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Impact of the COVID-19 Pandemic on the Delivery of Congenital Syphilis Care in the Military Health System. COVID-19 大流行对军队卫生系统提供先天性梅毒治疗的影响。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae392
Jennifer Teng, Sarah Prabhakar, Michael Rajnik, Apryl Susi, Elizabeth Hisle-Gorman, Cade M Nylund, Jill Brown

Introduction: Congenital syphilis (CS) case rates have increased significantly in the United States over the past 20 years, accelerating during the COVID-19 pandemic. Increasing rates may relate to access to care but have not been evaluated in a fully-insured population, such as the Military Health System.

Materials and methods: We performed a repeated monthly cross-sectional study of CS cases and total encounters (care rates) using the queried Military Health System database. We defined CS by International Classifications of Diseases 10th Revision Clinical Modification diagnosis codes in beneficiaries  ≤ 2 years old. We evaluated pre-COVID-19 (March 2018 to February 2020), pandemic year 1 (March 2020 to February 2021), and pandemic year 2 (March 2021 to February 2022) periods. We performed change-point and trend analyses and Poisson regression to evaluate differences by sponsor rank, TRICARE region, and pandemic period. The Uniformed Services University Institutional Review Board approved the study.

Results: A total of 69 unique CS cases were identified with a median monthly care rate of 0.90/100,000 eligible beneficiaries. The CS care rate showed a 5.8% average monthly percent increase throughout the study period (P < .001) and a 20.8% average monthly percent increase in year 2 (P < .05). Compared to the pre-pandemic era, CS care rates increased in pandemic years 1 and 2 (adjusted rate ratio [aRR] 2.76 [95% CI: 1.95-3.92], 5.52 [95% CI: 4.05-7.53], respectively). Congenital syphilis care rates were lower in children of senior enlisted sponsors versus junior enlisted, aRR 0.24 (95% CI: 0.17-0.33), and higher in the West and North regions versus South, aRR 2.45 (95% CI: 1.71-3.53) and aRR 2.88 (95% CI: 2.01-4.12), respectively.

Conclusions: Congenital syphilis care rates were substantially lower in this insured group than national rates but increased significantly during the COVID-19 pandemic. Higher care rates were seen in children of military members of lower rank. Regional trends differed from national data. These findings suggest that, even in a fully-insured population, income and regional differences impact CS, and the COVID-19 pandemic may have exacerbated differences in care delivery.

导言:在过去20年中,美国先天性梅毒(CS)病例率大幅上升,在COVID-19大流行期间上升速度更快。发病率的上升可能与获得医疗服务有关,但尚未在军队卫生系统等全额保险人群中进行过评估:我们使用查询过的军事卫生系统数据库对 CS 病例和总就诊人次(护理率)进行了每月重复横截面研究。我们根据国际疾病分类第 10 次修订版临床修正诊断代码对 2 岁以下受益人的 CS 进行了定义。我们对 COVID-19 前(2018 年 3 月至 2020 年 2 月)、大流行第一年(2020 年 3 月至 2021 年 2 月)和大流行第二年(2021 年 3 月至 2022 年 2 月)进行了评估。我们进行了变化点和趋势分析以及泊松回归,以评估赞助商等级、TRICARE 地区和大流行期间的差异。统一服务大学机构审查委员会批准了这项研究:结果:共发现了 69 个独特的 CS 病例,每月护理率的中位数为 0.90/100,000,符合条件的受益人为 0.90/100,000。在整个研究期间,先天性梅毒护理率平均每月增长 5.8%(P 结论:先天性梅毒护理率在整个研究期间平均每月增长 5.8%:该投保群体的先天性梅毒护理率大大低于全国的护理率,但在 COVID-19 大流行期间显著增加。军衔较低的军人子女的护理率较高。地区趋势与全国数据不同。这些研究结果表明,即使在全额参保的人群中,收入和地区差异也会对 CS 产生影响,而 COVID-19 大流行可能加剧了护理提供方面的差异。
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引用次数: 0
Solid Metal Chemical and Thermal Injury Management. 固体金属化学和热损伤管理。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae406
Phillip M Kemp Bohan, Stacy L Coulthard, Jay A Yelon, Gary A Bass, Mary A Decoteau, Jeremy W Cannon, Lewis J Kaplan

Introduction: Solid metals may create a variety of injuries. White phosphorous (WP) is a metal that causes both caustic and thermal injuries. Because of its broad use in munitions and smoke screens during conflicts and wars, all military clinicians should be competent at WP injury identification and acute therapy, as well as long-term consequence recognition.

Materials and methods: English-language manuscripts addressing WP injuries were curated from PubMed and Medline from inception to January 31, 2024. Data regarding WP injury identification, management, and sequelae were abstracted to construct a Scale for the Assessment of Narrative Review Articles guideline-consistent narrative review.

Results: White phosphorous appears to be ubiquitous in military conflicts. White phosphorous creates a characteristic wound appearance accompanied by smoke, a garlic aroma, and spontaneous combustion on contact with air. Decontamination and burning prevention or cessation are key and may rely on aqueous irrigation and submersion or immersion in substances that prevent air contact. Topical cooling is a key aspect of preventing spontaneous ignition as well. Disposal of all contaminated clothing and gear is essential to prevent additional injury, especially to rescuers. Long-term sequelae relate to phosphorous absorption and may lead to death. Chronic or repeated exposure may induce jaw osteonecrosis. Tactical Combat Casualty Care recommendations do not currently address WP injury management.

Conclusions: Education and management regarding WP acute injury and late sequelae is essential for acute battlefield and definitive facility care. Resource-replete and resource-limited settings may use related approaches for acute management and ignition prevention. Current burn wound management recommendations should incorporate specific WP management principles and actions for military clinicians at every level of skill and environment.

介绍:固体金属可造成各种伤害。白磷(WP)是一种可造成腐蚀性和热损伤的金属。由于白磷在冲突和战争期间被广泛用于弹药和烟幕中,所有军事临床医生都应具备识别白磷伤害、急性治疗和长期后果识别的能力:从 PubMed 和 Medline 上搜集了从开始到 2024 年 1 月 31 日有关可湿性粉剂损伤的英文稿件。对有关可湿性粉剂损伤的识别、管理和后遗症的数据进行了摘录,以构建符合指南的叙述性综述文章评估量表:白磷似乎在军事冲突中无处不在。结果:白磷在军事冲突中似乎无处不在,白磷会在伤口处产生特征性外观,并伴有烟雾、大蒜香味以及与空气接触后自燃。去污和防止或停止燃烧是关键所在,可能需要水冲洗、浸泡或浸入防止与空气接触的物质中。局部冷却也是防止自燃的一个关键方面。处理所有受污染的衣物和装备对防止造成额外伤害至关重要,尤其是对救援人员。长期后遗症与磷的吸收有关,可能导致死亡。长期或反复接触可能会诱发下颚骨坏死。战术战斗伤员救护建议目前并未涉及可湿性粉剂伤害管理:有关可湿性粉剂急性损伤和后期后遗症的教育和管理对于急性战场和最终设施护理至关重要。资源匮乏和资源有限的环境可采用相关方法进行急性处理和预防点火。当前的烧伤创面管理建议应包括针对不同技能水平和环境的军事临床医生的特定 WP 管理原则和行动。
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引用次数: 0
The Impact of Time to Anterior Cruciate Ligament Reconstruction on Return to Duty Among Active Duty Military Personnel. 前十字韧带重建的时间对现役军人重返岗位的影响》(The Impact of Time to Anterior Cruciate Ligament Reconstruction on Return to Duty Among Active Duty Military Personnel)。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae419
Brandon A Burt, Preston E Lopez, Marie L Chardon, Joshua Sakai, John T Evans
<p><strong>Introduction: </strong>After an anterior cruciate ligament (ACL) injury, service members often undergo ACL reconstruction (ACLR) to restore knee stability, which is critical for performing physically demanding and unconventional military-specific tasks. Despite advancements in surgical techniques and rehabilitation protocols, a large portion of service members will not fully return to duty (RTD) post-ACLR and will receive a permanent profile restriction (PP) or undergo a medical evaluation board (MEB). The timing of ACLR is a modifiable factor that can potentially impact RTD and remains underexplored in this population. This study aimed to assess the relationship between the timing of ACLR and its impact on RTD and meniscal procedures performed at index ACLR.</p><p><strong>Methods: </strong>This retrospective observational study was conducted among active duty military personnel who underwent primary ACLR at Madigan Army Medical Center between October 1, 2016, and December 31, 2022. The primary outcome was the number of RTD, PP, or MEB outcomes. Secondary outcomes included the incidence and type of meniscal procedure performed at index ACLR. Kruskal-Wallis analyses were employed to assess the relationships between time to ACLR and RTD, as well as the incidence and type of meniscal procedure performed. After separating time to ACLR into four distinct time-based groups (0-3 months, 3-6 months, 6-12 months, and >12 months), a chi-squared test with post hoc analysis via Dunn's test with Bonferroni correction was conducted to identify a time interval from injury to ACLR that impacted RTD.</p><p><strong>Results: </strong>Initial analysis to assess the relationship between time to ACLR and outcome (RTD, PP, or MEB) were significant (P = .02). Subsequent analyses performed between 4 distinct time-based groups (0-3 months, 3-6 months, 6-12 months, and >12 months) were also significant (P = .03). Pairwise comparisons revealed an 80% rate of RTD in the 0-3 month group compared to a 53% RTD rate in 3-6 month group (P = .006). However, comparisons between the 3-6 month and 6-12 month group (P = .68) and between the 6-12 month and greater than 12 month groups were not significant (P = .80).Additionally, time to ACLR significantly differed between service members who did not undergo any concurrent meniscal procedure to those who had a meniscal debridement (P = .002), and to those who underwent meniscal repair (P = .02). There was no significant difference in time to ACLR between those who underwent debridement versus repair (P = .22). Patients without any meniscal procedure had an average surgery time of 175 days, compared to 240 days for those undergoing meniscal repair and 295 days for those with meniscal debridement.</p><p><strong>Conclusion: </strong>The findings from this novel study suggest that ACLR within 3 months after injury can improve the likelihood of RTD without limitations. The timing of ACLR can also impact the incidence and type of m
导言:前交叉韧带(ACL)受伤后,军人通常会接受前交叉韧带重建术(ACLR)以恢复膝关节的稳定性,这对于执行体力要求高且非常规的军事任务至关重要。尽管手术技术和康复方案不断进步,但仍有很大一部分军人在 ACLR 术后无法完全重返岗位(RTD),而会受到永久性外形限制(PP)或接受医疗评估委员会(MEB)的检查。前交叉韧带重建的时机是一个可能影响 RTD 的可调整因素,但在这一人群中仍未得到充分探索。本研究旨在评估前交叉韧带置换术的时机及其对 RTD 的影响与在前交叉韧带置换术中进行的半月板手术之间的关系:这项回顾性观察研究的对象是 2016 年 10 月 1 日至 2022 年 12 月 31 日期间在马迪根陆军医疗中心接受初级 ACLR 的现役军人。主要结果是RTD、PP或MEB结果的数量。次要结果包括指数 ACLR 时进行的半月板手术的发生率和类型。Kruskal-Wallis 分析用于评估前交叉韧带重建时间与 RTD 之间的关系,以及半月板手术的发生率和类型。在将前交叉韧带重建时间分为四个不同的时间组(0-3个月、3-6个月、6-12个月和>12个月)后,通过Dunn's检验和Bonferroni校正进行了chi-squared检验和事后分析,以确定从受伤到前交叉韧带重建的时间间隔对RTD的影响:评估前交叉韧带损伤时间与结果(RTD、PP 或 MEB)之间关系的初步分析结果显著(P = .02)。随后在 4 个不同的时间组(0-3 个月、3-6 个月、6-12 个月和大于 12 个月)之间进行的分析也有意义(P = .03)。配对比较显示,0-3 个月组的 RTD 率为 80%,而 3-6 个月组的 RTD 率为 53%(P = .006)。然而,3-6个月组与6-12个月组之间的比较(P = .68)以及6-12个月组与超过12个月组之间的比较均无显著性(P = .80)。此外,未同时接受任何半月板手术的军人与接受半月板清创术的军人(P = .002)以及接受半月板修复术的军人(P = .02)的前交叉韧带重建时间存在显著差异。接受半月板清创术和半月板修复术的患者在进行 ACLR 的时间上没有明显差异(P = 0.22)。未接受任何半月板手术的患者平均手术时间为175天,而接受半月板修复术的患者平均手术时间为240天,接受半月板清创术的患者平均手术时间为295天:这项新研究的结果表明,在受伤后 3 个月内进行前交叉韧带修复术可提高无限制 RTD 的可能性。前交叉韧带置换术的时机也会影响半月板手术的发生率和类型,因为没有同时接受半月板手术的患者会在伤后6个月内接受前交叉韧带置换术。这项研究为我们提供了宝贵的见解,使我们认识到在服役人员中尽早进行前交叉韧带置换术的重要性,从而提高复位率并减少额外的同期半月板手术。
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引用次数: 0
Expectant Casualty Care Training Needs for Future Conflicts. 未来冲突的预期伤员护理培训需求。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae389
Rebekah Cole, Sean Keenan, Matthew D Tadlock, Shawna Grover, Melissa Givens, Sherri L Rudinsky

Introduct ion: The demands of future large-scale combat operations may require medics and corpsmen to increasingly perform expectant casualty care (ECC). However, no detailed guidelines currently exist for providing ECC within military medicine. To guide the development of education and training guidelines and advance team training of both medics and non-medics, an in-depth understanding is first needed regarding caregivers' experiences providing ECC in recent conflicts as well as perceived training gaps. Therefore, this study explored the experiences of medics and physicians providing ECC and investigated their perceptions of training needs in this area for future conflicts characterized by large-scale combat operations and prolonged casualty care operational settings.

Materials and methods: We conducted an engaged qualitative phenomenological study to explore ECC training needs for future conflicts. We interviewed 9 senior health care professionals (medics and physicians) who had extensive combat and deployment experiences and served primarily in the Role 1 environment. The interviews averaged 45 min each and were conducted via phone. To analyze this interview data, we reviewed the interview transcripts and then noted terms, phrases, and concepts within the interview transcripts that we found to be salient to answering the research question. Our team then met to review these codes and grouped them into categories. These categories served as the themes of this study that illustrated the participants' perceptions and experiences.

Results: Five themes emerged from our data: (1) There is a current gap in ECC training for enlisted Role 1 caregivers throughout the military; (2) ECC training is needed to shift organizational culture; (3) ECC training should be comprehensive; (4) ECC training should be deliberate; and (5) Time is the greatest challenge to implementing ECC training. Our participants noted that developing guidelines and filling training gaps is not only critical for preparing Role 1 providers for effective and ethical military medical decision-making but also for addressing death and dying on the battlefield and building moral resilience across the medical corps.

Conclusion: Our results provide direction for development of ECC clinical guidance and collective team training recommendations. Following these guidelines may increase life-saving capabilities on the far-forward battlefield and equip medical directors and medics to provide ethical and compassionate care to those who cannot be saved in the setting of limited resources and evacuation opportunities.

引言:未来大规模作战行动的需求可能会要求医护人员越来越多地执行预期伤员护理 (ECC)。然而,目前在军事医学领域还没有提供 ECC 的详细指南。为了指导教育和培训指南的制定,并推进医护人员和非医护人员的团队培训,首先需要深入了解护理人员在近期冲突中提供 ECC 的经验以及他们认为存在的培训差距。因此,本研究探讨了医护人员和医生提供紧急救护的经验,并调查了他们对未来以大规模作战行动和长期伤员救护行动环境为特点的冲突中这方面培训需求的看法:我们开展了一项参与式定性现象学研究,以探讨未来冲突中的紧急救护培训需求。我们采访了 9 名资深医护专业人员(医护人员和医生),他们都有丰富的作战和部署经验,主要在角色 1 环境中服役。访谈平均每次 45 分钟,通过电话进行。为了分析这些访谈数据,我们审阅了访谈记录,然后在访谈记录中记下了我们认为对回答研究问题有突出作用的术语、短语和概念。然后,我们的团队开会审查了这些代码,并将其归类。这些类别作为本研究的主题,说明了参与者的看法和经验:从我们的数据中得出了五个主题:(1)目前,全军在对士兵角色 1 护理人员进行 ECC 培训方面存在差距;(2)需要进行 ECC 培训以转变组织文化;(3)ECC 培训应该全面;(4)ECC 培训应该深思熟虑;以及(5)时间是实施 ECC 培训的最大挑战。我们的参与者指出,制定指导方针和填补培训空白不仅对角色 1 提供者为有效和合乎道德的军事医疗决策做好准备至关重要,而且对解决战场上的死亡和濒死问题以及建设整个医疗队的道德复原力也至关重要:我们的研究结果为制定 ECC 临床指南和团队集体培训建议提供了方向。遵循这些指导原则可以提高远征战场上的生命挽救能力,并使医务主任和医务人员能够在资源和撤离机会有限的情况下为那些无法挽救的人提供合乎道德和富有同情心的护理。
{"title":"Expectant Casualty Care Training Needs for Future Conflicts.","authors":"Rebekah Cole, Sean Keenan, Matthew D Tadlock, Shawna Grover, Melissa Givens, Sherri L Rudinsky","doi":"10.1093/milmed/usae389","DOIUrl":"10.1093/milmed/usae389","url":null,"abstract":"<p><strong>Introduct ion: </strong>The demands of future large-scale combat operations may require medics and corpsmen to increasingly perform expectant casualty care (ECC). However, no detailed guidelines currently exist for providing ECC within military medicine. To guide the development of education and training guidelines and advance team training of both medics and non-medics, an in-depth understanding is first needed regarding caregivers' experiences providing ECC in recent conflicts as well as perceived training gaps. Therefore, this study explored the experiences of medics and physicians providing ECC and investigated their perceptions of training needs in this area for future conflicts characterized by large-scale combat operations and prolonged casualty care operational settings.</p><p><strong>Materials and methods: </strong>We conducted an engaged qualitative phenomenological study to explore ECC training needs for future conflicts. We interviewed 9 senior health care professionals (medics and physicians) who had extensive combat and deployment experiences and served primarily in the Role 1 environment. The interviews averaged 45 min each and were conducted via phone. To analyze this interview data, we reviewed the interview transcripts and then noted terms, phrases, and concepts within the interview transcripts that we found to be salient to answering the research question. Our team then met to review these codes and grouped them into categories. These categories served as the themes of this study that illustrated the participants' perceptions and experiences.</p><p><strong>Results: </strong>Five themes emerged from our data: (1) There is a current gap in ECC training for enlisted Role 1 caregivers throughout the military; (2) ECC training is needed to shift organizational culture; (3) ECC training should be comprehensive; (4) ECC training should be deliberate; and (5) Time is the greatest challenge to implementing ECC training. Our participants noted that developing guidelines and filling training gaps is not only critical for preparing Role 1 providers for effective and ethical military medical decision-making but also for addressing death and dying on the battlefield and building moral resilience across the medical corps.</p><p><strong>Conclusion: </strong>Our results provide direction for development of ECC clinical guidance and collective team training recommendations. Following these guidelines may increase life-saving capabilities on the far-forward battlefield and equip medical directors and medics to provide ethical and compassionate care to those who cannot be saved in the setting of limited resources and evacuation opportunities.</p>","PeriodicalId":18638,"journal":{"name":"Military Medicine","volume":" ","pages":"e797-e803"},"PeriodicalIF":1.2,"publicationDate":"2025-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141971471","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Simultaneous Presentation of Swimming-Induced Pulmonary Edema in a Set of Monozygotic Twin Elite Maritime Warfare Candidates: A Novel Case Report. 一组单卵双胞胎精英海战候选人同时出现游泳诱发的肺水肿:新颖的病例报告。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae176
Tovar Matthew A, Gilbert Boswell, Benjamin Sebreros

Swimming-induced pulmonary edema (SIPE) is an incompletely understood condition that is often seen in U.S. special operations candidates participating in maritime qualification training courses. We present a case of two monozygotic twins with the simultaneous onset of acute respiratory distress during a crucible event of a maritime assessment and selection course. Subsequent pulmonary ultrasonography in both candidates showed wedge-shaped hyperechoic lines (B-lines) extending from the pleural interface into the interstitium. Chest radiography of both candidates revealed bilateral asymmetric hazy opacities consistent with SIPE. Both candidates recovered with supportive measures but were medically removed from training. Given the near-identical exposures of the candidates to the same ambient and water temperatures, duration of water submersion, magnitude of physical stressors, and viral colonization, this case study suggests that there may be underlying genetic factors, in addition to environmental factors, that predispose individuals to developing SIPE. Further benchtop and clinical research must be performed to identify potential genetic polymorphisms that contribute to the development of SIPE and to investigate safe interventions that address the underlying etiologies of SIPE pathophysiology.

游泳诱发肺水肿(SIPE)是一种尚未完全被理解的病症,经常出现在参加海上资格培训课程的美国特种作战候选人身上。我们介绍了一例在海上评估和选拔课程的一次关键活动中同时出现急性呼吸困难的两对单卵双胞胎。随后,两名考生的肺部超声波检查均显示出从胸膜界面延伸至肺间质的楔形高回声线(B 线)。两名候选人的胸片均显示双侧不对称混浊不透明,与 SIPE 一致。两名候选人在采取了支持性措施后均已康复,但在医疗方面均已退出培训。鉴于两名候选人几乎暴露于相同的环境和水温、浸入水中的时间、身体压力的大小以及病毒定植,本病例研究表明,除环境因素外,可能还有潜在的遗传因素导致个人易患 SIPE。必须开展进一步的台式研究和临床研究,以确定导致 SIPE 发生的潜在基因多态性,并研究针对 SIPE 病理生理学潜在病因的安全干预措施。
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引用次数: 0
A Unique Emotional Surgery: Removal of Unexploded Ordnance in a Patient With Vascular Injury. 独特的情感手术:在一名血管损伤患者身上清除未爆弹药。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae278
Tayfun Özdem, Tuna Demirkiran, Elgin Hacizade, Mehmet Fatih Yazici, Emre Kubat, Kubilay Karabacak

Cases of embedded unexploded ordnance are extremely rare and pose a risk to bystanders and health providers. A patient arrived at the Role 2 medical facility in the Turkish army, whose left arm was amputated due to a terrorist attack and major hemorrhages had been halted by clamping of the left subclavian artery and vein. A piece of metal wire running from the lateral chest wall was detected as an unexploded ordnance piece and it was removed surgically. In these challenging cases, safety principles should be acknowledged. Highlighting the basic precautions is important for similar scenarios and increases awareness of the utmost importance.

嵌入式未爆弹药的案例极为罕见,对旁观者和医疗服务提供者构成风险。土耳其军队的 Role 2 医疗设施收治了一名病人,他的左臂因恐怖袭击而被截肢,通过夹住左锁骨下动脉和静脉止住了大出血。胸腔外侧壁上的一根金属丝被检测出是未爆炸弹药,已通过手术将其取出。在这些具有挑战性的病例中,安全原则应得到认可。强调基本的预防措施对类似的情况非常重要,并能提高人们对其重要性的认识。
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引用次数: 0
Aintree Catheter Versus Gum Elastic Bougie for Airway Exchange Using the i-Gel Supraglottic Device: A Cadaver Study. 使用 i-Gel 声门上置物装置进行气道交换时,安特里导管与口香糖弹性布罩的对比:尸体研究。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae474
Lee Jin, Matthew J Perdue, Clifford Sandoval, Jerimiah D Walker, Christopher Mitchell

Introduction: Airway compromise is the third leading cause of preventable death on the battlefield. Most combat medics carry supraglottic airway (SGA) devices for airway management. However, exchanging an SGA device for a definitive airway can be challenging, especially in austere environments. This study aims to compare the Aintree intubation catheter (AIC) to the gum elastic bougie (GEB) as adjuncts for performing airway device exchange with the i-gel SGA device in place.

Materials and methods: This randomized crossover cadaver study of 48 participants examined the success rate of two endotracheal introducers (AIC and GEB) when performing a blind airway exchange with an i-gel in place. Study participants were combat medics (MOS 68W), physician assistant students, physician assistant staff, emergency medicine (EM) physician residents, and emergency medicine attending physicians attending classes at the installation Medical Simulations Training Center. Each participant performed up to three attempts using both endotracheal tube introducers on the same cadaver. The primary outcome was successful airway exchange rate with each device, and the secondary outcome was time to successful airway exchange.

Results: Although the AIC had a slightly higher success rate of 33% compared to the GEB success rate of 30%, this result was not statistically significant, P = .56. Similarly, participants completed successful airway exchanges with the AIC faster, with a mean time of 86.5 seconds (95% CI: 71.2 to 101.9) versus 101.2 seconds (95% CI: 85.5 to 116.9) with the GEB. However, this result was also not statistically significant, P = 0.18.

Conclusions: This study demonstrates no significant difference in success rate and time to completion of successful iterations of airway exchanges between the two devices. Although the AIC performed slightly better overall, these results are not statistically significant. Additionally, blind exchange intubations appear to be of high risk with minimal success, so we recommend against this technique in routine practice.

简介气道损伤是战场上可预防死亡的第三大原因。大多数作战医护人员都携带有用于气道管理的声门上气道(SGA)装置。然而,将 SGA 设备更换为确定性气道可能具有挑战性,尤其是在艰苦环境中。本研究旨在比较 Aintree 插管导管(AIC)和牙龈弹性通气导管(GEB)作为辅助工具,在使用 i-gel SGA 装置的情况下进行气道装置交换:这项由 48 名参与者参加的随机交叉尸体研究考察了两种气管导管(AIC 和 GEB)在使用 i-gel 装置进行盲气道交换时的成功率。研究参与者包括作战医护人员(MOS 68W)、助理医师学生、助理医师工作人员、急诊医学(EM)住院医师以及在安装医疗模拟训练中心上课的急诊医学主治医师。每位参与者在同一尸体上使用两种气管导管进行了最多三次尝试。主要结果是每种设备的气道置换成功率,次要结果是成功置换气道的时间:尽管 AIC 的成功率为 33%,略高于 GEB 的 30%,但这一结果并无统计学意义(P = .56)。同样,参与者使用 AIC 完成成功气道交换的时间更快,平均时间为 86.5 秒(95% CI:71.2 至 101.9),而使用 GEB 则为 101.2 秒(95% CI:85.5 至 116.9)。然而,这一结果也没有统计学意义,P = 0.18:这项研究表明,两种设备在气道交换的成功率和完成成功迭代的时间上没有明显差异。虽然 AIC 的总体表现略好,但这些结果并无统计学意义。此外,盲目交换插管似乎风险很高,成功率极低,因此我们建议在日常实践中不要使用这种技术。
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引用次数: 0
Examining Disparities in Regional Anesthesia Utilization, Opioid Prescriptions, and Pain Scores Among Patients Who Received Primary or Revision Total Knee Arthroplasty at a Veterans Affairs Medical Center: A Retrospective Cohort Study. 研究退伍军人事务医疗中心接受初次或翻修全膝关节置换术的患者在区域麻醉使用、阿片类药物处方和疼痛评分方面的差异:一项回顾性队列研究。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae463
Samuel Bennett, Anna Woodbury, Mercy Udoji
<p><strong>Introduction: </strong>Total knee arthroplasty (TKA) is one of the most performed surgical operations in the United States. Managing postoperative pain after TKA is of vital importance, as it is positively associated with outcome measures related to recovery of function and quality of life. Two commonly used methods to control postoperative pain are regional anesthesia (RA), consisting of a single or a combination of peripheral nerve and epidural blocks, and pain medication, such as opioids. Our retrospective analysis sought to better understand whether revision versus primary TKA impacted previously discovered disparities in perioperative pain management and use of RA at the Atlanta Veterans Affairs Health Care System (AVAHCS). Before data collection, we hypothesized that revision TKA would have a higher proportion of Black and older patients and that revision TKA patients would have lower postoperative pain scores.</p><p><strong>Materials and methods: </strong>This was a retrospective analysis of AVAHCS patients who underwent elective unilateral primary or revision TKA surgery between 2014 and 2020. After application of our exclusion criteria, data from 562 patients were analyzed. Data collected included demographics information, type of RA used, and pain scores. Statistical analyses included chi-square test, t-tests, multiple logistic regression, and multiple linear regression, as appropriate to the outcomes of interest.</p><p><strong>Results: </strong>Revision TKA patients were more likely to be Black (P = .018) and younger (P = .023 for <50 years of age group, P = .006 for 50 to 64 years of age compared to the >65 years group). Black patients, compared to White patients, had significantly higher pain scores at baseline (P = .0086) and at 24 hours postsurgery (P = .0037). Older patients (≥50 years old) had significantly higher baseline pain scores (P = .021 for the 50 to 64 years group, P < .01 for the >65 years group) and significantly lower first postanesthesia care unit pain scores (P < .05). Black race (P < .01) and age > 65 years (P < .01) were associated with a significant decrease in total oral morphine equivalents (OME) prescribed at discharge. None of the predictor variables-race, age, type of surgery (primary versus revision), baseline, and first postanesthesia care unit pain scores-were significantly associated with the use of RA in our cohort.</p><p><strong>Conclusions: </strong>Sociodemographic disparities in pain management have been reported in all healthcare systems, including the VAHCS. This moderately sized retrospective study, conducted at a single veterans affairs site, yielded several noteworthy findings. One finding of particular interest was that, despite Black patients reporting higher baseline and 24-hour postoperative pain scores, they were prescribed fewer opioids at discharge. Our results highlight the presence of clinically significant disparities in perioperative TKA pain management, emphasizing the ne
简介:全膝关节置换术(TKA)是美国实施最多的外科手术之一。治疗 TKA 术后疼痛至关重要,因为疼痛与功能恢复和生活质量的相关结果呈正相关。控制术后疼痛的两种常用方法是区域麻醉(RA)和止痛药物(如阿片类药物),前者包括单一或组合的周围神经和硬膜外阻滞。我们的回顾性分析旨在更好地了解亚特兰大退伍军人事务医疗保健系统(AVAHCS)先前发现的围手术期疼痛管理和区域麻醉使用方面的差异是否会影响翻修手术与初次TKA手术。在收集数据之前,我们假设翻修 TKA 的黑人和老年患者比例较高,翻修 TKA 患者的术后疼痛评分较低:这是一项回顾性分析,研究对象是在 2014 年至 2020 年期间接受了选择性单侧初次或翻修 TKA 手术的 AVAHCS 患者。在应用了我们的排除标准后,对 562 例患者的数据进行了分析。收集的数据包括人口统计学信息、使用的 RA 类型和疼痛评分。统计分析包括卡方检验、t检验、多元逻辑回归和多元线性回归(视相关结果而定):结果:翻修 TKA 患者更可能是黑人(P = .018)和年轻人(65 岁组的 P = .023)。与白人患者相比,黑人患者的基线疼痛评分(P = .0086)和术后 24 小时疼痛评分(P = .0037)明显更高。年龄较大的患者(≥50 岁)基线疼痛评分明显更高(50 至 64 岁组 P = .021 ,65 岁组 P = .021),麻醉后护理病房首次疼痛评分明显更低(65 岁组 P = .021 ,65 岁组 P = .021):所有医疗保健系统(包括 VAHCS)都曾报道过疼痛管理方面的社会人口差异。这项中等规模的回顾性研究是在一个退伍军人事务机构进行的,得出了几个值得注意的发现。其中一个特别值得关注的发现是,尽管黑人患者报告的基线和术后 24 小时疼痛评分较高,但他们在出院时获得的阿片类药物处方却较少。我们的研究结果凸显了 TKA 围手术期疼痛管理中存在的临床显著差异,强调了在退伍军人中进行持续调查和集中缓解的必要性。
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引用次数: 0
Comparative Analysis of Treatment Patterns in DoD Beneficiaries With Malignant Central Nervous System Tumors: A Focus on Care Setting. 国防部中枢神经系统恶性肿瘤受益人治疗模式的比较分析:关注护理环境。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae477
Aaron J Hill, Yvonne L Eaglehouse, Sarah Darmon, Heather J Tracy, Brett J Theeler, Kangmin Zhu, Craig D Shriver, Hong Xue

Introduction: Malignant brain and other central nervous system tumors (MBT) are deadly and disproportionately affect younger men and women in the age range of most active-duty service members. Timely and appropriate treatment is important to both survival and quality of life of patients. Information on treatment factors across direct care (DC) and private sector care (PSC) networks may be important for provider training and staffing for the DoD. The aim of this study was to analyze treatment patterns for patients with MBT within the DoD's universal access Military Health System (MHS), comparing DC and PSC networks.

Materials and methods: The Military Cancer Epidemiology database was used to identify patients 18 years and older who were diagnosed with an MBT between 1999 and 2014 who received primary treatment. Differences in first treatment type and time from diagnosis to initial treatment between DC and PSC were assessed using chi-square and Wilcoxon-Mann-Whitney tests, respectively. Frequency of treatment initiation beyond the 28-day TRICARE Prime access standard for Specialty Care was also compared between care settings using chi-square and Fisher's exact tests. Then logistic regression models generated odds of treatment initiation beyond 28 days and 95% confidence intervals (CIs) associated with care setting. Kaplan-Meier survival curves and log-rank tests compared survival between DC and PSC.

Results: The study included 857 patients, with n = 540 treated in DC and n = 317 treated in PSC. The proportion of patients receiving each initial treatment type did not differ by care setting (P = .622). Median time from diagnosis to initial treatment (interquartile range) varied significantly between DC at 6 (0 to 25) days and PSC at 12 (0 to 37) days for all treatment types combined (P < .001). For all years combined, treatment was initiated beyond 28 days for 21% of patients using DC compared to 31% of patients using PSC (P = .001). The odds of treatment initiation beyond 28 days for a patient treated in PSC were 1.61 (95% CI, 1.11 to 2.33, P = .012) compared to patients treated in DC when controlling for demographic, military, tumor, and patient variables. Survival did not differ by care setting (P = 1.000).

Conclusions: Based on the available data between 1999 and 2014, care setting was associated with differences in time to initial treatment and odds of treatment initiation beyond 28 days among DoD beneficiaries with MBT receiving care in the MHS. Information on these differences may help inform MHS leadership decisions on the most appropriate location for military provider training and staffing.

导言:恶性脑肿瘤和其他中枢神经系统肿瘤(MBT)是致命的疾病,对大多数现役军人年龄范围内的年轻男女的影响尤为严重。及时、适当的治疗对患者的生存和生活质量都很重要。有关直接护理(DC)和私营部门护理(PSC)网络中治疗因素的信息可能对国防部的提供者培训和人员配备非常重要。本研究的目的是分析美国国防部普及的军事医疗系统(MHS)中甲基溴转移癌患者的治疗模式,并对直接医疗和私营医疗网络进行比较:使用军事癌症流行病学数据库来识别 1999 年至 2014 年期间被诊断出患有 MBT 并接受初次治疗的 18 岁及以上患者。采用秩方检验和 Wilcoxon-Mann-Whitney 检验分别评估了 DC 和 PSC 首次治疗类型和从诊断到首次治疗时间的差异。此外,还使用卡方检验和费雪精确检验比较了不同医疗机构在超过 28 天 TRICARE Prime 专科护理准入标准后开始治疗的频率。然后,逻辑回归模型生成了超过 28 天开始治疗的几率以及与护理环境相关的 95% 置信区间 (CI)。Kaplan-Meier生存曲线和对数秩检验比较了DC和PSC的生存率:研究共纳入 857 例患者,其中 540 例在 DC 接受治疗,317 例在 PSC 接受治疗。接受每种初始治疗类型的患者比例在不同医疗机构之间没有差异(P = .622)。在所有治疗类型中,从诊断到初始治疗的中位时间(四分位数间距)差异显著,DC 为 6(0 至 25)天,而 PSC 为 12(0 至 37)天(P 结论:DC 和 PSC 的中位时间差异显著:根据 1999 年至 2014 年期间的可用数据,在接受医疗服务体系治疗的患有 MBT 的国防部受益人中,护理环境与初始治疗时间和 28 天后开始治疗几率的差异有关。有关这些差异的信息可能有助于医疗服务系统领导层就最合适的军事提供者培训和人员配置地点做出决策。
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引用次数: 0
Letter from the CEO Dr John Cho. 首席执行官John Cho博士的信。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae565
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引用次数: 0
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Military Medicine
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