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Fibromyalgia Diagnosis and Treatment Receipt in the U.S. Military Health System. 美国军队医疗系统中纤维肌痛的诊断和治疗情况。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae384
Germaine F Herrera, Patricia K Carreño, Ysehak Wondwossen, Alexander G Velosky, Michael S Patzkowski, Krista B Highland
<p><strong>Introduction: </strong>Meta-analytic findings and clinical practice guidance recommend pharmacological (e.g., pregabalin, duloxetine, and milnacipran) and non-pharmacological (e.g., exercise and sleep hygiene) interventions to reduce symptoms and improve quality of life in people living with fibromyalgia. However, some of these therapies may lack robust evidence as to their efficacy, have side effects that may outweigh benefits, or carry risks. Although the annual prevalence of fibromyalgia in active duty service members was estimated to be 0.015% in 2018, the likelihood of receiving a fibromyalgia diagnosis was 9 times greater in patients assigned female than male and twice as common in non-Hispanic Black than White service members. Therefore, the primary goal of this retrospective study is to examine co-occurring conditions and pain-management care receipt in the 3 months before and 3 months after fibromyalgia diagnosis in active duty service members from 2015 to 2022.</p><p><strong>Materials and methods: </strong>Medical record information from active duty service members who received a fibromyalgia diagnosis between 2015 and 2022 in the U.S. Military Health System was included in the analyses. Bivariate analyses evaluated inequities in co-occurring diagnoses (abdominal and pelvic pain, insomnia, psychiatric conditions, and migraines), health care (acupuncture and dry needling, biofeedback and other muscle relaxation, chiropractic and osteopathic treatments, exercise classes and activities, massage therapy, behavioral health care, other physical interventions, physical therapy, self-care management, and transcutaneous electrical nerve stimulation), and prescription receipt (anxiolytics, gabapentinoids, muscle relaxants, non-opioid pain medication, opioids, selective serotonin and norepinephrine inhibitors, and tramadol) across race and ethnicity and assigned sex. Pairwise comparisons were made using a false discovery rate adjusted P value.</p><p><strong>Results: </strong>Overall, 13,663 service members received a fibromyalgia diagnosis during the study period. Approximately 52% received a follow-up visit within 3 months of index diagnosis. Most service members received a co-occurring psychiatric diagnosis (35%), followed by insomnia (24%), migraines (20%), and abdominal and pelvic pain diagnoses (19%) fibromyalgia diagnosis. At least half received exercise classes and activities (52%), behavioral health care (52%), or physical therapy (50%). Less commonly received therapies included other physical interventions (41%), chiropractic/osteopathic care (40%), massage therapy (40%), transcutaneous electrical nerve stimulation (33%), self-care education (29%), biofeedback and other muscle relaxation therapies (22%), and acupuncture or dry needling (14%). The most common prescriptions received were non-opioid pain medications (72%), followed by muscle relaxers (44%), opioids (32%), anxiolytics (31%), gabapentinoids (26%), serotonin-norepine
简介Meta 分析结果和临床实践指南推荐了药物(如普瑞巴林、度洛西汀和米那西普兰)和非药物(如运动和睡眠卫生)干预措施,以减轻纤维肌痛患者的症状并改善其生活质量。然而,其中一些疗法的疗效可能缺乏有力证据,副作用可能大于益处,或存在风险。尽管 2018 年现役军人中纤维肌痛的年发病率估计为 0.015%,但在被分配到女性的患者中,纤维肌痛诊断的可能性是男性的 9 倍,在非西班牙裔黑人军人中的常见程度是白人的两倍。因此,这项回顾性研究的主要目的是检查 2015 年至 2022 年现役军人纤维肌痛诊断前 3 个月和诊断后 3 个月的并发症和疼痛管理护理接受情况:分析纳入了 2015 年至 2022 年期间在美国军事卫生系统接受纤维肌痛诊断的现役军人的病历信息。双变量分析评估了并发诊断(腹部和骨盆疼痛、失眠、精神疾病和偏头痛)、医疗保健(针灸和干针疗法、生物反馈和其他肌肉放松疗法、脊椎按摩和整骨疗法、运动课程和活动、按摩疗法、行为医疗保健、其他物理干预措施、物理治疗、自我保健)方面的不平等、其他物理干预、物理治疗、自我护理管理和经皮神经电刺激),以及不同种族和民族以及指定性别的处方接受情况(抗焦虑药、加巴喷丁类药物、肌肉松弛剂、非阿片类止痛药、阿片类药物、选择性血清素和去甲肾上腺素抑制剂以及曲马多)。使用假发现率调整后的 P 值进行配对比较:在研究期间,共有 13,663 名军人被诊断患有纤维肌痛。约 52% 的人在确诊后 3 个月内接受了随访。大多数军人接受了并发精神病诊断(35%),其次是失眠(24%)、偏头痛(20%)以及腹部和骨盆疼痛诊断(19%)纤维肌痛诊断。至少有一半人接受过运动课程和活动(52%)、行为健康护理(52%)或物理治疗(50%)。较少接受的疗法包括其他物理干预(41%)、整脊/整骨疗法(40%)、按摩疗法(40%)、经皮神经电刺激(33%)、自我保健教育(29%)、生物反馈和其他肌肉放松疗法(22%)以及针灸或干针疗法(14%)。最常见的处方是非阿片类止痛药(72%),其次是肌肉松弛剂(44%)、阿片类(32%)、抗焦虑药(31%)、加巴喷丁类(26%)、血清素-去甲肾上腺素再摄取抑制剂(21%)、选择性血清素再摄取抑制剂(20%)和曲马多(15%)。在各种结果中发现了许多不公平现象:总体而言,被诊断为纤维肌痛的军人在纤维肌痛确诊前后 3 个月内接受的与指南一致的医疗保健服务各不相同。几乎每3名军人中就有1人接受了阿片类药物处方,而指南中明确建议不要使用阿片类药物。配对比较显示,在并发健康状况和接受医疗服务方面,不同性别、种族和民族之间存在不必要的差异。造成健康和医疗不平等的根本原因可能是多方面的,也是可以改变的。目前尚不清楚美国军事卫生系统是否整合了患者资源来支持纤维肌痛患者,如果是,患者及其临床医生在多大程度上可以获得并了解这些资源。
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引用次数: 0
Emergency Operable Traumatic Pulmonary Injury at a Level 1 Trauma Center: A Retrospective Descriptive Study. 一级创伤中心的急诊可手术创伤性肺损伤:回顾性描述研究
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae417
Lisa Osborne-Smith, Barry Swerdlow
<p><strong>Introduction: </strong>Despite the use of body armor, emergency operable pulmonary trauma (EOPT) remains a major cause of battlefield morbidity and mortality. While EOPT during military conflicts has some features that distinguish it from EOPT in civilian settings, the 2 occurrences demonstrate overall parallel findings related to presentation, management, and outcome. The goals of the present study were to provide a descriptive analysis of the nature of EOPT and its management at a level 1 trauma center and to determine the associations between EOPT patient demographics and/or patient management and outcome in order to better understand battlefield EOPT.</p><p><strong>Materials and methods: </strong>This is a retrospective, descriptive analysis of EOPT at a level 1 trauma center during a recent 9-year period (2012-2020). The Oregon Health & Science University Trauma Registry was searched, and 106 patients met inclusion criteria for the study. Patients with primary cardiac trauma were excluded. Individual electronic medical records were reviewed to obtain descriptive data, and associations were evaluated for statistical significance.</p><p><strong>Results: </strong>In-hospital mortality in this cohort was 17.0%. The most common pulmonary injury associated with EOPT was unilateral diaphragmatic laceration (62.3%), and the most common single operation performed for EOPT was a laparotomy (71.7%) often involving diaphragmatic repair. In the remaining instances of EOPT, a thoracotomy (11.3%), a thoracotomy and a laparotomy (10.4%), or another surgery (6.6%) occurred. The primary indication for EOPT surgery was uncontrolled hemorrhage, and one-third of patients received massive transfusion. One-lung ventilation (OLV) was infrequently employed (8.5%). When OLV was used, it was equally likely to involve a single-lumen endotracheal tube (SLETT) with mainstem bronchus insertion, a SLETT with a bronchial blocker, or a double-lumen endotracheal tube. Time from EOPT to operating room arrival was inversely related to in-hospital mortality. Also, both initial in-hospital endotracheal intubation and low injury severity score were strongly associated with survival in the population studied.</p><p><strong>Conclusions: </strong>The most common indication for EOPT surgery was uncontrolled hemorrhage. The most frequent operation performed for this EOPT cohort was a laparotomy for diaphragmatic repair. A total of 91.5% of EOPT surgery was performed without OLV, an unexpected finding. When OLV occurred, it was equally likely to involve an SLETT with mainstem bronchus insertion, an SLETT with bronchial blocker, or a double-lumen endotracheal tube. The most common indication for OLV was surgical exposure. More extensive injury (expressed as an injury severity score), preadmission endotracheal intubation, and a shorter time from EOPT to operating room arrival were associated with increased odds ratios for mortality. A better understanding of the nature of EOPT
简介:尽管使用了防弹衣,紧急可手术肺创伤(EOPT)仍然是战场上发病和死亡的主要原因。虽然军事冲突中的 EOPT 与民用环境中的 EOPT 有一些不同之处,但这两种情况在表现形式、管理和结果方面的研究结果总体上是一致的。本研究的目的是对一级创伤中心 EOPT 的性质及其管理进行描述性分析,并确定 EOPT 患者人口统计学特征和/或患者管理与预后之间的关联,以便更好地了解战场 EOPT:这是一项对一级创伤中心最近 9 年(2012-2020 年)EOPT 进行的回顾性、描述性分析。研究人员搜索了俄勒冈健康与科学大学创伤登记处,106 名患者符合研究的纳入标准。排除了原发性心脏创伤患者。研究人员查阅了个人电子病历以获得描述性数据,并对相关性进行了统计学意义评估:结果:该队列的院内死亡率为 17.0%。EOPT最常见的肺损伤是单侧膈肌撕裂伤(62.3%),EOPT最常见的单次手术是开腹手术(71.7%),通常涉及膈肌修复。在其余的 EOPT 患者中,有 11.3% 的患者进行了开胸手术,有 10.4% 的患者进行了开胸和开腹手术,还有 6.6% 的患者进行了其他手术。EOPT 手术的主要适应症是出血无法控制,三分之一的患者接受了大量输血。单肺通气(OLV)很少使用(8.5%)。在使用单肺通气时,同样可能使用插入主支气管的单腔气管插管(SLETT)、带有支气管阻断器的单腔气管插管或双腔气管插管。从 EOPT 到到达手术室的时间与院内死亡率成反比。此外,在所研究的人群中,最初的院内气管插管和低损伤严重程度评分与存活率密切相关:结论:EOPT手术最常见的适应症是无法控制的大出血。结论:EOPT 最常见的手术指征是无法控制的大出血,EOPT 患者中最常进行的手术是开腹进行膈肌修复。91.5%的EOPT手术没有进行OLV,这是一个意想不到的发现。当发生 OLV 时,同样可能涉及插入主支气管的 SLETT、插入支气管阻断器的 SLETT 或双腔气管导管。OLV 最常见的适应症是手术暴露。更广泛的损伤(以损伤严重程度评分表示)、入院前气管插管以及从 EOPT 到到达手术室的时间更短与死亡率的几率比增加有关。更好地了解民用一级创伤中心 EOPT 的性质有助于确定在战场条件下与更有利的 EOPT 结果相关的条件,从而有助于管理决策,并帮助预后和分流该环境中的重伤患者。
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引用次数: 0
Precision Medicine Approach Using Triple Combination Antifungal Therapy for Fusarium Brain Abscesses and Endocarditis in an Adult Burn Patient. 使用三联抗真菌疗法治疗成年烧伤患者的镰刀菌脑脓肿和心内膜炎的精准医学方法。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae284
Evan L Barrios, Zachary Drabick, John Rodriguez, Brenda G Fahy, Amalia L Cochran, Ian R Driscoll, Andrea M Munden

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.

我们报告了对一名体表总面积 35% 的成年烧伤患者播散性茄科镰刀菌真菌感染的治疗策略,该患者患有脑脓肿,并同时患有肺动脉瓣心内膜炎,因此获得了烧伤患者中最长的存活期。在住院初期,患者被诊断为镰刀菌烧伤创面感染,同时伴有真菌血症,并接受了长期的静脉注射抗真菌单药治疗。此后不久,他出现局灶性神经功能缺损,核磁共振检查发现他有脑脓肿。他紧急接受了开颅手术并进行了清创,同时开始接受三联抗真菌治疗。经食道超声心动图显示他有肺动脉瓣植被,经三联抗真菌治疗后,植被消失。播散性梭菌感染非常罕见,死亡率接近 100%。鉴于这种疾病的罕见性,目前还没有既定的抗真菌治疗指南。然而,该患者在确诊后存活了约 1 年,治疗方法包括通过开颅手术和清创术控制病源,同时进行长期的联合抗真菌治疗(因为他的真菌感染几乎具有泛耐药性)。我们利用药物基因组学检测确定了患者对伏立康唑的代谢情况,并对剂量进行了相应调整,以提高联合疗法的疗效。据我们所知,成年烧伤患者在镰刀菌脑脓肿并发播散性感染后还能存活如此长的时间,这在以前还从未有过描述。
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引用次数: 0
Combat-Relevant Anesthesia Fellowships Help Sustain the Army's Multidomain Medical Force. 与战斗相关的麻醉研究奖学金有助于维持陆军的多领域医疗力量。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae508
Jonathan Custer

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.

在军队麻醉护士群体中,与战斗相关的研究金培训的潜力尚未得到充分利用,如果得到热情鼓励并加以利用,将为军队卫生系统及其护理受益者带来诸多益处。最重要的是,增加麻醉护士参加这些研究金培训的机会并鼓励他们参加,将成为一种技能维持工具,在为下一代战争做准备的过程中避免出现任何潜在的技能退化或战备差距。这些奖学金还将增强陆军麻醉护士在战斗和非战斗麻醉护理方面本已很强的广度、质量和安全性,有可能提高返岗率,有可能加快战场上的伤员清理工作,增加军事治疗设施中长期疼痛患者获得高级疼痛管理护理的机会,提高麻醉护士的留用率,增强军事麻醉界的知识基础,并有助于推动整个麻醉艺术的发展。为了在未来战争的多域作战环境中战胜预期的严酷考验,我们有责任作为士兵、专业人员和社区不断改进并努力成为最好的自己。本文将探讨陆军麻醉护士战斗相关奖学金尚未开发的效用。
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引用次数: 0
Joint Trauma System: Behind the Scenes.
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usaf014
Jennifer Gurney, Matthew D Tadlock, Jan-Michael Van Gent

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.

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引用次数: 0
Treating Post-Traumatic Stress Disorder in Canadian Special Operation Forces Command With Ketamine Plus Cervical Sympathetic Blockade.
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usaf051
Eugene Lipov, Hunter Rolain, Troy Neufeld

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.

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引用次数: 0
Impact of the COVID-19 Pandemic on the Delivery of Congenital Syphilis Care in the Military Health System. COVID-19 大流行对军队卫生系统提供先天性梅毒治疗的影响。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae392
Jennifer Teng, Sarah Prabhakar, Michael Rajnik, Apryl Susi, Elizabeth Hisle-Gorman, Cade M Nylund, Jill Brown

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.

导言:在过去20年中,美国先天性梅毒(CS)病例率大幅上升,在COVID-19大流行期间上升速度更快。发病率的上升可能与获得医疗服务有关,但尚未在军队卫生系统等全额保险人群中进行过评估:我们使用查询过的军事卫生系统数据库对 CS 病例和总就诊人次(护理率)进行了每月重复横截面研究。我们根据国际疾病分类第 10 次修订版临床修正诊断代码对 2 岁以下受益人的 CS 进行了定义。我们对 COVID-19 前(2018 年 3 月至 2020 年 2 月)、大流行第一年(2020 年 3 月至 2021 年 2 月)和大流行第二年(2021 年 3 月至 2022 年 2 月)进行了评估。我们进行了变化点和趋势分析以及泊松回归,以评估赞助商等级、TRICARE 地区和大流行期间的差异。统一服务大学机构审查委员会批准了这项研究:结果:共发现了 69 个独特的 CS 病例,每月护理率的中位数为 0.90/100,000,符合条件的受益人为 0.90/100,000。在整个研究期间,先天性梅毒护理率平均每月增长 5.8%(P 结论:先天性梅毒护理率在整个研究期间平均每月增长 5.8%:该投保群体的先天性梅毒护理率大大低于全国的护理率,但在 COVID-19 大流行期间显著增加。军衔较低的军人子女的护理率较高。地区趋势与全国数据不同。这些研究结果表明,即使在全额参保的人群中,收入和地区差异也会对 CS 产生影响,而 COVID-19 大流行可能加剧了护理提供方面的差异。
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引用次数: 0
Solid Metal Chemical and Thermal Injury Management. 固体金属化学和热损伤管理。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae406
Phillip M Kemp Bohan, Stacy L Coulthard, Jay A Yelon, Gary A Bass, Mary A Decoteau, Jeremy W Cannon, Lewis J Kaplan

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.

介绍:固体金属可造成各种伤害。白磷(WP)是一种可造成腐蚀性和热损伤的金属。由于白磷在冲突和战争期间被广泛用于弹药和烟幕中,所有军事临床医生都应具备识别白磷伤害、急性治疗和长期后果识别的能力:从 PubMed 和 Medline 上搜集了从开始到 2024 年 1 月 31 日有关可湿性粉剂损伤的英文稿件。对有关可湿性粉剂损伤的识别、管理和后遗症的数据进行了摘录,以构建符合指南的叙述性综述文章评估量表:白磷似乎在军事冲突中无处不在。结果:白磷在军事冲突中似乎无处不在,白磷会在伤口处产生特征性外观,并伴有烟雾、大蒜香味以及与空气接触后自燃。去污和防止或停止燃烧是关键所在,可能需要水冲洗、浸泡或浸入防止与空气接触的物质中。局部冷却也是防止自燃的一个关键方面。处理所有受污染的衣物和装备对防止造成额外伤害至关重要,尤其是对救援人员。长期后遗症与磷的吸收有关,可能导致死亡。长期或反复接触可能会诱发下颚骨坏死。战术战斗伤员救护建议目前并未涉及可湿性粉剂伤害管理:有关可湿性粉剂急性损伤和后期后遗症的教育和管理对于急性战场和最终设施护理至关重要。资源匮乏和资源有限的环境可采用相关方法进行急性处理和预防点火。当前的烧伤创面管理建议应包括针对不同技能水平和环境的军事临床医生的特定 WP 管理原则和行动。
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引用次数: 0
The Impact of Time to Anterior Cruciate Ligament Reconstruction on Return to Duty Among Active Duty Military Personnel. 前十字韧带重建的时间对现役军人重返岗位的影响》(The Impact of Time to Anterior Cruciate Ligament Reconstruction on Return to Duty Among Active Duty Military Personnel)。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae419
Brandon A Burt, Preston E Lopez, Marie L Chardon, Joshua Sakai, John T Evans
<p><strong>Introduction: </strong>After an anterior cruciate ligament (ACL) injury, service members often undergo ACL reconstruction (ACLR) to restore knee stability, which is critical for performing physically demanding and unconventional military-specific tasks. Despite advancements in surgical techniques and rehabilitation protocols, a large portion of service members will not fully return to duty (RTD) post-ACLR and will receive a permanent profile restriction (PP) or undergo a medical evaluation board (MEB). The timing of ACLR is a modifiable factor that can potentially impact RTD and remains underexplored in this population. This study aimed to assess the relationship between the timing of ACLR and its impact on RTD and meniscal procedures performed at index ACLR.</p><p><strong>Methods: </strong>This retrospective observational study was conducted among active duty military personnel who underwent primary ACLR at Madigan Army Medical Center between October 1, 2016, and December 31, 2022. The primary outcome was the number of RTD, PP, or MEB outcomes. Secondary outcomes included the incidence and type of meniscal procedure performed at index ACLR. Kruskal-Wallis analyses were employed to assess the relationships between time to ACLR and RTD, as well as the incidence and type of meniscal procedure performed. After separating time to ACLR into four distinct time-based groups (0-3 months, 3-6 months, 6-12 months, and >12 months), a chi-squared test with post hoc analysis via Dunn's test with Bonferroni correction was conducted to identify a time interval from injury to ACLR that impacted RTD.</p><p><strong>Results: </strong>Initial analysis to assess the relationship between time to ACLR and outcome (RTD, PP, or MEB) were significant (P = .02). Subsequent analyses performed between 4 distinct time-based groups (0-3 months, 3-6 months, 6-12 months, and >12 months) were also significant (P = .03). Pairwise comparisons revealed an 80% rate of RTD in the 0-3 month group compared to a 53% RTD rate in 3-6 month group (P = .006). However, comparisons between the 3-6 month and 6-12 month group (P = .68) and between the 6-12 month and greater than 12 month groups were not significant (P = .80).Additionally, time to ACLR significantly differed between service members who did not undergo any concurrent meniscal procedure to those who had a meniscal debridement (P = .002), and to those who underwent meniscal repair (P = .02). There was no significant difference in time to ACLR between those who underwent debridement versus repair (P = .22). Patients without any meniscal procedure had an average surgery time of 175 days, compared to 240 days for those undergoing meniscal repair and 295 days for those with meniscal debridement.</p><p><strong>Conclusion: </strong>The findings from this novel study suggest that ACLR within 3 months after injury can improve the likelihood of RTD without limitations. The timing of ACLR can also impact the incidence and type of m
导言:前交叉韧带(ACL)受伤后,军人通常会接受前交叉韧带重建术(ACLR)以恢复膝关节的稳定性,这对于执行体力要求高且非常规的军事任务至关重要。尽管手术技术和康复方案不断进步,但仍有很大一部分军人在 ACLR 术后无法完全重返岗位(RTD),而会受到永久性外形限制(PP)或接受医疗评估委员会(MEB)的检查。前交叉韧带重建的时机是一个可能影响 RTD 的可调整因素,但在这一人群中仍未得到充分探索。本研究旨在评估前交叉韧带置换术的时机及其对 RTD 的影响与在前交叉韧带置换术中进行的半月板手术之间的关系:这项回顾性观察研究的对象是 2016 年 10 月 1 日至 2022 年 12 月 31 日期间在马迪根陆军医疗中心接受初级 ACLR 的现役军人。主要结果是RTD、PP或MEB结果的数量。次要结果包括指数 ACLR 时进行的半月板手术的发生率和类型。Kruskal-Wallis 分析用于评估前交叉韧带重建时间与 RTD 之间的关系,以及半月板手术的发生率和类型。在将前交叉韧带重建时间分为四个不同的时间组(0-3个月、3-6个月、6-12个月和>12个月)后,通过Dunn's检验和Bonferroni校正进行了chi-squared检验和事后分析,以确定从受伤到前交叉韧带重建的时间间隔对RTD的影响:评估前交叉韧带损伤时间与结果(RTD、PP 或 MEB)之间关系的初步分析结果显著(P = .02)。随后在 4 个不同的时间组(0-3 个月、3-6 个月、6-12 个月和大于 12 个月)之间进行的分析也有意义(P = .03)。配对比较显示,0-3 个月组的 RTD 率为 80%,而 3-6 个月组的 RTD 率为 53%(P = .006)。然而,3-6个月组与6-12个月组之间的比较(P = .68)以及6-12个月组与超过12个月组之间的比较均无显著性(P = .80)。此外,未同时接受任何半月板手术的军人与接受半月板清创术的军人(P = .002)以及接受半月板修复术的军人(P = .02)的前交叉韧带重建时间存在显著差异。接受半月板清创术和半月板修复术的患者在进行 ACLR 的时间上没有明显差异(P = 0.22)。未接受任何半月板手术的患者平均手术时间为175天,而接受半月板修复术的患者平均手术时间为240天,接受半月板清创术的患者平均手术时间为295天:这项新研究的结果表明,在受伤后 3 个月内进行前交叉韧带修复术可提高无限制 RTD 的可能性。前交叉韧带置换术的时机也会影响半月板手术的发生率和类型,因为没有同时接受半月板手术的患者会在伤后6个月内接受前交叉韧带置换术。这项研究为我们提供了宝贵的见解,使我们认识到在服役人员中尽早进行前交叉韧带置换术的重要性,从而提高复位率并减少额外的同期半月板手术。
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引用次数: 0
Expectant Casualty Care Training Needs for Future Conflicts. 未来冲突的预期伤员护理培训需求。
IF 1.2 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL Pub Date : 2025-02-27 DOI: 10.1093/milmed/usae389
Rebekah Cole, Sean Keenan, Matthew D Tadlock, Shawna Grover, Melissa Givens, Sherri L Rudinsky

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.

引言:未来大规模作战行动的需求可能会要求医护人员越来越多地执行预期伤员护理 (ECC)。然而,目前在军事医学领域还没有提供 ECC 的详细指南。为了指导教育和培训指南的制定,并推进医护人员和非医护人员的团队培训,首先需要深入了解护理人员在近期冲突中提供 ECC 的经验以及他们认为存在的培训差距。因此,本研究探讨了医护人员和医生提供紧急救护的经验,并调查了他们对未来以大规模作战行动和长期伤员救护行动环境为特点的冲突中这方面培训需求的看法:我们开展了一项参与式定性现象学研究,以探讨未来冲突中的紧急救护培训需求。我们采访了 9 名资深医护专业人员(医护人员和医生),他们都有丰富的作战和部署经验,主要在角色 1 环境中服役。访谈平均每次 45 分钟,通过电话进行。为了分析这些访谈数据,我们审阅了访谈记录,然后在访谈记录中记下了我们认为对回答研究问题有突出作用的术语、短语和概念。然后,我们的团队开会审查了这些代码,并将其归类。这些类别作为本研究的主题,说明了参与者的看法和经验:从我们的数据中得出了五个主题:(1)目前,全军在对士兵角色 1 护理人员进行 ECC 培训方面存在差距;(2)需要进行 ECC 培训以转变组织文化;(3)ECC 培训应该全面;(4)ECC 培训应该深思熟虑;以及(5)时间是实施 ECC 培训的最大挑战。我们的参与者指出,制定指导方针和填补培训空白不仅对角色 1 提供者为有效和合乎道德的军事医疗决策做好准备至关重要,而且对解决战场上的死亡和濒死问题以及建设整个医疗队的道德复原力也至关重要:我们的研究结果为制定 ECC 临床指南和团队集体培训建议提供了方向。遵循这些指导原则可以提高远征战场上的生命挽救能力,并使医务主任和医务人员能够在资源和撤离机会有限的情况下为那些无法挽救的人提供合乎道德和富有同情心的护理。
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引用次数: 0
期刊
Military Medicine
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