Military Medicine最新文献

Introduction: Comorbid insomnia and obstructive sleep apnea (COMISA) are prevalent conditions with significant physical and mental health comorbidities. Our study sought to estimate the effect of COMISA vs. obstructive sleep apnea (OSA) alone on subjective and objective sleep, daytime symptoms including cognition, and healthcare resource utilization (HCRU) among military service members (SMs).

Materials and methods: Military SMs (n = 201) completed research questionnaires and then an intensive 10-day remote monitoring assessment, including wearing a commercial sleep tracker, completing daily sleep diaries, and completing twice-daily symptom surveys via a mobile application. Subjective cognition was measured using 3 self-report items assessing memory, concentration, and executive function. Between-groups (COMISA vs. OSA) differences in subjective and objective sleep, daytime symptoms, and HCRU were examined using a series of one-way ANOVAs.

Results: Compared to participants with OSA alone (n = 98; 48.8%), participants with COMISA (n = 81; 40.3%) demonstrated poorer subjective sleep and daytime symptoms as measured by traditional questionnaires (i.e., Epworth Sleepiness Scale and Insomnia Severity Index) and twice-daily symptom surveys, as well as increased HCRU. No between-groups differences were observed in objectively measured sleep.

Conclusions: Among military SMs and relative to OSA alone, COMISA was associated with worsened subjective but not objective sleep, worsened daytime symptoms including cognition, and greater HCRU.

In this case report, a patient developed new focal epileptiform discharges following electroconvulsive therapy (ECT). No current evidence to date has established an increased risk of epilepsy following ECT, raising the question of ECT potentially triggering focal epileptogenesis. To address this question, literature findings from epidemiologic studies to isolated case reports were compiled from PubMed with an emphasis on patient risk factors, number of treatments, and described electroencephalographic patterns and seizure semiology post-ECT. The relationship between ECT and new-onset epilepsy remains controversial based on these findings. Two retrospective epidemiologic surveys of patients treated with ECT could not demonstrate an increased risk of ECT-induced epilepsy when accounting for individual risk factors. However, newer isolated case reports have described patients on maintenance ECT who then developed definite or possible epilepsy. In some of these cases, patients who received bitemporal electrode placement then developed temporal lobe epilepsy. Previous animal model studies suggest a form of electrical kindling that may explain epileptogenesis. The compiled findings suggest that ECT may trigger focal epileptogenesis in some patients, particularly those with bitemporal electrode placement. Health care providers should be aware of this potential risk and carefully evaluate patients before recommending ECT.

Introduction: Battlefield pancreatic injury (BPI) is rare and difficult to diagnose and treat. Publications on this topic are limited. The aim of this study was to analyze our initial experience in treating BPI since the beginning of the full-scale Russian invasion of Ukraine.

Materials and methods: We retrospectively analyzed the medical records of military personnel treated between February and December 2022. XLSTAT's variable characterization tool, using an indicator called test value (TV), was used to assess possible associations between variables.

Results: BPIs were found in 11 of 252 (4.4%) patients with an average age of 36.6 ± 10.1 years. The main cause of injury was explosion (6/11, 54.6%) and gunshot (2/11, 18.2%). Head of pancreas injuries were the most common (5/11, 45.5%), followed by distal pancreas injuries (4/11, 36.4%). Our treatment was predominantly interventional (5/11, 45.5%) and/or surgical drainage (4/11, 36.4%). Two patients (18.2%) were treated conservatively. One patient (9.1%) underwent cystojejunostomy for pseudocyst and another (9.1%) distal pancreatectomy. There was a positive association between the number of frontline operations and concomitant jejunal (TV 2.289; P = .022) and ileal (TV 2.211; P = .027) injuries. There was also a positive association between stoma formation at primary surgery and ileal injury (TV 2.000; P = .045) and pancreatic fistula and concomitant rib fractures (TV 2.484; P = .013).

Conclusions: BPIs would be expected in victims with explosive damage to the upper body, often located in the head of the pancreas. Concomitant small bowel injury and rib fractures are associated with increased frequency of stoma formation, number of primary surgeries, and pancreatic fistula. Most patients can be successfully managed with interventional or surgical drainage without resection.

U.S. military regulatory bodies have identified the crucial need for standardized Joint Austere Resuscitative Surgical Care curricula focused on training small surgical teams. The Joint Trauma System and Service-appointed subject matter experts analyzed current available curricula and courses and developed the first joint Austere Resuscitative Care curriculum for Role 2 surgical teams.

Introduction: Approximately 1 in 4 Navy recruits will not complete their obligated service. Identifying factors associated with Navy attrition is essential to retaining a skilled and motivated fighting force. This study utilized machine learning and variable importance measures (VIM) extracted from random forest (RF) and extreme gradient boosting (XGBoost) decision trees to identify factors that contribute to Navy attrition. These methods are more robust and sensitive when assessing hundreds of predictor variables, offering superior performance relative to regression analyses. Leveraging advanced analytics is crucial to better understand these factors to maximize military retention.

Materials and methods: The study population included Navy personnel with an accession date in 2016. The outcome of interest was a discharge date before the end of obligated service (i.e., attrition). The analysis incorporated 542 independent variables, including demographic factors, medical outpatient visits, and outpatient pharmacy medications. RF, XGBoost, and logistic regression models were trained with different subsets of features to determine which set of variables best predicted attrition. Model performance metrics were generated describing the sensitivity, specificity, positive and negative predictive values, area under the curve, and classification accuracy for the validation data.

Results: Overall, there were 39,866 Navy personnel with accessions in 2016 and, of these, 28.15% (n = 11,177) did not complete their obligated service. The RF model provided the best accuracy for predicting attrition (81.7%) and area under the curve (90.0%). Both the RF and XGBoost models outperformed the logistic regression model. VIMs were then assessed, including mean decrease accuracy, mean decrease Gini impurity, gain, and cover. The resulting VIM identified five groups described as: mental health, occupations, demographics/sex-related issues, pain management, and medical compliance. The top 3 VIM and their overall relative risk on attrition were adjustment disorders (RR = 1.39 higher), Seaman Specialists (RR = 3.01 higher), and Electronic Equipment Repairers (RR = 0.44 lower).

Conclusions: Five groups of variables were found to be predictive of Navy attrition: Mental health (MH) disorder, alcohol-related problems, occupations, sex, medical appointment compliance, and pain management. These results demonstrate the utility of machine learning models in predicting attrition compared with regression analyses. VIM is a valuable tool that could be used in decision-making processes in the context of military personnel management and retention. Furthermore, ensemble approaches, compared with a single decision tree, improve overall predictive performance and result in a more robust model that is resistant to overfitting.

Introduction: Military-dependent young adults (17-25 years old) with autism spectrum disorder (ASD) face significant barriers to accessing services during their transition to adulthood. Frequent relocations, disrupted care, and limited ASD-tailored interventions exacerbate the challenges for these families, with many young adults experiencing a "service cliff" as they age out of pediatric care and school-based services. Addressing these gaps is critical, particularly given the rising mental health challenges and executive dysfunction in this population. This study evaluates the preliminary efficacy of an adapted telehealth intervention, the Military-Launching! program, designed to support young adults with ASD and their military families.

Materials and methods: A repeated measures design was used to evaluate changes in functioning, self-efficacy, and quality of life among 20 military-dependent young adults with ASD and 34 of their parents. Participants completed measures at baseline, mid-treatment, and post-treatment. Young adults met ASD diagnostic criteria and exclusion criteria included intellectual disability (IQ < 75) or severe mental health conditions. Recruitment was facilitated through military programs at bases in Texas.

Results: Significant improvements were observed in young adults' social cognition (η = 0.52, P = .016) and executive functioning (BRIEF-A GEC, η = 0.26, P = .016). Parents reported significant reductions in stress (BRIEF-A BRI, η = 0.28, P = .004) and enhanced quality of life in social relationships (WHOQOL-BREF, P = .047). While adaptive functioning improvements were limited to specific subscales, parent-perceived transition readiness showed a large effect size (η = 0.36).

Conclusions: Preliminary findings suggest that the Military-Launching! program improves social cognition, executive functioning, and family outcomes for military-dependent young adults with ASD. Tailored, evidence-based interventions addressing co-occurring mental health and military-specific stressors are essential for fostering successful transitions to adulthood.

Introduction: Trauma-induced hemorrhage is the leading cause of preventable death on the battlefield, with anatomical junctional wounds accounting for ∼19% of deaths. This highlights the need for effective hemorrhage control interventions. Consequently, CounterFlow-Gauze was developed to deliver thrombin, tranexamic acid (TXA), and calcium through a self-propelling acid-base reaction, eliminating the need for manual compression. This study evaluates the usability and efficacy of CounterFlow-Gauze to the Committee on Tactical Combat Casualty Care standard of care, Combat Gauze.

Materials and methods: Ten Canadian Armed Forces medics tested the usability CounterFlow-Gauze and Combat Gauze in a swine junctional hemorrhage model. A 4-mm vascular punch was used to induce femoral injury, followed by a 15-second free bleed. Medics packed the wound and applied 3-minute compression. Medics were blinded to the gauze treatment and completed surveys to evaluate the gauzes. Animals were observed for 3 hours or until death, and blood loss was measured. Blood samples were also collected to measure TXA levels and establish baseline and treated values for blood gas, hematological, and coagulation parameters.

Results: Medics reported enhanced usability and greater efficacy of CounterFlow-Gauze (4.3 ± 0.9/5) compared to Combat Gauze (3.0 ± 1.2 /5; P < .05) in attenuating bleeding. CounterFlow-Gauze achieved high survivability (10/10 animals) and low blood loss (10.21 ± 1.83 g/kg) compared to Combat-Gauze (9/10 animals, 12.72 ± 3.03 g/kg; P > .05), while delivering systemic therapeutic levels of TXA by 30 minutes (10.92 ± 0.17 µg/mL). Changes in mean arterial pressure and heart rate were less pronounced with CounterFlow-Gauze compared to Combat Gauze (P > .05), while no differences were observed between baseline and treated values for any of the other measured parameters.

Conclusions: The self-propelling hemostatic agents of CounterFlow-Gauze may compensate for suboptimal packing by novice users or in high-stress situations. These findings support the adoption of CounterFlow-Gauze, providing all soldiers access to superior but restricted hemostatic agents in a safe and easy-to-use gauze on the battlefield.

Introduction: Endometrial intraepithelial neoplasia (EIN) and atypical endometrial hyperplasia (AEH) are precancerous pathologies which carry a 40-50% concurrent cancer incidence. National guidelines recommend an individualized approach to gynecologic oncologist (GO) referral for a new EIN-AEH diagnosis. With the risk of underlying carcinoma, exactly who should manage EIN-AEH is controversial. In the military health system, gynecologic specialists (GS) may be remote with significant barriers to GO consultation, presenting a complex medical and social burden with potential impact to mission readiness. To our knowledge, no study has evaluated EIN-AEH practice patterns in the military health system. As practice patterns may vary, we surveyed EIN-AEH management by active duty GS and GO.

Materials and methods: An observational, voluntary, tri-service, survey-based study was conducted (eIRB protocol #966986) using two web-based surveys designed by military GO: one completed by active duty GS, the other by active duty GO. Demographics examining influential factors were collected. Surveys examined attitudes and practice patterns regarding referral and management of EIN-AEH. Univariate analysis was performed.

Results: Of eligible physicians, 72 of 269 GS (26.8%) and 18 of 19 GO (94.7%) responded. More than 80% of GS/GO completed military medical training (81.9% vs. 88.9%), 72.2% vs. 61.1% were specialty-specific board-certified, 72.2% vs. 88.9% had a CONUS assignment, and 52.8% vs. 100% were part of large gynecologic surgery and obstetrics (GS&O) departments, respectively. Most GS (61.1%) had access to a GO at their facility or within 60 miles and 56.9% had no formal EIN-AEH policy. Half of GS (50%) were willing to manage EIN-AEH in an appropriately counseled and biopsied patient; however, less than a quarter (23.6%) felt comfortable with fertility-sparing management. Most GS (68%) were willing to perform EIN-AEH surgical management if GO back-up was available and 83.5% of GOs indicated willingness to provide virtual consultation. When offered co-management with GO virtual consultation, GS expressed a 3-fold increased comfort with hysterectomy surgical management, including those stationed overseas (OR = 3.10; 95% CI = 1.55-6.21, P < .0014; overseas P = NS), and an 8-fold increased comfort with fertility-sparing management (OR = 7.86; 95% CI = 3.73-16.4, P < .0001).

Conclusions: Management and referral of EIN-AEH by military GS varies widely with no policy at most facilities. A solution is needed, particularly in remote and overseas locations, to reduce medical, health system and social burden, and to conserve the fighting strength.