Military Medicine最新文献

Introduction: Active duty service members (ADSMs) experience higher rates of unintended pregnancy compared to the general population. While the military has introduced programs aimed at improving access to sexual and reproductive healthcare services (SRH), significant barriers to care remain.

Materials and methods: A survey was completed by ADSMs with access to no-cost, walk-in SRH. Descriptive statistics, univariable analyses, and multivariable logistic regression analyses examined the association of ADSM characteristics with SRH outcomes.

Results: Of 1,077 participants (72% male, 61% <25 years), 49% reported intercourse that could result in pregnancy in the past 3 months, and 21% reported that they or their partners used emergency contraception in the past year. Overall, 51% of those who sought SRH reported barriers, such as feeling judged, lack of knowledge of available services, difficulty booking appointments, and/or work schedules. Female ADSMs (n = 133/228, 58%) were more likely than male ADSMs (n = 133/296, 45%) to report experiencing a barrier (Odds Ratio (OR) = 1.8, 95% Confidence Interval (CI), 1.3-2.6; P = .001).In univariable logistic regression analysis, ADSMs who experienced barriers getting SRH (OR=1.6, 95% CI, 1.1-2.5) or believed that receiving SRH care can negatively affect their careers (OR=3.7, 95% CI, 1.9-7.2) were more likely to use emergency contraception than those who did not. In multivariable logistic regression analysis of ADSMs with a history of sexual intercourse, adjusting for race, ethnicity, reported SRH barriers, use of a military clinic, and current contraceptive use, emergency contraception use by an ADSM or their partner in the past year was associated with being <25 years old (aOR = 2.8, 95% CI, 1.6-4.8) and believing that seeking SRH could negatively impact their career (aOR = 4.7, 95% CI, 1.5-14.7).

Conclusions: Active duty service members commonly perceive judgment and systemic barriers when accessing SRH. Active duty service members may benefit from additional efforts to destigmatize SRH and facilitate access to patient-centered SRH.

Introduction: Acute respiratory distress syndrome (ARDS) is associated with significant mortality and long-term morbidity, often preventing survivors from returning to work. This poses particular challenges in the military, where maintaining combat-ready forces depends on the health and readiness of service members. This study investigates ARDS in active duty U.S. military personnel to estimate its broader impact on the military.

Materials and methods: A retrospective cohort study was conducted with Institutional Review Board (IRB) approval, utilizing the U.S. Military Data Repository, which contains health data from all active duty service members. Acute respiratory distress syndrome was identified using Current Procedural Terminology (CPT) codes and confirmed with chart review. Data were collected on demographics, clinical course, underlying ARDS etiology, survival, and military separation. Statistical analyses included univariate comparisons to identify demographic and clinical factors associated with mortality.

Results: The overall incidence of ARDS in active duty personnel was 1.01 per 100,000 person-years, with a 2-fold increase in the post-COVID period (1.55 per 100,000 person-years) compared to the pre-COVID period (0.76 per 100,000 person-years). The most common cause of ARDS was infection (53%), followed by trauma (16%). The mean age of affected servicemembers was 32 years, with a mortality rate of 20%. Among those who survived, 43% failed to return to active duty and were medically separated; 70% of these separations were directly attributable to ARDS or related complications, while 30% were because of other etiologies.

Conclusions: Acute respiratory distress syndrome poses significant risks to active duty military personnel, with notable short-term mortality and long-term morbidity, including high rates of medical separation and failure to return to duty. These complications could impact the military overall by decreasing the workforce, impairing military readiness, and introducing financial burdens. Further studies are needed to fully assess functional limitations following ARDS and to optimize management strategies that enhance recovery outcomes for military service members affected by the condition.

Introduction: Prevalence studies on ocular diseases among veterans are limited and underreported. In this retrospective study, we examined the prevalence of vision-threatening ocular diseases among North Carolina veterans. We assessed the prevalence of 6 serious ocular conditions among veterans receiving primary care at the Salisbury Veterans Affairs Health Care System (SVAHCS) in North Carolina to better understand ocular disease prevalence among veterans. Glaucoma, the most common ocular disease in this population, underscores the need for targeted interventions to mitigate vision loss.

Materials and methods: A retrospective review of medical records from 34,530 veterans enrolled in SVAHCS primary care was conducted. Data collected included demographics such as age, gender, and race. The study focused on 6 vision-threatening diseases: glaucoma, vision-threatening diabetic retinopathy (VTDR), exudative age-related macular degeneration (AMD), retinal vein occlusions (RVO), retinal artery occlusions (RAO), and non-arteritic anterior ischemic optic neuropathy (NAION). Structured Query Language extracted disease frequency, and statistical analysis revealed prevalence rates and socio-demographic patterns.

Results: The average age of veterans was 69.5 years, with 94% male and 66% White. The most prevalent ocular condition was glaucoma (9%), followed by VTDR (1.3%), exudative AMD (0.9%), RVO (0.8%), RAO (0.4%), and NAION (0.4%). Older male veterans had a disproportionate burden of most ocular conditions. Racial disparities in disease prevalence highlight areas for focused healthcare strategies.

Conclusions: This study reveals the significant burden of vision-threatening ocular diseases among North Carolina veterans, with glaucoma being the most prevalent. The findings emphasize the need for targeted screening and personalized interventions to prevent vision loss and address disparities. Further research should explore systemic and behavioral contributors to these trends, guiding evidence-based strategies to improve veterans' ocular health outcomes.

Background: Emergency General Surgery (EGS) procedures are vital and high-risk interventions. Delivery of these procedures in military treatment facilities (MTFs) is important to beneficiaries of the U.S. Military Health System (MHS). Organizational changes, including consolidation of MTFs under the Defense Health Agency and personnel reductions, in conjunction with the COVID-19 pandemic, have led to concerns about potential declines in care quality. We assessed whether clinical outcomes remained consistent or were negatively influenced by the healthcare administrative changes and the COVID-19 pandemic.

Materials and methods: Claims data from the MHS Data Repository and ICD-10 diagnosis codes were used to identify patients, 18-64, admitted to U.S.-based MTFs between fiscal years 2016 and 2023 with an EGS condition. The main predictor was hospital EGS volume categorized into volume-based quartiles. Outcomes were 30-day mortality, complications, and readmissions. Patients were stratified into 2 time periods (FY 2016-2019 and FY 2020-2023) based on index admission date. Multivariable logistic regression models were used to assess the relationship between MTF volume and clinical outcomes.

Results: 113,626 EGS encounters treated across 40 MTFs were identified. Adjusted analyses showed that compared to the highest volume MTFs of 2016-2019, MTFs in the lower middle quartiles (LMQ) and upper middle quartiles (UMQ) of 2016-2019 (OR: 0.67; OR: 0.67) and LMQ of 2020-2023 (OR: 0.70) had a significantly decreased likelihood of 30-day mortality. Compared to 2016-2019's highest volume MTFs, the lowest volume MTFs of 2016-2019 were significantly less likely to experience complications (OR: 0.67), while MTFs from the UMQ of 2016-2019 (OR: 1.10) and all quartiles of 2020-2023 (OR: 1.22; OR: 1.61; OR: 1.43; OR: 1.27) were significantly more likely to develop complications. Patients treated at MTFs in the LMQ and UMQ of 2016-2019 (OR: 0.78; OR: 0.70) and those in the lowest and middle quartiles of 2020-2023 (OR: 0.67; OR: 0.71; OR: 0.76) had a significantly lower likelihoods of readmission compared to the highest volume MTFs of 2016-2019.

Conclusion: The likelihood of 30-day complications among all MTF quartiles in 2020-2023 was significantly higher compared to MTFs in 2016-2019. However, EGS patients treated in low-volume MTFs experienced similar, if not improved, clinical outcomes of mortality and readmissions compared to those treated in high-volume MTFs.

Introduction: Role 2 (R2) U.S. military treatment facilities provide lifesaving far forward damage control resuscitation and surgery. Given the austere conditions at R2s, infection risk is a major concern. We aimed to evaluate the infection rate after external fixation (EF) in military casualties based on where in the evacuation pathway the EF was performed, hypothesizing that lower-echelon EF would be associated with increased infections.

Materials and methods: The Department of Defense Trauma Registry (DoDTR) was retrospectively reviewed from 2003 to 2024. Non-U.S. military patients, deaths, and burns were excluded. Lower-echelon EF was defined as the first EF performed at R2, or Role 3 (R3) in cases of R2 bypass. Infection was defined as any one of seventeen infectious complications recorded in the DoDTR. We evaluated the independent association of lower-echelon EF on both wound infection (WI) and overall infection using multiple regression.

Results: In 6,115 patients, 2,529 met inclusion criteria, of whom 646 (25.5%) developed postoperative infection. 19.0% of all EFs were placed at R2, 67.7% at R3, 5.4% at Role 4 (R4), and 7.8% at R4-Continental United States (R4c). Overall infection rate after EF was 19.2% for R2, 24.9% for R3, 19.8% for R4, and 38.8% for R4c (25.5% overall). Wound infection was the most common infectious complication at (8.6% after EF at R2, 14.5% for R3, 15.3% for R4, and 24.5% for R4C, 15.2% overall). On adjusted analysis, higher-echelon EF was independently associated with WI and overall infection: adjusted odds ratio of 1.718 (97.5% CI, 1.311-2.250), and 1.514 (97.5% CI, 1.208-1.899), respectively.

Conclusions: For U.S. military casualties, lower-echelon external fixation is associated with decreased infection despite the austere setting. Although this study is unable to elucidate the specific factor(s) responsible for this association, it highlights the need to maintain orthopedic expertise close to point-of-injury and for future work to identify the specific characteristics of either the patients who receive lower-echelon EF, their injuries, or the EFs at the Role 2 and Role 3 facilities themselves that are responsible for this association.

Background: Whole blood is commonly used for casualty resuscitation in the prehospital setting. According to the 2021 Committee on Tactical Combat Casualty Care guidelines, whole blood is the preferred fluid for resuscitating casualties with signs of hemorrhagic shock, followed by fresh whole blood (FWB). There is limited literature on soldiers' physical and cognitive performance following donation, particularly regarding their small marksmanship accuracy immediately after 1 unit of FWB donation. Current research on marksmanship accuracy post-FWB donation among military personnel is limited to the Norwegian and Israeli militaries. The lack of Department of Defense clinical practice guidelines restricting soldiers' duties after FWB donation highlights the paucity of data. This study evaluates the effects of FWB donation on U.S. Army conventional soldiers' small marksmanship accuracy and provides quantifiable data for future U.S. Army post-FWB donation guidelines.

Methods: This was a prospective, controlled trial assessing small arms marksmanship accuracy pre- and post-FWB donation with a convenience sample of conventional U.S. Army conventional soldiers, using an indoor Electronic Skill Trainer (EST) simulator. The primary outcome assessed for a difference in small arms marksmanship accuracy following FWB donation. Participants served as their own controls, with baseline marksmanship accuracy testing performed before FWB donation and again immediately after. Secondary outcomes were the participants' pre- and post-FWB donation self-efficacy scores.

Results: Sixteen participants completed small arms marksmanship accuracy testing pre- and post-FWB donation. We found no significant difference in small arms marksmanship accuracy following FWB donation (24.69 vs. 26.32, P = .38). Similarly, we evaluated small arms marksmanship accuracy self-efficacy via a Bandura Scale and found no significant difference between pre-and post-FWB donation (86.25 vs. 85.63, P = .67).

Conclusions: The accuracy of U.S. Army conventional soldiers small arms marksmanship was not significantly different after donating 1 unit of FWB. This study provides data on post-FWB donation marksmanship accuracy, which could inform future guidelines for soldiers returning to duty after donating 1 unit of FWB blood. Larger, comparative studies need to be performed to further investigate soldiers' post-FWB donation marksmanship accuracy.

Introduction: Stress from the COVID-19 pandemic may have had a profound impact on the mental health of Reserve and National Guard (RNG) women Veterans, especially if they have a history of traumatic brain injury (TBI). This cross-sectional study aimed to assess the potential mediating effect of stress stemming from the COVID-19 pandemic on the association between TBI and depression symptoms.

Materials and methods: Women RNG Veterans between the ages of 18 and 60 were interviewed about their lifetime history of TBI, symptoms of depression, and any stressful experiences resulting from the COVID-19 pandemic. Using interview responses, we utilized exploratory factor analysis (EFA) to approximate COVID-19 stress. We then used the results from EFA in mediation analysis of linear regression models of TBI history on depression. Ethical approval for the study and analyses was obtained from the University of Iowa Institutional Review Board (IRB) (IRB ID #201911171).

Results: We identified 9 items across a 3-factor model ("Stress about Daily Necessities," "Stress about Health," "Increasing Alcohol Use") that approximated COVID-19 stress. Of the 351 women Veterans included in this study, 145 (41.3%) had history of TBI. Those with TBI had more severe symptoms of depression (risk difference: 1.81, 95% CI: 0.41-3.20) than those without TBI. Total COVID-19 stress mediated the association between TBI and symptoms of depression (indirect effect: 0.67; 95% CI: 0.24-1.21; 35.5% mediated). Stress about Daily Necessities alone also mediated the TBI-depression association (indirect effect: 0.65; 95% CI: 0.44-0.84; 34.8% mediated).

Conclusions: Women RNG Veterans with prior TBI reported more severe depression symptoms than those without TBI, and these depression symptoms seem to be exacerbated upon the introduction of stress because of the COVID-19 pandemic. Future research of this complex TBI-stress-depression relationship should be longitudinal in nature, especially as the long-term effects of the COVID-19 pandemic continue to emerge, to understand how events that introduce significant economic and health-related consequences affect how symptoms of depression and responses to stress evolve over time.

Introduction: Loneliness among older adults is a significant public health concern. There is a critical need to develop effective, tailored strategies to combat loneliness that accounts for the diverse nature of older adult populations, including those with unique life experiences, such as Veterans. In order to develop and implement these strategies and meet the specific needs of the diverse older population, the research field requires a comprehensive understanding of the various factors that contribute to loneliness across different subgroups of older adults, including Veterans and civilians. In this study, we aimed to address this research gap by investigating and comparing characteristics associated with loneliness among both older Veterans and civilians.

Materials and methods: In this cross-sectional exploratory study, we used data from the RAND Health and Retirement Study Longitudinal File 2020, derived from the Health and Retirement Study and provided by the RAND Center for the Study of Aging (N = 5,259) to assess and compare characteristics associated with loneliness among older Veterans and civilians. We conducted logistic regression and moderation analyses to investigate associations between demographic, health, health behavior, and psychosocial factors and loneliness.

Results: Our results showed significant positively associations between loneliness and being unmarried/unpartnered, greater depressive symptoms, and greater negative affect for both Veterans and civilians. Similarly, we found significant negative associations between loneliness and greater life satisfaction and positive affect for both subsamples. Our results showed that having health conditions that limit an individual's ability to work was a unique risk factor for loneliness among Veterans. Moderation analyses revealed that the positive association between being unmarried/unpartnered and loneliness and the negative association between rural residence and loneliness were significantly greater for Veterans, as compared to civilians.

Conclusions: Our findings suggest the importance of considering life course perspectives and developing targeted interventions to address loneliness among older adults, particularly Veterans. Future research should focus on longitudinal studies to investigate the effectiveness of such interventions, explore protective factors, and examine the impact of social interventions on reducing loneliness in these populations.

Historically, military anatomic pathology (AP) services have been significantly compartmentalized, with each branch independently executing its laboratory support mission. The result is redundant and costly duplication of nearly identical services in close geographic proximity. The duplication of AP services disperses the overall caseload, resulting in pathologist diagnostic acumen atrophy, excessive support personnel requirements, inadequate utilization of subspecialty expertise, and overall lower-quality patient care. Unlike many medical specialties, implementing AP services does not require direct patient interaction and is principally not as time-sensitive as other clinical laboratory testing. The practice of AP is conducive to a more consolidatory paradigm to achieve economies of scale. Pathology service unification would also afford the stationing of predominantly subspecialists at tertiary care centers to handle higher caseloads. Larger groups of pathologists increase patient safety enhancing peer-to-peer and subspeciality quality assurance processes during case review. Conversely, the nature of clinical pathology services requires a more widespread presence-even at the smaller, auxiliary clinics throughout the military health system. Clinical pathology services would also benefit from additional triservice cooperation including standardization of quality management processes, increased resource sharing, exchange, and cooperative contingency planning. Laboratory directorships also benefit from consolidating expertise, where pathologists could be physically located at a central site with remote oversight of laboratory services. Here, we propose a holistic triservice consolidation plan for military pathology to optimize resource utilization and ultimately realize the overarching strategic plan for military medicine set forth by the Defense Health Agency.

Introduction: Military satisfaction is an important determinant for military retention and subsequently military readiness. Military readiness is also impacted by food insecurity, which affected 25% of active duty service members in 2018 and 2020, much higher than the 10% prevalence observed in civilians. The objective of this study is to estimate the association between food insecurity and 3 indicators of satisfaction with military life: active duty service member's overall satisfaction with military life, active duty service member's intent to leave the military, and married active duty service members' perceptions regarding spousal desire to leave the military.

Materials and methods: The 2020 Status of Forces Survey of Active Duty Members is a probability-based sample of all active duty service members in the U.S. Military (n = 12,324). Weighted logistic regressions were used to estimate the associations between food insecurity and retention indicators controlling for observable confounders. This study was approved as public health practice by the Defense Centers for Public Health-Aberdeen.

Results: Respondents with either low food insecurity (adjusted odds ratio (AOR): 1.45; 95% confidence interval (CI), 1.18-1.78) or very low food insecurity (AOR: 1.68; 95% CI, 1.30-2.16) had greater odds of dissatisfaction with military way of life compared to food secure respondents. Additionally, very low food security was associated with greater odds of spousal desire to leave the active duty military. Respondents who reported they had lower levels of financial security had lower satisfaction with the military way of life, greater intent to leave the military, and greater spousal desire to leave active duty.

Conclusions: In the present era of an all-volunteer military, novel strategies are needed to recruit and retain service members and their families. Although food insecurity was only associated with overall satisfaction with the military way of life, lower financial security was associated with satisfaction and intent to leave the military. Future studies could determine how financial security, including food insecurity, can be bolstered among active duty service members to increase retention and maintain military readiness.