Military Medicine最新文献

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.

Swimming-induced pulmonary edema (SIPE) is an incompletely understood condition that is often seen in U.S. special operations candidates participating in maritime qualification training courses. We present a case of two monozygotic twins with the simultaneous onset of acute respiratory distress during a crucible event of a maritime assessment and selection course. Subsequent pulmonary ultrasonography in both candidates showed wedge-shaped hyperechoic lines (B-lines) extending from the pleural interface into the interstitium. Chest radiography of both candidates revealed bilateral asymmetric hazy opacities consistent with SIPE. Both candidates recovered with supportive measures but were medically removed from training. Given the near-identical exposures of the candidates to the same ambient and water temperatures, duration of water submersion, magnitude of physical stressors, and viral colonization, this case study suggests that there may be underlying genetic factors, in addition to environmental factors, that predispose individuals to developing SIPE. Further benchtop and clinical research must be performed to identify potential genetic polymorphisms that contribute to the development of SIPE and to investigate safe interventions that address the underlying etiologies of SIPE pathophysiology.

Cases of embedded unexploded ordnance are extremely rare and pose a risk to bystanders and health providers. A patient arrived at the Role 2 medical facility in the Turkish army, whose left arm was amputated due to a terrorist attack and major hemorrhages had been halted by clamping of the left subclavian artery and vein. A piece of metal wire running from the lateral chest wall was detected as an unexploded ordnance piece and it was removed surgically. In these challenging cases, safety principles should be acknowledged. Highlighting the basic precautions is important for similar scenarios and increases awareness of the utmost importance.

Introduction: Airway compromise is the third leading cause of preventable death on the battlefield. Most combat medics carry supraglottic airway (SGA) devices for airway management. However, exchanging an SGA device for a definitive airway can be challenging, especially in austere environments. This study aims to compare the Aintree intubation catheter (AIC) to the gum elastic bougie (GEB) as adjuncts for performing airway device exchange with the i-gel SGA device in place.

Materials and methods: This randomized crossover cadaver study of 48 participants examined the success rate of two endotracheal introducers (AIC and GEB) when performing a blind airway exchange with an i-gel in place. Study participants were combat medics (MOS 68W), physician assistant students, physician assistant staff, emergency medicine (EM) physician residents, and emergency medicine attending physicians attending classes at the installation Medical Simulations Training Center. Each participant performed up to three attempts using both endotracheal tube introducers on the same cadaver. The primary outcome was successful airway exchange rate with each device, and the secondary outcome was time to successful airway exchange.

Results: Although the AIC had a slightly higher success rate of 33% compared to the GEB success rate of 30%, this result was not statistically significant, P = .56. Similarly, participants completed successful airway exchanges with the AIC faster, with a mean time of 86.5 seconds (95% CI: 71.2 to 101.9) versus 101.2 seconds (95% CI: 85.5 to 116.9) with the GEB. However, this result was also not statistically significant, P = 0.18.

Conclusions: This study demonstrates no significant difference in success rate and time to completion of successful iterations of airway exchanges between the two devices. Although the AIC performed slightly better overall, these results are not statistically significant. Additionally, blind exchange intubations appear to be of high risk with minimal success, so we recommend against this technique in routine practice.

Introduction: Malignant brain and other central nervous system tumors (MBT) are deadly and disproportionately affect younger men and women in the age range of most active-duty service members. Timely and appropriate treatment is important to both survival and quality of life of patients. Information on treatment factors across direct care (DC) and private sector care (PSC) networks may be important for provider training and staffing for the DoD. The aim of this study was to analyze treatment patterns for patients with MBT within the DoD's universal access Military Health System (MHS), comparing DC and PSC networks.

Materials and methods: The Military Cancer Epidemiology database was used to identify patients 18 years and older who were diagnosed with an MBT between 1999 and 2014 who received primary treatment. Differences in first treatment type and time from diagnosis to initial treatment between DC and PSC were assessed using chi-square and Wilcoxon-Mann-Whitney tests, respectively. Frequency of treatment initiation beyond the 28-day TRICARE Prime access standard for Specialty Care was also compared between care settings using chi-square and Fisher's exact tests. Then logistic regression models generated odds of treatment initiation beyond 28 days and 95% confidence intervals (CIs) associated with care setting. Kaplan-Meier survival curves and log-rank tests compared survival between DC and PSC.

Results: The study included 857 patients, with n = 540 treated in DC and n = 317 treated in PSC. The proportion of patients receiving each initial treatment type did not differ by care setting (P = .622). Median time from diagnosis to initial treatment (interquartile range) varied significantly between DC at 6 (0 to 25) days and PSC at 12 (0 to 37) days for all treatment types combined (P < .001). For all years combined, treatment was initiated beyond 28 days for 21% of patients using DC compared to 31% of patients using PSC (P = .001). The odds of treatment initiation beyond 28 days for a patient treated in PSC were 1.61 (95% CI, 1.11 to 2.33, P = .012) compared to patients treated in DC when controlling for demographic, military, tumor, and patient variables. Survival did not differ by care setting (P = 1.000).

Conclusions: Based on the available data between 1999 and 2014, care setting was associated with differences in time to initial treatment and odds of treatment initiation beyond 28 days among DoD beneficiaries with MBT receiving care in the MHS. Information on these differences may help inform MHS leadership decisions on the most appropriate location for military provider training and staffing.