Robin Howard - Profile on Academia.edu (original) (raw)

Papers by Robin Howard

JAMA Network Open, 2019

IMPORTANCE The BCG vaccine is currently the only approved tuberculosis vaccine and is widely admi... more IMPORTANCE The BCG vaccine is currently the only approved tuberculosis vaccine and is widely administered worldwide, usually during infancy. Previous studies found increased rates of lymphoma and leukemia in BCG-vaccinated populations. OBJECTIVE To determine whether BCG vaccination was associated with cancer rates in a secondary analysis of a BCG vaccine trial. DESIGN, SETTING, AND PARTICIPANTS Retrospective review (60-year follow-up) of a clinical trial in which participants were assigned to the vaccine group by systematic stratification by school district, age, and sex, then randomized by alternation. The original study was conducted at 9 sites in 5 US states between December 1935 and December 1998. Participants were 2963 American Indian and Alaska Native schoolchildren younger than 20 years with no evidence of previous tuberculosis infection. Statistical analysis was conducted between August 2018 and July 2019. INTERVENTIONS Single intradermal injection of either BCG vaccine or saline placebo. MAIN OUTCOMES AND MEASURES The primary outcome was diagnosis of cancer after BCG vaccination. Data on participant interval health and risk factors, including smoking, tuberculosis infection, isoniazid use, and other basic demographic information, were also collected. RESULTS A total of 2963 participants, including 1540 in the BCG vaccine group and 1423 in the placebo group, remained after exclusions. Vaccination occurred at a median (interquartile range) age of 8 (5-11) years; 805 participants (52%) in the BCG group and 710 (50%) in the placebo group were female. At the time of follow-up, 97 participants (7%) in the placebo group and 106 participants (7%) in the BCG vaccine group could not be located; total mortality was 633 participants (44%) in the placebo group and 632 participants (41%) in the BCG group. The overall rate of cancer diagnosis was not significantly different in BCG vaccine vs placebo recipients (hazard ratio, 0.82; 95% CI, 0.66-1.02), including for lymphoma and leukemia. The rate of lung cancer was significantly lower in BCG vs placebo recipients (18.2 vs 45.4 cases per 100 000 person-years; hazard ratio, 0.38; 95% CI, 0.20-0.74; P = .005), controlling for sex, region, alcohol overuse, smoking, and tuberculosis. CONCLUSIONS AND RELEVANCE Childhood BCG vaccination was associated with a lower risk of lung cancer development in American Indian and Alaska Native populations. This finding has potentially important health implications given the high mortality rate associated with lung cancer and the availability of low-cost BCG vaccines.

Annals of Internal Medicine, 1994

JVlore than 12 million units of packed erythrocytes are transfused annually (1, 2). Because blood... more JVlore than 12 million units of packed erythrocytes are transfused annually (1, 2). Because blood products became widely used after World War II, hundreds of millions of units have been given (1-4). Major textbooks state that an increase of 10 g/L (1 g/dL) of hemoglobin is expected per unit of blood transfused (5-10). Authors (5, 8, 11) have implied that after transfusion, the rate at which the hemoglobin concentration equilibrates takes about 24 hours, but the supporting evidence is scant. The ability to rapidly determine the increase in hemoglobin levels after transfusion is important in managing outpatients and acutely ill patients. A standard time to measure the hemoglobin levels would save unnecessary blood draws. To clarify these issues, we did a prospective study of medical inpatients at a tertiary care medical center to determine the amount of increase in hemoglobin levels after transfusion and the rapidity of equilibration. Hemoglobin levels rather than hematocrit levels were chosen because they are directly measured, not calculated (12). Methods Participants Patients on the general medicine service of a 700-bed teaching hospital from January to June 1993 were eligible if they were to receive a 2-unit packed erythrocyte transfusion. Exclusion criteria included age younger than 18 years, recent active bleeding, and inability to give a written informed consent. Hemoglobin concentration was measured at 15 minutes, 1 hour, 2 hours, and 24 hours after the end of the transfusion.

The American Journal of Tropical Medicine and Hygiene, 2008

The rK39 test is a serologic assay for the rapid diagnosis of visceral leishmaniasis (VL). Serum ... more The rK39 test is a serologic assay for the rapid diagnosis of visceral leishmaniasis (VL). Serum from a North American cohort of 59 otherwise asymptomatic soldiers with cutaneous leishmaniasis (CL) was tested with the rK39 dipstick and ELISA assays, and 10.2% and 28.8% had positive results, respectively. CL is associated with a reactive rK39 assay result in some patients without clinical evidence of VL.

JAMA, 2004

Context The duration of protection from tuberculosis of BCG vaccines is not known. Objective To d... more Context The duration of protection from tuberculosis of BCG vaccines is not known. Objective To determine the long-term duration of protection of a BCG vaccine that was previously found to be efficacious. Design Retrospective record review using Indian Health Service records, tuberculosis registries, death certificates, and supplemental interviews with trial participants. Setting and Participants Follow-up for the period 1948-1998 among American Indians and Alaska Natives who participated in a placebo-controlled BCG vaccine trial during 1935-1938 and who were still at risk of developing tuberculosis. Data from 1483 participants in the BCG vaccine group and 1309 in the placebo group were analyzed. Main Outcome Measures Efficacy of BCG vaccine, calculated for each 10-year interval using a Cox regression model with time-dependent variables based on tuberculosis events occurring after December 31, 1947 (end of prospective case finding). Results The overall incidence of tuberculosis was 66 and 138 cases per 100000 personyears in the BCG vaccine and placebo groups, respectively, for an estimate of vaccine efficacy of 52% (95% confidence interval, 27%-69%). Adjustments for age at vaccination, tribe, subsequent BCG vaccination, chronic medical illness, isoniazid use, and bacille Calmette-Gué rin strain did not substantially affect vaccine efficacy. There was slight but not statistically significant waning of the efficacy of BCG vaccination over time, greater among men than women. Conclusion In this trial, BCG vaccine efficacy persisted for 50 to 60 years, suggesting that a single dose of an effective BCG vaccine can have a long duration of protection.

PloS one, 2015

Although myocarditis/pericarditis (MP) has been identified as an adverse event following smallpox... more Although myocarditis/pericarditis (MP) has been identified as an adverse event following smallpox vaccine (SPX), the prospective incidence of this reaction and new onset cardiac symptoms, including possible subclinical injury, has not been prospectively defined. The study's primary objective was to determine the prospective incidence of new onset cardiac symptoms, clinical and possible subclinical MP in temporal association with immunization. New onset cardiac symptoms, clinical MP and cardiac specific troponin T (cTnT) elevations following SPX (above individual baseline values) were measured in a multi-center prospective, active surveillance cohort study of healthy subjects receiving either smallpox vaccine or trivalent influenza vaccine (TIV). New onset chest pain, dyspnea, and/or palpitations occurred in 10.6% of SPX-vaccinees and 2.6% of TIV-vaccinees within 30 days of immunization (relative risk (RR) 4.0, 95% CI: 1.7-9.3). Among the 1081 SPX-vaccinees with complete follow-u...

$Research paper thumbnail of Goblet cell response after photorefractive keratectomy and laser in situ keratomileusis$

Journal of cataract and refractive surgery, 2016

To determine whether patients without dry eye preoperatively have an altered conjunctival goblet ... more To determine whether patients without dry eye preoperatively have an altered conjunctival goblet cell density and mucin secretion postoperatively and to explore what factors affect changes in goblet cell density and mucin secretion. The former Walter Reed Army Medical Center, Washington, DC, USA. Prospective nonrandomized clinical study. Impression cytology was used to determine conjunctival goblet cell density before and 1 week, 1 month, and 3 months after photorefractive keratectomy (PRK) or laser in situ keratomileusis (LASIK). The McMonnies questionnaire, Schirmer test, tear breakup time, corneal sensitivity, rose bengal staining, and computerized videokeratoscopy were also performed to assess tear-film and ocular-surface health. The ratio of goblet cell to total cells changed postoperatively from baseline in both groups (P < .001). The most significant change was a median 29% decrease 1 month postoperatively. However, there were no significant differences between groups over...

Surgery, 2010

Background. The Dysphonia Severity Index (DSI) is an objective multiparametric acoustic calculati... more Background. The Dysphonia Severity Index (DSI) is an objective multiparametric acoustic calculation of vocal function; however, its changes after thyroidectomy have not yet been described. Methods. Patient-reported symptoms, as well as auditory perceptual, acoustic, and videolaryngostroboscopic (VLS) data, were collected prospectively before and after thyroidectomy. Voice outcomes (normal versus negative voice outcome [NVO]) at 6 months after thyroidectomy were based on a combination of voice symptoms and objective findings. The DSI was assessed over the perioperative course, and differences were determined with Wilcoxon signed rank tests. The DSI was compared between study groups (normal versus NVO) using t tests, analyses of variance (ANOVAs), or rank sum tests as appropriate. The predictive value of DSI for long-term voice dysfunction was assessed by an area under the receiver operating characteristics curve analysis. Correlations between DSI and Consensus Auditory Perceptual Ratings of Voice (CAPE-V) and the patient reported Voice Handicap Index (VHI) were determined with Pearson's correlation coefficients. Results. In all, 62 patients were evaluated before, 1-4 weeks after, and 6 months after thyroidectomy. Eight (13%) patients were diagnosed with NVO at 6 months. The DSI was different postoperatively between NVO and normal voice (P = .005, repeated measures [RM]-ANOVA), with the NVO group demonstrating a lesser DSI value and greater change from pre-operative assessment at the first postoperative visit when compared with the normal group (P < .006 each). The DSI differed significantly for pre-operative and 6-month assessments according to sex, smoking status, and age. Short-term postoperative DSI (area under the curve [AUC] = 0.795) and DSI change from baseline to 1-4 weeks (AUC = 0.835) were highly predictive of 6-month NVO. DSI measurements over the post-thyroidectomy course were correlated poorly to moderately (maximum r =-0.62) with CAPE-V and VHI assessments for the same time points. Conclusion. The DSI is decreased in the early post-thyroidectomy period, mostly in persons who were ultimately found to have a long-term NVO. Early postoperative DSI and change of DSI from baseline at 1-4 weeks postoperation predict long-term post-thyroidectomy voice dysfunction. The modest correlations between the DSI and other vocal assessments point to the utility of DSI as an independent predictor of voice dysfunction after thyroidectomy, which can select patients who may benefit from voice therapy.

Prostate Cancer and Prostatic Diseases, 2002

The objective of this work was to determine the effect of androgen deprivation therapy (ADT) on r... more The objective of this work was to determine the effect of androgen deprivation therapy (ADT) on rates of bone mineral density (BMD) loss in men with prostate cancer. It was a prospective study comparing men receiving ADT to age matched controls for 2 y. Subjects received a history, physical exam, bone mineral density measurement, and laboratory evaluation every 6 months. Thirty-nine subjects receiving continuous ADT for prostate cancer (subjects) were compared to 39 agematched controls not receiving ADT (controls). Twenty-three subjects and 30 controls completed the study through 24 months. Men in the ADT group demonstrated greater rates of bone mineral density loss than men in the control group at every site except the lumbar spine. Twenty-four month per cent of bone mineral density loss is presented as mean AE standard error (s.e.). At the distal forearm, the ADT group value was 7 9.4% AE 1.0% and 7 4.4% AE 0.3% for controls (P < 0.0005). The ADT group femoral neck values were 7 1.9% AE 0.7% and 0.6% AE 0.5% in the control group (P ¼ 0.0016). The ADT group total hip value was 7 1.5% AE 1.0% and 0.8% AE 0.5% in the control group (P ¼ 0.0018). The ADT group trochanter value was 7 2.0% AE 1.3% and 7 0.1% AE 0.5% in the control group (P ¼ 0.0019). The ADT group lumbar spine value was 7 0.2% AE 0.8 % and 1.1% AE 0.6% in the control group (P ¼ 0.079). Our data demonstrate greater rates of bone mineral density loss in men receiving androgen deprivation therapy for prostate cancer.

Pain Medicine, 2010

Background. Paravertebral block (PVB) is an effective alternative to general anesthesia for breas... more Background. Paravertebral block (PVB) is an effective alternative to general anesthesia for breast cancer surgery. Continuous paravertebral block (CPVB) anesthesia may extend postoperative analgesia at home and improve quality of early postoperative recovery of breast cancer patients. Purpose. This double-blinded randomized trial was conducted to compare degree of pain, nausea, mood, level of symptom distress, and time to return to normal daily activity between PVB and PVB + CPVB in patients undergoing outpatient breast cancer surgery. Patients and Methods. Between July 2003 and April 2008 we randomly assigned 94 (73 evaluable) patients in a 1:1:1 ratio with early breast cancer to single injection PVB followed by CPVB infusion of 0.1% or 0.2% ropivacaine vs placebo (saline) for 48 hours postoperatively for unilateral breast cancer surgery without reconstruction. The primary study endpoint was the degree of pain, nausea, mood state, level of symptom distress, and recovery time. Results. Of the 468 patients assessed for eligibility, 94 consented and 21 with incomplete data or follow-up were excluded, leaving 73 subjects for analysis. There was no clinically significant difference in degree of postoperative pain, nausea, mood state, level of symptom distress, or return to normal activity among the three study groups. Conclusion. The current study does not support the routine use of continuous paravertebral catheter anesthesia in patients undergoing operative treatment for breast cancer.

Journal of the American College of Surgeons, 2014

BACKGROUND: Voice alteration remains a significant complication of thyroid surgery. We present a ... more BACKGROUND: Voice alteration remains a significant complication of thyroid surgery. We present a comparison of voice outcomes between total thyroidectomy (TT), partial thyroidectomy (PT), and non-neck (NN) surgery using a multifactorial voice-outcomes classification tool. STUDY DESIGN: Patients with normal voice (n ¼ 112) were enrolled between July 2004 and March 2009. The patients underwent TT (n ¼ 54), PT (n ¼ 35), or NN (n ¼ 23) surgery under general endotracheal anesthesia as part of a prospective observational study involving serial multimodality voice evaluation preoperatively, and at 2 weeks, 3 months, and 6 months postoperatively. Patients with adverse voice outcomes were grouped into the negative voice outcomes (NegVO) category, including patients with objective (abnormality on videolaryngostroboscopy and substantial voice dysfunction) and subjective (normal videolaryngostroboscopy but with notable voice impairment) NegVO. Voice outcomes were compared among study groups. RESULTS: Negative voice outcomes occurred in 46% (95% CI, 34e59%) and 14% (95% CI, 6e30%) of TT and PT groups, respectively. No NegVOs were observed after NN surgery. Early NegVOs were more common in the TT group than in the NN or PT groups (p < 0.001). Most voice disturbances resolved by 6 months (TT 84%; PT 92%) with no difference in NegVO among all groups (p ¼ 0.23). Black race and significant changes in certain voice outcomes measures at the 2-week follow-up visit were identified as predictors of late (3 to 6 months) NegVO. CONCLUSIONS: This comprehensive voice outcomes study revealed that the extent of thyroidectomy impacts voice outcomes in the early postoperative period, and identified risk factors for late NegVO in post-thyroidectomy patients who should be considered for early voice rehabilitation referral.

Journal of Neurosurgery, 2011

Object There are no published long-term data for patients with penetrating head injury treated wi... more Object There are no published long-term data for patients with penetrating head injury treated with bilateral supratentorial craniectomy, or supra- and infratentorial craniectomy. The authors report their experience with 33 patients treated with bilateral or bicompartmental craniectomy from the ongoing conflicts in Iraq and Afghanistan. Methods An exploratory analysis of Glasgow Outcome Scale (GOS) scores at 6 months in 33 patients was performed. Follow-up lasting a median of more than 2 years was performed in 30 (91%) of these patients. The association of GOS score with categorical variables was explored using the Wilcoxon rank-sum test or Kruskal-Wallis analysis of variance. The Spearman correlation coefficient was used for ordinal/continuous data. To provide a clinically meaningful format to present GOS scores with categorical variables, patients with GOS scores of 1–3 were categorized as having a poor outcome and those with scores of 4 and 5 as having a good outcome. This analys...

Journal of Diabetes Science and Technology, 2011

Abbreviations: (BDR) background diabetic retinopathy, (CI) confidence interval, (DME) diabetic ma... more Abbreviations: (BDR) background diabetic retinopathy, (CI) confidence interval, (DME) diabetic macular edema, (HbA1c) hemoglobin A1c, (LDL) low-density lipoprotein, (OCT) optical coherence tomography, (RM ANOVA) repeated measures analysis of variance, (SD) standard deviation, (TZD) thiazolidinedione, (WRAMC) Walter Reed Army Medical Center

The Journal of Clinical Endocrinology & Metabolism, 2012

Context: Decisions regarding initial therapy and subsequent surveillance in patients with differe... more Context: Decisions regarding initial therapy and subsequent surveillance in patients with differentiated thyroid cancer (DTC) depend upon an accurate assessment of the risk of persistent or recurrent disease. Objective: The objective of this study was to examine the predictive value of a single measurement of serum thyroglobulin (Tg) just before radioiodine remnant ablation (preablation Tg) on subsequent disease-free status. Data Sources: Sources included MEDLINE and BIOSYS databases between January 1996 and June 2011 as well as data from the author's tertiary-care medical center. Study Selection: Included studies reported preablation Tg values and the outcome of initial therapy at surveillance testing or during the course of long-term follow-up. Data Extraction: TwoinvestigatorsindependentlyextracteddataandratedstudyqualityusingtheQuality Assessment of Studies of Diagnostic Accuracy included in Systematic Reviews-2 (QUADAS-2) tool. Data Synthesis: Fifteen studies involving 3947 patients with DTC were included. Seventy percent of patients had preablation Tg values lower than the threshold value being examined. The negative predictive value (NPV) of a preablation Tg below threshold was 94.2 (95% confidence interval ϭ 92.8-95.3) for an absence of biochemical or structural evidence of disease at initial surveillance or subsequent follow-up. The summary receiver operator characteristic curve based on a bivariate mixed-effects binomial regression model showed a clustering of studies using a preablation Tg below 10 ng/ml near the summary point of optimal test sensitivity and specificity. Conclusion: Preablation Tg testing is a readily available and inexpensive tool with a high NPV for future disease-free status. A low preablation Tg should be considered a favorable risk factor in patients with DTC. Further study is required to determine whether a low preablation Tg may be used to select patients for whom radioiodine remnant ablation can be avoided.

$Research paper thumbnail of Oral gabapentin for photorefractive keratectomy pain$

Journal of Cataract and Refractive Surgery, 2011

To compare the efficacy of oral gabapentin versus placebo for the control of severe pain after ph... more To compare the efficacy of oral gabapentin versus placebo for the control of severe pain after photorefractive keratectomy (PRK).

Fertility and Sterility, 2013

Objective: To evaluate the correlation of preretrieval quantitative serum hCG level with oocyte m... more Objective: To evaluate the correlation of preretrieval quantitative serum hCG level with oocyte maturity. Design: Retrospective cohort study. Setting: Military assisted reproductive technology (ART) program. Patient(s): Fresh autologous ART cycles. Intervention(s): Serum hCG level the day before oocyte retrieval. Main Outcome Measure(s): Linear regression was used to correlate serum hCG levels and oocyte maturity rates. Normal oocyte maturity was defined as R75% and the Wilcoxon rank sum test was used to compare serum hCG levels in patients with normal and low oocyte maturity. Threshold analysis was performed to determine hCG levels that could predict oocyte maturity. Result(s): A total of 468 ART cycles were analyzed. Serum hCG level was not correlated with hCG dose; however, it was negatively correlated with body mass index (BMI). Serum hCG levels did not differ between patients with oocyte maturity of <75% and R75%. Serum hCG levels did not correlate with oocyte maturity rates. Receiver operator characteristic and less than efficiency curves failed to demonstrate thresholds at which hCG could predict oocyte maturity. Conclusion(s): Serum hCG levels were not correlated with oocyte maturity. Although a positive hCG was reassuring that mature oocytes would be retrieved for most patients, the specific value was not helpful. (Fertil Steril Ò 2013;99:1610-4. Ó2013 by American Society for Reproductive Medicine.

$Research paper thumbnail of The Effect of Fourth-Generation Fluoroquinolones Gatifloxacin and Moxifloxacin on Epithelial Healing Following Photorefractive Keratectomy$

American Journal of Ophthalmology, 2005

Annals of Surgery, 2007

Background: The principal role of sentinel lymph node (SLN) sampling and ultrastaging in colon ca... more Background: The principal role of sentinel lymph node (SLN) sampling and ultrastaging in colon cancer is enhanced staging accuracy. The utility of this technique for patients with colon cancer remains controversial. Purpose: This multicenter randomized trial was conducted to determine if focused assessment of the SLN with step sectioning and immunohistochemistry (IHC) enhances the ability to stage the regional nodal basin over conventional histopathology in patients with resectable colon cancer. Patients and Methods: Between August 2002 and April 2006 we randomly assigned 161 patients with stage I-III colon cancer to standard histopathologic evaluation or SLN mapping (ex vivo, subserosal, peritumoral, 1% isosulfan blue dye) and ultrastaging with pan-cytokeratin IHC in conjunction with standard histopathology. SLN-positive disease was defined as individual tumor cells or cell aggregates identified by hematoxylin and eosin (H&E) and/or IHC. Primary end point was the rate of nodal upstaging. Results: Significant nodal upstaging was identified with SLN ultrastaging (Control vs. SLN: 38.7% vs. 57.3%, P ϭ 0.019). When SLNs with cell aggregates Յ0.2 mm in size were excluded, no statistically significant difference in node-positive rate was apparent between the control and SLN arms (38.7% vs. 39.0%, P ϭ 0.97). However, a 10.7% (6/56) nodal upstaging was identified by evaluation of H&E stained step sections of SLNs among study arm patients who would have otherwise been staged node-negative (N0) by conventional pathologic assessment alone. Conclusion: SLN mapping, step sectioning, and immunohistochemistry (IHC) identifies small volume nodal disease and improves staging in patients with resectable colon cancer. A prospective trial is ongoing to determine the clinical significance of colon cancer micrometastasis in sentinel lymph nodes.

PLoS Neglected Tropical Diseases, 2010

Background: Cutaneous Leishmania major has affected many travelers including military personnel i... more Background: Cutaneous Leishmania major has affected many travelers including military personnel in Iraq and Afghanistan. Optimal treatment for this localized infection has not been defined, but interestingly the parasite is thermosensitive. Methodology/Principal Findings: Participants with parasitologically confirmed L. major infection were randomized to receive intravenous sodium stibogluconate (SSG) 20mg/kg/day for ten doses or localized ThermoMed (TM) device heat treatment (applied at 50uC for 30 seconds) in one session. Those with facial lesions, infection with other species of Leishmania, or more than 20 lesions were excluded. Primary outcome was complete re-epithelialization or visual healing at two months without relapse over 12 months. Fifty-four/56 enrolled participants received intervention, 27 SSG and 27 TM. In an intent to treat analysis the per subject efficacy at two months with 12 months follow-up was 54% SSG and 48% TM (p = 0.78), and the per lesion efficacy was 59% SSG and 73% TM (p = 0.053). Reversible abdominal pain/pancreatitis, arthralgias, myalgias, headache, fatigue, mild cytopenias, and elevated transaminases were more commonly present in the SSG treated participants, whereas blistering, oozing, and erythema were more common in the TM arm. Conclusions/Significance: Skin lesions due to L. major treated with heat delivered by the ThermoMed device healed at a similar rate and with less associated systemic toxicity than lesions treated with intravenous SSG.

Military medicine, 2017

To compare the circumference measurement (CM) body composition method and 8-point segmental bioel... more To compare the circumference measurement (CM) body composition method and 8-point segmental bioelectrical impedance analysis (DSM-BIA) to dual energy X-ray absorptiometry (DEXA) in military members. The objective was to compare three body composition methods. Our hypothesis was the CM is as accurate as DSM-BIA and DEXA in assessing body fat percentage (%BF). Cross sectional, observational study. Healthy active duty military males and nonpregnant females. Seventy-six participants (mean age 35.0 ± 9.7 years, mean body mass index 28.9 ± 4.7 kg/m(2)), outpatient clinic setting was used. Agreement between DEXA and the other two methods was examined using an intraclass correlation coefficient (ICC) using the two-way random method with absolute agreement. Repeated measures analysis of covariance was used to examine the effect of gender and waist circumference on differences in %BF. The agreement of DSM-BIA with DEXA for females was ICC = 0.93 (95% confidence interval [CI]: 0.87-0.96) and f...

Pain medicine (Malden, Mass.), Jan 10, 2016

Objective. Patients with complaints of orofacial pain (OFP) often have other body pain, yet many ... more Objective. Patients with complaints of orofacial pain (OFP) often have other body pain, yet many do not report these to their providers. Uncontrolled pain at any location may impact the successful management of an OFP complaint. The objective of this study was to determine the number of pain regions throughout the body, and the underreporting of pain, in patients who presented to a tertiary military OFP clinic. Design. A retrospective chart review was conducted on 423 consecutive new patients. Patients were given three assessment opportunities to report their pain on a whole-body pain map: 1) prior to evaluation (Pt1), 2) following an explanatory statement by their provider on the relationship between pain and prognosis (Pt2), and 3) during directed pain inquiry of specific body regions (Pro). The pain map was divided into nine anatomical regions that were assessed for the presence of pain after Pt1, Pt2, and Pro. Results. Initially, 60.5% of patients did not report all pain locations (Pt1). Following the explanatory statement (Pt2), 30.5% still did not report all pain. Following the completion of all assessment methods, the most commonly reported number of pain regions was five (17.0%), and 91.5% of patients reported multiple pain regions. Conclusions. Most patients had multiple pain complaints outside the chief complaint, yet the majority did not report these until multiple forms of assessment were utilized. These data encourage the use of a pain map, a verbal pain explanation, and directed pain questioning to more accurately capture pain location and facilitate multidisciplinary care.