Military medicine
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The Department of Veterans Affairs Veterans Health Administration (VA) Strategic Plan (Fiscal Year 2018-2024) identified four priorities for care including easy access, timely and integrated care, accountability, and modernization, all of which can be directly or indirectly impacted by telemedicine technologies. These strategic goals, coupled with an anticipated rheumatology workforce shortage, has created a need for additional care delivery methods such as clinical video telehealth application to rheumatology (ie, telerheumatology). Rheumatology clinician perceptions of clinical usefulness telerheumatology have received limited attention in the past. The present study aimed to evaluate rheumatologists' perceptions of and experiences with telemedicine, generally, and telerheumatology, specifically, within the VA. ⋯ While the majority of rheumatology clinicians did not report past experience with telerheumatology, they agreed that it has potential to further the VA mission of improved access and quality of care. Rheumatology clinicians felt the suitability of telerheumatology is dependent on the phase of care. As remote care technologies continue to be rapidly adopted into clinic, clinician perceptions of and experiences with telemedicine will need to be addressed in order to maintain high-quality and clinician- and patient-centric care within VA rheumatology.
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A patient presented to the emergency department with undifferentiated shock 4 days after discharge from a hospitalization for a lower gastrointestinal bleed. The patient fulfilled 4/4 of the Systemic Inflammatory Response Syndrome criteria and 3/3 of the quick Sequential Organ Failure Assessment criteria on presentation to the emergency department, notably, without a localized source of infection and no localizing symptoms. After admission, the patient's hemoglobin was found to have dropped more than expected after intravenous (IV) fluid administration, suggesting a potential alternative or concurrent etiology of the patient's shock state. ⋯ The patient was hemodynamically stabilized and taken for emergent grafting without confirmatory imaging. The patient was later found to also have 4/4 blood cultures positive with methicillin-sensitive Staphylococcus aureus associated with an aortic valvular vegetation and a mycotic aneurysm which contributed to the abdominal aortic aneurysm rupture. This case supports the use of comprehensive point-of-care ultrasound imaging to more rapidly and more definitively differentiate types of shock and etiologies of a shock state which can lead to more timely changes in management and improvement in outcomes.
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Endovascular variable aortic control (EVAC) is an automated partial resuscitative endovascular balloon occlusion of the aorta (REBOA) platform designed to mitigate the deleterious effects of complete REBOA. Long-term experiments are needed to assess potential benefits. The feasibility of a 24-hour experiment in a complex large animal trauma model remains unknown. ⋯ This study demonstrates the feasibility of intermediate-term experiments in a complex swine model of polytrauma with 90 minutes of REBOA. EVAC may be associated with improved survival at 24 hours when compared with complete REBOA. EVAC resulted in normalized physiology after 24 hours, suggesting that prolonged partial occlusion is possible. Longer studies evaluating partial REBOA strategies are needed.
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The U.S. Preventive Services Task Force (USPSTF) modified their screening guidelines for breast cancer in November 2009. Previous studies evaluated the impact of these guideline changes among privately and Medicare insured populations. Women in the military form a unique population exposed to many social, environmental, and occupational hazards that may increase breast cancer incidence. By evaluating mammography screening rates among women in the military before and after the USPSTF guideline changes, this study evaluated the impact of the USPSTF breast cancer guideline change on screening mammography use within the military population and determined whether current guidelines were followed for this high-risk population with universal health care access. ⋯ The USPSTF guidelines had differential impacts among some subpopulations. While older women, aged 50 to 64 years, had a greater temporary reduction immediately after the guideline change, younger women aged 40 to 49 years had a longer-term reduction in screening following the guideline changes. No racial disparities in the proportion screened or in the impact of the guideline change were noted in this population with universal health coverage. The lack of Department of Defense standard breast cancer screening guidelines was evident from the different patterns of mammography utilization observed among military branches. To completely understand the impact of the updated screening guidelines, future studies must incorporate research focusing on changes in breast cancer morbidity and mortality as well as updated cost-benefit analyses.
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E-cigarette use has rapidly increased in prevalence in the United States, and rates of use are even higher among military personnel compared to the general population. Descriptive and injunctive norms have previously been shown to impact tobacco use. However, little research has been conducted related to e-cigarette descriptive and injunctive norms, and no research has addressed e-cigarette norms among a military population. ⋯ Descriptive norms were more commonly mentioned than injunctive norms, which may indicate that injunctive norms are not as influential for e-cigarette use. Additionally, all estimates related to e-cigarette prevalence were higher than actual rates of use, showing an overestimation of use, which previous literature has shown increases likelihood of e-cigarette use. Future research should specifically ask about injunctive norms as well as determine if descriptive and injunctive norms influence actual e-cigarette use behaviors among military personnel.