Military surgeon最新文献

Shortness of breath is an important complaint in the austere setting with a broad differential diagnosis. The difficulty of deployed patient movement and lack of diagnostic testing at treatment sites complicates its evaluation. This case highlights a young Soldier presenting with shortness of breath caused by a Morgagni hernia. A 25-year-old deployed male presented with a 1-month history of dyspnea with exertion and right-sided chest tightness. After initial diagnoses of bronchitis, later chest radiographs demonstrated a linear opacity in the right middle lobe (RML). The patient was transferred to a higher level of care where a chest computer tomography scan was consistent with Morgagni hernia. Morgagni hernias can present with a wide variety of clinical complaints, including gastrointestinal symptoms, dyspnea, and chest pain. A lack of familiarity among providers who care for adults and the nonspecific nature of the symptoms frequently cause a diagnostic delay in diagnosis. CXR is helpful in this diagnosis, although this case demonstrates that this hernia may appear similar to RML atelectasis or pneumonia.6 Computed tomography remains the modality of choice to confirm the diagnosis, as well as provide anatomical details and rule out complications. While most experts agree that Morgagni hernias should be surgically repaired, the optimal surgical technique remains uncertain.3 Despite its rarity, Morgagni hernia is important to consider in a broad range of clinical presentations. Its nonspecific symptoms, combined with radiographs that can mimic other disease entities, can lead to a delay in diagnosis, mistreatment, prolonged patient suffering, and complications.

Introduction: Traumatic brain injury (TBI) remains a significant source of disability for active duty service members in both deployed and training settings as well as those who have left active service. Service members with ocular trauma are at risk for a TBI and should be screened appropriately. Early detection results in treatment to minimize long-term sequelae which can often be debilitating. This study is the first to evaluate different combat-related ocular injuries and their associations with TBI.

Materials and methods: A secondary analysis of existing data was conducted from a prospective study of patients who sustained combat ocular trauma (COT) during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) between 2006 and 2020. Clinical data of a total of 88 participants were gathered and each case reviewed, including patient demographics, injury-related factors, history of TBI, and treatments rendered. All cases were then categorized to compare COT (n = 13) versus COT-T (Combat Ocular Trauma associated with TBI; n = 75). The Fisher's exact test was completed for each category to assess for predictive factors of TBI within the ophthalmic trauma cohort. Odds ratios were calculated with their 95% CI.

Results: When compared to COT, COT-T was significantly associated with closed globe injuries (56%; OR 4.24, 95% CI 1.08-16.67), blast injuries (89.3%; OR 3.72, 95% CI 0.93-14.9), multiple surgeries (89%; OR 2.51, 95% CI 0.57-11.08), anterior segment injuries (69.3%; OR 1.41, 95% CI 0.42-4.79), optic nerve injuries (24%; OR 1.05, 95% CI 0.26-4.25), orbital fractures (48%; OR 2.08, 95% CI 0.59-7.34), enucleation (17.3%; OR 2.52, 95% CI 0.300-21.08), the use of eye protection (68.6%; OR 2.18, 95% CI 0.57-8.32), and the need to undergo plastic surgery (78.7%; OR 2.30, 95% CI 0.66-8.02). Significant factors associated with COT included penetrating injury (30.8%; OR 0.027, 95% CI 0.07-1.08), posterior segment injuries (92%; OR 0.264, 95% CI 0.032-2.17), bilateral injuries (76.9%; OR 0.678, 95% CI 0.17-2.69), and bilateral blindness (7.7%; OR 0.857, 95% CI 0.092-7.99).

Conclusions: Patients who have sustained combat-related ocular injuries, specifically blast injury, anterior segment injury, or an orbital fracture, were noted to be more likely to have also sustained a TBI. However, of the evaluated variables in predicting the co-occurrence of TBI, only closed globe injury was identified as statistically significant. Service members with injuries requiring multiple surgical procedures, reconstructive plastic surgery, or enucleation of an eye were also more likely to be diagnosed with a TBI, but these variables were not found to be predictive of TBI among ocular trauma patients. The presence of eye protection was not protective against TBI. Further studies are needed to find significant predictors of TBI in combat ocular trauma patients to assist in th

Introduction: Promoting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine acceptance and uptake became necessary to achieve a high vaccination rate and subsequently herd immunity. Although the Israeli population has been largely acceptant of the SARS-CoV-2 vaccine, vaccine hesitancy has remained a major concern, especially in younger adults. We hypothesized that young adults who refused SARS-CoV-2 vaccination differed from those who have been adherent and could be characterized. Studying this specific population and recognizing individuals within this group who might be more probable to refuse vaccination can enable to target measures to further promote vaccination acceptance.

Methods: We conducted a cross-sectional comparison in a study population comprised of 17,435 Israeli Defense Forces (IDF) personnel who were SARS-CoV-2 vaccine eligible. This group included 14,834 vaccinated and 2,601 nonvaccinated individuals. Patient characteristics including occupational parameters, demographic features, psychotechnical grading (an intelligence assessment score), education level, and medical background were collected.

Results: The median age was 20.57 years and almost 80% were males. At the time of data collection, most individuals (85.1%, n = 14,834) have been vaccinated. Officers and noncommissioned officers were more likely to be vaccinated compared with regular soldiers (96%, and 90.2% vs. 83.3% respectively, P < .001), as well as combat battalions stationed personnel compared to their peers in rear and administrative units (89.4% vs. 78.4%, P < .001). Socioeconomic clusters were also associated with vaccination adherence, with 92.9% vs. 79.5% vaccination rates in the highest and lowest clusters, respectively (P < .001). Younger age, no previous immigration status, higher education level, and higher psychotechnical grades were also found associated with an increased likelihood of being vaccinated (P < .001).

Conclusions: In a large cohort of enlisted IDF personnel, disparity in SARS-CoV-2 vaccine adherence was found to be related to multiple socioeconomic, educational, and military service-related variables. Although some differences were substantial, others were small and of questionable public health significance. Acknowledging these differences may enable community leaders, health care providers, and administrators to target specific populations in order to further promote SARS-CoV-2 vaccination acceptance.

Introduction: The Army uses permethrin-treated uniforms as the primary method to protect soldiers from tick-borne diseases. Permethrin binds strongly to fabric and provides long-term protection against many blood-feeding arthropods. However, protection decreases if the uniforms are not washed and cared for according to label instructions. This study was conducted among cadets at the United States Military Academy (USMA) at West Point, NY, to determine what the cadets know about permethrin and how they care for and wear their uniforms. West Point is in an area with high rates of tick-borne disease transmission. A survey was developed to determine what cadets know about the threat of tick-borne diseases and if they wear and maintain their uniforms in a manner that effectively maintains permethrin levels.

Materials and methods: A 16-question survey was developed and submitted to the local review board for approval. The study was classified as human subjects research according to 32CFR219 and met the requirements for exempt status under 32CFR219.104(d)(2)(i). After receiving approval, a hard copy survey was distributed among cadets with efforts to sample at least 50 members from each cadet class.

Results: A total of 319 cadets provided responses to the survey questions, representing more than 7% of the cadet population at the USMA. The results showed most cadets knew their uniforms were treated with permethrin, but less than half knew there are specific instructions attached to their uniforms describing how the uniforms should be laundered. From the cadets who knew there were instructions, most admittedly did not follow the instructions. Sixteen percent of cadets said they had dry-cleaned their uniforms. This is a process known to remove most of the permethrin. The majority of cadets viewed the risk of tick-borne disease at West Point to be moderate or lower.

Conclusions: This study provides a basic understanding of the wear patterns of permethrin-treated uniforms among cadets at the USMA. It is also one of the few studies to measure knowledge and uniform-wearing behavior among service members since the Army switched to factory-treated uniforms in 2013. The results indicate that compliance with uniform laundry and care instructions is low. This information is useful to develop training plans and educate cadets how they can wear and take care of their permethrin-treated uniforms to better protect themselves from tick-borne diseases.

Introduction: Veterans transitioning from military service to civilian life manage numerous changes simultaneously, in health, employment, social relationships, and finances. Financial problems may impact financial well-being as well as adjustment to civilian life in general; yet, research on Veterans' financial challenges remains limited. This study examined six indicators of perceived financial status among newly transitioned Veterans over a period of 3 years and then examined perceived financial well-being measured in two domains-satisfaction and functioning-and difficulty adjusting to civilian life as functions of financial status.

Materials and methods: A sample representing 48,965 Veterans who separated from active duty/activated status in fall 2016 provided informed consent and survey data over their first 33 post-military months; data were analyzed in weighted regression models that included demographics, military characteristics, social support, resilience, life stress, and indicators of financial status.

Results: Financial status immediately post-separation included having stable housing (88%), being able to pay for necessities (83%), keeping up with creditors (88%), having insurance for catastrophic events such as disability (79%), saving for retirement (62%), and setting aside 3 months of salary (50%). Thirteen percent of Veterans disclosed troubled financial status, having achieved no more than two of these financial goals; 38% had moderate and 49% excellent financial status. Troubled or moderate financial status, Black race, enlisted, and higher levels of stress predicted lower financial functioning. Older age, college degree at baseline, employment, and social support predicted better financial satisfaction. Veterans with troubled financial status reported greater difficulty adjusting to civilian life (odds ratio 1.34); women were less likely to report difficulty adjusting to civilian life (odds ratio 0.85).

Conclusions: Findings indicate that financial satisfaction and functioning may be sensitive to psychosocial factors (social support and stress). Findings also underscore the value of assessing Veterans' financial status (poor debt management and lack of future planning), providing encouragement and assistance to pursue a college degree, and improving household financial management, thus increasing the likelihood that Veterans will have the necessary tools to manage their finances after separation and achieve whole health well-being.

Introduction: Tactical triage replaces primary triage in the exclusion zone in mass murder or terrorist events to prioritize victims requiring life-saving interventions (LSIs) and/or rapid extraction in an environment with a lack of resources and under active threat. French gendarmerie tactical unit medical teams use triage bracelets during mass casualty incidents (MCIs). This study assessed the value of these bracelets in the tactical triage performance of nonhealthcare combat rescue operators in an MCI simulation.

Objectives: To compare triage performance with and without the use of bracelets based on categorization accuracy, LSIs, and time to end triage.

Materials and methods: Two groups of operators were randomly assigned to participate in an MCI simulation alone (10 simulated patients) with (intervention group) or without (control) bracelets. The primary outcome was triage performance assessed by the mass casualty triage performance assessment tools. The results were measured based on the LSI required, triage category, and time of completion of the task. Secondary outcomes were operator-perceived stress and self-efficacy.

Results: Eleven operators (intervention group n = 5, control group n = 6) participated. Triage performance, based on a maximum score of 90, was better for the intervention group [72.200 (SD = 10.330) vs. 57.000 (SD = 12.961), P = .045]. Self-efficacy was increased after the simulation in the intervention group [45.00 47.2 (SD = 4.147) vs. 50.400 (SD = 5.505), P = .034)].

Conclusions: This is the first study to show the best triage performance among nonhealthcare combat rescuers using triage bracelets in an MCI simulation. The small sample size did not allow for external validity of the results. The initially calculated number of participants (N = 12) was not reached for operational reasons. The use of bracelets may have a place in the medico-organizational act of tactical triage during MCIs in exclusion zones. Further studies should be conducted to assess the value of triage bracelets by other first responders, including physician-nurse teams.

Introduction: The COVID-19 pandemic created challenges for forward-deployed military units to Western Africa. Austere military environments afford multiple avenues to transmit COVID-19 amongst service members.

Materials and methods: A COVID-19 outbreak on a military base in Western Africa spanning over 100 days is statistically analyzed using a Pearson's correlation coefficient. Furthermore, a COVID-19 reproductive number (R0) is evaluated to examine the relationship between specific command-directed policies to mitigate COVID-19 transmission.

Results: The multidisciplinary partnership of military command, medical, and public health leadership implemented evidence-based and epidemiologically informed COVID-19 preventive base-wide policies, including appropriate isolation/quarantine policies. The R0 for the outbreak was 0.03 and remained <1 for the outbreak duration. This base remained COVID-19 free for multiple weeks after policy implementation.

Conclusions: The implementation of practical mitigating base-wide policies through seamless communication between military command/medical/public health leadership resolved the COVID-19 outbreak while maintaining mission readiness. Weekly COVID-19 testing epidemiological data may be utilized by commanders to direct further decision-making on tightening/loosening base-wide policy restrictions for continued mission-essential operations, e.g., security, food service, or airfield operations.

Introduction: The aim of this observational pilot study was to assess the safety, feasibility, preliminary outcomes, and predictors of participant response as a result of implementing an equine-assisted intervention within a residential substance abuse treatment program at a large Veterans Administration medical center. A secondary aim was to evaluate psychological instruments for use in future, more rigorous studies. The overarching goal was to complete the necessary work to prepare for a large randomized controlled trial of this intervention for Veterans with addictive disorders.

Materials and methods: Participants were 33 Veterans, 29 males and 4 females, who participated in one 4-hour session of combined equine-assisted learning and equine-assisted psychotherapy during an admission to a residential substance abuse treatment program. Preintervention and postintervention instruments were utilized to assess changes in affect, anxiety, and craving. Demographic and diagnostic variables were evaluated for the potential to predict outcomes.

Results: The intervention was safe and feasible to utilize as there were no adverse outcomes to patients, staff, or equines. The State-Trait Anxiety Inventory, Craving Experience Questionnaire, and Positive and Negative Affect Scale revealed preliminary findings of significant preintervention to postintervention decreases in anxiety, negative affect, and craving, as well as increased positive affect. Lastly, the presence or absence of a history of suicide attempts and/or suicidal ideation were predictive of some postintervention scores.

Conclusion: While more rigorous studies are needed, these results indicate that the intervention evaluated in this study is safe and feasible to utilize for Veterans admitted to a residential substance abuse treatment program. Furthermore, preliminary outcomes suggest that this intervention, and perhaps other equine-assisted interventions, has the potential to be beneficial to Veterans with addictive disorders as well as those at risk of suicide. The psychological instruments used in this intervention appear to be appropriate for use in future investigations. Additionally, more rigorous studies are warranted, and this work provides the necessary first steps needed to proceed with those investigations.

Introduction: Decay of military surgeons' critical wartime skills is a persistent and growing concern among leaders in the military health system (MHS). The Knowledge, Skills and Abilities (KSA) Clinical Readiness Program was developed to quantify the readiness of clinicians in the MHS; however, the utility of the data is questionable due to a lack of focus on the operative expeditionary skillset in the original methodology. A revised methodology emphasizing the most relevant to expeditionary orthopedic surgery procedures is described.

Materials and methods: All Current Procedural Terminology (CPT) codes included in the original KSA methodology were reviewed and, if appropriate, removed, or reassigned to more suitable categories. Category scores were weighted to better align with the most performed procedures in the deployed environment. All surgical cases and procedures performed from 2017-2019 in military treatment facilities by orthopedic surgeons were recorded in total and by MHS market. Cases were recorded for all military orthopedic surgeons who performed at least one KSA credit procedure during the study period. The 10 MHS markets with the greatest number of procedures were included in the analysis. The change in creditable KSA procedure codes and procedures performed from the original to revised methodology was determined for each KSA category and MHS market.

Results: Overall, 403 CPT codes were recategorized and 79 were deleted from the original KSA methodology. The deletions represented less than 4% of the original creditable CPT codes, with most being supply or injection codes. Three of the five most common expeditionary KSA categories increased in the number of creditable procedure codes. The impact of the revision on the MHS markets was mixed, but the overall volume of credited procedures decreased. The weighted scoring did not disproportionately affect the analyzed markets.

Conclusions: The revised methodology is better aligned with the most common procedures in the most recent large-scale military engagements. The improved applicability of the KSA scoring to necessary CWS will allow military medical leaders to better determine the readiness opportunities available in the MHS.