Military medicine
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Surgery is a known gateway to opioid use that may result in long-term morbidity. Given the paucity of evidence regarding the appropriate amount of postoperative opioid analgesia and variable prescribing education, we investigated prescribing habits before and after institution of a multimodal postoperative pain management protocol. ⋯ Appropriate preoperative counseling and utilization of nonopioid analgesics can dramatically reduce opioid use while maintaining high patient satisfaction. Patient-reported data suggest that even greater reductions may be possible.
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Medical error is the third leading cause of death in the United States, contributing to suboptimal care, serious patient injury, and mortality among beneficiaries in the Military Health System. Recent media reports have scrutinized the safety and quality of military healthcare, including surgical complications, infection rates, clinician competence, and a reluctance of leaders to investigate operational processes. Military leaders have aggressively committed to a continuous cycle of process improvement and a culture of safety with the goal to transform the Military Health System into a high-reliability organization. The cornerstone of patient safety is effective clinician communication. Military surgical teams are particularly susceptible to communication error because of potential barriers created by military rank, clinical specialty, and military culture. With an operations tempo requiring the military to continually deploy small, agile surgical teams, effective interpersonal communication among these team members is vital to providing life-saving care on the battlefield. ⋯ The findings have important implications for safety and quality. Stronger connections in the interaction frequency, close working relationship, socialization, and advice networks were associated with smaller differences in communication effectiveness. The ability of team members to communicate clinical information effectively is essential to building a culture of safety and is vital to progress towards high-reliability. The military faces distinct communication challenges because of policies to rotate personnel, the presence of a clear rank structure, and antifraternization regulations. Despite these challenges, overall communication effectiveness in military teams will likely improve by maintaining team consistency, fostering team cohesion, and allowing for frequent interaction both inside and outside of the work environment.
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There is a dearth of research on the impact of pre-treatment assessment effort and symptom exaggeration on the treatment outcomes of Veterans engaging in trauma-focused therapy, handicapping therapists providing these treatments. Research suggests a multi-method approach for assessing symptom exaggeration in Veterans with posttraumatic stress disorder (PTSD), which includes effort and symptom validity tests, is preferable. Symptom exaggeration has also been considered a "cry for help," associated with increased PTSD and depressive symptoms. Recently, research has identified resilience as a moderator of PTSD and depressive symptom severity and an important predictor of treatment response among individuals with PTSD. Thus, it is important to examine the intersection of symptom exaggeration, resilience, and treatment outcome to determine whether assessment effort and symptom exaggeration compromise treatment response. ⋯ These results suggest that Veterans with PTSD whose validity testing scores are indicative of poor effort and symptom exaggeration may be less resilient but may still complete a CPT group treatment and benefit from treatment at a rate comparable to Veterans who evidence good assessment effort and genuine symptom reporting pre-treatment. These findings also challenge the assumption that pre-treatment assessment effort failure and symptom exaggeration accurately predict poor effort in trauma-focused psychotherapy.
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Epigenetics can serve as a marker of susceptibility to many known psychiatric diseases. DNA methylation patterns of multiple genes have been studied in both civilian populations and military personnel with post-traumatic stress disorder (PTSD). Many of these genes serve various functions that span the hypothalamic-pituitary-adrenal axis, immune system, and central nervous system (CNS) growth factors and neurotransmission. It is thought that the methylation levels of such genes may be able to identify individuals who are at higher risk of developing PTSD. Our study seeks to establish whether previously reported PTSD genes possess a particular methylation pattern that is predictive of PTSD in active duty military members with combat exposure. ⋯ Our study suggests that methylation of key genes involved in synaptic plasticity and the hypothalamic-pituitary-adrenal axis is associated with lower levels of methylation in military PTSD subjects exposed to combat when compared to their non-PTSD counterparts. Strengths of this study include controlling for antidepressant use and excluding TBI patients. Similar studies in an active duty population of this size are scarce. What is not clear is whether methylation changes are driving PTSD symptomology or whether they are merely a marker of disease. Future areas of research include prospective studies that measure methylation pre- and postcombat exposure in the same individual.
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Baseline symptom, balance, and neurocognitive scores have become an integral piece of the concussion management process. Factors such as sleep, learning disorders, fitness level, and sex have been linked to differences in performance on baseline assessments; however, it is unclear how tobacco use may affect these scores. The objective of this study was to compare baseline concussion assessment scores between service academy cadets who use and do not use tobacco. ⋯ Tobacco users performed significantly worse than tobacco nonusers on the impulse control section of the ImPACT, reported greater symptom severity scores on the ImPACT, and were more likely to take risks as measured by the BSSS. Despite statistical significance, these results should be interpreted with caution, as the overall effect sizes were very small. Future research should examine the influence of tobacco use on recovery post-concussion.