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.
Introduction: This study examined how the U.S. Department of Defense (DoD) and military branches disseminate information about behavioral health topics, including sexual assault and harassment, mental health, resilience, substance use, suicide, and other violence-related issues, through their official media platforms and online newsletters. This is key since a significant number of military personnel experience these issues, yet available health services remain underutilized. The goal is to analyze the frequency, timing, and content of the DoD, military branches, and installations' messaging around these behavioral health topics across their digital communication channels.
Materials and methods: Researchers manually collected data from official social media accounts (i.e., Twitter, Facebook, Instagram) and online newsletters of the DoD, military branches, and installations from January to November 2021. Data was coded for behavioral health topics, content types, and evidence-based interventions. Engagement metrics were also analyzed for social media posts. The Institutional Review Board of New York University approved the study protocol.
Results: The study found notable variations in how frequently different behavioral health topics were addressed across the DoD, military branches, and installations, with sexual assault and harassment, mental health, and suicide prevention being the most prevalent. Messaging often aligned with designated awareness months. The most common content shared about the included behavioral health topics focused on providing information and details about available services, although fewer posts addressed military culture, policies, or program/initiative effectiveness. Social media engagement was highest for mental health, sexual assault and harassment, and suicide-related topics.
Conclusions: The findings suggest a lack of coordination and standardization in the military's digital health communication strategies, which can lead to ineffective and undesired outcomes. This study has also identified missed opportunities in military digital communications to leverage evidence-based best practices. Recommendations include developing a cohesive, systematic framework to guide consistent, effective messaging across branches and platforms to better reach and engage the military population on critical behavioral health issues. Although the study provides valuable insights, limitations include its manual data collection process, single-year timeframe, and focus on only three social media platforms. Future studies should expand the scope by including other social media platforms with distinct user demographics and engagement patterns, as well as extended timeframes, to better understand the full landscape of military digital health communication.
Introduction: Hypospadias is a congenital birth defect characterized by abnormal placement of the urethral opening in male infants. In the United States, hypospadias prevalence is estimated to be ∼60-80 per 10,000 male live births; however, reported estimates are higher among births to military beneficiaries. The present study leveraged a cohort of births among military families to investigate reportedly high hypospadias prevalence in a military birth cohort from 2010 to 2020.
Materials and methods: The Birth and Infant Health Research program data identified male live births among military medical (i.e., TRICARE) beneficiaries, January 2010 through December 2020. Hypospadias cases were identified in TRICARE claims data by 1 inpatient or 2 outpatient diagnoses during infancy; more conservative case definitions were also assessed (e.g., 2 diagnoses within (1) 1 year, (2) 3 months, and (3) 1 month of life). To examine characteristics associated with hypospadias, adjusted prevalence ratios (PRs) with 95% CIs were calculated using modified Poisson regression models.
Results: The prevalence of hypospadias was 111.6 per 10,000 military-connected male live births. Estimates were high (>110.0 per 10,000) for both military and non-military pregnant parents, with PRs indicating a slight positive association for military parents (PR 1.07, 95% CI 1.00-1.14). Requiring 2 diagnoses by age 3 months yielded a prevalence of 79.5 per 10,000; associations by military status were attenuated (1.03, 95% CI 0.96-1.11).
Conclusions: Reportedly elevated hypospadias among military-connected births is likely influenced by broad case ascertainment methods rather than military occupational exposures. These findings underscore the importance of evaluating differences in surveillance case definitions and considering associated data limitations (e.g., reliability of diagnosis codes) when comparing prevalence estimates.
Introduction: The United States (U.S.) Military has been performing laser refractive surgery to enhance combat readiness, operational capability, and the quality of life for service members since fiscal year 2000. The latest laser refractive surgery adopted by the U.S. Military is small-incision lenticule extraction (SMILE) (Carl Zeiss Meditec AG, Jena, Germany), a type of keratorefractive lenticule extraction (KLEx). However, a limited number of studies have been conducted to determine whether varying levels of altitude have any effect on vision following the procedure. The purpose of this study was to evaluate the effect of decreased barometric pressure and atmospheric oxygen tension (simulated increased altitude up to 22,500 ft) on refractive stability in patients who have undergone bilateral SMILE.
Material and methods: Study subjects included active duty military personnel who had undergone bilateral SMILE using the VisuMax femtosecond laser (Carl Zeiss Meditec AG) for the correction of myopia. After being cleared to participate in the study by a military flight medicine physician, each participant underwent altitude chamber training. Uncorrected visual acuity (UCVA), 5% low contrast (LC) UCVA, refractive error, corneal thickness, and anterior chamber volume and depth were each measured at ground level, 10,000 ft, 15,000 ft, 18,000 ft, and 22,500 ft simulated altitude in a hypobaric chamber. Mixed-effects linear regression models were used to evaluate the statistical significance of changes in individual outcome measures across different altitudes.
Results: Data from 34 eyes (17 participants) was collected during the study. A statistically significant increase was found in UCVA (-0.04 ± 0.01 LogMAR; P < .001) and LC UCVA (-0.05 ± 0.01 LogMAR; P < .001) as simulated altitude increased from ground level to 22,500 ft. A myopic shift (-0.14 ± 0.05 D; P = .050) was observed at 22,500 ft, as well as decreases in corneal thickness at central (-3.94 ± 0.83 µm; P < .001) and thinnest point (-3.65 ± 0.90 µm; P < .001). There were no statistically significant changes in mean keratometry, anterior chamber volume, or anterior chamber depth.
Conclusion: The current study suggests that while high altitude may influence certain aspects of visual performance and corneal properties, overall visual acuity and anterior segment parameters remain stable in military personnel who underwent SMILE.
Introduction: Historically, women in the U.S. Military have been prohibited from serving in ground combat occupational specialties (GCS) until the Secretary of Defense lifted the exclusion in January 2016, prompting studies into health outcomes for this new cohort. Phillips et al.(2016-2019) found that active duty servicewomen (ADSW) in GCS had lower odds of musculoskeletal injury (MSKI) and behavioral health (BH) diagnoses than peers in non-ground combat specialties (NGCS), likely because of a "healthy warrior" selection effect. With continued integration, cohort maturation, and factors such as the COVID-19 pandemic, this study updates MSKI and BH trends among ADSW from 2020 to 2023 and compares findings with the earlier cohort.
Materials and methods: This retrospective cross-sectional study used data from the Military Health System Data Repository (MDR), including all ADSW (n = 77,568) who served from January 1, 2020, to December 31, 2023. Women in the Guard, Reserve, or with pregnancy diagnoses during or in the year prior were excluded. Primary outcomes-MSKI and BH diagnoses-were identified via ICD-10 codes. Adjusted odds ratios (AORs) and 95% CIs were calculated using multivariable logistic regression, comparing GCS vs. NGCS ADSW while adjusting for age, race & ethnicity, rank, and BMI. Two-sample z-tests assessed differences from Phillips et al.s 2016 to 2019 estimates. This study received an exempt determination from the Institutional Review Board at the Uniformed Services University of the Health Sciences.
Results: Of 77,568 ADSW, 5,024 (6.5%) served in GCS. Compared to NGCS, GCS women were younger (72.1% vs. 47.0% aged 18-23), more often enlisted (68.4% vs. 57.0%), and had lower obesity rates (8.4% vs. 12.6%), but higher rates of tobacco (7.7% vs. 7.6%), alcohol (7.9% vs. 6.7%), and substance use (2.5% vs. 1.9%). Adjusted analyses showed higher MSKI odds in GCS (AOR = 1.21, 95% CI: 1.13-1.30), a significant reversal from Phillips et al.(AOR = 0.86, 95% CI: 0.79-0.93; z = 6.01, P < .001). BH odds were lower in GCS (AOR = 0.83, 95% CI: 0.78-0.89), consistent with earlier findings (Phillips AOR = 0.87; 95% CI: 0.80-0.95).
Conclusions: The increase in MSKI odds for GCS women contrasts sharply with prior findings, suggesting the dissipation of the initial selection effect as more women enter and remain in combat roles. This shift may reflect greater exposure duration, cumulative physical demands, or pandemic-era fitness disruptions. The continued lower BH odds in GCS, despite higher substance use, may reflect resilience, unit cohesion, or underreporting tied to stigma. These findings highlight the need for targeted, female-specific injury prevention and confidential, destigmatized mental health support as the Army moves toward sex-neutral standards in combat fitness.
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