Military medicine
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A systems perspective was used to describe U.S. Department of Defense (DoD) Global Health Engagement (GHE). This description was based on DoD instructions and higher-level documents related to DoD GHE. A complex system of systems such as health care can benefit from using modeling approaches to help understand the interactions among major components. Models (conceptual, computer-based programs, realistic simulations, or training exercises) can be used to help stakeholders prioritize options and to identify important components and gaps for making performance improvements. Based on the cited documents, we identified major DoD GHE components to create a conceptual model. ⋯ Examining the composition of DoD GHE and creating a defined model can help identify interacting features of this complex system. All of the identified components have been associated with gaps, such as the need for monitoring and measuring tools, and standards. The current state of this system is dynamic and is evolving when confronting gaps. DoD GHE represents an intersection of global health and security in supporting U.S. national security objectives by establishing access and influence with partner nations and among health care-related government and non-government organizations, and as a result, improves the readiness, health, and safety of our military personnel.
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No-shows are detrimental to both patients' health and health care systems. Literature documents no-show rates ranging from 10% in primary care clinics to over 60% in mental health clinics. Our model predicts the probability that a mental health clinic outpatient appointment will not be completed and identifies actionable variables associated with lowering the probability of no-show. ⋯ The National Initiative to Reduce Missed Opportunities-2 confirmed findings that previous patient attendance is one of the key predictors of a future attendance and provides an additional layer of complexity for analyzing the effect of a patient's past behavior on future attendance. The National Initiative to Reduce Missed Opportunities-2 establishes that appointment attendance is related to medication adherence, particularly for medications used for treatment of mood disorders or to block the effects of opioids. However, there is no way to confirm whether a patient is actually taking medications as prescribed. Thus, a low medication possession ratio is an informative, albeit not a perfect, measure. It is our intention to further explore how diagnosis and medications can be better captured and used in predictive modeling of no-shows. Our findings on the effects of different factors on no-show rates can be used to predict individual no-show probabilities, and to identify patients who are high risk for missing appointments. The ability to predict a patient's risk of missing an appointment would allow for both advanced interventions to decrease no-shows and for more efficient scheduling.
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Consistent procedural volume is important for emergency physicians (EPs) to maintain opportunities for critical lifesaving skills. While non-EP literature demonstrates improved patient outcomes with higher volumes, few studies examine the optimal number of repetitions needed to maintain procedural competency in EP populations. The largely young, healthy active duty population that constitutes the majority of patients in military treatment facilities (MTFs) decreases the likelihood to utilize emergent procedures. Despite this likelihood, EPs are expected to maintain proficiency and readiness to perform critical procedures in deployed settings. ⋯ This retrospective analysis demonstrates a significant variation in procedural volumes across MTFs, illustrating disproportionate opportunities for procedural skill maintenance among Army EPs. Low procedural volume threatens the maintenance of critical EP skills. These numbers could also suggest low skills for other providers (such as physician assistants), further illustrating decreased skill readiness throughout the force. Further research is needed to examine procedural volumes per individual EP, as well as those performed by other providers to evaluate for overall procedural readiness across the military force.
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The purpose of this pilot study was to assess for biomarkers indicative of passing intense physical training and establishing normative values within the tactical athlete population. Unfortunately, none of the biomarkers assessed were indicative of passing training, however, glucose, blood urea nitrogen, and creatine kinase (CK) levels stood out as abnormal. CK levels are commonly used in conjunction with muscle pain and/or myoglobinurea to diagnose exertional rhabdomyolysis (ER) in athletes and the military population. However, research shows that high CK levels may not correlate with acute kidney failure in ER. ⋯ In our low-powered case control study (pilot study), a nonpathologic elevation of CK is prevalent in high-intensity military training, but not shown to correlate with values associated with acute kidney injury. We assume that real-time collection of these markers could be used once sensors are capable of real-time collection and have the potential for diagnostic affordance. When measured in a between subjects design, our study showed a lack of significance when correlating markers of acute renal injury and elevation of CK. However, when utilized for tracking purposes (within subjects design), the results do show a positive correlation between CK and renal failure biomarkers-specifically only at high physiological stress points.
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The process for working up scaphoid fractures from frontline providers to the specialty care clinic is variable. Initial imaging can often be negative and the management algorithm is not clearly defined. Delays in diagnosis are a contributing factor to scaphoid nonunion. Fractures may not be identified by frontline providers on initial presentation because of radiographically occult injuries. If not treated promptly, scaphoid fractures may be complicated by nonunion, avascular necrosis, and osteoarthritis. ⋯ Delayed diagnosis of a scaphoid fracture is a contributing factor for excessive light duty, high rates of LIMDU utilization, and ultimately medical separation of service members. Overall, in all patients who had scaphoid nonunions, the average time to diagnosis was 42.1 days with 35% of patients presenting with negative initial imaging. A delayed diagnosis subgroup was identified and notable for a higher rate of initial negative X-rays, an average of 139.7 days until diagnosis, and a 33% PEB rate. In total, 77% of patients with a delay in diagnosis of more than 30 days had an initial negative X-ray. An evidence-based algorithm for diagnosing occult scaphoid fractures may prevent delays in diagnosis, thus increasing the readiness of active duty service members.