Military Medicine最新文献

We report a management strategy for disseminated Fusarium solani fungal infection in an adult 35% total body surface area burn patient with brain abscesses and concomitant pulmonic valve endocarditis resulting in the longest survival reported in a burn patient. Early in his hospital course, the patient was diagnosed with a Fusarium burn wound infection with concomitant fungemia and was treated with a prolonged course of intravenous (IV) antifungal monotherapy. Shortly thereafter, he developed focal neurologic deficits and was found to have brain abscesses on MRI. He underwent emergent craniotomy with debridement, and triple antifungal therapy was initiated. Transesophageal echocardiography demonstrated pulmonic valve vegetations, which resolved with triple antifungal therapy. Disseminated Fusarium solani infection is quite rare with mortality approaching 100%. Given the rarity of this disease process, there are no established antifungal treatment guidelines. However, this patient survived for approximately 1 year after diagnosis with treatment including source control via craniotomy and debridement coupled with prolonged courses of combination antifungal therapy (given the near pan-resistance of his fungal infection). Pharmacogenomic testing was utilized to establish the patient's metabolism of voriconazole and dosing adjusted accordingly to improve the efficacy of the combination therapy. To our knowledge, an adult burn patient surviving this length of time after Fusarium brain abscesses with disseminated infection has not been previously described.

In the community of Army Nurse Anesthetists, there is an underutilized potential for Combat-Relevant Fellowship training that, if enthusiastically encouraged and taken advantage of, would proffer many benefits to the Military Health System and the beneficiaries of its care. Most importantly, increased access to and encouragement for participation in these fellowships for Nurse Anesthetists would act as a tool for skill sustainment, denying any potential for skill degradation or readiness gaps in preparation for the next-generation war. These fellowships would also augment the already robust breadth, quality, and safety of Army Nurse Anesthetists' combat and noncombat anesthesia care, potentially increase Return-To-Duty rates, potentially expedite casualty clearance of the battlefield, increase the often-limited access to advanced pain management care for chronic pain patients in Military Treatment Facilities, increase the retention rates of Nurse Anesthetists, augment the military anesthesia community's knowledge-base, and help to advance the art of anesthesia as a whole. To triumph against the anticipated rigors of the future war's multidomain operational environment, we are duty bound to continually improve and strive to be the best versions of ourselves as soldiers, as professionals, and as communities. This paper will explore the untapped utility of Combat-Relevant Fellowships for Army Nurse Anesthetists.

The Joint Trauma System was created out of a crucial need for the integration of battlefield medicine. The Joint Trauma System supports the execution and advancement of combat casualty care throughout the continuum of care by medical and nonmedical providers, leaders, and commanders at all levels.

Introduction: Canadian Special Operation Forces Command (CANSOFCOM) operators have been extensively deployed in recent conflicts. They are at risk of trauma and blast exposure as well as the development of post-traumatic stress disorder (PTSD) and blast traumatic brain injury (bTBI). Current psychotherapy and pharmacological approaches provide suboptimal resolution of PTSD and bTBI symptoms. Prior research has shown that ketamine infusion and cervical sympathetic blockade (CSB) have reduced PTSD and bTBI symptoms.

Material and methods: A total of 11 patients, including CANSOFCOM members, were treated and followed. Pre- and post-intervention PTSD Checklist-5 and Neurobehavioral Inventory Scale (NSI) scores were recorded. Neurobehavioral Inventory Scale questionnaire was administered only to patients with a history of traumatic brain injury. Each patient received 4 ketamine infusion and bilateral CSB treatments, as per previously published by IRB protocol #00000971.

Result: Two weeks post-intervention, average PTSD Checklist score reduction of 45.09 (n = 11). Two weeks post-intervention, average NSI score reduction of 40.7 (87.0% reduction) (n = 6). No other NSI scores were available.

Conclusion: These findings highlight the importance of early intervention and ongoing evaluation in PTSD treatment. Ketamine infusion combined with bilateral CSB can provide a clinically significant reduction of PTSD and bTBI in the CANSOFCOM cohort. Of interest, another study of CSB alone as a treatment of bTBI, which used NSI assessment, showed a reduction of 53% on a 1-month follow-up. Our report demonstrated an 87% reduction in NSI score at 2 weeks. Possible physiological explanations and study limitations are discussed.

Introduction: Congenital syphilis (CS) case rates have increased significantly in the United States over the past 20 years, accelerating during the COVID-19 pandemic. Increasing rates may relate to access to care but have not been evaluated in a fully-insured population, such as the Military Health System.

Materials and methods: We performed a repeated monthly cross-sectional study of CS cases and total encounters (care rates) using the queried Military Health System database. We defined CS by International Classifications of Diseases 10th Revision Clinical Modification diagnosis codes in beneficiaries  ≤ 2 years old. We evaluated pre-COVID-19 (March 2018 to February 2020), pandemic year 1 (March 2020 to February 2021), and pandemic year 2 (March 2021 to February 2022) periods. We performed change-point and trend analyses and Poisson regression to evaluate differences by sponsor rank, TRICARE region, and pandemic period. The Uniformed Services University Institutional Review Board approved the study.

Results: A total of 69 unique CS cases were identified with a median monthly care rate of 0.90/100,000 eligible beneficiaries. The CS care rate showed a 5.8% average monthly percent increase throughout the study period (P < .001) and a 20.8% average monthly percent increase in year 2 (P < .05). Compared to the pre-pandemic era, CS care rates increased in pandemic years 1 and 2 (adjusted rate ratio [aRR] 2.76 [95% CI: 1.95-3.92], 5.52 [95% CI: 4.05-7.53], respectively). Congenital syphilis care rates were lower in children of senior enlisted sponsors versus junior enlisted, aRR 0.24 (95% CI: 0.17-0.33), and higher in the West and North regions versus South, aRR 2.45 (95% CI: 1.71-3.53) and aRR 2.88 (95% CI: 2.01-4.12), respectively.

Conclusions: Congenital syphilis care rates were substantially lower in this insured group than national rates but increased significantly during the COVID-19 pandemic. Higher care rates were seen in children of military members of lower rank. Regional trends differed from national data. These findings suggest that, even in a fully-insured population, income and regional differences impact CS, and the COVID-19 pandemic may have exacerbated differences in care delivery.

Introduction: Solid metals may create a variety of injuries. White phosphorous (WP) is a metal that causes both caustic and thermal injuries. Because of its broad use in munitions and smoke screens during conflicts and wars, all military clinicians should be competent at WP injury identification and acute therapy, as well as long-term consequence recognition.

Materials and methods: English-language manuscripts addressing WP injuries were curated from PubMed and Medline from inception to January 31, 2024. Data regarding WP injury identification, management, and sequelae were abstracted to construct a Scale for the Assessment of Narrative Review Articles guideline-consistent narrative review.

Results: White phosphorous appears to be ubiquitous in military conflicts. White phosphorous creates a characteristic wound appearance accompanied by smoke, a garlic aroma, and spontaneous combustion on contact with air. Decontamination and burning prevention or cessation are key and may rely on aqueous irrigation and submersion or immersion in substances that prevent air contact. Topical cooling is a key aspect of preventing spontaneous ignition as well. Disposal of all contaminated clothing and gear is essential to prevent additional injury, especially to rescuers. Long-term sequelae relate to phosphorous absorption and may lead to death. Chronic or repeated exposure may induce jaw osteonecrosis. Tactical Combat Casualty Care recommendations do not currently address WP injury management.

Conclusions: Education and management regarding WP acute injury and late sequelae is essential for acute battlefield and definitive facility care. Resource-replete and resource-limited settings may use related approaches for acute management and ignition prevention. Current burn wound management recommendations should incorporate specific WP management principles and actions for military clinicians at every level of skill and environment.

Introduct ion: The demands of future large-scale combat operations may require medics and corpsmen to increasingly perform expectant casualty care (ECC). However, no detailed guidelines currently exist for providing ECC within military medicine. To guide the development of education and training guidelines and advance team training of both medics and non-medics, an in-depth understanding is first needed regarding caregivers' experiences providing ECC in recent conflicts as well as perceived training gaps. Therefore, this study explored the experiences of medics and physicians providing ECC and investigated their perceptions of training needs in this area for future conflicts characterized by large-scale combat operations and prolonged casualty care operational settings.

Materials and methods: We conducted an engaged qualitative phenomenological study to explore ECC training needs for future conflicts. We interviewed 9 senior health care professionals (medics and physicians) who had extensive combat and deployment experiences and served primarily in the Role 1 environment. The interviews averaged 45 min each and were conducted via phone. To analyze this interview data, we reviewed the interview transcripts and then noted terms, phrases, and concepts within the interview transcripts that we found to be salient to answering the research question. Our team then met to review these codes and grouped them into categories. These categories served as the themes of this study that illustrated the participants' perceptions and experiences.

Results: Five themes emerged from our data: (1) There is a current gap in ECC training for enlisted Role 1 caregivers throughout the military; (2) ECC training is needed to shift organizational culture; (3) ECC training should be comprehensive; (4) ECC training should be deliberate; and (5) Time is the greatest challenge to implementing ECC training. Our participants noted that developing guidelines and filling training gaps is not only critical for preparing Role 1 providers for effective and ethical military medical decision-making but also for addressing death and dying on the battlefield and building moral resilience across the medical corps.

Conclusion: Our results provide direction for development of ECC clinical guidance and collective team training recommendations. Following these guidelines may increase life-saving capabilities on the far-forward battlefield and equip medical directors and medics to provide ethical and compassionate care to those who cannot be saved in the setting of limited resources and evacuation opportunities.