benefited from the approach. DISCUSSION Simulation is an effective and enjoyable way to train infectious disease fellows in AS and team utilization. Fellows demonstrated improvement in AS knowledge, skills, and attitudes and developed evidence-based interdisciplinary plans to solve AS challenges. Faculty also viewed this strategy as effective and sustainable.
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Affiliation(s)
| | - Brian K White
- Infectious Disease Specialist, Brooke Army Medical Center
| | - Heather C. Yun
- Infectious Disease Specialist, Brooke Army Medical Center
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24
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Marcus JE, Webber BJ, Cropper TL, Wilson MC, Yun HC. Diagnostic evaluation of military blood donors screening positive for Trypanosoma cruzi infection. MSMR 2018; 25:16-19. [PMID: 29485892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Routine blood donor screening for Trypanosoma cruzi, the causative parasitic agent of Chagas disease, began in the U.S. in 2007. Results of follow-up testing and evaluation after a positive screen have not been studied in the armed forces. Among first-time donors at the Joint Base San Antonio- Lackland Blood Donor Center between January 2014 and December 2016 (N=43,402), a total of 23 (0.05%) screened positive for T. cruzi. This descriptive study highlights demographic and follow-up information for all 22 active duty service members who screened positive; a non-active duty member was excluded due to unavailability of clinical records. Members who screened positive received 13 different combinations of confirmatory testing (mean: 2.7 tests per person). In select cases, clinical evaluation included electrocardiogram (n=15) and 30-second rhythm strip (n=5). Two patients met criteria for Chagas disease; 11 patients were considered negative; and nine patients were indeterminate. Among a small cohort of active duty service members who screened positive for T. cruzi infection on blood donation, diagnostic evaluation varied considerably. Opportunities exist to decrease heterogeneity of clinical workup and improve evaluation of persons who screen positive.
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25
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Chang D, Webber BJ, Hetrick SM, Owen JB, Blasi AA, Steele BM, Yun HC. Challenges with diagnosing and investigating suspected active tuberculosis disease in military trainees. MSMR 2017; 24:12-16. [PMID: 28895749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Between 1 January 2010 and 31 December 2016, a total of 14 U.S. and international military personnel in training at Joint Base San Antonio-Lackland, TX, were hospitalized due to suspected pulmonary tuberculosis (TB); of these, five personnel were diagnosed with active TB disease. Only one TB case had pulmonary symptoms, but these symptoms were not suggestive of TB. The incidence rate in the training population was 1.89 per 100,000 population (95% CI: 0.81, 4.42), with a higher rate when restricted to international military students attending the Defense Language Institute English Language Center. No instances of TB transmission were identified. The variety of atypical presentations and their resulting diagnostic and public health challenges prompted this retrospective review of all hospitalized cases. This case series highlights both the importance of a high index of clinical suspicion when TB is being considered in close congregate settings as well as the risk of overreliance on acid-fast bacilli staining and nucleic acid amplification testing for ruling out active pulmonary disease in young, otherwise healthy trainees. Practical solutions are suggested.
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26
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Green C, Pamplin JC, Chafin KN, Murray CK, Yun HC. Pulsed-xenon ultraviolet light disinfection in a burn unit: Impact on environmental bioburden, multidrug-resistant organism acquisition and healthcare associated infections. Burns 2017; 43:388-396. [DOI: 10.1016/j.burns.2016.08.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 08/25/2016] [Indexed: 10/20/2022]
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27
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Lindholm DA, Myers T, Widjaja S, Grant EM, Telu K, Lalani T, Fraser J, Fairchok M, Ganesan A, Johnson MD, Kunz A, Tribble DR, Yun HC. Mosquito Exposure and Chikungunya and Dengue Infection Among Travelers During the Chikungunya Outbreak in the Americas. Am J Trop Med Hyg 2017; 96:903-912. [PMID: 28115671 DOI: 10.4269/ajtmh.16-0635] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractTravelers are at risk for arbovirus infection. We prospectively enrolled 267 Department of Defense beneficiaries traveling to chikungunya-outbreak regions in the Americas between December 2013 and May 2015 and assessed travel characteristics and serologic exposure to chikungunya virus (CHIKV) and dengue virus (DENV). Ten ill-returning travelers were also assessed retrospectively. Self-reported mosquito exposure was common (64% of 198 evaluable travelers saw mosquitoes; 53% of 201 reported ≥ 1 bite). Increased exposure was associated with active-duty travelers (odds ratio [OR] = 2.6 [1.3-5.4] for seeing mosquitoes) or travelers visiting friends and relatives (VFR) (OR = 3.5 [1.0-10.0] for high-intensity bite exposure). Arbovirus infection was defined as seroconversion on plaque reduction neutralization testing (PRNT) of pre- and posttravel sera. For ill subjects enrolled posttravel, infection was defined by a positive convalescent PRNT and/or a positive reverse transcription polymerase chain reaction for CHIKV or DENV. We identified seven cases of arbovirus infection: four with CHIKV, five with DENV, and two with both. The composite attack rate for CHIKV and DENV infection was 3.7% of 108 evaluable, immunologically naïve, prospectively assessed travelers; there was serologic and/or polymerase chain reaction evidence of arbovirus infection in three of four evaluable (three of 10 total) ill-returning travelers. We identified both symptomatic and asymptomatic cases. Military purpose of travel and VFR travel accounted for five of seven cases. Pretravel counseling is important and should target higher risk groups. Given a shared vector between CHIKV, DENV, and Zika virus (ZIKV), this study can also help guide counseling for travelers to ZIKV-outbreak regions.
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Affiliation(s)
| | - Todd Myers
- Naval Infectious Diseases Diagnostic Laboratory, Silver Spring, Maryland
| | - Susana Widjaja
- Naval Infectious Diseases Diagnostic Laboratory, Silver Spring, Maryland
| | - Edward M Grant
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kalyani Telu
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Naval Medical Center, Portsmouth, Virginia
| | - Jamie Fraser
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Mary Fairchok
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Madigan Army Medical Center, Tacoma, Washington
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Mark D Johnson
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Naval Health Research Center, San Diego, California
| | - Anjali Kunz
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Madigan Army Medical Center, Tacoma, Washington
| | - David R Tribble
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Heather C Yun
- San Antonio Military Medical Center, San Antonio, Texas.,Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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28
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Garcia MN, Cropper TL, Gunter SM, Kramm MM, Pawlak MT, Roachell W, Ronca SE, Stidham RA, Webber BJ, Yun HC. Vector-borne diseases of public health importance for personnel on military installations in the United States. US Army Med Dep J 2017:90-101. [PMID: 28511278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Melissa N Garcia
- National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas
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29
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Webber BJ, Wozniak EJ, Chang D, Bush KN, Wilson MC, Watts JA, Yun HC. A case of Chagas cardiomyopathy following infection in south central Texas. US Army Med Dep J 2017:55-59. [PMID: 28511274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Between 5 and 8 million people globally are infected with Trypanosoma cruzi, the causative parasitic agent of Chagas disease. The vast majority of incident infections originate in pockets of Latin America where domestic vector-borne transmission cycles are more common. Since 1955, when the first locally-acquired case was reported, fewer than 30 autochthonous cases have been documented in the United States. We describe the case of an 18-year-old US Air Force trainee, a native Texan with no travel history beyond the continental United States, who screened positive for T cruzi infection on blood donation and was subsequently found to have chronic Chagasic cardiomyopathy. This is the first documented case of Chagas disease in a US military trainee and one of the first known autochthonous cases of Chagasic cardiomyopathy in a Texas resident. Diagnostic, therapeutic, and military implications are discussed.
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Affiliation(s)
- Bryant J Webber
- Preventive Medicine Element, 559th Trainee Health Squadron, Wilford Hall Ambulatory Surgical Center, JBSA-Lackland, Texas
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Murray CK, Yun HC, Markelz AE, Okulicz JF, Vento TJ, Burgess TH, Cardile AP, Miller RS. Operation United Assistance: infectious disease threats to deployed military personnel. Mil Med 2016; 180:626-51. [PMID: 26032379 DOI: 10.7205/milmed-d-14-00691] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
As part of the international response to control the recent Ebola outbreak in West Africa, the Department of Defense has deployed military personnel to train Liberians to manage the disease and build treatment units and a hospital for health care volunteers. These steps have assisted in providing a robust medical system and augment Ebola diagnostic capability within the affected nations. In order to prepare for the deployment of U.S. military personnel, the infectious disease risks of the regions must be determined. This evaluation allows for the establishment of appropriate force health protection posture for personnel while deployed, as well as management plans for illnesses presenting after redeployment. Our objective was to detail the epidemiology and infectious disease risks for military personnel in West Africa, particularly for Liberia, along with lessons learned from prior deployments.
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Affiliation(s)
- Clinton K Murray
- San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | - Heather C Yun
- San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | | | - Jason F Okulicz
- San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | - Todd J Vento
- San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | - Timothy H Burgess
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889
| | - Anthony P Cardile
- U.S. Army Medical Research Institute of Infectious Disease, Fort Detrick, 1425 Porter Street, Frederick, MD 21702
| | - R Scott Miller
- Preventive Medicine & Biostatistics Department, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
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Yun HC, Weintrob AC, Conger NG, Li P, Lu D, Tribble DR, Murray CK. Healthcare-associated pneumonia among U.S. combat casualties, 2009 to 2010. Mil Med 2016; 180:104-10. [PMID: 25562865 DOI: 10.7205/milmed-d-14-00209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Although there is literature evaluating infectious complications associated with combat-related injuries from Iraq and Afghanistan, none have evaluated pneumonia specifically. Therefore, we assessed a series of pneumonia cases among wounded military personnel admitted to Landstuhl Regional Medical Center, and then evacuated further to participating U.S. military hospitals. Of the 423 casualties evacuated to the United States, 36 developed pneumonia (8.5%) and 30 of these (83.3%) were ventilator-associated. Restricting to 162 subjects admitted to intensive care, 30 patients had pneumonia (18.5%). The median Injury Severity Score was higher among subjects with pneumonia (23.0 vs. 6.0; p < 0.01). There were 61 first-isolate respiratory specimens recovered from 31 pneumonia subjects, of which 56.1% were gram-negative, 18.2% were gram-positive, and 18.2% were fungal. Staphylococcus aureus and Pseudomonas aeruginosa were most commonly recovered (10.6%, and 9.1%, respectively). Thirteen bacterial isolates (26.5%) were multidrug-resistant. Outcome data were available for 32 patients, of which 26 resolved their infection without progression, 5 resolved after initial progression, and 1 died. Overall, combat-injured casualties suffer a relatively high rate of pneumonia, particularly those requiring mechanical ventilation. Although gram-negative pathogens were common, S. aureus was most frequently isolated. Continued focus on pneumonia prevention strategies is necessary for improving combat care.
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Affiliation(s)
- Heather C Yun
- San Antonio Military Medical Center, 3551 Roger Brooke Drive MCHE-MDI, JBSA Fort Sam Houston, TX 78234
| | - Amy C Weintrob
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20814
| | - Nicholas G Conger
- Keesler Medical Center, 301 Fisher Street, Keesler Air Force Base, MS 39534
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine and Biometrics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Dan Lu
- Infectious Disease Clinical Research Program, Preventive Medicine and Biometrics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biometrics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Clinton K Murray
- San Antonio Military Medical Center, 3551 Roger Brooke Drive MCHE-MDI, JBSA Fort Sam Houston, TX 78234
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Wallum TE, Yun HC, Rini EA, Carter K, Guymon CH, Akers KS, Tyner SD, White CE, Murray CK. Pathogens present in acute mangled extremities from Afghanistan and subsequent pathogen recovery. Mil Med 2016; 180:97-103. [PMID: 25562864 DOI: 10.7205/milmed-d-14-00301] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Given the changing epidemiology of infecting pathogens in combat casualties, we evaluated bacteria and fungi in acute traumatic wounds from Afghanistan. From January 2013 to February 2014, 14 mangled lower extremities from 10 explosive-device injured casualties were swabbed for culture at Role 3 facilities. Bacteria were recovered from all patients on the date of injury. Pathogens recovered during routine patient care were recorded. The median injury severity score was 29, median initial Role 3/4 blood product support was 32 units, and median evacuation time was 42 minutes to first surgical care. Gram-positive bacteria were found in some wounds but not methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus. Most wounds were colonized with low-virulence, environmental gram-negative bacteria, and not recovered again during therapy, reflecting wound contamination. Only one wound had the same bacteria (E. cloacae) throughout care at the Role 3, 4, and 5 facilities. Three cultures from two patients had multidrug-resistant bacteria (E. cloacae, E. coli), all detected at Role 5 facilities. Molds were not detected at Role 3, whereas one patient had a mold at Role 4 and 5. Mangled lower extremity injuries have a high contamination rate with environmental organisms, which are not typically associated with infections during the course of the patient's care.
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Affiliation(s)
- Timothy E Wallum
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234
| | - Heather C Yun
- San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | - Elizabeth A Rini
- Landstuhl Regional Medical Center, CMR 402, Box 1559, APO AE 09180, Landstuhl, Germany
| | - Kristina Carter
- Naval Environmental Preventive Medicine Unit 5 San Diego, 3235 Albacore Alley, San Diego, CA 92136
| | - Charles H Guymon
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234
| | - Kevin S Akers
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234
| | - Stuart D Tyner
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234
| | - Christopher E White
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234
| | - Clinton K Murray
- San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
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Yun HC, Tully CC, Mende K, Castillo M, Murray CK. A single-center, six-year evaluation of the role of pulsed-field gel electrophoresis in suspected burn center outbreaks. Burns 2016; 42:1323-30. [DOI: 10.1016/j.burns.2016.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 03/24/2016] [Accepted: 03/28/2016] [Indexed: 11/25/2022]
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Yun HC, Murray CK. Infection Prevention in the Deployed Environment. US Army Med Dep J 2016:114-118. [PMID: 27215877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Up to 50% of combat injured patients from recent conflicts have suffered infectious complications, predominantly with multidrug-resistant (MDR) bacteria acquired nosocomially in the chain of tactical combat casualty care. These bacteria have ranged from MDR Acinetobacter baumannii-calcoaceticus associated with Operation Iraqi Freedom (OIF), to extended spectrum beta-lactamase producing Enterobacteriaceae from operations in Afghanistan. Experience from interventions at Level III facilities demonstrate that basic infection control (IC) procedures, such as improvements in hand hygiene, use of ventilator associated pneumonia bundles, and antimicrobial stewardship, can improve outcomes even in austere environments. While some systematic interventions have been implemented to mitigate this risk, including development of the Deployed Infection Control Course, the Multidrug-Resistance Surveillance Network, and the Trauma Infectious Disease Outcomes Study, ongoing vulnerabilities remain. Deployed microbiology capabilities should be strengthened, theater-level IC standard operating procedures should be implemented, and a joint, theater-level expert IC consultant should be appointed to be responsible for directing IC activities from Levels I to IV.
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Affiliation(s)
- Heather C Yun
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
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Gilbert LJ, Li P, Murray CK, Yun HC, Aggarwal D, Weintrob AC, Tribble DR. Multidrug-resistant gram-negative bacilli colonization risk factors among trauma patients. Diagn Microbiol Infect Dis 2015; 84:358-60. [PMID: 26867965 DOI: 10.1016/j.diagmicrobio.2015.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/15/2015] [Accepted: 12/20/2015] [Indexed: 10/22/2022]
Abstract
Prior studies have demonstrated high rates of colonization and infection with multidrug-resistant gram-negative bacilli (MDR-GNB) in injured military personnel. Our analysis shows that injuries inflicted during peak combat periods, massive blood transfusion requirement, and posttrauma cefazolin prophylaxis (additive effect with fluoroquinolones) were risk factors for MDR-GNB colonization.
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Affiliation(s)
- Laura J Gilbert
- Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Ping Li
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD USA
| | - Clinton K Murray
- San Antonio Military Medical Center, Joint Base San Antonio, Fort Sam Houston, TX, USA
| | - Heather C Yun
- San Antonio Military Medical Center, Joint Base San Antonio, Fort Sam Houston, TX, USA
| | - Deepak Aggarwal
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD USA
| | - Amy C Weintrob
- Walter Reed National Military Medical Center, Bethesda, MD, USA; Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Yun HC, Young AN, Caballero MY, Lott L, Cropper TL, Murray CK. Changes in Clinical Presentation and Epidemiology of Respiratory Pathogens Associated With Acute Respiratory Illness in Military Trainees After Reintroduction of Adenovirus Vaccine. Open Forum Infect Dis 2015; 2:ofv120. [PMID: 26380351 PMCID: PMC4569648 DOI: 10.1093/ofid/ofv120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 08/17/2015] [Indexed: 01/01/2023] Open
Abstract
Adenovirus vaccine reintroduction in military trainees has resulted in dramatic decreases in adenovirus disease, with no observed serotype shift, and milder illness in trainees with upper respiratory infection. However, other pathogens, especially rhinovirus, are detected with increasing frequency. Background. Adenovirus (Ad) has long been the predominant cause of acute respiratory illness (ARI) in military trainees. In 2011, live oral Ad vaccines for serotypes 4 and 7 were reintroduced into US basic military training populations. This study evaluated the impact on clinical presentations and other respiratory pathogens. Methods. The Center for Advanced Molecular Detection at Joint Base San Antonio-Lackland prospectively collects demographic, clinical, and polymerase chain reaction data from respiratory specimens (throat swab and nasal wash) among Air Force trainees presenting for care of ARI. Results. From June 2008 to August 2013, 2660 trainees enrolled and were tested for selected respiratory pathogens. Post-vaccine introduction (VI), reported systemic symptoms were less frequent, including fever (38% vs 94%) and myalgia (37% vs 67%; P < .01). Median temperature and heart rate decreased (98.4 vs 101.3°F, 81 vs 96 beats per minute; P < .01). Ad detection decreased for all Ad (3% vs 68%), Ad4 (1% vs 70%), 7 (0% vs 8%), 14 (0% vs 5%), and 3 (0.1% vs 2%); P < .01). Rhinovirus and cases with no pathogen identified increased in frequency (35% vs 18%, 51% vs 14%; P < .01). Conclusions. Acute respiratory illness in military trainees post-VI is associated with decreased severity of systemic symptoms and reduced fever and heart rate. Marked reductions in frequency of Ad serotypes are seen, including those in the vaccine, with no serotype shift. However, detection of several other respiratory pathogens, most notably rhinovirus, is observed in increasing proportions, and a majority are now undiagnosed clinical syndromes.
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Affiliation(s)
- Heather C Yun
- San Antonio Military Medical Center , Joint Base San Antonio-Fort Sam Houston , Texas ; Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Adam N Young
- San Antonio Military Medical Center , Joint Base San Antonio-Fort Sam Houston , Texas
| | | | - Lisa Lott
- 59MDW/ST Joint Base San Antonio-Lackland
| | - Thomas L Cropper
- Trainee Health Surveillance , Joint Base San Antonio-Lackland , Texas
| | - Clinton K Murray
- San Antonio Military Medical Center , Joint Base San Antonio-Fort Sam Houston , Texas ; Uniformed Services University of the Health Sciences , Bethesda, Maryland
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Okulicz JF, Yun HC, Murray CK. Occupational Exposures and the Prevalence of Blood-Borne Pathogens in a Deployed Setting Data from a US Military Trauma Center in Afghanistan. Infect Control Hosp Epidemiol 2015; 34:74-9. [DOI: 10.1086/668784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.Occupational exposures to blood and other bodily fluids occur in approximately 5 per 100 persons every year in US hospitals. Since the provision of health care in the deployed environment poses unique challenges to hospital personnel, it is important to characterize the rates of occupational exposures and understand the prevalence of blood-borne pathogens (BBPs) in host nations.Methods.A retrospective review of public health and laboratory records at a US military trauma center in Afghanistan from October 1, 2010, to March 31, 2012.Results.A total of 65 occupational exposures were reported, including 47 (72%) percutaneous and 18 (28%) mucocutaneous, with a yearly rate of 8.6 exposures per 100 persons. During 6-month deployment cycles, the majority of exposures (46.2%) occurred in the first 2 months after arrival in Afghanistan. Physicians reported the most exposures (26%), and the operating room (48%) was the most common hospital location. The prevalence of hepatitis B and hepatitis C among local national source patients (n= 59 ) was 8.9% and 2.3%, respectively, with no cases of HIV or syphilis detected. In contrast, there were no BBPs detected in coalition source (n= 12) or exposed (n = 57) patients.Conclusions.The characteristics of occupational exposures in this deployed environment were comparable to those of US-based hospitals. Standard practices used to reduce occupational exposures, such as use of personal protective equipment and safety devices, should continue to be prioritized in the deployed setting. Although BBP rates are not well defined in Afghanistan, our results were consistent with those of prior epidemiologic studies.
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Young A, Valtier S, Lott L, Cropper TL, Yun HC. 131Changes in clinical presentation and epidemiology of respiratory pathogens associated with upper respiratory infection in military trainees following reintroduction of adenovirus vaccine. Open Forum Infect Dis 2014. [PMCID: PMC5781560 DOI: 10.1093/ofid/ofu051.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Adam Young
- Internal Medicine, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, TX
| | - Sandra Valtier
- Center for Advanced Molecular Detection, 59MDW/ST, Joint Base San Antonio-Lackland, TX
| | - Lisa Lott
- Center for Advanced Molecular Detection, 59 MDW/ST, Joint Base San Antonio-Lackland, TX
| | - Thomas L. Cropper
- Trainee Health Surveillance Flight, Joint Base San Antonio-Lackland, TX
| | - Heather C. Yun
- Infectious Disease, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, TX
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Webber BJ, Ayers KJ, Winterton BS, Yun HC, Cropper TL, Foster J, Kren MC, Meek BY, Oliver TA, Hudson CM. Assessment of rabies exposure risk in a group of U.S. Air Force basic trainees - Texas, January 2014. MMWR Morb Mortal Wkly Rep 2014; 63:749-52. [PMID: 25166925 PMCID: PMC5779441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In January 2014, members of the Joint Base San Antonio (JBSA)-Lackland, Texas, preventive medicine and public health teams evaluated a U.S. Air Force basic training squadron for potential exposure in sleeping bays to rabies virus carried by Mexican free-tailed bats (Tadarida brasiliensis). Exposure to bats while asleep or otherwise unaware is an important risk factor for rabies in the United States. Over the past several decades, most indigenous human rabies infections in the United States have resulted from the bite of an infected bat, and the bite was not reported in more than half of the cases. Mexican free-tailed bats in Texas often carry rabies virus. Among 8,904 bats tested during 2001-2010, a total of 1,558 (18%) tested positive for rabies. To assess the risk to the Air Force trainees and identify those for whom rabies postexposure prophylaxis (PEP) might be indicated, Lackland preventive medicine and public health teams interviewed 922 persons (866 trainees and 56 instructors) and determined that PEP, consisting of human rabies immune globulin and the 4-dose vaccination series given over 14 days, was indicated for 200 persons (22%). This report describes the public health response to a mass indoor exposure to bats, including group-based rabies risk stratification, adverse reactions to PEP, and infestation remediation. These interventions can be considered for future mass exposures to bats.
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Affiliation(s)
- Bryant J. Webber
- Trainee Health Surveillance, 559 MDOS, Joint Base San Antonio (JBSA)-Lackland,Corresponding author: Bryant J. Webber, , 210-671-4087
| | | | | | - Heather C. Yun
- San Antonio Military Medical Center, JBSA-Fort Sam Houston
| | - Thomas L. Cropper
- Trainee Health Surveillance, 559 MDOS, Joint Base San Antonio (JBSA)-Lackland
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Yun HC, Fugate WH, Murray CK, Cropper TL, Lott L, McDonald JM. Pandemic influenza virus 2009 H1N1 and adenovirus in a high risk population of young adults: epidemiology, comparison of clinical presentations, and coinfection. PLoS One 2014; 9:e85094. [PMID: 24416345 PMCID: PMC3885690 DOI: 10.1371/journal.pone.0085094] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 11/22/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In 2009, pandemic H1N1 influenza virus (2009 H1N1) emerged worldwide, causing morbidity and mortality that disproportionately affected young adults. Upper respiratory infection (URI), largely due to adenovirus, is an endemic cause of morbidity in military training. Whether clinical presentations differ or excess morbidity results from coinfection is unclear. METHODS The Center for Advanced Molecular Detection evaluates epidemiology and rapid diagnostics of respiratory pathogens in trainees with URI. From May 1, 2009, to November 30, 2009, demographic, clinical, and PCR data from throat and nasal specimens for adenovirus and 2009 H1N1 were prospectively collected. RESULTS 375 trainees with URI enrolled and were tested for both adenovirus and 2009 H1N1 by PCR (median age 20; 89% male). Adenovirus PCR was positive in 72% (96% serotype E-4) and 2009 H1N1 in 20%. Males were more likely to have adenovirus and females more likely to have 2009 H1N1 (p = 0.047). Subjects with 2009 H1N1 presented an average of 1 week earlier in training, had shorter illness duration before enrollment, less sore throat, diarrhea, and fewer abnormal findings on throat exam. Coryza and cough were more common with 2009 H1N1 compared to adenovirus. Subjects with 2009 H1N1 were less likely to have adenovirus than those without, despite persistently high frequencies of adenovirus detections during peak 2009 H1N1 weeks (15% vs. 83%, p < 0.01). Coinfection with adenovirus and 2009 H1N1 was rare (4%). Rates of hospitalization and pneumonia did not differ between the adenovirus, 2009 H1N1, or coinfected groups. CONCLUSION Military trainees with 2009 H1N1 vs. adenovirus have differing clinical presentations, and males are more likely to have adenovirus. Despite high frequencies of adenovirus infection, coinfection with adenovirus and 2009 H1N1 is rare and apparently does not result in increased morbidity.
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Affiliation(s)
- Heather C. Yun
- San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas, United States of America
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- * E-mail:
| | - William H. Fugate
- Center for Advanced Molecular Detection, 59th MDW/ST, Joint Base San Antonio-Lackland, Texas, United States of America
| | - Clinton K. Murray
- San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas, United States of America
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Thomas L. Cropper
- Trainee Health Surveillance, Joint Base San Antonio-Lackland, Texas, United States of America
| | - Lisa Lott
- Center for Advanced Molecular Detection, 59th MDW/ST, Joint Base San Antonio-Lackland, Texas, United States of America
| | - J. Matthew McDonald
- Center for Advanced Molecular Detection, 59th MDW/ST, Joint Base San Antonio-Lackland, Texas, United States of America
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Yun HC, Kreft RE, Castillo MA, Ehrlich GD, Guymon CH, Crouch HK, Chung KK, Wenke JC, Hsu JR, Spirk TL, Costerton JW, Mende K, Murray CK. Comparison of PCR/electron spray ionization-time-of-flight-mass spectrometry versus traditional clinical microbiology for active surveillance of organisms contaminating high-use surfaces in a burn intensive care unit, an orthopedic ward and healthcare workers. BMC Infect Dis 2012; 12:252. [PMID: 23050585 PMCID: PMC3526496 DOI: 10.1186/1471-2334-12-252] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 09/20/2012] [Indexed: 11/24/2022] Open
Abstract
Background Understanding nosocomial pathogen transmission is restricted by culture limitations. Novel platforms, such as PCR-based electron spray ionization-time-of-flight-mass spectrometry (ESI-TOF-MS), may be useful as investigational tools. Methods Traditional clinical microbiology (TCM) and PCR/ESI-TOF-MS were used to recover and detect microorganisms from the hands and personal protective equipment of 10 burn intensive care unit (ICU) healthcare workers providing clinical care at a tertiary care military referral hospital. High-use environmental surfaces were assessed in 9 burn ICU and 10 orthopedic patient rooms. Clinical cultures during the study period were reviewed for pathogen comparison with investigational molecular diagnostic methods. Results From 158 samples, 142 organisms were identified by TCM and 718 by PCR/ESI-TOF-MS. The molecular diagnostic method detected more organisms (4.5 ± 2.1 vs. 0.9 ± 0.8, p < 0.01) from 99% vs. 67% of samples (p < 0.01). TCM detected S. aureus in 13 samples vs. 21 by PCR/ESI-TOF-MS. Gram-negative organisms were less commonly identified than gram-positive by both methods; especially by TCM. Among all detected bacterial species, similar percentages were typical nosocomial pathogens (18-19%) for TCM vs. PCR/ESI-TOF-MS. PCR/ESI-TOF-MS also detected mecA in 112 samples, vanA in 13, and KPC-3 in 2. MecA was associated (p < 0.01) with codetection of coagulase negative staphylococci but not S. aureus. No vanA was codetected with enterococci; one KPC-3 was detected without Klebsiella spp. Conclusions In this pilot study, PCR/ESI-TOF-MS detected more organisms, especially gram-negatives, compared to TCM, but the current assay format is limited by the number of antibiotic resistance determinants it covers. Further large-scale assessments of PCR/ESI-TOF-MS for hospital surveillance are warranted.
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Affiliation(s)
- Heather C Yun
- San Antonio Military Medical Center, San Antonio, TX, USA.
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Keen EF, Mende K, Yun HC, Aldous WK, Wallum TE, Guymon CH, Cole DW, Crouch HK, Griffith ME, Thompson BL, Rose JT, Murray CK. Evaluation of potential environmental contamination sources for the presence of multidrug-resistant bacteria linked to wound infections in combat casualties. Infect Control Hosp Epidemiol 2012; 33:905-11. [PMID: 22869264 DOI: 10.1086/667382] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether multidrug-resistant (MDR) gram-negative organisms are present in Afghanistan or Iraq soil samples, contaminate standard deployed hospital or modular operating rooms (ORs), or aerosolize during surgical procedures. DESIGN Active surveillance. SETTING US military hospitals in the United States, Afghanistan, and Iraq. METHODS Soil samples were collected from sites throughout Afghanistan and Iraq and analyzed for presence of MDR bacteria. Environmental sampling of selected newly established modular and deployed OR high-touch surfaces and equipment was performed to determine the presence of bacterial contamination. Gram-negative bacteria aerosolization during OR surgical procedures was determined by microbiological analysis of settle plate growth. RESULTS Subsurface soil sample isolates recovered in Afghanistan and Iraq included various pansusceptible members of Enterobacteriaceae, Vibrio species, Pseudomonas species, Acinetobacter lwoffii, and coagulase-negative Staphylococcus (CNS). OR contamination studies in Afghanistan revealed 1 surface with a Micrococcus luteus. Newly established US-based modular ORs and the colocated fixed-facility ORs revealed no gram-negative bacterial contamination prior to the opening of the modular OR and 5 weeks later. Bacterial aerosolization during surgery in a deployed fixed hospital revealed a mean gram-negative bacteria colony count of 12.8 colony-forming units (CFU)/dm(2)/h (standard deviation [SD], 17.0) during surgeries and 6.5 CFU/dm(2)/h (SD, 7.5; [Formula: see text]) when the OR was not in use. CONCLUSION This study demonstrates no significant gram-negative bacilli colonization of modular and fixed-facility ORs or dirt and no significant aerosolization of these bacilli during surgical procedures. These results lend additional support to the role of nosocomial transmission of MDR pathogens or the colonization of the patient themselves prior to injury.
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Affiliation(s)
- Edward F Keen
- San Antonio Military Medical Center, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
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Farmer AR, Murray CK, Mende K, Akers KS, Zera WC, Beckius ML, Yun HC. Effect of HMG-CoA reductase inhibitors on antimicrobial susceptibilities for gram-negative rods. J Basic Microbiol 2012; 53:336-9. [PMID: 22736455 DOI: 10.1002/jobm.201100614] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 02/24/2012] [Indexed: 11/08/2022]
Abstract
Epidemiologic evidence suggests a beneficial effect of HMG-CoA reductase inhibitors (statins) in sepsis, and in-vitro data exist for antimicrobial activity of statins against some bacteria and fungi. We examined whether statin exposure at physiologic concentrations enhances activity of selected antimicrobials against Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli. Broth microdilution was performed with and without dose-ranging concentrations of lovastatin, fluvastatin, atorvastatin, pravastatin and simvastatin. No effects on antimicrobial activity were demonstrated.
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Affiliation(s)
- Aaron R Farmer
- Department of Medicine, San Antonio Military Medical Center, Fort Sam Houston, TX, USA.
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Sensenig RA, Murray CK, Mende K, Wolf SE, Chung KK, Hospenthal DR, Yun HC. Longitudinal characterization of Acinetobacter baumannii-calcoaceticus complex, Klebsiella pneumoniae, and methicillin-resistant Staphylococcus aureus colonizing and infecting combat casualties. Am J Infect Control 2012; 40:183-5. [PMID: 21802175 DOI: 10.1016/j.ajic.2011.03.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 03/21/2011] [Accepted: 03/21/2011] [Indexed: 10/17/2022]
Abstract
Drug-resistant Acinetobacter baumannii-calcoaceticus complex, Klebsiella pneumoniae, and methicillin-resistant Staphylococcus aureus colonize and infect combat casualties from Iraq and Afghanistan. We retrospectively evaluated relatedness, by pulsed-field gel electrophoresis and antibiotic susceptibility testing, of isolates colonizing and infecting casualties over 2 years. Colonizing organisms were unrelated to isolates producing later infection in up to 27% of cases; most isolates underwent change in antibiotic susceptibilities. The same is true for serial infecting isolates recovered during hospitalization.
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Abstract
Air Force (AF) Medical Service leadership considers education, training, and research as key priorities. However, AF academic physicians' perceptions about the academic environment and challenges to success are not well described. AF faculty physicians were surveyed in autumn 2009. One hundred seventy-two responded and rated the academic environment as needing improvement (median Likert-like score 2 [interquartile range 1] on 1-5 scale). The impact of stepping away from an academically oriented career path for other executive positions was rated negatively (median Likert-like score 2, interquartile range 1). Concerns included loss of clinical skills, career disruption, and the challenge of returning to and/or competing for positions within the academic pathway. New policies limiting deployment of Program Directors and/or key teaching faculty were viewed favorably. Most physicians (59%) completing this survey expressed concerns about the AF academic environment and identified numerous challenges. Information from this survey can guide future initiatives to enhance leadership's goals.
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Affiliation(s)
- Woodson S Jones
- Graduate Medical Education 6B04, 59th Medical Wing, Wilford Hall Medical Center, 2200 Bergquist Drive, Suite i, Lackland Air Force Base, TX 78236, USA
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Vento TJ, Prakash V, Murray CK, Brosch LC, Tchandja JB, Cogburn C, Yun HC. Pneumonia in military trainees: a comparison study based on adenovirus serotype 14 infection. J Infect Dis 2011; 203:1388-95. [PMID: 21502080 DOI: 10.1093/infdis/jir040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Adenovirus serotype 14 (Ad-14) recently emerged as a respiratory pathogen in the United States, with studies suggesting higher morbidity and mortality. This study was conducted to determine whether Ad-14 is associated with clinical outcomes in otherwise healthy patients with pneumonia. METHODS Medical records of military trainees hospitalized with pneumonia during an outbreak of Ad-14 infection were reviewed. Clinical, radiographic, and laboratory parameters were compared on the basis of Ad-14 infection. RESULTS Two hundred thirty-four trainees received a diagnosis of pneumonia, and 83(35%) were hospitalized. Sixty-one percent of patients with pneumonia were Ad-14 positive; 43% of patients with Ad-14 pneumonia were hospitalized (83% of female patients and 40% of male patients; P = .04), compared with 40% of patients with Ad-14 negative cases. Ad-14 infection was associated with higher admission temperature (38.3°C [interquartile range, (IQR) 37.7, 39.4] vs 37.3°C [IQR (36.7, 38.5)]; P < .01) and lower white blood cell count (8.3 × 1000 cells/μL [IQR, 5.7, 12.4] vs 13 × 1000 cells/μL [IQR, 7.5, 12.9]; P = .01), neutrophil count (6.7 × 1000 cells/μL [IQR, 2.8, 9.7] vs 9.7 × 1000 cells/μL [IQR, 5.6, 12.1]; P = .02), lymphocyte count (0.9 × 1000 cells/μL [IQR, 0.8, 1.1] vs 1.3 × 1000 cells/μL [IQR, 1, 1.9]; P = .001), and platelet count (210 × 1000 cells/μL [IQR, 145, 285] vs 261 × 1000 cells/μL [IQR, 238, 343]; P < .01). Ad-14 pneumonia was not associated with specific radiographic findings, pneumonia severity score, intensive care unit admission, longer hospitalization, or 30-day mortality. CONCLUSIONS During an outbreak of Ad-14 infection, Ad-14 infection was not associated with excess overall morbidity or mortality. Ad-14 infection was associated with specific laboratory and clinical parameters and higher hospitalization rates in female trainees. These data provide new insight to the epidemiology of Ad-14 infection.
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Affiliation(s)
- Todd J Vento
- Infectious Diseases Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA.
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Yun HC, Blackbourne LH, Jones JA, Holcomb JB, Hospenthal DR, Wolf SE, Renz EM, Murray CK. Infectious Complications of Noncombat Trauma Patients Provided Care at a Military Trauma Center. Mil Med 2010; 175:317-23. [DOI: 10.7205/milmed-d-09-00098] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Robertson JL, Yun HC, Murray CK. Teaching of interdisciplinary and core curriculum topics using alternative strategies. Mil Med 2009; 174:1132-6. [PMID: 19960818 DOI: 10.7205/milmed-d-01-3809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE In the San Antonio Uniformed Services Health Education Consortium Infectious Diseases Fellowship program, didactic lecture formats were previously used to present training in interdisciplinary topics, journal discussions, and core curriculum topics, but herein is described the recent modification of the fellowship's teaching techniques along with a satisfaction survey. METHODS The initial modification to the curriculum included the institution of debates covering controversial core curriculum topics in parliamentary fashion. The second change was the teaching of interdisciplinary topics utilizing a conference moderator. To evaluate the impact of the new teaching strategies, an anonymous Likert-based survey was distributed to the staff and fellows. RESULTS The staff and fellows were uniformly satisfied with the changes in the curriculum and new strategies are preferred over the traditional teaching methods. CONCLUSIONS Creating innovative forums to enhance the education of trainees has improved fellow and staff satisfaction with the teaching of these topics.
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Affiliation(s)
- Janelle L Robertson
- Infectious Disease Service (MCHE-MDI-7E), Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA
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Murray CK, Yun HC, Griffith ME, Thompson B, Crouch HK, Monson LS, Aldous WK, Mende K, Hospenthal DR. Recovery of Multidrug-Resistant Bacteria From Combat Personnel Evacuated From Iraq and Afghanistan at a Single Military Treatment Facility. Mil Med 2009; 174:598-604. [DOI: 10.7205/milmed-d-03-8008] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Yun HC, Ellis MW, Jorgensen JH. Activity of ceftobiprole against community-associated methicillin-resistant Staphylococcus aureus isolates recently recovered from US military trainees. Diagn Microbiol Infect Dis 2007; 59:463-6. [PMID: 17911001 DOI: 10.1016/j.diagmicrobio.2007.06.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 06/21/2007] [Accepted: 06/26/2007] [Indexed: 11/16/2022]
Abstract
Ceftobiprole MICs at which 50% and 90% of isolates were inhibited (MIC50 and MIC90), determined by the Clinical and Laboratory Standards Institute broth microdilution method, were both 1 microg/mL (range, 0.5-1 microg/mL) against 143 community-associated methicillin-resistant Staphylococcus aureus isolates and 0.5 microg/mL (range, 0.25-0.5 microg/mL) with 29 methicillin-susceptible isolates recovered from military trainees during 2 prospective investigations.
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Affiliation(s)
- Heather C Yun
- Department of Infectious Disease, Wilford Hall Medical Center, Lackland Air Force Base, TX 78236, USA.
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