Bailey K. Ashford and Robert A. Phillips Research Awards

Last week I ended up spending more time than I would have liked at Walter Reed National Military Medical Center, because on Monday and Wednesday, I was competing for the two research awards at the hospital the Bailey K. Ashford Award and Robert A. Phillips Award. It was the first year that preventive medicine residents from WRAIR were allowed to compete, so I submitted my abstract on poisoning hospitalizations that I did at AFHSC several months ago, and was selected as a finalist for both.

Here's a picture of Bailey K. Ashford. He was an Army physician in the Spanish American War. After the war, he was sent to Puerto Rico to command the medical department troops (which today would a job given to a Medical Service Corps officer, not a doctor, because it's a pretty thankless job and kinda like herding cats. We don't listen to directions well). While he was there, he noticed that the Puerto Ricans were not only shorter than Americans, but that most of them were anemic. This led him to discovering a new species of hookworm and spent a year working on treating around 300,000 Puerto Ricans, reducing the death rate from anemia by 90% on the island. After this, he established the Puerto Rican Institute of Tropical Medicine and Hygiene, which is now part of the University of Puerto Rico School of Medicine. 

And this is Robert A. Phillips. He was a Navy physician and served in the Naval Reserves during WWII. In 1945-46, he was sent to Cairo to study typhus and ended up establishing the US Navy Medical Research Unit #3 (NAMRU-3), which is still there today. His first big assignment as the commanding officer of NAMRU-3 was a cholera outbreak in Egypt. In that outbreak, his research on cholera and treatment made him pretty much the world expert in it until he died in 1976.

In the good old days of the National Capital Region, when the Army had Walter Reed and the Navy had Bethesda, these were two separate competitions (Bailey K. Ashford at Walter Reed and Robert A. Phillips at Navy), and the two had nothing to do with each other. Four years ago, however, we all had to learn how to play well together, and both competitions were open to residents and fellows from either service. The main difference is that Bailey K. Ashford is for graduating residents, and Robert A. Phillips is for any resident. So there was quite a lot of overlap in the people competing for these awards, including me.

I didn't get the Robert A. Phillips award--it went to an Army orthopedic surgery resident who came up with a new system of classifying lumbosacral fractures--and the Bailey K. Ashford won't be announced until residency graduation in June, but I'm not exactly holding my breath. These are clinical research awards, which judges who are clinicians, and these people rarely consider epidemiology to be clinical research. Whatever. I was just happy that I was selected to be a finalist in both, because that meant that: a) someone recognizes the value of epidemiologic research; and/or b) someone thought my research was interesting enough that they wanted to hear me talk about it. And it got me out of clinic for two days, which is always a plus.

Poisoning project

I'm actually starting on my second week at Ft. Meade, which means I've really procrastinated about summing up my AFHSC rotation. As I mentioned before, my project was on poisoning hospitalizations in the military from 2001-2010, figuring out which of those were intentional, and finding risk factors of intentional poisoning compared to those that are unintentional. Here's what we got for total numbers:

I also looked into what people were being poisoned with. The top contenders are pain medications and psych medications (surprise, surprise).

The next part was to look into which hospitalizations were intentional. For this, I used an algorithm that was published in the civilian medical literature that looks into certain psych diagnoses during the hospitalization for poisoning. Surprisingly enough, despite the increases in psych diagnoses in the military over the last ten years, the percentage of poisonings that were intentional has remained fairly constant (with a very slight increase).

Risk factors for intentional poisonings were drug (medication) overdoses, being female, married, black, a recruit, in the Navy, and multiple deployments. Protective factors are age over 40, currently being deployed, being in the Marine Corps, and increasing rank (which goes along with being older).

I presented that about a week and a half ago and got a fairly good reception. Previous residents were only on that rotation for four weeks, instead of the six that I (and my fellow residents) have, so I was able to do more analysis than they were accustomed to seeing. All in all, it was a good rotation and a good refresher on the epidemiology. I'm still trying to get in the swing of my current rotation (preventive medicine department at Ft. Meade). I hope this one ends up being a good learning experience as well.

Week 4 at AFHSC

I realized today that it's been a few weeks since I've updated anything, so here goes. Things are going well at the Armed Forces Health Surveillance Center. I got data on hospitalizations for poisoning at the end of the second week, so I've been spending my time since then staring at numbers and analyzing data.

To do all this analyzing, I'm using a statistical software called STATA (I don't know what, if anything, it stands for). I used STATA last year in school (yay for flashbacks to Epi 3...), so I'm somewhat familiar with it, which is good, since we're getting our STATA review tomorrow. Yeah, about two weeks later than I needed, but whatever.

I spent most of my first day with the data playing with the software, trying to remember simple commands and trying to figure out why I couldn't get anything to work the way I wanted it to (I eventually figured it out), and then the next few days doing some more complicated analyses. Since then, I've been working on more complicated analyses and putting my presentation together.

My project is actually in two parts: the first part is to describe who has been hospitalized for poisonings (both drug overdose and toxic exposures, such as to petroleum or lead); the second part is to figure out which poisonings were intentional, and what the differences are between those who purposely poisoned themselves and those who didn't. The first part was easy enough; there are a few simple commands (that I had to do over and over again) to do all the descriptive epidemiology, but the second part required much more thought (and probably isn't all that accurate).

As far as describing who in the military has been hospitalized for poisonings, there have been almost 15,000 over ten years. There are some minor fluctuations from year to year, but for the most part, the rate has been fairly constant. While there were more men (because the military has more men), the rate was higher for women. The rates are also highest for the lowest ages (17-19), lowest ranks (E1-E4), those in the Army (because we're Army strong...?),  least education, never married, and white (although the differences in races were pretty small).

With the second part--figuring out which poisonings were intentional--I used a few different things. The first are that there are certain diagnostic codes that can be used to say that a hospitalization was due to suicide attempt. The second is that there was a paper a few years ago that used a combination of psychiatric diagnoses within six months of the hospitalization to say that it was likely intentional. They did this in a civilian population, though, which has different baseline rates of psychiatric diagnoses than military populations.

Long story short, according to my calculations, 63% of all hospitalizations for poisoning in the military over the last ten years have been intentional. Risk factors include being female, in the Army (again, we're Army strong), multiple deployments, being married (yes, married people are at a higher risk of trying to poison themselves), and working in healthcare. Protective factors--those that make people less likely to try to poison themselves--are age over 40, increasing rank, and being in the Air Force or Marine Corps.

So, it's been a lot of analyses and a lot of math over the last few weeks, but I actually have some results to present, so that's a good thing. Pretty much, all I have left for the next two and a half weeks is to do my presentation and write my paper. Fun and exciting, I know.

First week at AFHSC

Last week was my first of six weeks at the Armed Forces Health Surveillance Center (AFHSC--don't try to say it as a word; it's not one of those kinds of acronyms. Just the letters). I wish I could say I accomplished a lot, but that wouldn't be entirely true. I do have a project, so that's a start (and honestly, all anyone ever accomplishes in the first week).

My original idea for a project came from my surgeon friends, who have said that they've noticed different rates of mucor infections in war wounded between Walter Reed and Bethesda, suggesting that maybe there's a difference in either the conditions the Army and Marine Corps are fighting in, or there's a difference in care. (Mucor, by the way, is an invasive fungal infection that's pretty rare and very bad). Well, difference in rates between the two hospitals or not, there haven't been enough cases in the last ten years to do any sort of analysis. So that idea was scrapped.

I didn't really have any back-up plans, so my project mentors suggested that I read through the Medical Surveillance Monthly Report (http://www.afhsc.mil/msmr?clear), which is the military's version of CDC's Morbidity and Mortality Weekly Report. Well, I didn't see too much exciting, but I did notice that they always clumped injuries and poisonings together, and while injuries have been a big priority, nobody's ever done an analysis of poisonings. So that's what I'm doing. I'm going to do an analysis of who has the highest rates of being hospitalized for poisonings (of both medical and non-medical types), looking at age, sex, race, branch of military service, rank, education level, and marital status (and maybe more categories; I don't remember).

We also found an article from the civilian medical literature that described how you can estimate which injuries and poisonings are intentional (ie, suicide attempt), using the type of injury/poisoning (all poisonings fit this category) and certain psych diagnoses within 180 days of being hospitalized. So we're going to be looking at psych diagnoses before poisonings, to estimate which ones were intentional and which were not.

At least, that's the plan. My request for data just went in today, so we'll see if I get any usable data from any of that.

As if I didn't have enough to do with that project, my project proposal that I presented for my degree is just getting started (yes, I was supposed to have this done before finishing my degree...). At this point, we're still at the stage where we contact people and beg them to participate in the study. There are over 200 people on the list, and we've gotten (wait for it...) one set of surveys back. Yes, one. So part of my job is to find a way to reach the ones we haven't to also beg them to join. It's all sorts of fun. At least it's not very intellectually challenging. Just time consuming. It's great fun.

AFHSC and serum repository

Yesterday we had a tour of the Armed Forces Health Surveillance Center (AFHSC) and the serum repository. The serum repository is the largest one in the world, containing almost 60 million blood samples, the blood that's left over every time the DoD draws blood for a routine HIV test. So three of those samples in the repository are from me.

They have all sorts of fun toys in there, to make dealing with that many blood samples manageable, including one that pipettes blood into vials and unscrews tube tops. Here's a video, if you want to watch how it works:

And in case you can't visualize 60 million blood samples, here's the view in one of 7 freezers (at -30 degrees C), each of which is about 7000 square feet.

And down the aisle:

After the tour of the serum repository, we had a three hour epidemiology review, which was all sorts of fun (not really). That's what we were doing when the earthquake happened. Unfortunately, it only rescued us from about two minutes of reviewing (enough time to leave the conference room, confirm that the world wasn't coming to an end, and return). Here's what the white board looked like at one point:

I start at AFHSC full-time on Monday (hopefully without the epidemiology reviews). While there, I'll do a surveillance project on a disease of military interest. My surgeon friends tell me that they're seeing a lot of war-wounded patients with invasive fungal infections of the wounds, and for some reason, the patients at Walter Reed do worse than the patients at Bethesda, even though Bethesda gets more patients with this type of infection. I'm hoping to do an analysis of how patients do based on which service (Army, Navy, Marine Corps, Air Force) and where in Afghanistan the patients were when wounded. We'll see if that's deemed a good project or not.

Goodbye, Kenya

 I've been back from Kenya for a few days now, procrastinating about posting my last few pictures onto the blog. The last couple of days in Malindi were pretty low-key. On Thursday, we took the German medical students out to lunch at the Hilton. The one on the right, Maria (who is actually Norwegian, but goes to school in Germany), ran the 5K as part of the marathon on Saturday (day after I left) and placed third for women. Apparently, there was a girl about 10 years old who showed up for that run in ballet slippers. Dr. Childs told Maria she had to beat the girl, and she did--just barely. Even Kenyan children are good runners.

The girls were quite a hit with the children at the Hilton.

Here's a random picture of the waiting area of the outpatient clinics at the hospital:

Friday I packed up my belongings (which reminds me... I still need to fumigate my duffle bag, my laundry smelled that bad) and attempted to check out of the hotel, but they told me that their credit card machine was down (whether it was or not, I don't know), so they told me to go to the ATM. Well, my government credit card only lets me pull $600/month out in cash, which wouldn't cover the 95000 KSH hotel bill (about $1000), and the ATM that took my personal debit card wasn't working, so I had to take my personal credit card to the bank with my passport to pull the cash out. Long and frustrating story short, two hours later I had the cash to check out of the hotel, and then it was time to head to the airport.

This was the plane that carried me from Malindi to Nairobi, the first of four flights until I landed at Reagan. I had a very long layover in Nairobi (almost eight hours), so I spent some of that time in one of COL Coldren's favorite bars, The Pub (it's at the airport). He discovered that bar when he was in Kenya as a preventive medicine resident and had a long lay-over in Nairobi, so I kept alive the tradition of preventive medicine residents working on data at The Pub while waiting for the next flight.

After Nairobi was Amsterdam, then Detroit (where I again confirmed that the entire state of Michigan is worthless... no USO, no free wifi, and bad cell phone reception in the airport), and then it was back to DCA. I had from Saturday afternoon until Monday morning to recover, and then it was into WRAIR at 7:30 to officially begin my third year of residency. I have a week of in-processing and administrative stuff, and then begin at the Armed Forces Health Surveillance Center (AFHSC) next Monday.