Military Medicine最新文献

Introduction: While the U.S. DoD mandates preventive health measures for service members overseas, the health needs of their accompanying children are poorly described. This study aims to quantify and characterize the recommended travel health preventive services, with attention to malaria, dengue, yellow fever, Japanese encephalitis, tick-borne encephalitis (TBE), typhoid, and rabies, in military-connected expatriate children.

Materials and methods: The registered country of residence of active duty service members and their families in December 2022 as reported by the Defense Manpower Data Center was assessed to quantify military-connected children living abroad. Data were sorted by age group and geographic Combatant Command. Country-level populations were mapped against CDC Yellow Book Health Information for International Travel country guidelines and Shoreland Travax recommendations.

Results: In 2022, there were 63,592 children of active duty service members living abroad. The largest populations were in Indo-Pacific Command (INDOPACOM) and European Command regions, reflecting long-standing bases in the regions. Of all conditions studied, Japanese encephalitis posed risk to the largest number of military children. Within INDOPACOM, 25,161 had regional to widespread endemic risk, while 357 children lived in countries with rare/focal risk for transmission. Relatively few children lived in areas with endemic risk for the other studied mosquito-borne illnesses, malaria (7454), dengue (3377), and yellow fever (533). With the emergence of TBE in much of Europe, 29,752 children were living in regions with some TBE risk. Only 1609 children lived in regions with both wildlife and domestic canine transmission cycles of rabies established. Typhoid risk for 13,607 children, largely in INDOPACOM, was sufficiently high for vaccination to be recommended for long-term travelers by the CDC and Travax.

Conclusions: Military-connected children living abroad have differing preventive health service needs from their counterparts in the United States. With these children living in countries with and without permanent military bases, there is a clear need for further investigation with attention to both uptake of preventive measures and incidence of disease. While risk assessments for any particular travel are unique and very much itinerary- and activity-specific, the risk stratification and terminology applied are both practical and consistent with the guidelines and resources available to clinicians. While for some children, risk may be overestimated because of their specific location within a country, there is also likely underestimation of risk assumed with regional travel to other countries with increased risk profiles. Understanding the utilization of preventive services and associated health outcomes in this population is crucial for their well-being.

Introduction: Long-chain n-3 polyunsaturated fatty acids (LC n-3 PUFA), primarily eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have received considerable interest from the scientific community as a dietary strategy to enhance physical performance, recovery, and neuroprotection in addition to the well-established role of supporting cardiovascular health. Given that military personnel are routinely subjected to psychologically and physiologically (e.g., cardiovascular, musculoskeletal) stressful environments, LC n-3 PUFA intake may represent a simple, yet meaningful, nutritional intervention to support Warfighter health and fitness. Dietary EPA + DHA, via fish or supplement, can be reliably tracked using the omega-3 index (O3i), which is the relative amount of EPA + DHA in red blood cells (RBC) expressed as a percentage of total fatty acids. The purpose of this systematic review was to establish a baseline O3i status in active duty military personnel with the intent of providing actionable evidence-based nutrition recommendations.

Materials and methods: Three databases (PubMed, Google Scholar, and the Omega-3 Clinical Study Database) were searched systematically. A total of 645 articles were screened, of which 11 studies (13 observations) were eligible for inclusion. Non-RBC EPA + DHA (e.g., plasma) was converted to the O3i via validated equations. Data were reported as pooled mean O3i and analyzed based on service type (e.g., Army, Air Force).

Results: Based on 11 studies (13 total observations) composed of 3,615 military personnel, the average O3i was 3.18% (95% CI: 3.15, 3.21) and ranged from 2.47% and 4.62%. Most observations reported an average O3i <4% (76.9%). The Army (combined), U.S. Army only, and Special Forces personnel had O3i <4%, whereas Austrian Army and Air Force personnel had an O3i between 4% and 5%.

Conclusions: Military personnel, without exception, exhibit suboptimal O3i. Achieving optimal O3i is a low cost, modifiable risk factor that can be used in conjunction with traditional medicine and appropriate training to support the military mission and the health and performance of military personnel. Given what we know about LC n-3 PUFAs and the present suboptimal O3i in military personnel, it is paramount that Defense organizations acknowledge the supporting evidence and implement policies and strategies to promote change.

Clinical trial registration: None, but systematic review registration (PROSPERO): CRD42023410361.

Introduction: The diagnosis of traumatic arthrotomy is often accomplished using the saline load test. The introduction of large volumes of saline into the joint is uncomfortable for the patient and has been reported to have low sensitivity and specificity. Computed tomography (CT) scan has been previously validated as a fast and reliable method of detecting free air in the knee joint. The primary objective of this study was to evaluate the use of CT scan for the detection of intra-articular free air in the ankle joint.

Methods: Eighteen fresh-frozen cadaver distal lower extremities were thawed, and then CT scans were obtained at their baseline harvested state. The tibiotalar joint was injected with 0.05cc free air, and then repeat CT scans of each specimen were obtained. Specimens with instrumentation, intra-articular air, or ambiguous free air prior to intervention were excluded from the study. Scans were performed from the mid leg through the entire foot at institution standard radiation dose (120 kV, 170 mA) and a slice thickness of 0.6 mm. Images were anonymized, randomized, and sent to 4 reviewers (2 orthopedic surgeons, 1 musculoskeletal radiologist, and 1 radiology resident) for evaluation of free air. Sensitivity and specificity of CT to detect free air were calculated, and Fleiss's Kappa coefficient was used to determine interobserver reliability.

Results: The sensitivity and specificity of CT to detect free air in cadaver ankles was 100%. Twenty-two CT scans (11 natural state and 11 with simulated air arthrotomies) were correctly identified for the presence or absence of intra-articular free air by all reviewers with kappa coefficient 1.0 (complete agreement).

Conclusions: Computed tomography is a fast, reproducible method for detecting small volumes of free air in the ankle and may offer clinical benefit in evaluation of traumatic arthrotomy of the ankle.

The WHO reports 8% of global fatalities each year, which are because of injury and violence. In addition to 4.4 million deaths, morbidity associated with injuries drains health care systems and leads to significant economic burden. The key to reducing injury-related death and disability is to develop and implement organized and inclusive trauma systems. Trauma systems and their components address the full continuum of injury care from prevention through rehabilitation, and consistently and predictably reduce injury-related morbidity and mortality. Trauma system development is a critically underused strategy for economic development and medical diplomacy. The U.S. DoD acknowledges the critical value of trauma systems in the expeditionary environment. Operations in Afghanistan and Iraq proved that an established trauma system (modeled after civilian systems) played a key role in sustaining military readiness, minimizing casualties, and enabling operational success. Data showed a 44% reduction in battlefield mortality because of the expeditionary trauma system. The DoD is attempting to scale these successes by building nascent trauma systems in each Geographic Combatant Command through a Combatant Command Trauma System. The Combatant Command Trauma System sets up a framework to aid deployed medical professionals in structuring downrange trauma systems to ensure casualties get to the right capability at the right time, while continuously gathering data to adapt and improve the expeditionary trauma system. Leveraging Combatant Command Trauma System expertise in collaboration with regional partners to build a Pacific Island Trauma System (PITS) would be one of many potential opportunities where regional and DoD interests align. Establishing an integrated PITS supports 5 U.S. Government priorities: (1) integrated deterrence, (2) build partnerships, (3) support veterans, (4) optimize global health engagement, and (5) enhance self-reliance. The PITS concept could be applied to other geographic regions and combatant commands, such as U.S. Southern Command, which experiences similar natural disasters, and struggles with limited resources, physical dispersion, and Chinese competition. Given these global challenges and opportunities, now is the time with a newly elected administration for the U.S. Government to chart a novel course in saving lives and supporting national security; a PITS would be a great place to start.

Cases of flea-borne spotted fever (FBSF) have been on a steady increase in the southern United States and produce the highest numbers of reported vector-borne disease cases in Texas. Historically, cases were largely murine typhus caused by Rickettsia typhi and characterized by exposure to rodent fleas. However, more recently, spotted fever rickettsiosis caused by R. felis and characterized by exposure to the cat flea, Ctenocephalides felis, may be the dominant disease. We describe the management of a child with a complex clinical picture, including sickle cell β-thalassemia, bullous pemphigoid, and initially diagnosed with murine typhus infection. We also explain the clinical response to a case cluster of FBSF (R. felis) among a military family residing in on-post housing and the quantitative polymerase chain reaction testing of associated flea samples to confirm the pathogen species. This case cluster highlights some of the important challenges faced in managing the re-emergence of FBSF in the United States including: (1) difficulty diagnosing FBSF, (2) lack of resources to determine the specific pathogen involved, (3) vertical transmission of R. felis in fleas, and (4) the importance of effective coordination between medical providers and public health personnel with pest management professionals to ensure effective control of the fleas. FBSF presents a risk to the health and morale of military personnel stationed in the region and potentially a risk to operational effectiveness.

Introduction: Hyperbaric oxygen therapy (HBOT) is used to treat acute carbon monoxide poisoning. However, few reports have detailed its use in large patient cohorts, and optimal management guidelines have yet to be established. Herein, we report the clinical presentation and simultaneous treatment of multiple patients experiencing acute carbon monoxide poisoning on an offshore ship within the territorial waters of Japan.

Case presentation: Eleven patients were promptly transported to our hospital from a Japanese Maritime Self-Defense Force destroyer owing to accidental acute carbon monoxide poisoning. We opted to treat this incident as a mass casualty and immediately appointed a medical control officer and established medical teams. The medical control officer guided the general treatment plan and coordinated with the various sections, and the medical teams treated the patients. The patients were immediately administered normobaric oxygen via a facial mask. Those with the most severe conditions underwent simultaneous HBOT within 3 hours of hospital arrival. Two and 4 weeks after the second therapy session, all symptoms had resolved, with no physical or cognitive sequelae.

Conclusion: We report the successful treatment of patients with concurrent acute carbon monoxide poisoning via HBOT at a single facility. This report highlights the feasibility of efficacious treatment at a single facility in scenarios in which multiple individuals experience carbon monoxide poisoning. It is important that all staff members, including those in administration, understand the concept of disaster medicine. Additionally, in HBOT facilities, regular training is needed for events involving a large number of HBOT-indicated patients.

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.

Background: Global interconnectedness has led to an increasing reliance on international coalitions for military and peacetime operations. Effective collaboration among multinational partners is essential for success in these contexts, yet the potential benefits of internationalization within military medical education and training are unknown. To close this gap, this study explored the experiences of military health professions students integrating with international partners during a high-fidelity military medical exercise, Operation Bushmaster, conducted by the Uniformed Services University (USU).

Methods: We used a qualitative case study approach to explore the experiences of military health professions students training alongside international peers during Operation Bushmaster. We conducted more than 70 hours of observations, interviewed ten USU students during the exercise, and reviewed these students' written reflections on their experiences. We then used the constant comparison method to come to a consensus on patterns within our interview and observational data, which we organized into themes.

Results: Five themes emerged as the results of our study. Our participants reported that integrating with international students in their training at Operation Bushmaster: (1) enhanced fidelity of the exercise, (2) provided opportunity to practice cross-national interoperability and develop positive working relationships with international students, (3) broadened perspectives of international relations, (4) increased personal and professional development, and (5) sparked desire for future collaboration.

Conclusion: Our results reveal the value of involving international partners in preparing military health professions students for future coalition operations, ultimately enhancing their professional development and readiness. Expanding such opportunities may further strengthen military medical readiness in the increasingly interconnected global landscape.

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.