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Studies

On this page you can find various studies developed by Military Health System. Please scroll down or use the search box to find specific studies.

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We found 213 items resulting from your search.

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All Military Adolescents Are Not the Same: Sexuality and Substance Use among Adolescents in the U.S. Military Healthcare System.

Study

Abstract

Data examining sexuality and substance use among active duty and military-dependent youth is limited; however, these psychosocial factors have military implications. Adolescents and young adults aged 12-23 were recruited from an active-duty trainee clinic (n = 225) and a military pediatric clinic (n = 223). Active duty participants were more likely to be older, male, White, previous tobacco users, and report a history of sexual activity and less contraception use at their most recent intercourse, compared to the dependent group. Over 10% of all participants indicated attraction to members of the same gender or both genders. In logistic regression analysis, non-White participants were less likely to use contraception compared to White participants. Adolescents and young adults seen in military clinics frequently engage in high-risk behavior. Clinicians who care for military youth should assess their patient's psychosocial history. Further study of this population is warranted to identify factors that may influence risk and resilience.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source: Air Force
  • Release Date/Publication: October 01, 2015
  • Citation: Klein DA, Adelman WP, Thompson AM, Shoemaker RG, Shen-Gunther J. All Military Adolescents Are Not the Same: Sexuality and Substance Use among Adolescents in the U.S. Military Healthcare System. PLoS One. 2015 Oct 29;10(10):e0141430

Protecting military personnel from high risk dietary supplements.

Study

Abstract

It is legal to market most naturally occurring substances as dietary supplements in the USA without manufacturers demonstrating they are safe or effective, and an endless variety of ingredients, from esoteric botanicals to unapproved pharmaceuticals, can be found in dietary supplements. Use of certain supplements can pose a risk, but since a robust reporting system does not exist in the USA it is difficult to know which are problematic and the number of adverse events (AE) resulting from their use. Certain populations, including military personnel, are more likely to use dietary supplements than the general population. Approximately 70% of military personnel take dietary supplements while about 50% of civilians do. Service members prefer supplements purported to enhance physical performance such as supposedly natural stimulants, protein and amino acids, and combination products. Since some of these may be problematic, Service members are probably at higher risk of injury than the general population. Ten percent of military populations appear to be taking potentially risky supplements, and the US Department of Defense (DoD) has taken various measures to protect uniformed personnel including education, policy changes, and restricting sales. Actions taken include launching Operation Supplement Safety (OPSS), introducing a High Risk Supplement list, educating health care professionals on reporting AE that might be associated with dietary supplements, recommending policy for reporting AE, and developing an online AE reporting system. OPSS is a DoD-wide effort to educate service members, leaders, health care providers, military families, and retirees on how to safely select supplements

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source:
  • Release Date/Publication: October 01, 2015
  • Citation: Deuster PA, Lieberman HR. Protecting military personnel from high risk dietary supplements. Drug Test Anal. 2015 Oct 16.

Palliative Care in the U.S. Military Health System.

Study

Abstract

No abstract available

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Walter Reed National Military Medical Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: October 01, 2015
  • Citation: Snyder S. Palliative Care in the U.S. Military Health System. Mil Med. 2015 Oct;180(10):1024-6.

Chikungunya infection in DoD healthcare beneficiaries following the 2013 introduction of the virus into the Western Hemisphere, 1 January 2014 to 28 February 2015.

Study

Abstract

The introduction and rapid spread of chikungunya virus (CHIKV) into the Western Hemisphere after December 2013 pose a potentially significant risk to Department of Defense (DoD) personnel, operations, and the military healthcare system. This report describes the DoD experience with CHIKV between January 2014 and February 2015 using case reports in the Defense Medical Surveillance System's (DMSS) Reportable Medical Events database and the Navy and Marine Corps Public Health Center's laboratory test results database. Case finding identified 157 confirmed cases; of these, 118 (75.2%) were either active or reserve component service members and 39 (24.8%) were other beneficiaries. Exposure locations were known for 117 (74.5%) of all cases, and of these, 113 (96.6%) reported likely exposures in the Western Hemisphere; 85 (75.2%) of those cases occurred in Puerto Rico. Although historical data on CHIKV in DoD populations are scant, introduction of CHIKV into the Western Hemisphere with ongoing transmission appears to have resulted in a significant increase in the number of cases among DoD healthcare beneficiary populations.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Armed Forces Health Surveillance Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: October 01, 2015
  • Citation: Chikungunya infection in DoD healthcare beneficiaries following the 2013 introduction of the virus into the Western Hemisphere, 1 January 2014 to 28 February 2015. MSMR. 2015 Oct;22(10):2-6.

Ethics, Human Use, and the Department of Defense Serum Repository.

Study

Abstract

The Department of Defense Serum Repository (DoDSR) contains a growing archive of sera from service members collected to perform medical surveillance, clinical diagnosis, and epidemiologic studies to identify, prevent, and control diseases associated with military service. The specimens are a mandatory collection under DoD and U.S. regulations and do not include informed consent for uses beyond force health protection. Any use of the specimens for research requires deidentification of the samples and must be approved by Institutional Review Boards. However, as expansion of the DoDSR is contemplated, ethical considerations of sample collection, storage, and use must be carefully reconsidered. Other similar programs for research use of specimens collected for public health purpose are also undergoing similar reviews. It is recommended that at a minimum, service members are informed of the potential storage and use of their specimens and are allowed to opt out of additional use, or a broad informed consent is provided. The DoDSR provides a tremendous resource to the DoD and global health community, and to ensure its continued existence and improvement, the DoD must stay consistent with all principles of research ethics.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Armed Forces Health Surveillance Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: October 01, 2015
  • Citation: Pavlin JA, Welch RA. Ethics, Human Use, and the Department of Defense Serum Repository. Mil Med. 2015 Oct;180(10 Suppl):49-56.

Outcomes After Post-Traumatic AKI Requiring RRT in United States Military Service Members.

Study

Abstract

BACKGROUND AND OBJECTIVES:

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Walter Reed National Military Medical Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: October 01, 2015
  • Citation: Bolanos JA, Yuan CM, Little DJ, Oliver DK, Howard SR, Abbott KC, Olson SW. Outcomes After Post-Traumatic AKI Requiring RRT in United States Military Service Members. Clin J Am Soc Nephrol. 2015 Oct 7;10(10):1732-9.

The vital civilian-military link in combat casualty care research: Impact of attendance at scientific conferences.

Study

Abstract

BACKGROUND: Attendance by military medical personnel (MMP) at scientific meetings (SMs) of civilian associations has been centrally managed since 2012. We aimed to document the importance of civilian-military interaction to and the impact of this change on combat casualty care (CCC) research. METHODS: (1) We identified 25 clinically significant CCC articles published by MMP between 2005 and 2014; we determined whether these articles were preceded by presentation by MMP at an SM. (2) We examined the changing civilian-military mix of publications on "damage control resuscitation" (DCR). (3) We analyzed the number of presentations by MMP each year at the American Association for the Surgery of Trauma. (4) We reviewed whether past presidents of the AAST (for 1992-2014) had military experience. RESULTS: (1) Ninety-two percent of the CCC articles were previously presented at an SM; 66% were presented at civilian association venues such as AAST. (2) DCR was first described in 2006; the civilian-military mix of publications rose steadily from 0 in 2006 to 80% in 2014. (3) The number of MMP oral presentations at AAST peaked during 2005 to 2007 and has declined to one to two per year since 2012. (4) Thirty-three percent of recent AAST presidents had military experience, versus 100% for the previous era. CONCLUSION: Recent conflicts led to intense civilian-military collaboration in CCC research and to the spread of ideas such as DCR from military to civilian care. However, long-term trends (e.g., declining rates of military service nationally) place such collaboration at risk. Vigorous efforts to foster the vital civilian-military link in CCC are needed. PMID: 26406434 [PubMed - indexed for MEDLINE]

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source:
  • Release Date/Publication: October 01, 2015
  • Citation: Cancio LC, Rasmussen TE, Cannon JW, Dubick MA. The vital civilian-military link in combat casualty care research: Impact of attendance at scientific conferences. J Trauma Acute Care Surg. 2015 Oct;79(4 Suppl 2):S221-6.

Survival and Racial Differences of Non-Small Cell Lung Cancer in the United States Military.

Study

Abstract

BACKGROUND: Lung cancer is the leading cause of cancer-related death in the United States (US) Military and worldwide, with non-small cell lung cancer (NSCLC) accounting for 87 % of cases. OBJECTIVES: Using a US military cohort who receives equal and open access to healthcare, we sought to examine demographic, clinical features and outcomes with NSCLC. DESIGN AND PARTICIPANTS: We conducted a retrospective cohort analysis of 4,751 patients, aged ≥ 18 years and diagnosed with a first primary NSCLC between 1 January 2003 and 31 December 2013 in the US Department of Defense (DoD) cancer registry. MAIN MEASURES: Differences by patient and disease characteristics were compared using Chi-square and t-test. Kaplan Meier curves and Cox proportional hazards regression assessed overall survival. RESULTS: The mean age at diagnosis was 66 years, 64 % were male, 72 % were Caucasian, 41 % were diagnosed at early stage, 77 % received treatment and 82 % had a history of tobacco use. Mean age at diagnosis was highest among Caucasians (67 years) and lowest among African Americans (AA; 62 years). Asian/Pacific Islanders (PI) were more likely to be female (p < 0.0001), have adenocarcinoma histology (p = 0.0003) and less likely to have a history of tobacco use (p < 0.0001) compared to other racial/ethnic groups. In multivariable survival analysis, older age, male gender, increasing stage, not receiving treatment, and tobacco history were associated with higher mortality risk. Untreated patients exhibited a 39 % higher mortality risk compared to treated patients (HR = 1.39; 95%CI = 1.23-1.57). Compared to Caucasian patients, Asian/PIs demonstrated a 20 % lower risk of death (HR = 0.80; 95%CI = 0.66-0.96). There was no difference in mortality risk between AAs and Hispanics compared to Caucasians. CONCLUSION: The lack of significant outcome disparity between AAs and Caucasians and the earlier stage at diagnosis than usually seen in civilian populations suggest that equal access to healthcare may play a role in early detection and survival.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Walter Reed National Military Medical Center
  • Congressionally Mandated: No
  • Funding Source:
  • Release Date/Publication: October 01, 2015
  • Citation: Brzezniak C, Satram-Hoang S, Goertz HP, Reyes C, Gunuganti A, Gallagher C, Carter CA. Survival and Racial Differences of Non-Small Cell Lung Cancer in the United States Military. J Gen Intern Med. 2015 Oct;30(10):1406-12

Impact of Mucorales and Other Invasive Molds on Clinical Outcomes of Polymicrobial Traumatic Wound Infections.

Study

Abstract

Combat trauma wounds with invasive fungal infections (IFIs) are often polymicrobial with fungal and bacterial growth, but the impact of the wound microbiology on clinical outcomes is uncertain. Our objectives were to compare the microbiological features between IFI and non-IFI wounds and evaluate whether clinical outcomes differed among IFI wounds based upon mold type. Data from U.S. military personnel injured in Afghanistan with IFI wounds were examined. Controls were matched by the pattern/severity of injury, including blood transfusion requirements. Wound closure timing was compared between IFI and non-IFI control wounds (with/without bacterial infections). IFI wound closure was also assessed according to mold species isolation. Eighty-two IFI wounds and 136 non-IFI wounds (63 with skin and soft tissue infections [SSTIs] and 73 without) were examined. The time to wound closure was longer for the IFI wounds (median, 16 days) than for the non-IFI controls with/without SSTIs (medians, 12 and 9 days, respectively; P < 0.001). The growth of multidrug-resistant Gram-negative rods was reported among 35% and 41% of the IFI and non-IFI wounds with SSTIs, respectively. Among the IFI wounds, times to wound closure were significantly longer for wounds with Mucorales growth than for wounds with non-Mucorales growth (median, 17 days versus 13 days; P < 0.01). When wounds with Mucorales and Aspergillus spp. growth were compared, there was no significant difference in wound closure timing. Trauma wounds with SSTIs were often polymicrobial, yet the presence of invasive molds (predominant types: order Mucorales, Aspergillus spp., and Fusarium spp.) significantly prolonged the time to wound closure. Overall, the times to wound closure were longest for the IFI wounds with Mucorales growth.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Walter Reed National Military Medical Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: July 01, 2015
  • Citation: Warkentien TE, et.al., Impact of Mucorales and Other Invasive Molds on Clinical Outcomes of Polymicrobial Traumatic Wound Infections. J Clin Microbiol. 2015 Jul;53(7):2262-70.

Third-Party Evaluation: A Review of Dietary Supplements Dispensed by Military Treatment Facilities From 2007 to 2011.

Study

Abstract

INTRODUCTION: Third-party certification/verification of dietary supplements (DS), although not mainstream, is one way to help ensure high-quality products. In the medical setting, physicians may prescribe DS to correct a deficiency or improve a health care outcome, and they want products of a certain standard of quality, free of adulteration/contamination. OBJECTIVE: We reviewed DS dispensed from all Department of Defense military treatment facilities over a 5-year period to determine which products had been third-party reviewed and certified/verified. METHODS: By using product name, manufacturer, and/or National Drug Codes, we examined product listings on the websites of three independent-evaluating organizations. RESULTS: Over 1.5 million dietary supplement prescriptions consisting of 753 different products were dispensed from 2007 through 2011. Less than 3.6% of the products examined were third-party certified/verified by any of the three most well-known evaluation organizations: 19 were verified by United States Pharmacopeial Convention; 9 products were reviewed and 8 certified by ConsumerLab; and none of the products were certified by NSF International. CONCLUSION: Most DS dispensed by military treatment facilities are not reviewed by a third party. This is not unexpected, as third party certification is not yet mainstream. However, one way to reduce potential hazards and exposure to unsafe products is to encourage use of supplements that have third-party certification/verification.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: July 01, 2015
  • Citation: Jones DR, Kasper KB, Deuster PA. Third-Party Evaluation: A Review of Dietary Supplements Dispensed by Military Treatment Facilities From 2007 to 2011. Mil Med. 2015 Jul;180(7):737-41.

Respiratory Infections in the U.S. Military: Recent Experience and Control.

Study

Abstract

This comprehensive review outlines the impact of military-relevant respiratory infections, with special attention to recruit training environments, influenza pandemics in 1918 to 1919 and 2009 to 2010, and peacetime operations and conflicts in the past 25 years. Outbreaks and epidemiologic investigations of viral and bacterial infections among high-risk groups are presented, including (i) experience by recruits at training centers, (ii) impact on advanced trainees in special settings, (iii) morbidity sustained by shipboard personnel at sea, and (iv) experience of deployed personnel. Utilizing a pathogen-by-pathogen approach, we examine (i) epidemiology, (ii) impact in terms of morbidity and operational readiness, (iii) clinical presentation and outbreak potential, (iv) diagnostic modalities, (v) treatment approaches, and (vi) vaccine and other control measures. We also outline military-specific initiatives in (i) surveillance, (ii) vaccine development and policy, (iii) novel influenza and coronavirus diagnostic test development and surveillance methods, (iv) influenza virus transmission and severity prediction modeling efforts, and (v) evaluation and implementation of nonvaccine, nonpharmacologic interventions.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Armed Forces Health Surveillance Center
  • Congressionally Mandated: No
  • Funding Source:
  • Release Date/Publication: July 01, 2015
  • Citation: Sanchez JL, Cooper MJ, Myers CA, Cummings JF, Vest KG, Russell KL, Sanchez JL, Hiser MJ, Gaydos CA. Respiratory Infections in the U.S. Military: Recent Experience and Control. Clin Microbiol Rev. 2015 Jul;28(3):743-800.

Group Prenatal Care Outcomes in a Military Population: A Retrospective Cohort Study.

Study

Abstract

OBJECTIVE: To evaluate pregnancy outcomes in Centering Pregnancy patients. METHODS: This was an IRB-approved retrospective cohort study from November 2009 to January 2013 involving 202 Centering Pregnancy patients and 202 Certified Nurse Midwife patients. The primary outcome was mean gestational age at time of delivery. Secondary outcomes included cesarean and operative vaginal delivery rate, triage visit frequency, Neonatal Intensive Care Unit admission rate, 1 and 5 minute APGAR scores, birth weight, breastfeeding rate at discharge and 6 weeks postpartum, third and fourth degree laceration rate, weight gain in pregnancy, and excessive weight gain rate. RESULTS: There was no statistically significant difference in any obstetric outcome including preterm delivery rate. Centering Pregnancy patients were more likely to be active duty (52.0 vs. 35.6%, p = 0.001), younger (24.8 vs. 26.3 years old, p < 0.001), and nulliparous (75.2 vs. 56.9%, p < 0.001). There was a statistically significant increase in triage visit frequency ≥ 6 for Centering Pregnancy patients (11.9% vs. 8.9%, p = 0.011). CONCLUSION: There were no clinically significant differences in the primary or secondary outcomes. Significant cost savings could be realized by expanding Centering Pregnancy in the military health system.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Walter Reed National Military Medical Center
  • Congressionally Mandated: No
  • Funding Source:
  • Release Date/Publication: July 01, 2015
  • Citation: Walton RB, Shaffer S, Heaton J. Group Prenatal Care Outcomes in a Military Population: A Retrospective Cohort Study. Mil Med. 2015 Jul;180(7):825-9.

Trends in Androgen Prescriptions From Military Treatment Facilities: 2007 to 2011.

Study

Abstract

INTRODUCTION: The role of testosterone in health and quality of life has become increasingly visible and overtly marketed to the public. Some evidence suggests that testosterone levels in men may be low because of a variety of reasons, including stress and environmental exposures. OBJECTIVE: This study examines trends in testosterone prescriptions dispensed by military treatment facilities (MTFs). METHODS: We examined data from the Department of Defense Pharmacy Data Transaction Service to determine the nature of androgen prescriptions dispensed through MTFs from 2007 through 2011. RESULTS: The number of androgen prescriptions increased more than two-fold across the military from 19,494 in 2007 to 45,270 in 2011. Most prescriptions (99%) were for men. Androgen prescription rates rose 23% per year from 2007 through 2011 (p < 0.001, CI 23-24%). The prescription rate for 35- to 44-year-olds increased more than any other age group, with annual increases averaging 33% (p < 0.001, CI 32-34%). CONCLUSION: The number of androgen prescriptions within MTFs rose significantly from 2007 through 2011. This is similar to rises in androgen prescriptions seen in civilian medical systems. Clinical indications for the sharp increase in testosterone prescriptions are unknown, and the indications for clinically appropriate testosterone replacement need further clarification.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: July 01, 2015
  • Citation: Canup R, Bogenberger K, Attipoe S, Jones DR, Olsen CH, Stephens MB, Deuster PA. Trends in Androgen Prescriptions From Military Treatment Facilities: 2007 to 2011. Mil Med. 2015 Jul;180(7):728-31.

Trends in B-Vitamin Prescriptions From Military Treatment Facilities: 2007 to 2011.

Study

Abstract

INTRODUCTION:

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: July 01, 2015
  • Citation: Krieger JA, Arnold RM, Attipoe S, Jones DR, Stephens MB, Deuster PA. Trends in B-Vitamin Prescriptions From Military Treatment Facilities: 2007 to 2011. Mil Med. 2015 Jul;180(7):732-6.

Development and validation of trauma surgical skills metrics: Preliminary assessment of performance after training.

Study

Abstract

BACKGROUND: Maintaining trauma-specific surgical skills is an ongoing challenge for surgical training programs. An objective assessment of surgical skills is needed. We hypothesized that a validated surgical performance assessment tool could detect differences following a training intervention. METHODS: We developed surgical performance assessment metrics based on discussion with expert trauma surgeons, video review of 10 experts and 10 novice surgeons performing three vascular exposure procedures and lower extremity fasciotomy on cadavers, and validated the metrics with interrater reliability testing by five reviewers blinded to level of expertise and a consensus conference. We tested these performance metrics in 12 surgical residents (Year 3-7) before and 2 weeks after vascular exposure skills training in the Advanced Surgical Skills for Exposure in Trauma (ASSET) course. Performance was assessed in three areas as follows: knowledge (anatomic, management), procedure steps, and technical skills. Time to completion of procedures was recorded, and these metrics were combined into a single performance score, the Trauma Readiness Index (TRI). Wilcoxon matched-pairs signed-ranks test compared pretraining/posttraining effects. RESULTS: Mean time to complete procedures decreased by 4.3 minutes (from 13.4 minutes to 9.1 minutes). The performance component most improved by the 1-day skills training was procedure steps, completion of which increased by 21%. Technical skill scores improved by 12%. Overall knowledge improved by 3%, with 18% improvement in anatomic knowledge. TRI increased significantly from 50% to 64% with ASSET training. Interrater reliability of the surgical performance assessment metrics was validated with single intraclass correlation coefficient of 0.7 to 0.98. CONCLUSION: A trauma-relevant surgical performance assessment detected improvements in specific procedure steps and anatomic knowledge taught during a 1-day course, quantified by the TRI. ASSET training reduced time to complete vascular control by one third. Future applications include assessing specific skills in a larger surgeon cohort, assessing military surgical readiness, and quantifying skill degradation with time since training.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source:
  • Release Date/Publication: July 01, 2015
  • Citation: Shackelford S, et. al., . Development and validation of trauma surgical skills metrics: Preliminary assessment of performance after training. J Trauma Acute Care Surg. 2015 Jul;79(1):105-10.
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