Interdisciplinary treatment of diabetes mellitus in a military treatment facility

The American Diabetes Association emphasizes interdisciplinary management as the standard of care for patients with diabetes. Many times, however, interdisciplinary means various health care professionals treating a patient but not necessarily interacting with each other regarding the patient's care. Recently, Tripler Army Medical Center replicated the Joslin Diabetes Center's diabetes outpatient intensive treatment program as part of a Joslin Diabetes Center/Department of Defense/Veteran's Administration research collaboration. Tripler Army Medical Center named this interdisciplinary program Holopono, which is Hawaiian for success. Holopono is a team of health care professionals providing integrated care and education to a group of diabetes patients over 3.5 days. Individual care management, aided by an Internet-based telemedicine system, then continues for 1 year after entry into the program. This article describes the Holopono program, the role of each team member, and how the team functions together to provide comprehensive diabetes care.     

Development of a core curriculum in professional growth: practice management military model

Military medicine has faced some big challenges in recent years. Military treatment facilities have not been exempt from these alterations, as the American public has sought to reinvent government practices with regard to medicine. Until recently, professional education consisted almost entirely of emphasis in the particular content of the chosen field. Obstetrics and gynecology was one of the first medical specialties to recognize the importance of practice management, professional growth and development, and to require exposure to it as part of the residency process. The Department of Obstetrics and Gynecology's instructional objectives dealing with professional growth and development originated as part of the military-unique curriculum for physicians implemented at Tripler Army Medical Center in Hawaii. Later, these objectives were used at Madigan Army Medical Center in Tacoma, Washington. Recent changes in the health care environment, coupled with an increasing awareness of professional liability and the newer specter of managed care, force physicians to learn the cost of each health encounter and to be more familiar with the business aspects of health care. As medicine in general is changing, the curricula have been revised and tailored to the needs of our physicians with the addition of ethics, managed care, utilization, and practice management.     

Availability of smoking cessation resources for U.S. Army general medical officers

Adequate resources are a necessity in providing effective smoking cessation interventions to active duty soldiers. The availability of smoking cessation resources was measured by a survey of Army general medical officers (GMOs). Questionnaires were successfully mailed to 232 Army GMOs, which was the entire population of this group in 1997. One hundred fifty GMOs (65%) returned the questionnaire voluntarily and anonymously. Fifty-three percent of GMOs identified the nicotine patch as a formulary item. All responders indicated that some form of nicotine replacement was available on formulary or for purchase in the area. Eighty-two percent of GMOs reported that group smoking cessation programs were available. The widespread availability of group smoking cessation programs may reflect an emphasis on this strategy by the Army's health promotion program. Additional attention needs to address the availability of nicotine replacement items and other adjunctive medications without cost to the beneficiary at military installations.     

Controlled trial for smoking cessation in a Navy shipboard population using nicotine patch, sustained-release buproprion, or both

This study reports an experimental, randomized controlled clinical trial comparing three treatments for smoking cessation: sustained-release bupropion, nicotine patch, and combination nicotine and bupropion, to a counseling-only control group (N = 140), for smoking sailors aboard seven Navy ships. The purpose was to determine the effectiveness of different pharmcotherapies used in smoking cessation programs. Continuous abstinence was defined as the percentage of subjects who did not smoke since the quit date assessed at 6 and 12 months and having an expired carbon monoxide concentration of <10 ppm at educational sessions 2, 3, and 4. Nine subjects dropped out of the study, and 40 subjects were lost to follow-up. Eleven percent (15/140 subjects) had continuous abstinence at 12 months. The abstinence rates at 12 months were 47% in the control group, as compared with 27% in the nicotine patch/bupropion group, 20% in the nicotine patch group, and 7% in the bupropion group.     

The clinical implications of a smoking ban on submarines in the U.S. Navy

By the end of calendar year 2010, a total smoking ban on submarines is expected to be implemented throughout the submarine force because of the negative health effects of environmental tobacco smoke and the recently demonstrated exposure of nonsmoking submariners to measurable levels of nicotine during submarine deployments. Historically, smoking has been highly prevalent in the military, but new data on the negative health effects of tobacco have led the military to change its policies, restricting its use in certain environments. A number of research studies have examined the effect of smoking on the military, cessation and prevention interventions, effect of environmental tobacco smoke onboard the submarine, and treatment modalities aimed at smokers attempting to quit. With the potential for considerable physical and psychological effects, a mass tobacco cessation program is being implemented to support the prohibition onboard the submarine. Recommendations for a successful implementation program are included.     

Comparing the tolerability and effectiveness of two treatment regimens in a smoking clinic

This study compares the effectiveness and tolerability of bupropion versus bupropion plus nicotine patch for smoking cessation in a routine clinical setting. Patients at the Sepulveda Veterans Health Administration Smoking Cessation Clinic completed a baseline survey and received counseling over 2 months, along with bupropion or bupropion plus nicotine patch. Of the 227 patients randomized to treatment, 112 (49%) received bupropion only and 115 (51%) received the combination therapy. At least one side effect was noted in 55% of bupropion patients and 70% of combination therapy patients; treatment regimens were changed in 7% and 14%, respectively. Abstinence rates at 2 months were 26% for the bupropion group and 37% for the combination therapy group (p = 0.1), and at 6 months were 42% versus 35%, respectively (p = 0.4). Although 6-month abstinence rates were derived from patient self-report and should be interpreted with caution, these results suggest that most patients referred to the clinic are able to take these medications. There was no difference in the rate of switching treatments, or in long-term abstinence rates.     

The short-term impact of Army smoking policies

A cross-sectional study was performed among soldiers of an infantry battalion to determine smoking prevalence and to assess the short-term impact of Army smoking policies instituted within the preceding 6 months. Data were collected using a structured pretested questionnaire. The response was 91.5%. Smoking prevalence was 45%. This study yielded conflicting data on the effectiveness of the new policies. The importance of educating the smoker on health risks was corroborated. Army health care providers had questioned the majority of the soldiers regarding their smoking status, but failed to suggest they quit or provide suggestions on how to quit.     

戒烟对部队官兵消化性溃疡复发治疗的影响

目的探讨戒烟对部队官兵消化性溃疡复发治疗的影响。方法 82例部队官兵消化性溃疡复发患者均采用奥美拉唑胶囊和枸橼酸铋钾胶囊治疗,同时劝其在治疗过程中戒烟,疗程2个月。将82例患者根据治疗过程中有无戒烟分为两组:戒烟组(整个疗程中完全戒烟)40例和非戒烟组(整个疗程中持续吸烟或不完全戒烟)42例。观察两组患者的临床疗效。结果戒烟组、非戒烟组总有效率分别为92.5%、52.4%,戒烟组总有效率显著高于非戒烟组(P<0.01)。结论戒烟能明显提高部队官兵消化性溃疡复发治疗的效果。     

Smoking cessation therapy and the return of aviators to flying duty

Smoking cessation is an important part of every primary care physician's work. The importance of smoking cessation in the reduction of cardiovascular morbidity and mortality and the reduction of cancer incidence cannot be overstated. Various treatments have been established to encourage smoking cessation; these include group and individual psychological therapy, nicotine replacement in various forms, and drug therapy. The best-known drug used for smoking cessation is bupropion SR (Zyban). Smoking in aviators is not different than in the general population in terms of prevalence. Thus it is important for flight surgeons worldwide to be familiar with the magnitude of the problem and the available treatment options. Yet, it is also important for this community to become familiar with the relevance of this treatment to aviation and to recognize the limitations pertinent to flying personnel who are attempting to quit smoking. We present treatment options for smoking cessations and their limitations on flying personnel.     

The Tripler LE3AN Program: a two-year follow-up report.

This paper provides a review of 2-year follow-up data on the Tripler Army Medical Center LE3AN Program. The LE3AN Program (emphasizing healthy Lifestyles, reasonable Exercise, realistic Expectations, Emotions, and Attitudes, and Nutrition) provides active duty service members a treatment strategy that involves a reasonable low-intensity exercise regimen, behavior modification, intensive nutritional counseling healthy meal planing, relapse prevention strategies, cognitive coping strategies, and healthy lifestyle principals to lose weight and maintain weight loss. Based on the 2-year data and additional clinical findings, we expand upon earlier preliminary reports. The 2-year follow-up data suggest that the program is a safe and efficacious treatment program.     

A suicide prevention advisory group at an academic medical center

During a 15-month period, there were seven suicides among patients who were in active treatment or who had been seen recently by providers in the Department of Psychiatry of Tripler Army Medical Center, Honolulu, Hawaii. As a result, a Suicide Prevention Advisory Group was formed to identify possible causes and make recommendations aimed at improving the identification and treatment of suicidal patients. The group made 11 specific recommendations. No known suicides occurred during the 22 months after the implementation of the Suicide Prevention Advisory Group's recommendations.     

Humanitarian assistance medicine: perceptions of preparedness: a survey-based needs assessment of recent U.S. Army internal medicine residency graduates

The U.S. military provides humanitarian assistance in many areas around the globe. With recent changes in the force structure of the U.S. Army, internal medicine physicians are now at the forefront of providing this care, but the extent of their involvement is not known. This study measured the frequency with which recently trained Army internists provided humanitarian assistance, and it assessed their perceived preparedness for such missions. All graduates from Army internal medicine programs for 4 consecutive years were invited by e-mail to participate in an Internet-based survey. Eighty-nine personnel (49% of those contacted) completed the survey. Of those in a deployable position for >6 months, 72% provided medical humanitarian assistance. Most thought that additional training was needed, especially in tropical disease management, sanitation, and the practices of civilian humanitarian workers. This study demonstrates that military-trained internists are frequently involved in humanitarian assistance medicine, and it suggests that they might benefit from additional training.     

The Walter Reed Army Medical Center Nephrology Service website: a tool for military-wide provider and patient education

OBJECTIVES: Military medical subspecialists consult with referring physicians, direct patient care and education, support isolated subspecialists, and maintain cohesive readiness plans. The World Wide Web appears promising in fulfilling these roles. METHODS: A website providing directed resources, the Walter Reed Army Medical Center Nephrology Service website (http:@www.wramc.amedd.army. mil/departments/medicine/nephro/NEPHROLOGY/index.htm!), is described in the context of its role in military medicine and online publishing. RESULTS: The Walter Reed Army Medical Center Nephrology Service website provides educational resources for both patients and physicians worldwide. It remains the only Army internal medicine website to offer online category I continuing medical education credits free to military physicians, and it also allows online graduate medical education. CONCLUSIONS: Military medical subspecialty programs can use the World Wide Web to provide consultation and education to distant and isolated patients and providers in a practical, feasible manner. This process can be expanded to education in operational medicine and other military-specific medical topics.     

Assessing the institutional approach to implementing smoking cessation practice guidelines in veterans health administration facilities

National smoking cessation guidelines include recommended strategies for providers and health care organizations, but they offer little guidance on how to structure care. We conducted a cross-sectional survey at 40 Veterans Health Administration facilities, to describe the structure of smoking cessation care, to assess adherence to national guidelines, and to assess facilities' preferred approach to providing smoking cessation treatment. We categorized sites as those using a primary care approach (most smokers treated by the primary care provider) versus a specialty approach (medication restricted to smoking cessation clinics, to which most patients were referred). Nearly all sites reported systematic screening for smoking and counseling of smokers, usually by both nursing staff members and the primary care provider. Most sites used a specialty approach, restricting medication access to smokers attending a cessation program. Future research should evaluate whether this approach provides adequate access and responsiveness to patient preferences for the full population of smokers in primary care.     

Comparison of home and clinic well-baby visits in a military population

Patient satisfaction is an indicator of quality of care received. Home-visit programs are associated with increased satisfaction and equivalent clinical outcomes but increased cost, compared with clinic visits. We hypothesized that home visits for routine well-child care would also be associated with increased satisfaction and equivalent outcomes. One thousand infants born at Tripler Army Medical Center were identified, and 630 were enrolled. Army and Air Force dependents received 2-week clinic visits. Navy and Marine Corps dependents were offered home visits. At 4 to 6 weeks, families completed a questionnaire. Maternal satisfaction and quality of anticipatory guidance were higher in the home-visit group. Clinical outcomes were equal. Home visits for routine well-child care are valid and are associated with greater maternal satisfaction, better anticipatory guidance, and equivalent clinical outcomes.     

Scaphoid fracture detection in a military population: a standardized approach for medical referral

OBJECTIVE: The objective was to test, refine, and implement an algorithm for early detection and referral of clinical scaphoid fractures by U.S. Army medical personnel. Our goal was to reduce complications resulting from delayed diagnosis and to improve outcomes affecting soldier health and unit readiness. METHODS: Data on scaphoid fractures treated in the orthopedic department at Tripler Army Medical Center were collected from January 1, 2001, through December 31, 2003. Demographic variables included gender, age, and military rank. RESULTS: The incidence of scaphoid fractures in our population was 43 cases per 100,000 personnel per year. An algorithm to guide nonorthopedic providers was developed after review of the medical literature. CONCLUSION: We present an algorithm-based approach to soldiers presenting with post-traumatic wrist pain. The algorithm was fashioned with the aim of reducing complications and poor outcomes associated with delayed diagnosis of scaphoid fractures, affecting soldier health and unit readiness. A prospective study of the algorithm is underway.     

Pregnant soldiers' participation in physical training: a descriptive study

This study identifies factors that influence U.S. Army soldiers' participation in the Pregnant Soldiers Wellness Program (PSWP), an exercise and wellness education program for soldiers who are either pregnant or in the postpartum period. A retrospective survey was administered prior to initial postpartum hospital discharge. Seventy-four soldiers who delivered babies at Womack Army Medical Center participated in this study. Of those surveyed, 66.2% of respondents participated in the PSWP, 59.5% were encouraged to participate by their provider. Few participants stated that the overall safety, structure, and quality of the PSWP were important factors contributing to their participation. Additionally, less than 20% reported that instructor's knowledge influenced their decision to participate in the PSWP. Most soldiers participated in the program for the health of their fetus and to quickly return to required Army weight standards. This study offers insights that will potentially increase the overall soldier participation rate in the PSWP, thus promoting greater health benefits for the pregnant soldier and increasing sustainment of force readiness.     

Relapse to smoking after basic military training in the U.S. Air Force

This study examined predictors of smoking relapse in the year after the mandatory smoking ban during basic military training (BMT) in the U.S. Air Force. Participants were all smokers who completed BMT from August 1995 to August 1996 and relapsed to smoking in the subsequent year (N = 4,303). Results demonstrated that the vast majority of airmen (69.8%) returned to smoking within 1 month after BMT and that most (90%) were still in training status when they smoked their first cigarette after BMT. Relapsed smokers appeared more motivated to quit smoking at 1-year follow-up compared with when they were in BMT. Individuals making serious quit attempts after BMT were younger and had greater levels of physical activity, more confidence in quitting, and more favorable perceptions of the BMT ban than individuals not attempting to quit. Based on these findings, recommendations are discussed for improving abstinence rates after BMT.