Military Medicine最新文献

Introduction: Sacrococcygeal pilonidal disease (PD) is a common surgical problem in the U.S. Military. Despite recent advancements, treatment strategies remain heterogenous and incompletely described, particularly among the active duty component in the Military Health System (MHS). This study's objectives were to identify the burden of PD and describe current healthcare utilization and treatment patterns in the MHS during a recent 10-year study period.

Materials and methods: The study population included all active duty U.S. service members with at least one PD diagnosis in the MHS Data Repository between January 1, 2013, and December 31, 2022. For each patient, the first PD diagnosis during the study period was the incident case, and a subsequent case was defined as a second PD diagnosis >30 days after the first and categorized as recurrent (procedure performed at incident encounter) or persistent (no procedure performed at incident encounter). Procedures were identified by Current Procedural Terminology codes.

Results: During the study period, 25,039 active duty service members were diagnosed with an incident case of PD. The study population was mostly male, less than 30 years old, enlisted, and in the Army or Navy. The overall incidence rate was 1.7 per 1,000 person-years. Prevalence of recurrence was 44.6% (2,494 of 5,598) and persistence was 50.1% (9,731 of 19,441). Overall, there were 115,387 medical encounters with a PD diagnosis during the study period, and service members in the top 25% for healthcare utilization had ≥11 encounters with a PD diagnosis.

Conclusions: Pilonidal disease imposes a significant burden on the MHS and is a threat to overall force medical readiness. Treatment strategies remain heterogeneous, and prospective studies are needed to refine clinical guidelines.

Introduction: Unintended pregnancy is linked to maternal depression, substance use, late prenatal care, low birthweight, and preterm birth. Our objective was to examine the incidence of unintended pregnancies in the military, the effects on maternal mental health and the effects of Social Determinants of Health (SDOH).

Materials and methods: This was an institutional research board-approved secondary analysis of two independent military datasets of pregnant individuals participating in two prospective clinical trials of a pregnancy mentorship program, collected 2012-2017 (n = 246) and 2018-2022 (n = 1,523), and compared to assess relationships of SDOH and maternal mental health measures for those with and without intended pregnancies.

Results: The rate of unintended pregnancy reported by participants was higher, 42.8% in 2012-2017 compared to 34.4% in 2018-2022. The rates of unintended pregnancy in both periods were lower than the national average and was lower in the second study period compared to the first. There were significantly higher scores for both anxiety and depression for those with unintended pregnancies, regardless of the sample. Over the same periods, the perception of support (as measured by the social support index) was higher in 2012-2017 compared to 2018-2022. Although the measures do not significantly differ by age, military branch, or rank, there was a significant relationship between the level of education and a lower rate of unintended pregnancy.

Conclusion: Exploration of Military Health System pregnancy data is important as it provides one of the best pictures of family and force readiness. The recent issue of unintended pregnancy and the increasing incidence of depression and anxiety, with lowered perceived support have long-term implications for the overall health and well-being of the U.S. military force, which demands continued investigation.

Survey research has long been a cornerstone of behavioral health and medical research. With the growth of Internet-based survey platforms, accelerated by the COVID-19 pandemic, conducting surveys completely online has become the standard. Online surveys provide the field with a fast, cost-effective method for gaining insights into relationships among health variables or in obtaining preliminary data to inform larger-scale studies. Additionally, online surveys enable researchers to recruit from a larger geographical area, thus increasing the generalizability of findings and, importantly, allowing participants to complete study activities completely de-identified. Although participating anonymously can increase one's comfort with disclosing sensitive or stigmatizing information, this can pose significant challenges to ensuring the legitimacy of participants' eligibility. This may be particularly true when compensation is available, increasing the likelihood of a prospective participant falsely reporting characteristics such as current or former military service. The following commentary provides an overview of the current landscape for researchers conducting military-related research via online surveys, with a specific emphasis on challenges in ensuring participants have a military background. In support of this, we present several real-world challenges for conducting de-identified online surveys, such as difficulties ensuring participants have a military background and preventing the use of "bots." Additionally, the evolving challenge of artificial intelligence is discussed in the context of its impact on knowledge-based screening methods such as the Military Screener Questionnaire. Alternative approaches, such as compensated screening surveys, are presented. Surveys will continue to be an important tool for advancing military medical research; however, researchers must discuss findings within the context of the inherent limitations of the methodology. The field should carefully monitor the evolving challenges to conducting online surveys.

Introduction: The Airborne Hazards and Open Burn Pits Registry (AHOBPR) examination was a service for Veterans with concerns about environmental exposures during military deployments. Interested Veterans enrolled in the AHOBPR online, completed a questionnaire, and indicated interest in a clinical examination by a Veterans Health Administration clinician. Several factors (e.g., COVID, unanticipated demand, and personnel turnover) resulted in a large number of pending examinations nationwide by 2022, prompting an evaluation and implementation effort to accelerate completion of high-quality examinations.Our objective was to assess Veterans' and clinical team members' perspectives of AHOBPR examinations to improve their delivery.

Meterials and methods: Qualitative interviews with Veterans who had completed an AHOBPR examination and clinical team members (CTMs) at 2 Veterans Affairs (VA) sites participating in our implementation. We recruited Veterans within 6 months of completing their examination and home facility complexity and performance metrics. We recruited CTMs for interviews from 2 purposefully selected VA facilities that completed all assessments conducted by our implementation team. Interviews were conducted between September 2022 and January 2023. We analyzed transcripts using rapid analysis. We apply the Promoting Action on Research Implementation in Health Service (PARiHS) framework to inform our interpretation of findings.

Results: Twenty-one Veterans and 9 CTMs from 2 sites completed interviews. Themes identified in the interviews were consistent with the PARiHS elements of evidence, context, and facilitation. Both Veterans and CTMs wanted evidence of appropriate knowledge about the AHOBPR and deployment and understanding AHOBPR structures and facility processes, including appropriate documentation of Veteran concerns. Contextually, Veterans and CTMs shared their strategies or experiences in clinical interactions especially the focus on developing patient-provider rapport and being prepared for examinations. Examples of facilitation included both groups' personal and professional motivations for conducting or pursuing examinations. Facilitation also involved local administrators and leaders providing the necessary staff, support, and resources.

Conclusions: Assessing Veteran and clinical team member (CTM) perceptions of AHOBPR examinations revealed clinically relevant opportunities important to addressing military and environmental exposure concerns of veterans (i.e., "exposure-informed care"). Clinical leaders can use the PARiHS framework and lessons learned from the AHOBPR experience to assess implementation and improve delivery of other novel services.

Introduction: Notifying a patient's family that the patient has died is a delicate and sensitive task in medical practice. This is particularly true in the military population due to the frequent unexpected and sudden nature of death. Medical students in France receive no systematic training in death notification, either in civilian or military settings. Therefore, the researchers sought to (1) assess the initial level of training of military medical residents in announcing death, (2) design an adapted simulation-based training program after the observation of possible gaps, (3) evaluate its impact on their perceived self-efficacy, and (4) assess the program's long-term relevance.

Materials and methods: The researchers conducted an observational study followed by a simulation-based educational intervention. First, a questionnaire was distributed to two cohorts of military medical residents, who began their residency in 2023 and 2024. The questionnaire assessed their training level, experience, and perceptions regarding death announcement. Based on the findings, a tailored theoretical and practical simulation-based training was developed and delivered. Pre- and post-training self-assessment questionnaires and a 5-month follow-up survey were used to evaluate the impact and retention of learning outcomes.

Results: A total of 72 residents (45%) completed the initial questionnaire. The mean age of the participants was 25 ± 1.5 years, and 61% of the respondents were female. Most participants (57/72, 79%) specialized in general practice. Only 19% (14/72) had previously announced a death, and 44% (32/72) declared that they had received some form of related training during their curriculum, which was simulation-based for 35% (25/72). Of the 14 residents who had to announce a death, 9 (65%) felt little or not at all prepared. Overall, 40 residents participated in the simulation-based training, which led to a statistically significant improvement (P < .05) in eight out of 10 assessed skills. At 5-month follow-up, all residents who had to deliver a death notification reported the training as useful.

Conclusions: The initial assessment revealed a clear need for specialized training in announcing death for future military physicians. The implemented simulation-based program significantly enhanced the residents' sense of self-efficacy. There is strong support for integrating the program into the curriculum annually, as it appears to effectively improve the quality of care provided to grieving families.

Introduction: In recent years, there has been increased recognition and awareness surrounding mental health among US military personnel. However, the prevalence of postpartum depression (PPD) among female service members is significantly higher than that of the general US population. There is currently a gap in the literature characterizing the unique factors of the military experience accounting for the higher predisposition to PPD relative to civilian Americans. This qualitative review aims to address this gap by isolating risk factors which have been consistently identified in the available literature as contributing to the prevalence discrepancy.

Materials and methods: A MeSH database-built search utilizing key terms "postpartum depression" and "military" was used to gather sources that fit the inclusion criteria. These sources were analyzed for explicitly identified PPD risk factors pertaining to US military personnel and spouses.

Results: Of the 14 sources meeting inclusion criteria, a history of a mental health disorder and a lack of social support were identified in seven distinct articles as significant risk factors for PPD among military personnel. Low rank and pay, as well as deployments of self and/or spouse, were specified in six papers. A history of depression, history of anxiety, and exposure to combat were identified in five papers. Four papers isolated branch of service and young age as risk factors. Factors that were recognized in three papers or less included, but are not limited to: tobacco use, history of PTSD, history of sexual assault, low education attainment, high number of child dependents, race, and job stress.

Conclusions: Women in the military and spouses of military personnel are subject to an environment with distinct stressors, increasing their predisposition for PPD. Identifying specific risk factors is critical for quality screening, diagnosis, and care of PPD among this population. Significant risk factors consistently isolated from the available literature include history of mental health disorders, lack of adequate social support, low rank and pay, deployment of self or spouse, history of combat exposure, branch of service, and young maternal age. Findings of this review also suggest that early detection via thorough screening and disease mitigation by means of a 12-week maternity leave led to lower rates of PPD and better disease outcomes. Military-specific family health resources are widely available across branches of service and individual bases, though the use and quality of these resources are inconsistent. Providers of women experiencing at least one of these stressors should increase PPD precautions and refer patients to the appropriate preventative and acute care.

Introduction: Military field medicine providers often operate in resource-limited environments where improvization with available equipment is essential. Whole blood transfusion has had significant benefits in treating severely injured trauma patients in these settings. Current protocols often mandate anticoagulant-containing intravenous (IV) fluid bags for fresh whole blood transfusion, which can pose logistical challenges for forward-placed medical units. This study explores the feasibility of using a syringe without anticoagulant as an alternative method.

Materials and methods: Whole blood was collected from healthy volunteer donors and divided into syringes with and without citrate-phosphate-dextrose (CPD) solution. Samples were stored for varying durations and infused through a standard IV setup to simulate transfusion conditions. To assess coagulation, infusion rate under standardized infusion pressure, clot mass, and coagulation parameters (PT/INR, PTT) was measured. Hemolysis was assessed by measuring plasma hemoglobin, potassium, lactate dehydrogenase (LDH), bilirubin pre- and post-infusion at either 100 mL/minute, 200 mL/minute or maximal manual compression.

Results: We performed a nested analysis of variance (ANOVA) analysis on coagulation and hemolysis parameters. Tukey post-hoc testing was used to determine mean subgroup differences. Analyses were carried out using R version 4.3.0 (R Core Team, 2024). Significant differences were observed in infusion rates across different storage times but not between CPD and non-CPD conditions. There was significantly greater clot burden in non-CPD groups compared to CPD at 30 minutes (6.5 ± 2.1 g) and 60 minutes (8.8 ± 1.9 g), but no significant difference was observed in the 30 second (0.001 ± 2.0 g) and 5 minute (1.1 ± 2.0 g) groups. Coagulation parameters (INR, PT, and PTT) showed no significant differences based on storage time but were impacted by the presence of CPD. Hemolysis markers indicated significant changes in plasma hemoglobin with higher infusion rates but no significant alterations in LDH, potassium, or bilirubin at any of the infusion rates.

Conclusions: These findings suggest that non-anticoagulated fresh whole blood may be transfused within 5 minutes at infusion rates of 100 mL/minute or less with no significant clot burden and no evidence of hemolysis. Longer storage times and faster infusion rates may also be clinical safe but require further investigation. This study indicates that there may be some potential use of this method in military units executing a fresh whole blood draw with short donor-to-recipient times.