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Role of Pain Catastrophizing in the Effects of Cognitive Behavioral Therapy for Chronic Pain in Different Subgroups: An Exploratory Secondary Data Analysis Using Finite Mixture Models. 疼痛灾难化在不同亚群慢性疼痛认知行为疗法效果中的作用:使用有限混合模型的探索性二次数据分析》。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-05 DOI: 10.1093/milmed/usae288
Dahee Wi, Jeffrey C Ransom, Diane M Flynn, Alana D Steffen, Chang Park, Larisa A Burke, Ardith Z Doorenbos

Introduction: Providing effective treatment for debilitating chronic pain is a challenge among many populations including military service members. Cognitive behavioral therapy for chronic pain (CBT-CP) is a leading psychological pain treatment. Pain catastrophizing is a pivotal mediator of pain-related outcomes. The purpose of this study was (1) to identify patient subgroups who differ in response to CBT-CP and (2) to explore the characteristics that define these patient subgroups. The overall goal was to obtain a better understanding of factors that may influence response to CBT-CP.

Materials and methods: This study was a secondary analysis of data from a clinical trial of 149 U.S. active duty service members with chronic pain. Participants underwent group-based CBT-CP for 6 weeks and completed pre- and posttreatment assessments. Finite mixture models were employed to identify subgroups in treatment response, with pain impact score as the primary outcome measure.

Results: We identified two classes of nearly equal size with distinct pain impact responses. One class reported improved pain impact scores following CBT-CP. This improvement was significantly associated with lower (better) baseline depression scores and greater improvement in posttreatment pain catastrophizing. In contrast, the other class reported slightly worse mean pain impact scores following CBT-CP treatment; this response was not related to baseline depression or change in pain catastrophizing.

Conclusions: Our findings demonstrate that a sizable proportion of individuals with chronic pain may not respond to group-based CBT-CP and may require a more individualized treatment approach.

导言:在包括军人在内的许多人群中,为使人衰弱的慢性疼痛提供有效治疗是一项挑战。慢性疼痛认知行为疗法(CBT-CP)是一种主要的疼痛心理治疗方法。疼痛灾难化是疼痛相关结果的关键中介因素。本研究的目的是:(1)识别对 CBT-CP 反应不同的患者亚群;(2)探索定义这些患者亚群的特征。总体目标是更好地了解可能影响 CBT-CP 反应的因素:本研究是对 149 名患有慢性疼痛的美国现役军人的临床试验数据进行的二次分析。参与者接受了为期 6 周的 CBT-CP 团体治疗,并完成了治疗前后的评估。我们采用有限混合物模型来识别治疗反应亚组,并以疼痛影响评分作为主要结果测量指标:结果:我们确定了两个规模几乎相等的组别,它们对疼痛的影响反应各不相同。其中一类患者在接受 CBT-CP 治疗后,疼痛影响评分有所改善。这种改善与较低的(较好的)基线抑郁评分和治疗后疼痛灾难化的较大改善明显相关。与此相反,另一类患者在接受 CBT-CP 治疗后,平均疼痛影响评分略有下降;这种反应与基线抑郁或疼痛灾难化的变化无关:我们的研究结果表明,有相当一部分慢性疼痛患者可能对以小组为基础的 CBT-CP 治疗无效,可能需要更个性化的治疗方法。
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引用次数: 0
The Exploration of the GWOT Combat Amputee's Experience With Longitudinal Care: A Qualitative Study. 探索 GWOT 战斗截肢者的纵向护理经验:定性研究。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-05 DOI: 10.1093/milmed/usad490
Alexander Pursel, Ryoma Nichols, Dan Evans, Kristina Lindquist

Introduction: Contemporary advances in combat medicine have allowed greater numbers of wounded service members to survive their injuries. An estimated 1,705 combat veterans sustained major lower or upper extremity amputations between 2001 and 2017 during the Global War on Terror. This study intends to answer the following question utilizing a qualitative study design: What were the common and abnormal experiences of the Global War on Terror combat amputees relative to their mechanism of injury, perception of injury, and systems of care utilized during their recovery and rehabilitation process?.

Methods: During the months of December 2022 and January 2023, individual semi-structured interviews were conducted with U.S. Marines that served in the Global War on Terror (total n = 10). Deductive and inductive approaches were employed to identify codes, themes, and meta-themes in the data.

Results: All participants deployed to Afghanistan between the years 2010 and 2014 and were assigned to the following military occupational specialties: Explosive Ordnance Disposal technicians (total n = 2); combat engineers (total n = 2); and infantrymen (total n = 6). Analysis of data collected from interviews highlighted these key observations: (1) Themes in the combat amputee experience include support, systems of care, and mindset and (2) the themes synergistically contribute to the meta-themes mental health and pain and vice versa. As all participants were subjected to a blast mechanism of injury, it is difficult to determine if this played a role in deviating rehabilitation and recovery processes. Perception of injury and how well participants adapted to their new lifestyle, meaning how optimistic they were, appeared to play a significant role in recovery. Participants had mixed feelings about the care they had received but generally spoke favorably of military hospitals and were frustrated with the Veteran Affairs, and there was no clear consensus on their relationship with civilian health care, though most participants chose to seek most of their care through the Veteran Affairs.

Conclusion: Based on the research question, this study found an intricate relationship between mental health, pain, and the experiences of the participants regarding their care and rehabilitation. However, the nature of qualitative research makes it impossible to determine generalizations that can be used to create meaningful change to address improving combat amputee veteran care. Further research into long-term health outcomes based on hypotheses not evaluated in existing literature would further improve the ability of health care providers to care for this unique patient population.

导言:当代作战医学的进步使更多的伤员得以幸存。在 2001 年至 2017 年的全球反恐战争期间,估计有 1 705 名退伍军人的下肢或上肢截肢。本研究旨在利用定性研究设计回答以下问题:全球反恐战争中截肢者在受伤机制、受伤感知以及恢复和康复过程中使用的护理系统方面有哪些常见和异常经历?在 2022 年 12 月和 2023 年 1 月期间,对参加过全球反恐战争的美国海军陆战队员(总人数 = 10 人)进行了个人半结构化访谈。采用演绎法和归纳法确定数据中的代码、主题和元主题:所有参与者均在 2010 年至 2014 年期间部署到阿富汗,并被分配到以下军事职业专业:爆炸物处理技术员(共 2 人)、战斗工兵(共 2 人)和步兵(共 6 人)。对访谈中收集到的数据进行分析后,我们得出了以下重要结论:(1) 战斗截肢者经历的主题包括支持、护理系统和心态;(2) 这些主题协同作用,共同促成了心理健康和疼痛这两个元主题,反之亦然。由于所有参与者都遭受了爆炸伤害,因此很难确定这是否在偏离的康复和恢复过程中起了作用。对受伤的看法以及参与者对新生活方式的适应程度,即他们的乐观程度,似乎对康复起着重要作用。虽然大多数参与者选择通过退伍军人事务部寻求大部分医疗服务,但他们与民间医疗服务的关系并没有明确的共识:根据研究问题,本研究发现心理健康、疼痛以及参与者在护理和康复方面的经历之间存在着错综复杂的关系。然而,由于定性研究的性质,我们无法确定可用于创造有意义的变革以改善战斗截肢退伍军人护理的概括性结论。根据现有文献中未评估的假设对长期健康结果进行进一步研究,将进一步提高医疗服务提供者护理这一特殊患者群体的能力。
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引用次数: 0
Refractory Osteomyelitis in a Military Service Member Resolved With Adjunctive Hyperbaric Oxygen Therapy. 辅助高压氧疗法治疗一名军人的难治性骨髓炎
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-05 DOI: 10.1093/milmed/usad505
Jeffrey Spiro, Michael Gedestad, Piotr Wisniewski

Refractory osteomyelitis is typically defined as a chronic infection that persists or recurs despite definitive surgical management and antibiotic therapy. Cases often involve complex wounds or fractures and can be challenging to treat, resulting in multiple courses of broad-spectrum antibiotic therapy and numerous surgeries over periods of months to years. Adjuncts to improve resolution of these complicated infections are sorely needed. Here, we describe the case of a 47-year-old active duty military member who sustained an open right ankle fracture during a skydiving accident that was subsequently complicated by refractory osteomyelitis. The patient failed more than three courses of combined medical and surgical management over a 9-month period before undergoing adjunctive hyperbaric oxygen therapy (HBOT), ultimately resulting in resolution of the infection. Adjunctive HBOT for treatment of conditions such as refractory osteomyelitis may be an underutilized resource in part because of a general paucity of high-quality data in the literature supporting its use, as well as a relative lack of availability of this resource. Nonetheless, the overall accumulating body of evidence indicates that the use of adjunctive HBOT in select patients with refractory osteomyelitis is safe and effective and further research may be warranted given its relevance and potential impact to military populations.

难治性骨髓炎通常是指在接受明确的手术治疗和抗生素治疗后仍持续存在或复发的慢性感染。病例往往涉及复杂的伤口或骨折,治疗起来极具挑战性,患者需要接受多个疗程的广谱抗生素治疗,并在数月至数年的时间里进行多次手术。我们亟需辅助药物来改善这些复杂感染的治疗效果。在这里,我们描述了一名 47 岁现役军人的病例,他在一次跳伞事故中右脚踝关节开放性骨折,随后并发了难治性骨髓炎。患者在接受辅助高压氧治疗(HBOT)9 个月后,经过三个多疗程的内外科综合治疗无效,最终导致感染缓解。用于治疗难治性骨髓炎等疾病的辅助高压氧疗法可能是一种未充分利用的资源,部分原因是支持其使用的高质量文献数据普遍较少,而且这种资源相对缺乏。尽管如此,不断积累的证据表明,对部分难治性骨髓炎患者辅助使用 HBOT 是安全有效的。
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引用次数: 0
Correction To: Spinal Pathology and Muscle Morphologies With Chronic Low Back Pain and Lower Limb Amputation. Correction To:脊柱病理和肌肉形态与慢性腰背痛和下肢截肢的关系
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-05 DOI: 10.1093/milmed/usae448
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引用次数: 0
World War I and the Origins of Blood Transfusion for the Trauma Patient. 第一次世界大战与创伤患者输血的起源。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-05 DOI: 10.1093/milmed/usad483
Joseph R Danford

The use of blood transfusion to treat hemorrhagic shock is a relatively new treatment with its origins in World War I. Due to the severity and nature of injuries seen, World War I provided the stimulus to propel medicine forward and accept whole blood transfusion for the trauma patient.

输血治疗失血性休克是一种相对较新的治疗方法,起源于第一次世界大战。由于创伤的严重程度和性质,第一次世界大战推动了医学的发展,并接受为创伤患者输注全血。
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引用次数: 0
Disguised Among the Sea: The Implications of Artificial Islands on Casualty Care in the Indo-Pacific. 伪装在海洋之中:人工岛对印度洋-太平洋地区伤员护理的影响》。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-05 DOI: 10.1093/milmed/usae002
Ryan M Leone, Mason H Remondelli, Jason B Brill, Jay B Baker

As reported in the 2022 Biden-Harris National Security Strategy, China is perceived as the primary U.S. competitor with the intent and means to become the world's greatest superpower. China's efforts, which are at odds with America's ambition to maintain its global influence, are complemented by ostensibly harmless "gray zone tactics," defined as coercive geopolitical, economic, military, and cyber activities below the use of kinetic military force. Such tactics may be utilized with seemingly innocuous intentions, but in reality, they can complicate U.S. combat casualty care in the event of an Indo-Pacific conflict. One tactic of particular impact is China's development of artificial islands throughout the South China Sea. By creating these islands, China is expanding its reach beyond its continental borders. These islands, alongside China's well-developed naval and missile capabilities, will cause disruptions to U.S. casualty care staging, medical resupply, and aeromedical evacuations. To mitigate those threats, the USA should implement a robust regional Combatant Command Trauma System, improve global health security cooperation with local partner nations, and implement irregular or guerilla trauma systems that meet medical needs in impromptu, clandestine settings. Operational recommendations based on these efforts could include pre-positioning tactical combat casualty care and damage control resuscitation supplies and developing with nearby host-nation evacuation platforms such as small boat operators. These solutions, among others, require years of training, relationship-building, and capability development to institute successfully. As a result, U.S. Military leaders should act now to incorporate these strategies into their irregular warfare, low-intensity conflict, and large-scale combat operation toolkits.

正如 2022 年拜登-哈里斯国家安全战略报告所述,中国被视为美国的主要竞争对手,其意图和手段都是成为世界上最大的超级大国。中国的努力与美国保持其全球影响力的野心相悖,而表面上无害的 "灰色地带战术 "则是对中国的补充。"灰色地带战术 "的定义是在动武之下的地缘政治、经济、军事和网络胁迫活动。使用此类战术的意图看似无害,但实际上,一旦发生印太冲突,它们会使美国的战斗伤亡护理工作复杂化。其中一个影响特别大的战术是中国在整个南中国海开发人工岛屿。通过建造这些岛屿,中国正在将其势力范围扩展到大陆边界之外。这些岛屿以及中国发达的海军和导弹能力将对美国的伤员救护中转、医疗补给和航空医疗后送造成干扰。为减轻这些威胁,美国应实施强大的地区作战司令部创伤系统,改善与当地伙伴国的全球卫生安全合作,并实施非正规或游击创伤系统,以满足临时、秘密环境下的医疗需求。在这些努力的基础上提出的行动建议可包括预先部署战术战斗伤员救护和损害控制复苏物资,并与附近的东道国后送平台(如小船运营商)合作开发。除其他外,这些解决方案需要多年的培训、关系建立和能力发展才能成功实施。因此,美国军事领导人应立即采取行动,将这些战略纳入其非正规战争、低强度冲突和大规模作战行动工具包。
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引用次数: 0
Ultrasound-Guided Lidocaine Injection as a Novel Predictor of Response to Botulinum for Patients With Myofascial Pain Syndrome: A Case Report. 超声引导下的利多卡因注射是预测肌筋膜疼痛综合征患者对肉毒素反应的新方法:病例报告。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-05 DOI: 10.1093/milmed/usae201
Olivia A Agee, Jeffery C Leggit

Botulinum injection is a well-known non-surgical intervention utilized in the management of myofascial pain syndrome (MPS). However, sparse evidence exists regarding the utility of ultrasound guidance of injectate or lidocaine as a predictive marker of patient response to botulinum toxin A (BTX-A). A 39-year-old male active duty service member demonstrated typical signs and symptoms of MPS. He reported a 10-year history of neck and back spasms that were triggered by exertion but also could occur spontaneously. Based on the characteristic regional motor-sensory defects, treatment options were discussed. With shared decision-making, the patient opted to try ultrasound-guided injection of lidocaine followed by xenomin brand BotoxA. Immediately following lidocaine injection, the patient reported complete relief of symptoms. Both injections were uncomplicated, and the patient reported great reduction in symptoms during the subsequent visit 2 months later. Relief of pain following ultrasound-guided injection of lidocaine may serve as an indicator of successful patient response to BTX-A in patients with MPS.

肉毒杆菌注射是治疗肌筋膜疼痛综合征(MPS)的一种众所周知的非手术干预方法。然而,关于注射剂或利多卡因的超声引导作为患者对 A 型肉毒毒素(BTX-A)反应的预测标志物的效用,目前证据还很稀少。一名 39 岁的男性现役军人表现出 MPS 的典型体征和症状。他报告说自己有 10 年的颈部和背部痉挛病史,这些痉挛会在用力时触发,但也可能自发发生。根据特征性区域运动感觉缺陷,讨论了治疗方案。在共同决策的情况下,患者选择尝试在超声引导下注射利多卡因,然后再注射xenomin品牌的肉毒杆菌毒素A。注射利多卡因后,患者立即报告症状完全缓解。两次注射都不复杂,患者在两个月后的复诊中表示症状大为减轻。超声引导下注射利多卡因后疼痛的缓解可作为 MPS 患者对 BTX-A 成功应答的指标。
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引用次数: 0
Exploring Combat Tourniquet Application Errors and Duration Among Skilled and Novice Medical Trainees. 探讨熟练和新手受训医护人员使用战斗止血带的错误和持续时间。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-05 DOI: 10.1093/milmed/usae277
Bradley A Drahos, Katelyn R Schwieters, Curtis M Craig, Jack E Norfleet, Mark V Mazzeo, Nichole L Morris

Introduction: The use of tourniquets in combat medicine continues to be a key focus as they have consistently been shown to combat one of the leading causes of preventable death on the battlefield, massive hemorrhage to extremities. The present study analyzed tourniquet application among combat medics (68W) and combat lifesavers (CLSs) in a training environment to determine whether trainees' performance is consistent among one another and whether performance can be associated with participant demographics such as experience or role.

Materials and methods: Study participants treated male and female patient simulators within a tactical field care phase, both of which experienced an amputated leg and required the application of a Combat Application Tourniquet (CAT). To assess tourniquet application variability and performance, a series of application subtasks and potential errors were measured via video coding of the scenarios by a team of 5 coders. Time to tourniquet application and tourniquet application duration were also coded to assess correlations between application duration and variability or performance.

Results: Results from analyzing tourniquet application subtasks and errors through a series of one-way ANOVA tests showed that application of the CAT first, hasty CAT application, and high tourniquet application were not predictive of participant role, time within the role, and self-reported tourniquet skill, confidence, or experience. Such demographic variables were also not predictive of successful tourniquet application as defined by the number of windlass rod rotations. Results from binomial logistic regressions showed that participant role and self-reported tourniquet skill and experience were predictors of tourniquet application duration.

Conclusion: The findings suggest that high variability in CAT application methodology and performance exists among CLS and combat medics, which is largely not predictable by various demographics such as role, experience within the designated role, and self-reported confidence, skill, or experience. The observed disconnect between training or experience and CAT application performance suggests substantial variability in the consistency of training for both CLS and 68W soldiers. These inconsistencies may stem from variability in instructor knowledge, teaching styles, or training materials or may be developed through informal methods such as experiences in the field or recommendations from colleagues and experts. These findings highlight a potential need to reassess CAT application training, particularly in regard to consistency and validation. Finally, it should be noted that the study's findings may be limited or fail to capture some study effects because of the sample size and wide range of reported experience among participants.

简介:止血带在战斗医疗中的使用仍然是一个重点,因为止血带一直被证明可以消除战场上可预防死亡的主要原因之一--四肢大出血。本研究分析了战斗医护人员(68W)和战斗救生员(CLS)在训练环境中使用止血带的情况,以确定学员之间的表现是否一致,以及表现是否与学员的人口统计学特征(如经验或角色)有关:研究人员在战术野战护理阶段对男性和女性患者模拟人进行了治疗,这两名模拟人都经历了截肢,需要使用战斗应用止血带(CAT)。为了评估止血带应用的可变性和性能,由 5 名编码员组成的小组通过对场景进行视频编码,对一系列应用子任务和潜在错误进行了测量。此外,还对使用止血带的时间和使用止血带的持续时间进行了编码,以评估使用止血带的持续时间与可变性或表现之间的相关性:结果:通过一系列单因子方差分析对使用止血带的子任务和错误进行分析的结果表明,首先使用 CAT、匆忙使用 CAT 和大量使用止血带与参与者的角色、在角色中的时间以及自我报告的止血带技能、信心或经验无关。这些人口统计学变量也无法预测成功使用止血带的情况(以卷扬杆旋转次数来定义)。二项逻辑回归结果表明,参与者的角色、自我报告的止血带技能和经验是预测使用止血带持续时间的因素:研究结果表明,CLS 和作战医护人员在使用止血带的方法和表现上存在很大差异,这在很大程度上无法通过各种人口统计学特征(如角色、指定角色的经验以及自我报告的信心、技能或经验)来预测。观察到的训练或经验与 CAT 应用表现之间的脱节表明,CLS 和 68W 士兵的训练一致性存在很大差异。这些不一致性可能源于教官知识、教学风格或培训材料的差异,也可能是通过非正式方法形成的,如实战经验或同事和专家的建议。这些发现凸显了重新评估 CAT 应用培训的潜在必要性,特别是在一致性和验证方面。最后,需要指出的是,由于样本量和参与者报告的经验范围较广,研究结果可能存在局限性或未能反映某些研究效果。
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引用次数: 0
An Analysis of the Association of Arrival Hemoglobin With Overtransfusion at 24 Hours in a Trauma Population. 分析创伤患者到达时的血红蛋白与 24 小时内输血过量的关系。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-05 DOI: 10.1093/milmed/usae293
Nicholas K Lahvic, Steven G Schauer, Sophie S Higgins, Jay A Johannigman, Kurt W Grathwohl

Background: Hemorrhage control and resuscitative concepts have evolved in recent years, leading to aggressive use of blood products in trauma patients. There is subsequently a potential risk for overtransfusion, adverse effects, and waste associated with unnecessary transfusion. Methods for conserving blood products are of particular importance in future large-scale combat operations where supply chains are likely to be strained. This study examined the association of emergency department (ED) arrival hemoglobin (HGB) with overtransfusion among survivors at 24 hours after major trauma at a military trauma center.

Materials and methods: We performed a retrospective cohort study of patients who had a "major trauma" activation and received any red blood cells. Overtransfusion was defined as a HGB level ≥11.0 g/dL at 24 hours (outcome variable). Multivariable logistic regression statistics were used to compare groups and adjust for confounders (injury severity score, arrival modified shock index, injury type, age, and gender). A receiver operating characteristic was constructed with overtransfusion at 24 hours as the outcome (binary) and arrival HGB (continuous) as the independent variable.

Results: A total of 382 patients met inclusion criteria. Overtransfusion occurred in 30.4% (n = 116) of patients, with mean ED HGB levels of 13.2 g/dL (12.9 to 13.6) versus 11.6 g/dL (11.3 to 11.8, P < .001). Receiver operating characteristic analysis showed that ED HGB was highly sensitive (0.931) for predicting 24-hour overtransfusion. In our multivariable logistic regression analysis, when adjusting for injury severity score, arrival modified shock index, injury type, age, and gender, we found that the ED HGB value had a per-unit odds ratio of 1.60 (95% CI, 1.38 to 1.86) for 24-hour overtransfusion. Hospital and intensive care unit length of stay, mechanical ventilator days, and mortality did not increase.

Conclusion: We found that the arrival HGB value was associated with overtransfusion among 24-hour survivors in a civilian trauma setting. Our findings will inform future prospective studies that investigate blood sparing clinical practice guidelines.

背景:近年来,出血控制和复苏理念不断发展,导致创伤患者积极使用血液制品。随之而来的是过度输血、不良反应以及不必要输血造成浪费的潜在风险。在未来的大规模作战行动中,保存血液制品的方法尤为重要,因为在这种情况下,供应链可能会出现紧张。本研究探讨了急诊科(ED)到达血红蛋白(HGB)与军事创伤中心重大创伤后 24 小时内幸存者过度输血的关系:我们对发生 "重大创伤 "并接受过任何红细胞的患者进行了一项回顾性队列研究。输血过量的定义是 24 小时内 HGB 水平≥11.0 g/dL(结果变量)。多变量逻辑回归统计用于比较各组,并调整混杂因素(损伤严重程度评分、到达时修正休克指数、损伤类型、年龄和性别)。以 24 小时内输血量过大为结果(二元),以到达时 HGB(连续)为自变量,构建了接收者操作特征:共有 382 名患者符合纳入标准。30.4%的患者(n = 116)发生了过度输血,平均 ED HGB 水平为 13.2 g/dL(12.9 至 13.6)对 11.6 g/dL(11.3 至 11.8,P 结论:我们发现,在平民创伤环境中,到达时的 HGB 值与 24 小时幸存者的过度输血有关。我们的研究结果将为今后调查血液稀释临床实践指南的前瞻性研究提供参考。
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引用次数: 0
Tips: Leading From the Middle of an Organization. 提示:从组织中层开始领导。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-05 DOI: 10.1093/milmed/usae444
Kristin Mangalindan, Elexis McBee

The vast majority of medical officers and physicians are called upon to lead from the middle of the organization. To be effective, one must understand the different approaches needed to exert positive influence up, down, and across the chain of command while delineating the overlapping relationship between leadership and management.

绝大多数医务官员和医生都被要求从组织的中层进行领导。要想有效地发挥领导作用,就必须了解在指挥链的上下左右施加积极影响所需的不同方法,同时划清领导与管理之间的重叠关系。
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Military Medicine
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