Practice Patterns of Pancreatic Surgery Within the Military.

INTRODUCTION: Pancreatic surgery is technically challenging, with mortality rates at high-volume centers ranging from 0% to 5%. An inverse relationship between surgeon volume and perioperative mortality has been reported suggesting that patients benefit from experienced surgeons at high-volume centers. There is little published on the volume of pancreatic surgeries performed in military treatment facilities (MTF) and there is no centralization policy regarding pancreatic surgery. This study evaluates pancreatic procedures at MTFs. We hypothesize that a small group of MTFs perform most pancreatic procedures, including more complex pancreatic surgeries. METHODS: This is a retrospective review of de-identified data from MHS Mart (M2) from 2014 to 2020. The database contains patient data from all Defense Health Agency treatment facilities. Variables collected include number and types of pancreatic procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each MTF. RESULTS: Twenty-six MTFs performed pancreatic surgeries from 2014 to 2020. There was a significant decrease in the number of cases from 2014 to 2020. Nine hospitals performed one surgery over eight years. The most common surgery was a distal pancreatectomy, followed by a pancreaticoduodenectomy. There was a decrease in the number of pancreaticoduodenectomies and distal pancreatectomies performed over this period. CONCLUSIONS: Pancreatic surgery is being performed at few MTFs with a downward trajectory over time. Further studies would be needed to assess the impact on patient care regarding postoperative complications, barriers to timely patient care, and impact on readiness of military surgeons.

Side effects of the BNT162b2 vaccine in the personnel of the Military Central Hospital.

OBJECTIVE: The pandemic disease by SARS-CoV-2 infection does not have an effective treatment. To prevent the disease, scientists developed vaccines that the clinicians use as an emergency licensed vaccine. The objective of this study was to determine the side effects in personnel vaccinated at the Military Central Hospital of Mexico with the BNT162b2 vaccine. PATIENTS AND METHODS: This study included the subjects who had received both doses of the BNT162b2 vaccine between December 2020 and February 2021. We asked about the side effects after the first and the second vaccine doses. One group had no history of COVID-19, and the second had a history of COVID-19. ANTI-SARS-CoV-2 antibodies were measured by the immunodetection technique in the second group only. RESULTS: We included 946 participants, 62% were women, and 80% were without comorbidities; 680 were included in the first group, and only 266 were in the second group. After the first dose, 77% of the first group and 86% of the second group presented some side effects. After the second dose, 84% of the first group and 89% of the second group showed some side effects. The main side effect was mild pain. All participants (126) were IgG positive, and only 26.9% were IgM positive at 17.5 days (12.8 days, 20.3 days) after the second dose. CONCLUSIONS: There is a positive correlation between side effects after the first dose in patients with a history of previous SARS-CoV-2 infection compared to those who did not. Nevertheless, this correlation is not present after the second dose. The low percentage of IgM could be related to the time interval between vaccination and sample measure.

Impact of the Coronavirus Disease 2019 (COVID-19) Pandemic on Medical Use of Military Hospitals in Korea.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic began in December 2019. While it has not yet ended, COVID-19 has already created transitions in health care, one of which is a decrease in medical use for health-related issues other than COVID-19 infection. Korean soldiers are relatively homogeneous in terms of age and physical condition. They show a similar disease distribution pattern every year and are directly affected by changes in government attempts to control COVID-19 with nonpharmaceutical interventions. This study aimed to identify the changes in patterns of outpatient visits and admissions to military hospitals for a range of disease types during a pandemic. METHODS: Outpatient attendance and admission data from all military hospitals in South Korea from January 2016 to December 2020 were analyzed. Only active enlisted soldiers aged 18-32 years were included. Outpatient visits where there was a diagnosis of pneumonia, acute upper respiratory tract infection, infectious conjunctivitis, infectious enteritis, asthma, allergic rhinitis, allergic conjunctivitis, atopic dermatitis, urticaria, and fractures were analyzed. Admissions for pneumonia, acute enteritis, and fractures were also analyzed. All outpatient visits and admissions in 2020 for each disease were counted on a weekly basis and compared with the average number of visits over the same period of each year from 2016 to 2019. The corrected value was calculated by dividing the ratio of total weekly number of outpatient visits or admissions to the corresponding medical department in 2020 to the average in 2016-2019. RESULTS: A total of 5,813,304 cases of outpatient care and 143,022 cases of admission were analyzed. For pneumonia, the observed and corrected numbers of outpatient visits and admissions in 2020 decreased significantly compared with the average of other years (P < 0.001). The results were similar for outpatient visits for acute upper respiratory tract infection and infectious conjunctivitis (P < 0.001), while the corrected number of outpatient visits for infectious enteritis showed a significant increase in 2020 (P = 0.005). The corrected number of outpatient visits for asthma in 2020 did not differ from the average of the previous 4 years but the number of visits for the other allergic diseases increased significantly (P < 0.001). For fractures, the observed and corrected numbers of outpatient visits and admissions in 2020 decreased significantly compared with the average of other years (P < 0.001). CONCLUSION: During the COVID-19 pandemic, outpatient visits to military hospitals for respiratory and conjunctival infections and fractures decreased, whereas visits for allergic diseases did not change or increased only slightly. Admissions for pneumonia decreased significantly in 2020, while those for acute enteritis and fractures also decreased, but showed an increased proportion compared with previous years. These results are important because they illustrate the changing patterns in lifestyle as a result of public encouragement to adopt nonpharmaceutical interventions during the pandemic and their effect on medical needs for both infectious and noninfectious diseases in a select group.

Prevention of Pruritis following Spinal Morphine for Scheduled Cesarean Birth.

BACKGROUND: Intrathecal morphine provides effective analgesia after cesarean birth, yet up to 90% of women who receive it experience excessive itching, an undesirable dose-dependent effect. Pruritis may increase nursing workload, delay breastfeeding, and decrease patient satisfaction. When 0.1 mg spinal morphine is given, pruritis is markedly reduced while analgesia is preserved. PURPOSE: The purpose of this project was to determine possible causes and solutions for pruritus after cesarean birth. METHODS: Anesthesia providers were educated and encouraged to limit spinal morphine to 0.1 mg as a strategy to prevent pruritus. In a repeated measures design, the rate of treatment-required pruritus and opioid consumption were measured 24 hours after surgery. The project included an evaluation of 30 medical records before and 30 medical records after the project intervention. RESULTS: Preintervention rate of treatment-required pruritis was 37%, all received spinal morphine ≥ 1.5 mg. Postintervention rate of treatment-required pruritis was 13% and 57% after spinal morphine 0.1 mg and 0.2 mg, respectively. Opioid consumption was similar between groups. CLINICAL IMPLICATIONS: Mother-baby nurses can have an impact on the practice of anesthesia providers by advocating for evidence-based dosing of intrathecal morphine to reduce the incidence of pruritis while maintaining effective analgesia for women after cesarean birth.

Concept of error and nature of nursing error detectors in military hospitals: a qualitative content analysis.

BACKGROUND AND OBJECTIVES: Nursing errors can cause irreparable consequences. Understanding the concept of error and the nature of nursing error detectors can significantly reduce this type of errors. The present study was conducted to explain the concept of error and the nature of nursing error detectors in military hospitals. MATERIALS AND METHODS: The present study was conducted on eight nurses working in different wards of military hospitals using a qualitative approach to content analysis proposed by Graneheim and Lundman. Data were collected through in-depth semistructured interviews. FINDINGS: 'The concept of error' and 'the nature of error detectors' in military hospitals were the two main categories extracted from data analysis. The present findings showed that the nature of errors in military hospitals is inevitable, a threat to job position and bipolar. Nurses use different resources to identify errors, including personal, environmental and organisational factors of detection. DISCUSSION AND CONCLUSION: Given the military nature of the study hospitals, organisational factors of detection played a key role in identifying errors. Moreover, given the perception of military nurses of errors, they were not inclined to personal detectors. The managers of military hospitals are therefore recommended to pursue a justice-oriented and supportive culture to help nurses play a more active role in identifying errors.

Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014).

INTRODUCTION: The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care. METHODS: The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004-2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR). RESULTS: 2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5-75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0-21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant. CONCLUSION: Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.

Cutaneous manifestations in an Italian military COVID hub.

BACKGROUND: The outbreak of the pandemic Coronavirus disease 2019 (COVID-19), caused by a novel coronavirus named Severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2), affecting a high number of patients in Italy, forced a great number of doctors, even dermatologists, to work in the first lines in the dedicated departments. We analyzed the features and the incidence of dermatological issues emerged during the hospitalization due to COVID-19 and absent before. METHODS: All the SARS-CoV-2 positive patients hospitalized in Celio Military Hospital - COVID hub no-intensive care wards from March 16, 2020 until May 4, 2020 were evaluated by dermatologists several times during the hospital stay. RESULTS: Ninety-six patients (15 civilians and 81 Italian servicepeople) were enrolled: 34 (35.4%) patients developed cutaneous manifestations; 15 (16.0%) suffered from skin dryness; 5 (5.2%) irritant contact dermatitis; 4 (4.2%) seborrheic dermatitis; 4 (4.2%) morbilliform rashes; 3 (3.1%) petechial rashes and 3 (3.1%) widespread hives. CONCLUSIONS: A deeper knowledge of cutaneous manifestations in military and civilian hospitalized COVID-19 patients could suggest more effective treatments to win the battle against SARS-CoV-2.

The Relationship between Patient Safety Climate and Medical Error Reporting Rate among Iranian Hospitals Using a Structural Equation Modeling.

BACKGROUND: Improving patient safety is a global health imperative, and patient safety climate is one of the components one that plays an important role in promoting patient safety. Medical error reporting is a way through which it can be evaluated and prevented in the future. The aim of this study was to assess the relationship between patient safety climate and medical error reporting in military and civilian hospitals. METHODS: This research was conducted by using structural equation modeling in the selected hospitals of Iran in 2018. The study community consisted of 200 nurses in the military and 400 nurses in the civilian hospitals. By using Structural Equation Modeling, the relationship between patient safety climate and the rate of medical error reporting in the hospitals was measured by a questionnaire. Data was analyzed using SPSS 17 and LISREL 8.8 software. RESULTS: The mean score of patient safety climate was moderate in the hospitals. There was no significant relationship between the rate of medical error reporting and patient safety climate, while a significant difference was found between patient safety climate score and age, sex, job category, and type of hospital (P < 0.05). CONCLUSION: The results suggested that patient safety climate and the rate of reporting errors were not favorable in the studied hospitals, while there was a difference between safety climate dimensions.

Comparison between Conventional Cytology and Liquid-Based Cytology in the Tertiary Brazilian Navy Hospital in Rio de Janeiro.

INTRODUCTION: Cervical cancer screening is an important tool in public health. Liquid-based cytology (LBC) has been performed at the studied hospital for 7 years. The present study compares the performance of 2 LBC techniques with conventional cytology. OBJECTIVE: Our objective is to verify the sensitivity for the detection of neoplastic and preneoplastic epithelial atypia, as well as the positive predictive value of the 3 methodologies. METHODS: We analyzed retrospectively 24,529 cases and evaluated the conventional cytology, ThinPrep®, and BD SurePath® performance categorizing the results according to the Bethesda system. We also compared the level of unsatisfactory samples, the presence of elements from the squamocolumnar junction, and the detection of pathogenic microorganisms. RESULTS: ThinPrep® (1.43%) showed superior sensitivity over BD SurePath® (0.91%) and conventional cytology (0.71%) in terms of the detection of high-grade lesions; however, in terms of squamous atypia as a whole (ASC-US+), BD SurePath® (6.44%) proved to be more sensitive than conventional cytology (5.28%) and ThinPrep® (3.73%). CONCLUSIONS: The results show the advantage of implementing LBC in routine screening for cervical lesions. In this study, BD SurePath® achieved the overall best performance considering the studied variables.

Shotgun injuries. Need for a special point of view.

BACKGROUND: Shotgun injuries (SGI) are infrequent, but due its special ballistics, are related to adverse outcomes. OBJECTIVE: To analyze operative and administrative variables, critical for the institution. METHOD: Demographics and health-care related variables from SGI patients admitted to Military Central Hospital (Mexico City) between July 2006 and August 2019, were retrospectively studied. Statistics methods used were dispersion measures and relative occurrence frequency. RESULTS: Over a 15 months-span, 21 SGI patients were admitted. Mean age was 36.9 ± 13.6 years (range: 14-61) and male gender was dominant (n = 20; 95%). Type II SGI were the most common injuries (62%; 13/21). Mean hospital length of stay was 37.1 ± 28.7 days (range: 3-109) while stay at ICU was 20.3 ± 22.5 days (range: 3-99). Global rate of morbidity was 82% (17/21) and most frequent complications were infective. Global mortality rate was 24% (5/21). CONCLUSIONS: Once SGI cause prolonged length of stay, high rate of morbidity and of enormous consuming of material and human resources, primary prevention strategies are convenient for health-care systems compromised to the care of these cases.

ANTECEDENTES: Las lesiones por disparo de escopeta (LE) son infrecuentes, pero debido a su balística especial se relacionan con un pronóstico adverso. OBJETIVO: Analizar variables operativas y administrativas de los pacientes con LE, de interés para la institución. MÉTODO: Se estudiaron retrospectivamente variables demográficas y asistenciales de pacientes con LE admitidos al Hospital Central Militar (Ciudad de México) entre julio de 2006 y agosto de 2019. Los métodos estadísticos usados fueron medidas de dispersión y frecuencia relativa de ocurrencia. RESULTADOS: En 158 meses se admitieron 21 pacientes con LE. La edad media fue de 36.9 ± 13.6 años (rango: 14-61) y predominó el sexo masculino (n = 20; 95%). La LE tipo II fue la más frecuente (62%; 13/21). La estancia hospitalaria media fue de 37.1 ± 28.7 días (rango: 3-109) y en cuidados intensivos fue de 20.3 ± 22.5 días (rango: 3-99). La tasa global de morbilidad fue del 82% (17/21) y las complicaciones más frecuentes fueron infecciosas. La tasa gobal de mortalidad fue del 24% (5/21). CONCLUSIONES: Las LE son causa de estancia hospitalaria prolongada, alta tasa de morbilidad y un enorme consumo de recursos humanos y materiales, por lo que las estrategias de prevención primaria son convenientes para los sistemas de salud comprometidos con el cuidado de estos casos.

La mortalidad del primer cuatrimestre de 2020 en la pandemia por COVID-19. Análisis del Comité de Mortalidad del Hospital Central de la Defensa «Gómez Ulla», Madrid / Mortality in the first four months of 2020 in the COVID-19 pandemic. Analysis of the Mortality Committee of the Hospital Central de la Defensa «Gómez Ulla», Madrid

INTRODUCCIÓN: En diciembre de 2019, Wuhan, China, tuvo un brote de la enfermedad COVID-19, causado por el síndrome respiratorio agudo severo coronavirus 2 (SARS-CoV-2). La enfermedad en poco tiempo se convirtió en pandemia. Los factores de riesgo asociados a su mortalidad están aún por determinar. El Comité de Mortalidad estudia los fallecimientos hospitalarios con el objetivo principal de reducir las muertes evitables. OBJETIVOS: Describir las características de comorbilidad y demográficas de los exitus del primer cuatrimestre de 2020 en el Hospital Central de la Defensa y su relación con COVID-19. MATERIAL Y MÉTODOS: Estudio transversal, descriptivo, observacional y retrospectivo. Datos clínicos y demográficos de los exitus en relación a la presencia de COVID-19. RESULTADOS: De 371 fallecidos, 271 COVID-19 positivos y 100 COVID-19 negativos. Casi 1,8 veces más de la mortalidad esperada en el cuatrimestre (208 a 371). Edad media de los grupos 80 y 84 años, rango entre 35 y 104 años. Estancia hospitalaria en COVID-19 positivos del 10,1% frente a 5,5% en COVID-19 negativos. Exitus extranjeros menor de 70 años 80%. Lugar del exitus: planta hospitalaria (84%). Puntuación media del índice de Charlson: 4 puntos (intercuartil, 2-6), 53% supervivencia estimada a 10 años. Comorbilidades más frecuentes: HTA (70,5%); DM (36,5%); Oncológico (31%); Neumonía (86,7%). Mal estado general al ingreso (81,9%). CONCLUSIONES: La variable con mayor potencia relacionada con la mortalidad fue la edad avanzada. Otro grupo, sin comorbilidades, menor de 51 años, presentó evolución fatal. A pesar de la dificultad para establecer la tasa de mortalidad real por COVID-19, la diferencia entre los exitus esperados y los registrados por el Comité de Mortalidad Hospitalario constituye el valor más aproximado

INTRODUCTION: In December 2019, Wuhan, China had an outbreak of the COVID-19 disease, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease quickly turned into a pandemic. The risk factors associated with its mortality are yet to be determined. The Mortality Committee studies hospital deaths with the main objective of reducing preventable deaths. OBJECTIVES: To describe the comorbidity and demographic characteristics of the deaths from the first four-month period of 2020 at the Central Defense Hospital and their relationship with COVID-19. MATERIAL AND METHODS: Cross-sectional, descriptive, observational and retrospective study. Clinical and demographic data of deaths in relation to the presence of COVID-19. RESULTS: Of 371 deceased, 271 positive COVID-19 and 100 negative COVID-19-. Almost 1.8 times more than the expected mortality in the four-month period (208 to 371). Average age of the groups 80 and 84 years, range between 35 and 104 years. Hospital stay at positive COVID-19 10.1% compared to 5.5% at negative COVID-19. Foreign exitus under 70 years 80%. Exit location: hospital plant (84%). Average Charlson index score: 4 points (interquartile, 2-6), 53% estimated survival at 10 years. Most frequent comorbidities: HTN (70.5%); DM (36.5%); Oncological (31%); Pneumonia (86.7%). Poor general condition at admission (81.9%). CONCLUSIONS: The variable with the greatest power related to mortality was advanced age. Another group, without comorbidities, younger than 51 years, presented fatal evolution. Despite the difficulty in establishing the actual mortality rate from COVID-19, the difference between the expected deaths and those recorded by the Hospital Mortality Committee constitutes the most approximate value

Pre-exposure prophylaxis, a new approach for HIV prevention: experience from the HIV Center of the Military University Hospital Prague.

AIMS: To present our experience with pre-exposure prophylaxis (PrEP) at the HIV Center of the Military University Hospital Prague, to characterize a set of PrEP candidates, to assess the efficiency and safety of PrEP and to measure the incidence of sexually transmitted diseases (STDs) in the studied cohort. MATERIAL AND METHODS: In total, 99 PrEP candidates (98 men who have sex with men and one woman) were monitored during an 18-month period. An initial examination included acquiring a history, performing a physical examination, screening for HIV (serology) and other STDs and performing renal function tests. RESULTS: In total, 81 candidates (in the cohort of 99 candidates) received PrEP. During the course of the 18-month period, none of the clients were newly infected with HIV, and no side effects of the provided medication were recorded. A total of 21% of the 99 PrEP candidates were initially tested positive for STDs, including two clients with HIV. A total of 14% of the 81 PrEP clients contracted an STD during the monitoring period. CONCLUSIONS: Experience amassed at the HIV Center of the Military University Hospital Prague over an 18-month period documented the demand for PrEP, assessed PrEP efficacy, indicated good tolerance and suggested that PrEP played a role in the decline in the HIV incidence in the Czech Republic. In addition, several new HIV cases and cases of other asymptomatic STDs were also detected.

COVID-19 autopsy reports from the Ga-East Municipal and the 37 Military Hospitals in Accra, Ghana.

INTRODUCTION: Since the declaration of COVID-19 by the World Health Organisation (WHO) as a global pandemic on 11th March 2020, the number of deaths continue to increase worldwide. Reports on its pathologic manifestations have been published with very few from the Sub-Saharan African region. This article reports autopsies on COVID-19 patients from the Ga-East and the 37 Military Hospitals to provide pathological evidence for better understanding of COVID-19 in Ghana. METHODS: Under conditions required for carrying out autopsies on bodies infected with category three infectious agents, with few modifications, complete autopsies were performed on twenty patients with ante-mortem and/or postmortem RT -PCR confirmed positive COVID-19 results, between April and June, 2020. RESULTS: There were equal proportion of males and females. Thirteen (65%) of the patients were 55years or older with the same percentage (65%) having Type II diabetes and/or hypertension. The most significant pathological feature found at autopsy was diffuse alveolar damage. Seventy per cent (14/20) had associated thromboemboli in the lungs, kidneys and the heart. Forty per cent (6/15) of the patients that had negative results for COVID-19 by the nasopharyngeal swab test before death had positive results during postmortem using bronchopulmonary specimen. At autopsy all patients were identified to have pre-existing medical conditions. CONCLUSION: Diffuse alveolar damage was a key pathological feature of deaths caused by COVID-19 in all cases studied with hypertension and diabetes mellitus being major risk factors. Individuals without co-morbidities were less likely to die or suffer severe disease from SARS-CoV-2. FUNDING: None declared.

Outcomes of Right Thoracoscopic Esophagectomy Combined with Laparotomy: a Preliminary Vietnamese Study.

BACKGROUND: Esophageal cancer is the fourth-most-common cancerous disease of the gastrointestinal tract, with increasing incidence rates. AIM: The present study aimed to assess the outcomes of right thoracoscopic esophagectomy combined with laparotomy for esophageal cancer treatment in Vietnamese patients. METHODS: A cross-sectional study of 71 patients was conducted at 108 Military Central Hospital, Hanoi, Vietnam, from January 2010 to December 2017. RESULTS: Right thoracoscopic esophagectomy combined with laparotomy was performed in 71 patients with esophageal cancer. The mean patient age was 55.8 years, and 100% were male. Patients were diagnosed with the following cancer stages: Stage 0: 4.2%; Stage I: 14.1%; Stage II: 59.2%; and Stage III: 22.5%. The lymph node metastasis rate was 33.8%. The overall complication rate was 42.3%, which included a pneumonia rate of 12.3%, a respiratory failure rate of 7.0%, an anastomotic leak rate of 11.3%, and a chylothorax rate of 4.2%. The mean postoperative time was 16.4 days. The mean follow-up time was 21.7 months. The median overall survival was 45.7 months. The 1-year, 2-year, 3-year, and 4-year survival rates were 79.7%, 62.3%, 52.3%, and 43.6%, respectively. CONCLUSIONS: Thoracoscopic esophagectomy combined with laparotomy for esophageal cancer was a safe, effective, and minimally invasive procedure that should play a continued role in cancer treatment.

Predicting Opioid Use, Increased Health Care Utilization and High Costs for Musculoskeletal Pain: What Factors Mediate Pain Intensity and Disability?

This study determined the predictive capabilities of pain intensity and disability on health care utilization (number of condition-specific health care visits, incident, and chronic opioid use) and costs (total condition-specific and overall medical costs) in the year following an initial evaluation for musculoskeletal pain. We explored pain catastrophizing and spatial distribution of symptoms (ie, body diagram symptom score) as mediators of these relationships. Two hundred eighty-three military service members receiving initial care for a musculoskeletal injury completed a region-specific disability measure, numeric pain rating scale, Pain Catastrophizing Scale, and body pain diagram. Pain intensity predicted all outcomes, while disability predicted incident opioid use only. No mediation effects were observed for either opioid use outcome, while pain catastrophizing partially mediated the relationship between pain intensity and number of health care visits. Pain catastrophizing and spatial distribution of symptoms fully mediated the relationship between pain intensity and both cost outcomes. The mediation effects of pain catastrophizing and spatial distribution of symptoms are outcome specific, and more consistently observed for cost outcomes. Higher pain intensity may drive more condition-specific health care utilization and use of opioids, while higher catastrophizing and larger spatial distribution of symptoms may drive higher costs for services received. PERSPECTIVE: This article examines underlying characteristics that help explain relationships between pain intensity and disability, and the outcomes of health care utilization and costs. Health care systems can use these findings to refine value-based prediction models by considering factors that differentially influence outcomes for health care use and cost of services.

Pattern and Outcome of Uveitis in a Tertiary Military Hospital in Thailand.

BACKGROUND: Causes of uveitis vary upon the epidemiologic, racial, and geographical variations. OBJECTIVE: The objective of the study is to analyze pattern and outcome of uveitis in Phramongkutklao Hospital. METHODS: This is a retrospective study. RESULTS: Rate of uveitis was 580 cases per 100 000 persons including infectious uveitis (20%), idiopathic (36%), and noninfectious (44%). The male-to-female ratio was 1.2:1. Anterior uveitis was the most common (50%) followed by panuveitis (25.6%), posterior uveitis (12.3%), and intermediate uveitis (7.3%). The three most common causes were Behçet's disease, HLA-B27-associated uveitis, and herpetic iridocyclitis. A total of 62 patients (10.6%) suffered from blindness, for which the most diagnostic disease was Behçet's disease. The most common complication was glaucoma (21%). Acute onset, unilateral, posterior uveitis, granulomatous inflammation, and complications differed significantly between the infectious and noninfectious groups (p < 0.001). CONCLUSION: The rate of uveitis was 0.58% and noninfectious uveitis was common. Clinical presentations regarding acute onset, unilateral, posterior uveitis, and granulomatous inflammation suggest infectious causes.

Emergency General Surgery Volume and Its Impact on Outcomes in Military Treatment Facilities.

BACKGROUND: Low hospital volume for emergency general surgery (EGS) procedures is associated with worse patient outcomes within the civilian health care system. The military maintains treatment facilities (MTFs) in remote locations to provide access to service members and their families. We sought to determine if patients treated at low-volume MTFs for EGS conditions experience worse outcomes compared with high-volume centers. MATERIALS AND METHODS: We analyzed TRICARE data from 2006 to 2014. Patients were identified using an established coding algorithm for EGS admission. MTFs were divided into quartiles based on annual EGS volume. Outcomes included 30-d mortality, complications, and readmissions. Logistic regression models adjusting for clinical and sociodemographic differences in case-mix including EGS condition, surgical intervention, and comorbidities were used to determine the influence of hospital volume on outcomes. RESULTS: We identified 106,915 patients treated for an EGS condition at 79 MTFs. The overall mortality rate was 0.21%, with complications occurring in 8.55% and readmissions in 4.45%. After risk adjustment, lowest-volume MTFs did not demonstrate significantly higher odds of mortality (OR: 2.02, CI: 0.45-9.06) or readmissions (OR: 0.77, CI: 0.54-1.11) compared with the highest-volume centers. Lowest-volume facilities exhibited a lower likelihood of complications (OR: 0.76, CI: 0.59-0.98). CONCLUSIONS: EGS patients treated at low-volume MTFs did not experience worse clinical outcomes when compared with high-volume centers. Remote MTFs appear to provide care for EGS conditions comparable with that of high-volume facilities. Our findings speak against the need to reduce services at small, critical access facilities within the military health care system.

Characterization of patients with bacteremia by methicillin-resistant Staphylococcus aureus in a high-complexity military hospital / Caracterización de los pacientes con bacteriemia por Staphylococcus aureus resistente a la meticilina en un hospital militar de alta complejidad

Introduction: In Colombia, there are about 500,000 members in the national armed forces who consult military health institutions. In this population, methicillin-resistant Staphylococcus aureus (MRSA) has become a high-incidence pathogen. Objective: The aim of this study was to characterize patients with MRSA bacteremia in the Hospital Militar Central between 2012 and 2015. Materials and methods: This was an observational descriptive study with a retrospective review of clinical histories of hospitalized patients older than 18 years of age with positive blood cultures for methicillin-resistant S. aureus. The identification of the patients was made using the Whonet system, version 5.6. Results: From cultures positive for S. aureus, 24.8% were methicillin-resistant strains, with a higher prevalence in active military personnel. A similar frequency was observed for community-acquired MRSA bacteremias and those acquired at the hospital, with the community phenotype being the most frequent in both groups. The main infectious focus related to the development of bacteremia was soft tissue, followed by pulmonary tissue. There were higher complication rates in nosocomial bacteremias; 34.9% of the patients had prolonged stays attributable to complications triggered by the bacteremia. Conclusions: Active military personnel was the most affected population by MRSA, with a similar frequency in community-acquired and nosocomial bacteremias. The main infectious focus was soft tissue. Taking into account these data, studies that establish the prevalence of skin infections by MRSA should be carried out.

Introducción. En las Fuerzas Militares de Colombia, cerca de 500.000 de sus miembros asisten a consulta en los establecimientos sanitarios militares. En esta población, Staphylococcus aureus resistente a la meticilina (SAMR) se ha convertido en un agente patógeno de gran incidencia. Objetivo. Caracterizar los pacientes con diagnóstico de bacteriemia por SAMR en el Hospital Militar Central entre el 2012 y el 2015. Materiales y métodos. Se llevó a cabo un estudio observacional descriptivo de revisión retrospectiva de historias clínicas de pacientes mayores de 18 años, hospitalizados y con hemocultivos positivos para S. aureus resistente a la meticilina. Para la identificación de los pacientes se empleó el sistema Whonet, version 5.6. Resultados. De los 177 cultivos positivos para S. aureus, el 24,8 % (n=44) correspondió a SAMR, con mayor prevalencia en pacientes militares activos (n=20m 45,4 %). Se observó una frecuencia similar para la bacteriemia por SAMR adquirida en la comunidad y la adquirida en el hospital, siendo más frecuente (n=37, 84 %) el fenotipo de la comunidad en ambos grupos. El principal foco infeccioso fueron los tejidos blandos, seguidos por el tejido pulmonar. Se presentaron mayores tasas de complicaciones (61%, n=13) en la bacteriemia adquirida en el hospital; 34,9 % (n=15),de los pacientes tuvieron una estancia hospitalaria prolongada atribuible a las complicaciones desencadenadas por la bacteriemia. Conclusiones. La población más afectada por SAMR fueron los pacientes militares activos (n=20, 45,4 %), con una frecuencia similar de la bacteriemia adquirida en la comunidad (n=18, 43,2 %) y la adquirida en el hospital (n=25, 56,8 %), y el principal foco infeccioso fueron los tejidos blandos. Dados estos resultados, es necesario adelantar estudios para establecer la prevalencia de infecciones por SAMR en la piel.

Evaluation of Surgical Disparities Between African American and European American Women Treated for Breast Cancer Within an Equal-Access Military Hospital.

BACKGROUND: Survival disparities between African American women (AAW) and European American women (EAW) with invasive breast cancer may be attributable, in part, to access to or quality of medical care. In this study, we evaluated surgical disparities between AAW and EAW treated within an equal-access military treatment facility (MTF). METHODS: All AAW (N = 271) and EAW (N = 628) with Stage I-III breast cancer who had their initial diagnosis performed at Murtha Cancer Center at Walter Reed National Military Medical Center were identified. Differences in surgical interval (time between diagnosis and definitive breast surgery) and surgical procedures were evaluated using χ2 and Student t-tests while survival was analyzed using Kaplan-Meier survival estimates and log-rank tests. A P value < 0.05 was used to define significance. RESULTS: Surgical intervals did not differ significantly between populations with an average of 36.3 days in AAW and 33.9 days in EAW. Frequency of the percentage of women undergoing reexcision, mastectomy, and prophylactic removal of the contralateral breast did not differ significantly between populations. Likewise, frequency of sentinel lymph node biopsy and 5-year survival were not significantly different between AAW compared to EAW. DISCUSSION: Surgical intervals and procedures were similar between AAW and EAW treated within an equal-access MTF. These data demonstrate that the availability of quality surgical care to all patients with stage I-III breast cancer may eliminate survival disparities between AAW and EAW, emphasizing the importance of equalizing access to breast care.