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    • Past contributions of military medicine to civilian health c

    2018-10-23

    Past contributions of military medicine to civilian health care are numerous and substantive. They include improvements in ground and aeromedical medical evacuation (Larrey, 1814; Connor, 2010), regulation (Anon., 1937), open treatment of severe wounds (Moorhead, 1942a, 1942b; Gould, 1917), the combination of surgical débridement with local and systemic use of tranylcypromine manufacturer to reduce surgical site infection and sepsis (Moorhead, 1942a, 1942b; Meleney, 1948; Neushul, 1993), the application of vascular surgical techniques (Rich and Hughes, 1969), and, more recently, renewed use of tourniquets and other modalities to achieve field hemostasis (Lakstein et al., 2003). Each of these advances was catalyzed by one or more armed conflicts that stimulated quantum improvements in the treatment of severely injured patients. Most of these medical advances are now ubiquitous in modern civilian health care or, in the case of tourniquets, rapidly becoming so (Biddinger et al., 2013). Efforts to apply advanced analytics to support clinical decision making have the potential to transform healthcare, as dramatically as advanced analytics have transformed the financial, manufacturing, logistics and telecommunications industries (Brown et al., 2011). In addition to reducing lengths of stay and therefore inpatient costs, precision medicine can improve patient outcomes and save lives. Increasing the efficiency may be particularly important in ICUs, which represent only 10% of inpatient beds, but 20–35% of hospital operating costs (Krell, 2010). We are not the first group to attempt to apply knowledge gained in armed conflict to benefit future trauma victims. For example, the practice of quantitative bacterial cultures gained popularity after animal studies demonstrated the deleterious effects of high bacterial counts on split thickness skin graft healing (Liedberg et al., 1955). The technique was further developed for use in blast and burn wounds during the Vietnam era to estimate the likelihood of wound healing (Robson and Heggers, 1969; Krizek and Robson, 1975). Though the technique was successfully translated to the civilian setting in the treatment of burns, the use of quantitative culturing to predict the clinical course of blast wounds was lost. By reaffirming this observation that clinical decisions can be guided by biologic data in trauma patients, and demonstrating its utility in a preliminary sample of civilian trauma patients, we seek to reintroduce civilian practitioners to the value of this approach using modern assays and analytical capabilities. If the clinical decision support models we describe perform equally well in larger samples of patients, they may reduce the rate of open wound dehiscence to 5%. It this were accomplished, flowers would represent a 68% improvement over current practice in the US (Hostetler et al., 2006). In order to gauge the economic impact of improved decision making in critically injured patients, we performed an analysis on cost savings from reduced need for inpatient ICU care, general ward care, outpatient rehabilitation, and reduced exposure to hospital-acquired infections. Considering the 67,486 patients with traumatic extremity wounds, our approach could save the US healthcare system approximately $1 billion (£670 million) per year, primarily by reducing ICU, general ward, and rehabilitation stays by 1.7, 2.1, and 4.2days respectively (Fig. 4). Additionally, if the data we report had been available during the past decade of conflict, this approach we describe could decrease treatment costs in the military health system by more than $470 million (£314 million).
    Acknowledgments
    Introduction The publication of the 2014 Lancet Commission on liver disease has highlighted how the burden of liver disease in the UK has risen sharply over the past few decades and that it poses a major public health issue (Williams et al., 2014). It is the only major cause of mortality and morbidity which is on the increase in England, while at the same time decreasing in most other European countries, with cirrhosis accounting for 83% of deaths (Davies, 2012). It is the third biggest cause of premature mortality, with three quarters of liver deaths due to alcohol (Williams et al., 2014). Liver disease has a widespread effect not only to the patient, encompassing physical and psychological morbidity and mortality, but also incurring significant societal costs. One of the main difficulties is that often patients do not present symptoms or signs until the disease is advanced. Even then diagnosis is difficult and the symptoms and signs are often general and can be mistaken for other pathologies. Non-invasive diagnostic techniques currently used, namely serum biomarkers and transient elastography (TE) are not ideal. Serum biomarkers are not liver specific and TE results require an expert clinician for interpretation (Castera et al., 2015).