When Minutes Matter: A Comparison of Whole Blood Collection Techniques.

BACKGROUND: Fast and reliable blood collection is critical to emergency walking blood banks (WBB) because mortality significantly declines when blood is quickly administered to a warfighter with hemorrhagic shock. Phlebotomy for WBB is accomplished via either the "straight stick" (SS) or "ruggedized lock" (RL) method. SS comprises a 16-gauge phlebotomy needle connected to a blood collection bag via tubing. The RL device collects blood through the same apparatus, but has a capped, intravenous (IV) catheter between the needle and the donor's arm. This is the first study to compare these two methods in battlefield-relevant metrics. METHODS: Military first responders and licensed medical providers (N=86) were trained in SS and RL as part of fresh whole blood training exercises. Outcomes included venipuncture success rates, time to IV access, blood collection times, total time, and user preferences, using a within-subjects crossover design. Data were analyzed using ANOVA and nonparametric statistics at p<0.05. RESULTS: SS outperformed RL in first venipuncture success rates (76% vs. 64%, p=0.07), IV access times (448 [standard error of the mean; SE 23] vs. 558 [SE 31] s, p<0.01), and blood collection bag fill times (573 [SE 48] vs. 703 [SE 44] s, p<0.05), resulting in an approximate 3.5-minute faster time overall. Survey data were mixed, with users perceiving SS as simpler and faster, but RL as more reliable and secure. CONCLUSION: SS is optimal when timely collection is imperative, while RL may be preferable when device stability or replacing the collection bag is a consideration.

Military Medical Students' Perspectives on Medical Education in the COVID-19 Era.

In response to the COVID pandemic, Uniformed Services University (USU) suspended clerkships. As the nation's military medical school, USU had to keep students safe while still preparing them to be military physicians. In this commentary, we, a group of USU students, explore what this experience taught us about military medicine.

Project Reach: A Pilot Cross-Sectional Study of the Telemedical Capabilities of Special Operations Medical Personnel.

BACKGROUND: While the US military has relied on the "Golden Hour" for casualty evacuation in Iraq and Afghanistan during most of the last two decades, Special Operations Forces (SOF) personnel have found themselves operating further outside of this established medical infrastructure. This has required prolonged casualty care beyond doctrinal timelines. Telemedicine is increasingly used by medical personnel to bridge this gap, augmenting the local staff with the expertise of a distant consultant. This pilot study was launched to establish a baseline of current SOF telemedical capabilities. METHODS: This is a cross-sectional study of a 292 Department of Defense (DoD) SOF medical personnel via an online questionnaire during the period of October 2018-May 2019. RESULTS: Approximately 16.1% of the 292 respondents stated they received telemedicine equipment, 51.1% of respondents who received telemedicine equipment reported also receiving training on their equipment. Overall, 40.6% of respondents were "actively looking to add telemedicine to their practice," with prolonged field care as the primary intended use. Ideal characteristics of telemedicine equipment were described as a device weighing 6 lb or less, with real-time video and ultrasound transmission capabilities. DISCUSSION: The data demonstrated a gap between provider demand for telemedicine capabilities and their comfort to employ these capabilities downrange. CONCLUSIONS: This study suggests a need to increase the self-reported telemedicine competency of deployed local providers. Authors believe that this is best accomplished through incorporation of early integration of teleconsulting systems into mission rehearsals and unit exercises. Further study should be considered to investigate the efficacy of ongoing acquisition and training programs, along with how telemedicine is being incorporated in the unit during the predeployment training period.

Challenges in mitigating context specificity in clinical reasoning: a report and reflection.

Objectives Diagnostic error is a growing concern in U.S. healthcare. There is mounting evidence that errors may not always be due to knowledge gaps, but also to context specificity: a physician seeing two identical patient presentations from a content perspective (e.g., history, labs) yet arriving at two distinct diagnoses. This study used the lens of situated cognition theory - which views clinical reasoning as interconnected with surrounding contextual factors - to design and test an instructional module to mitigate the negative effects of context specificity. We hypothesized that experimental participants would perform better on the outcome measure than those in the control group. Methods This study divided 39 resident and attending physicians into an experimental group receiving an interactive computer training and "think-aloud" exercise and a control group, comparing their clinical reasoning. Clinical reasoning performance in a simulated unstable angina case with contextual factors (i.e., diagnostic suggestion) was determined using performance on a post-encounter form (PEF) as the outcome measure. The participants who received the training and did the reflection were compared to those who did not using descriptive statistics and a multivariate analysis of covariance (MANCOVA). Results Descriptive statistics suggested slightly better performance for the experimental group, but MANCOVA results revealed no statistically significant differences (Pillai's Trace=0.20, F=1.9, df=[4, 29], p=0.15). Conclusions While differences were not statistically significant, this study suggests the potential utility of strategies that provide education and awareness of contextual factors and space for reflective practice.

Impact of prophylactic oseltamivir on INR in patients on stable warfarin therapy.

Influenza prophylaxis with oseltamivir is recommended for exposed high-risk patients. Patients with many comorbidities have an increased likelihood of co-administration of oseltamivir and warfarin. Evidence of a drug interaction is conflicting in the literature and is limited to a 5-day treatment course. This study evaluates the impact of prophylactic oseltamivir on international normalized ratio (INR) in patients taking warfarin. This retrospective cohort study conducted within the Veterans Health Administration included patients on warfarin who received oseltamivir for influenza prophylaxis. The primary endpoint was change in INR from baseline to day 10 of oseltamivir treatment. Secondary endpoints included change in INR based on renal function and duration of oseltamivir prophylaxis, trend in INR, and frequency of bleeding and thrombosis events. A total of 1041 patients were included and received oseltamivir for a mean of 12.9 days. The mean post-oseltamivir INR was significantly increased compared to the pre-oseltamivir INR (2.39 to 2.52; p < 0.001). Patients with a creatinine clearance of 31-60 mL/min had a significant increase in INR (2.40 to 2.59; p < 0.01). There was an increase in INR when oseltamivir was used for 7 or 8-10 days. Of included patients, 5.1% and 1.8% had a recorded thrombosis or bleeding event, respectively. There was a significant increase in INR in patients on chronic warfarin therapy and concomitant prophylactic oseltamivir, but this change may only be clinically significant for certain patient populations. The most impact on INR was within 7-10 days of oseltamivir initiation and in patients with impaired renal function.

Influence of Successful Chronic Hepatitis C Virus Treatment with Ledipasvir/Sofosbuvir on Warfarin Dosing Requirements in Four Veterans.

STUDY OBJECTIVE: To describe international normalized ratio (INR) trends and warfarin dosage adjustments required for four veterans who were receiving warfarin therapy and started treatment for hepatitis C virus (HCV) with ledipasvir/sofosbuvir with or without ribavirin. DESIGN: Case series. SETTING: Pharmacist-led anticoagulation clinic in a Veterans Affairs Health Care System. PATIENTS: Four patients aged 59-66 years who were receiving warfarin and had stable, therapeutic INRs and started ledipasvir/sofosbuvir therapy with or without ribavirin for HCV infection. MEASUREMENTS AND MAIN RESULTS: All four patients developed subtherapeutic INRs after the addition of ledipasvir/sofosbuvir with or without ribavirin. An increase in weekly warfarin dose ranging from 14-67% was required, with changes in warfarin doses starting 2-3 weeks after ledipasvir/sofosbuvir initiation. Two patients required dose reductions after HCV treatment completion, whereas the other two did not. Use of the Drug Interaction Probability Scale indicated that the interaction between warfarin and ledipasvir/sofosbuvir was doubtful (score of 1 [two patients]) or possible (score of 4 [two patients]). The mechanism of this interaction is unknown but may be related to improvements in hepatic function during HCV treatment. CONCLUSION: To our knowledge, this is the first case series describing a possible drug interaction between warfarin and ledipasvir/sofosbuvir (with or without ribavirin). Close monitoring is warranted when ledipasvir/sofosbuvir is initiated in patients receiving anticoagulation therapy with warfarin, especially those with evidence of cirrhosis prior to treatment. This is particularly important in the first month after starting treatment and the first month after completion. Failure to monitor and achieve therapeutic INR after HCV therapy completion may have the potential to result in adverse outcomes.

Splice isoforms of phosducin-like protein control the expression of heterotrimeric G proteins.

Heterotrimeric G proteins play an essential role in cellular signaling; however, the mechanism regulating their synthesis and assembly remains poorly understood. A line of evidence indicates that the posttranslational processing of G protein ß subunits begins inside the protein-folding chamber of the chaperonin containing t-complex protein 1. This process is facilitated by the ubiquitously expressed phosducin-like protein (PhLP), which is thought to act as a CCT co-factor. Here we demonstrate that alternative splicing of the PhLP gene gives rise to a transcript encoding a truncated, short protein (PhLPs) that is broadly expressed in human tissues but absent in mice. Seeking to elucidate the function of PhLPs, we expressed this protein in the rod photoreceptors of mice and found that this manipulation caused a dramatic translational and posttranslational suppression of rod heterotrimeric G proteins. The investigation of the underlying mechanism revealed that PhLPs disrupts the folding of Gß and the assembly of Gß and Gγ subunits, events normally assisted by PhLP, by forming a stable and apparently inactive tertiary complex with CCT preloaded with nascent Gß. As a result, the cellular levels of Gß and Gγ, which depends on Gß for stability, decline. In addition, PhLPs evokes a profound and rather specific down-regulation of the Gα transcript, leading to a complete disappearance of the protein. This study provides the first evidence of a generic mechanism, whereby the splicing of the PhLP gene could potentially and efficiently regulate the cellular levels of heterotrimeric G proteins.