Military Medicine最新文献

Introduction: This study explored healthcare providers' intentions to diagnose Adjustment Disorder (AjD) in Active Duty Service Members (ADSMs) within the U.S. military, utilizing the Theory of Planned Behavior (TPB) as a guiding framework.

Materials and methods: Focusing on 3 key TPB constructs-attitudes, subjective norms, and perceived behavioral control-we conducted interviews with fifty healthcare providers experienced in caring for ADSMs. Initial coding involved categorizing data according to these theoretical constructs. This was followed by inductive and deductive thematic analysis to identify emergent themes within each construct.

Findings: Under the Attitudes construct, themes included patient-focused attitudes, clinician-focused attitudes, and an overarching spectrum of attitudes. Perceived Behavioral Control themes consisted of diagnostic criteria, military policies, and command involvement. Finally, Subjective Norms themes included formal and informal training, patient motivation, and military duty.

Conclusions: Our aim was to enhance understanding of diagnostic practices for AjD in this unique context. Recognizing the inherent adjustment that is required for military service, providers demonstrated confidence in diagnosing AjD, but also expressed a clear need for ongoing education and training surrounding this disorder. Providers identified younger, enlisted individuals at their first duty station as the most frequently diagnosed demographic, with adaptation to military expectations as a primary stressor. Varying perspectives on AjD's diagnostic validity were observed, with some viewing it as a necessary diagnosis, while others considered it an overused placeholder diagnosis. Providers underscored the complexity of AjD's diagnostic criteria, the impact of military policies on accession and retention, and the influence of military leadership as key factors in their intent to diagnose AjD. Moreover, while confident in their ability, providers valued peer review and discussions for accurate diagnosis and consideration of ADSMs' career implications. Overall, our findings highlight the nuanced considerations within military mental health, particularly regarding AjD diagnosis.

The Department of Defense predicts that future conflicts will involve large-scale combat operations (LSCOs) characterized by high-intensity warfare between technologically advanced nations. These conflicts may result in prolonged exposure to violence, increasing the risk of severe mental health consequences for military personnel, veterans, and civilians. Research on past wars and ongoing conflicts, such as the war in Ukraine, demonstrates the heightened risks of post-traumatic stress disorder, depression, moral injury, and compassion fatigue in LSCOs. Unlike previous conflicts in Iraq and Afghanistan, LSCOs may involve prolonged deployments, limited medical evacuations, and greater use of cyber and psychological warfare, exacerbating psychological distress. Given these anticipated threats, we urge mental health professionals to proactively address the anticipated mental health challenges associated with LSCOs. Preemptive strategies may include predeployment resilience training, increased access to deployable and telehealth mental health resources, and targeted interventions for preventing and mitigating moral injury. Additionally, civilian populations in conflict zones may experience displacement and exposure to violence. Given the long-term psychological impact of large-scale warfare, ongoing mental health program development and evaluation is needed to support affected populations. By anticipating these challenges posed by LSCOs, mental health professionals can implement strategic interventions to mitigate their psychological burden on service members, veterans, and civilians.

Introduction: Femoral neck bone stress injuries (FNBSI) are a significant problem among soldiers in the U.S. Military. The trainee military population experiences stress fractures at a rate of 43.75 per 1,000 person-years. This scoping review aimed to summarize the available evidence regarding the clinical findings to indicate FNBSI. This information can be used to better guide clinical decision making and identify gaps in current research concerning the diagnosis of FNBSI in clinical settings.

Materials and methods: This study included any article who provided information on the method of clinical diagnosis specific to FNBSI with subjective or objective measures. This was completed with exclusion of articles in non-English language, utilized cadavers or non-human subjects, were intervention or surgical procedure based, included pediatrics, or related to injuries other than a FNBSI. We retrieved subjective and objective clinical indicators who could aid in the diagnosis of FNBSI. We summarized our findings by case study, cohort, and systematic review.

Results: The most common publication type concerning clinical indicators for the diagnosis of FNBSI were case reports (n = 30, 58%). This was followed by cohort studies (n = 20, 38%), and systematic reviews (n = 2, 4%). Common clinical indicators of FNBSI within the literature were an increase in physical activity and insidious pain at hip or groin.

Conclusions: This review can be utilized in future studies to inform clinicians of commonly identified clinical indicators of FNBSI and more appropriate utilization of diagnostic imaging in the diagnosis of FNBSI.

Introduction: Thermobaric weapons (TW) are a class of explosive weapons designed to use oxygen from the surrounding environment to deliver blasts generating intense pressure and heat, penetrating structures more efficiently than conventional weapons. Despite the increasing use of TW in conflicts globally, no comprehensive evaluation of the literature on TW has been published to date. This review aims to assess current evidence on the medical Impacts of TW.

Materials and methods: A scoping review of the literature was conducted in accordance with PRISMA Scoping Review (PRISMA-ScR) methodology. Structured searches of databases including Web of Science, Embase, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Global Index Medicus, Military and Government Collection, Global Health, SciELO, and Google Scholar as well as grey literature sources were performed to identify records that described injuries related to TW use.

Results: The search identified 7,365 records. After title-abstract, full text screening and exclusion of duplicative data, 16 eligible reports, including 3 grey literature reports, were included in analysis. Represented regions included Eastern Europe, the Middle East, East Africa, and Southeast Asia. Of the reports, 8 were narrative reviews, 3 were case series, one was a case control, one was a modelling study, and 3 were grey literature reports. Four reports were conducted in high-resource settings in North America and Europe, although 6 were in low-resource conflict settings in the Middle East and Eastern Europe. Ten reports described disability, with only 6 reports presenting primary data, and no reports including analysis on patient physiology, hemodynamics, or psychological trauma. Six reports collected data from combatants only, one incorporated both combatant and civilian data, and the remaining did not specify population status. Non-uniform reporting across eligible reports prevented pooled analysis thus limited conclusions that could be drawn.

Conclusion: All reports included in analysis highlighted the complex multidimensional injury patterns associated with TW, exceeding the severity of normal blast injury including pulmonary barotrauma, full-thickness burns, chemical inhalation injuries, and tertiary injuries resulting from confined-space detonations. Despite the significance of TW use and impact on casualties in modern conflict, this review identified a significant gap in the evidence base on the medical effects of TW. This lack of primary clinical data significantly constrains efforts to guide data-driven approaches to treatment algorithms, performance improvement, and rehabilitation needs for survivors of TW-related injuries. The establishment of a global registry on TW could address this evidence gap through documentation of the injuries caused by TW.

Introduction: Noncompressible torso hemorrhage (NCTH) is a major cause of preventable death in both civilian and military trauma settings. It involves vascular disruptions within the thoracic cavity, major axial torso vessels, severe solid organ injuries, or pelvic ring fractures leading to hemodynamic instability resistant to direct pressure control. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a minimally invasive technique used to temporarily occlude aortic blood flow, mitigating distal hemorrhage and preserving proximal perfusion until surgical intervention. This meta-analysis compares the effectiveness of REBOA with alternative surgical techniques in managing NCTH in trauma patients.

Materials and methods: A systematic review was conducted to investigate peer-reviewed studies on the outcomes of REBOA when compared to alternative surgical techniques in the management of NCTH. Databases searched include PubMed, Embase, Ovid EBM reviews (Cochrane), CINAHL, and Web of Science. The review included cohort, case-control, or randomized trials on patients 18 years or older with NCTH, comparing REBOA with alternative surgical techniques. Data on in-hospital mortality and acute kidney injury (AKI) were extracted. Critical appraisal of the risk of bias was assessed using the Cochrane Collaboration's ROBINS-I tool. Statistical analyses were performed using R version 4.2.2.

Results: Eight studies (n = 2,197) met the inclusion criteria. Resuscitative Endovascular Balloon Occlusion of the Aorta was associated with lower mortality compared to resuscitative thoracotomy and combined REBOA/thoracotomy, but higher mortality compared to pelvic angioembolization. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta (p-REBOA) showed a significant reduction in AKI compared to full REBOA. No significant differences in AKI were found between REBOA and other treatments like preperitoneal packing or open aortic occlusion.

Conclusions: Resuscitative Endovascular Balloon Occlusion of the Aorta may offer a survival advantage over resuscitative thoracotomy in NCTH management, but pelvic angioembolization may be more effective for pelvic trauma. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta is associated with a lower risk of AKI compared to full REBOA. The study is limited by the small number of included studies and heterogeneity. Further research, particularly randomized controlled trials, is needed to optimize NCTH treatment protocols, especially in military settings.

Introduction: Veterans are at an elevated risk for suicide, with notably high suicide rates over recent years. Additionally, veterans are also at elevated risk for a variety of psychiatric and mental health comorbidities, one of them being gambling disorder (GD). However, limited research has examined the relationship between GD and suicidality among veteran populations. The present study links suicidality with GD including comorbid diagnoses, gambling preferences, gambling severity, and impulsivity in a sample of military veterans with GD.

Materials and methods: This study was an archival analysis of data from 603 United States veterans who received inpatient treatment for GD at a Veterans Affairs Hospital between the years of 2010 and 2024. Gambling disorder and comorbid diagnoses were determined at intake through clinician interviews and assessment. The South Oaks Gambling Screen (SOGS) and the Urgency, Premeditation, Perseverance, Sensation Seeking, and Positive Urgency Scale (UPPS-P) assessed gambling severity and impulsivity. Chi-squares, independent t-tests, and logistical regressions were conducted. Additional tests were conducted on a subset of 157 veterans for which suicide attempt reason was reported.

Results: Suicide attempt history is extremely common in veterans receiving treatment for gambling disorder, with over 40% reporting such a history. Veterans who reported a past suicide attempt were more likely to be nonstrategic gamblers, to have a current psychiatric diagnosis, and to report greater levels of impulsivity. Women veterans were especially likely to report a suicide attempt history (60% of women in our sample). Lastly, veterans who reported their suicide attempt was related to gambling were more likely to be a strategic gambler, have greater gambling severity, and impulsivity.

Conclusions: Veterans with GD are particularly vulnerable to increased risk for suicidality and its associations. Our findings point to the importance of customizing treatment for veterans with GD to target these potential risk profiles (e.g., gambling preferences, heightened impulsivity facets, and comorbidities) and therefore decrease the risks of suicidality.

Introduction: The Air Force Ground Surgical Team (GST) Phase 1 course is a 2-week pre-deployment training for the Air Force's conventional austere surgical care platform. A prior study evaluated the deployed experiences of GSTs from 2017 to 2020. This study is an update on the 2021-2023 deployed experience and also specifically seeks to understand the effects of low-volume deployments on clinical preparedness.

Materials and methods: A total of 366 surgeons, emergency physicians, CRNAs, and anesthesiologists took the course from 2017 to 2024. Respondents were included if they deployed between 2021 and 2023, and excluded if they deployed to Afghanistan. A total of 16 surgeons, 12 anesthesia providers, and 18 emergency physicians met the inclusion and exclusion criteria and responded. An Institutional Review Board exemption was issued before study initiation.

Results: Of the 16 surgeons, they performed a median of 3 surgical procedures during a 6-month deployment, but after excluding the surgeons who did not operate during deployment, the remaining 10 surgeons performed a median of 5 surgical procedures in 6 months. A total of 40% of the surgeons who performed surgical procedures took care of pediatric patients who were younger than 5 years old. A total of 61% of providers felt that their deployment had a negative impact on their ability to practice in their specialty.

Conclusions: Air Force Ground Surgical Teams in the deployed environment continue to encounter prolonged periods of clinical inactivity over the traditional 6-month period, in line with the previous study from 2017 to 2020, which has a negative impact on providers' ability to practice in their field post deployment. When teams did provide care, they very frequently managed special populations of patients who did not align with the primary objective for the team. Whether training and equipment should be introduced to manage these populations must be balanced with mission requirements. Although a future fight can be anticipated where clinical volume will be much higher, efforts to mitigate the effects of current GST deployments with low clinical activity should be addressed.

Introduction: During interwar transition periods, military medical volume, particularly surgical volume, declines dramatically. The Knowledge, Skills, and Abilities (KSA) metric was developed to assess "readiness" and the ability of the Military Treatment Facilities (MTFs) to prepare active duty (AD) surgeons for deployment. The KSA metric, or threshold for readiness, has not been validated externally. We seek to provide that validation by comparing KSA statistics of the military neurosurgery community to those of civilian neurosurgeons at level 1 civilian trauma centers.

Materials and methods: The Carepoint Health Data base compiles KSA totals for each surgeon over a 12-month period for their current stationed MTF. Forty-six AD attending neurosurgeons were included for the 2022 calendar year. To determine reliability of the Carepoint database, we secondarily analyzed the 2023-2024 academic year case logs of every AD neurosurgeon at 2 individual MTFs (N = 11). Civilian neurosurgeon KSA data was compiled by evaluating the case logs of neurosurgeons from 4 level 1 trauma centers (N = 29). We additionally utilized the database to analyze local Purchased Care Markets for each of the neurosurgery supported MTFs during that year to explain the historically low case volumes at the MTFs.

Results: In 2022, the average KSA per AD neurosurgeon per month was 393, extrapolated to 4,725 annually. Two of the 46 surgeons reached the KSA threshold. For the 2023-2024 academic year, the average AD military annual KSA was 3,192 (N = 9) and the average civilian KSA was 11,272 (N = 29) (P < .0001). Twenty-four of the 29 civilian surgeons met KSA goal 8,000; none of the AD surgeons met goal. Total neurosurgical KSA in Purchased Care was 3,01,535 compared to 1,39,005 for all MTFs. Operative cases were 7,324 deferred to the civilian sector compared to 2,286 performed at MTFs.

Conclusions: The KSA Metric is a reasonable and attainable readiness standard based on civilian level 1 trauma center statistics but does have its limitations. The current MTF neurosurgery case volume does not support wartime readiness as described by the KSA Metric.

One of the most critical skills a psychology-intern can possess is the ability to make accurate mental health dispositions. Through reflection of my own lessons learned, I hope to impart knowledge of the different types of dispositions and encourage curiosity and frequent consultation among trainees.