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Military Medicine
Journal Prestige (SJR): 0.373
Citation Impact (citeScore): 1
Number of Followers: 9  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0026-4075 - ISSN (Online) 1930-613X
Published by Oxford University Press Homepage  [425 journals]
  • Correction to: Understanding the Strengths and Limitations of Current
           Methods for Surveying Partner Nation Medical Facilities

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      Pages: e460 - e460
      PubDate: Mon, 09 Oct 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad408
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • A Case of Hematogenous Osteomyelitis in a 5-Week-Old Male

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      Pages: e457 - e459
      Abstract: ABSTRACTPediatric osteomyelitis is a rare diagnosis associated with devastating consequences when treatment is delayed. We report a case of hematogenous osteomyelitis in a 5-week-old male presenting to the emergency department (ED) with a flaccid right upper extremity. In the ED, the patient was evaluated with comprehensive infectious and trauma workups. Initial CT imaging of the head and X-ray imaging of the extremity were unremarkable. C-reactive protein was elevated at 0.8; all other laboratory markers were within normal range. Over the course of the ED evaluation, the extremity weakness spontaneously resolved; however, the infant developed a fever of 100.5 F. Empiric broad spectrum antibiotics were initiated, and the infant was admitted to the pediatric service. At 48 hours following presentation, cultures resulted positive for Staphylococcus aureus and MRI imaging revealed osteomyelitis of the proximal right humeral metadiaphysis. Given the subtle presentation of early hematogenous osteomyelitis, emergency providers should maintain a high index of suspicion for infection as the underlying cause in infants presenting with a flaccid extremity.
      PubDate: Mon, 18 Sep 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad348
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Training to Improve Spatial Hearing and Situation Awareness when
           Wearing Hearing Protection

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      Pages: e306 - e312
      Abstract: ABSTRACTIntroductionHearing protection devices (HPDs) are standard personal protective equipment in military settings, but many service members may choose to not use HPDs because they impair spatial hearing and situation awareness. In an effort to reduce barriers to compliance by improving situation awareness while wearing HPDs, this study investigated whether brief training could counteract spatial hearing deficits when wearing HPDs. Participant’s ability to correctly apply the HPDs across days was also examined.Materials and MethodsYoung adults were randomly assigned to one of two groups: training or control (n = 25/group). Participants in each group performed a spatial hearing task while wearing HPDs and in an open ear condition without HPDs. Individual targets were battlefield sounds or white noise presented from a speaker array that surrounded the participant in the horizontal plane. After presentation of each target sound, the participant then controlled a white noise “auditory pointer,” which they moved to the perceived location of the target. The two primary measures were the percent of trials with very large errors (> 45°), which were usually due to confusing front and back locations, and absolute localization, which is the difference between the pointer location and the true sound location. Both groups were tested on Days 1 (baseline) and 5 (post-test). On Days 2 to 4, the training group wore HPDs while receiving auditory and visual feedback after each trial.ResultsAcross all participants on Day 1, wearing HPDs increased the frequency of very large errors by about 3× and impaired localization by about 40%, relative to the open ear condition. When comparing performance at baseline (Day 1) and post-training Day 5, the training group with HPDs had significant reductions in very large errors and improved absolute localization (P values < .001). The training group also had significant improvements from Days 1 to 5 in the open ear condition. When the control group wore HPDs, there were also significant improvements from Days 1 to 5 (fewer very large errors and better localization), with smaller effect sizes vs. the training group. Controls did not have significant improvement in the open ear condition, but had similar trends. Most participants consistently applied the HPDs, but a subset of ∼20% frequently failed to achieve the criterion attenuation of 15 dB (over 0.25–4.0 kHz) in both ears.ConclusionsThese findings show that simple, relatively brief practice and training can substantially reduce HPD impairments on spatial hearing and situation awareness. The gains from training and practice can inform the development of relatively simple, brief methods to reduce HPD spatial hearing impairments, potentially leading to increased HPD compliance. Longitudinal data show that a subset of participants would not have received the full benefit of hearing protection because of improper application of the HPDs.
      PubDate: Sat, 16 Sep 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad352
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • First Case of Surgically Treated Chronic Exertional Compartment
           Syndrome of the Arm

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      Pages: e454 - e456
      Abstract: ABSTRACTThis paper reports the first case of chronic exertional compartment syndrome in the arm treated surgically. The diagnosis was made in a patient who is under 30 years old, military, and very athletic, with recurrent exertional pain in the anterior compartment of the arms associated with rhabdomyolysis. The high-pressure measurements in the arms’ anterior compartment after exertional exercise confirmed the diagnosis. Given the patient’s functional demands, a surgical treatment of fasciotomy of the anterior compartment by miniapproach was performed and allowed the resolution of symptomatology with a return to sport at the same level after 3 months.
      PubDate: Wed, 30 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad349
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Close-Range Fire Inflicting Behind Armor Blunt Trauma: Case-Series
           and Implications for Battlefield Care

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      Pages: e448 - e453
      Abstract: ABSTRACTBehind armor blunt trauma (BABT) is a non-penetrating injury caused by energy transfer and rapid deformation of protective body armor. Although modern military body armor is designed to prevent penetrating trunk injuries, high-energy projectiles can produce a significant energy transfer to tissues behind the armor and inflict injuries such as fractures or organ contusions. However, knowledge of BABT is limited to biomechanical and cadaver modeling studies and rare case reports. We report two cases of BABT resulting from close-range fire and discuss the potential implications for triaging patients with BABT in battlefield scenarios. In the first case, a 19-year-old male soldier sustained a single close-range 5.56-mm assault rifle gunshot to his chest body armor. The soldier initially reported mild pain in the parasternal region and assessment revealed a 4 cm × 3 cm skin abrasion. Following emergency department evaluation, the soldier was diagnosed with a non-displaced transverse fracture of the sternal body. In the second case, a 20-year-old male sustained five machine gun bullets (7.62 mm) to his body armor. Computed tomography of the chest revealed pulmonary contusions in the right lower and middle lobes. Both soldiers achieved full recovery and returned to combat duty within several weeks. These cases highlight the potential risks of energy transfer from high-velocity projectiles impacting body armor and the need for frontline providers to be aware of the risk of underlying blunt injuries. Further reporting of clinical cases and modeling studies using high-velocity projectiles could inform recommendations for triaging, evacuating, and assessing individuals with BABT.
      PubDate: Wed, 30 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad340
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Management of Severe Burn Wounds Colonized With Multi-resistant
           Pseudomonas aeruginosa and Fusarium Using Marine Omega3 Wound Matrix
           in a Female Victim of War

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      Pages: e424 - e428
      Abstract: ABSTRACTWar-related burns are common injuries, also among the civilian population. Additional trauma such as fractures or shrapnel wounds may add significant morbidity. Burn injuries in war zones are furthermore frequently undertreated and hence prone to complications. We report a case of a young female victim of war, whose severely infected burn wounds could be successfully healed using a combination of targeted antimicrobial therapy, wound conditioning using decellularized fish skin, and subsequent skin grafting.
      PubDate: Tue, 29 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad338
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Expanding Behavioral and Occupational Health Research
           in Military Police

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      Pages: e267 - e273
      Abstract: ABSTRACTIntroductionIt is important to understand the behavioral and occupational health needs of military police personnel, a high-risk and understudied population.Materials and MethodsThe incidence rates of behavioral and occupational conditions were examined from the years of 2005 to 2021 from the Defense Medical Epidemiology Database. Single-sample chi-square analyses were performed to analyze the differences in the incidence rates across demographic groups relative to population density.ResultsThere were moderate-to-large increases in sleep-related disorders and mood or stress-related disorders. There were also patterns of overrepresentation or underrepresentation in diagnoses of various conditions by sex, age group, marital status, race, service branch, and pay grade.ConclusionsIt is important to provide tailored resources and programming to employees in high-stress settings to help prevent or manage behavioral and occupational health conditions and reduce the stigma surrounding the utilization of such resources and programs.
      PubDate: Sat, 12 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad312
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Comparing Body Composition Methods for Air Force Reserve
           Officers’ Training Corps Cadets

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      Pages: e274 - e278
      Abstract: ABSTRACTIntroductionIn special populations, such as Reserve Officers’ Training Corps (ROTC) cadets, body composition is used not only as a predictor of fitness but for additional purposes such as qualification for enlistment, load carriage, and duty fulfillment. Body mass index (BMI) is the initial measurement recorded and is considered a representation of health and physical performance capabilities. Personnel exceeding threshold values of body weight based upon their height measurement are typically further evaluated using a circumference-based method that predicts the cadets’ percent body fat. Military personnel who fail to meet these body composition standards may be penalized by being denied specific positions or promotions or risk being relieved from all military duties. In order to differentiate and accurately assess the components that constitute body composition, other methods of measuring body composition that provide greater accuracy should be explored. The purpose of this study was to compare multiple body composition methods, including the military’s method of circumference-based measurement, in order to identify a suitable method for Air Force ROTC programs.Materials and MethodsParticipants were recruited from an Air Force ROTC Detachment at a large university in the Midwest United States. Anthropometric (height and weight) and body composition measurements (air displacement plethysmography [ADP], bioelectrical impedance analysis, skinfolds, and circumferences) were collected for each participant. A repeated-measure analysis of variance was used to compare body composition measurement methods. A Bonferroni adjustment was utilized for multiple comparisons. BMI and circumference results were displayed as a percentage of compliance according to Air Force Instruction guidelines. The university institutional review board approval was established to ensure that the design of this study protected the rights of the participants.ResultsTwenty-four (21 males and 3 females) participants completed the study. A significant difference between skinfolds and bioelectrical impedance analysis occurred (P = .025). There were no other significant differences identified between other methods of body composition. Using the BMI and circumference compliant/non-compliant scale listed in the Air Force Instruction guidelines, a greater number of cadets fell into the non-compliant category according to BMI (n = 7) versus circumferences (n = 1). The circumference-based method underestimated body fat compared to the “gold standard” ADP.ConclusionsThe findings from this investigation suggest that the circumference-based method can appropriately provide accurate body composition results among Air Force ROTC cadets. Results also determined that the military’s circumference-based method underestimated body fat compared to the “gold standard” ADP. Although circumference-based measurements might be efficient for use in larger populations, Air Force ROTC programs should evaluate other methods of measuring body composition to best fit the needs of individual cadets. Further research should be conducted to identify body composition methods that are easy to implement and provide accurate results at the individual level.
      PubDate: Fri, 11 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad311
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • The Antietam Staff Walk at the Uniformed Services University: A Program
           Evaluation

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      Pages: e298 - e305
      Abstract: ABSTRACTIntroductionThe battle along Antietam Creek in September 1862 was pivotal in shaping future combat medical readiness practices. With the full confidence of his commander, Major (Dr) Jonathan Letterman implemented an innovative ambulance corps system, which contributed immensely to modern-day battlefield medicine. Each year, the Uniformed Services University (USU) holds the Antietam Staff Walk, during which military medical students are engaged by faculty at various “stops” along the 6-mile walk. The four learning objectives for the Antietam Staff Walk are to (1) introduce the role of the “staff ride,” (2) orient learners to reading terrain, (3) reinforce the six principles of health service support, and (4) recall the heritage of the military medical officer. The Department of Military and Emergency Medicine at USU commissioned a program evaluation to determine if these course objectives were being met, evaluate the effectiveness of the Antietam Staff Walk as a teaching tool, and make recommendations for improving its educational impact.Materials and MethodsWe engaged in qualitative program evaluation to evaluate the Antietam Staff Walk course objectives. Our research team analyzed 156 reflection papers written by second-year military medical students attending Antietam in August 2021. We coded each of the papers, noting important words and phrases that were salient to the students’ learning experiences at Antietam. Our research team then compiled each of these codes into a master list and then determined how to divide this list into major categories. We collectively defined each of these categories, which served as the resulting themes of this program evaluation.ResultsThree themes emerged: (1) creation of an ambulance corps allows for proximal battlefield medicine, (2) a lack of buddy aid inspires Tactical Casualty Combat Care, and (3) disease/nonbattle injury necessitates preventative medicine. The students foremost gained an appreciation for the impact of the ambulance corps and recognized that the ambulance corps not only impacted medical care, but also the mission as a whole. However, may not have completely understood the long, slow evolution of battlefield care and may have overestimated the knowledge of physicians practicing mid-19th century medicine. We provided recommendations for addressing these learning opportunities during future Antietam Staff Walks at USU.ConclusionsOur review of the Antietam Staff Ride resulted in several curricular recommendations for enhancing its learning impact. Our program evaluation serves as a model for line units and other military organizations to optimize the impact of the historical staff ride as a teaching tool.
      PubDate: Fri, 11 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad317
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Improving Resiliency in U.S. Air Force Healthcare Personnel: A
           Randomized Preventive Trial

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      Pages: e250 - e258
      Abstract: ABSTRACTIntroductionThe effectiveness of the Stress Management and Resilience Training (SMART) with U.S. military personnel has not been reported in the literature. The purpose of this study was to examine the effectiveness of SMART in increasing resilience in Air Force healthcare personnel.Materials and MethodsWe conducted a pilot, randomized preventive trial with active component Air Force healthcare personnel. SMART was offered via an in-person, 2-h training session delivered through face-to-face or synchronous video teleconference training, or via a self-paced, computer-based training. A baseline survey included demographics questions and the Connor–Davidson-10 Resilience Scale (CD-10), Perceived Stress Scale (PSS), Generalized Anxiety Disorder Scale (GAD-7), and overall quality of life (QOL) measure. Follow-up surveys with the CD-10, PSS, GAD-7, and quality of life were sent to participants at 12, 18, and 24 weeks after completing SMART.ResultsFifty-six service members completed the baseline assessment and were randomized to either the in-person modality (comprised of video teleconference or face-to-face training) or the computer-based training modality, and 49 participants completed SMART. Significant increases in median CD-10 scores were observed among all participants, showing a 4-point (14%), 6-point (21%), and 5-point (17%) increase at week-12, -18, and -24, respectively, from the baseline. A significant overall decrease in median PSS scores from baseline were observed, with 5.5-points (22%), 7.81-points (32%), and 8.5-points (35%) decrease at 12, 18, and 24 weeks post-SMART, respectively.ConclusionsIn this pilot study, SMART demonstrated significant and meaningful improvements in self-reported CD-10 and PSS-14 scores at 12, 18, and 24 weeks post-training completion. A future replication of the study is necessary to evaluate the effectiveness of SMART on a larger scale.
      PubDate: Tue, 08 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad303
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Clustering Research Proposal Submissions to Understand the Unmet Needs
           of Military Clinicians

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      Pages: e291 - e297
      Abstract: ABSTRACTIntroductionThe Advanced Medical Technology Initiative (AMTI) program solicits research proposals for technology demonstrations and performance improvement projects in the domain of military medicine. Advanced Medical Technology Initiative is managed by the U.S. Army Telemedicine and Advanced Technology Research Center (TATRC). Advanced Medical Technology Initiative proposals span a wide range of topics, for example, treatment of musculoskeletal injury, application of virtual health technology, and demonstration of medical robots. The variety and distribution of central topics in these proposals (problems to be solved and technological solutions proposed) are not well characterized. Characterizing this content over time could highlight over- and under-served problem domains, inspire new technological applications, and inform future research solicitation efforts.Methods and MaterialsThis research sought to analyze and categorize historic AMTI proposals from 2010 to 2022 (n = 825). The analysis focused specifically on the “Problem to Be Solved” and “Technology to Demonstrated” sections of the proposals, whose categorizations are referred to as “Problem-Sets” and Solution-Sets” (PS and SS), respectively. A semi-supervised document clustering process was applied independently to the two sections. The process consisted of three stages: (1) Manual Document Annotation—a sample of proposals were manually labeled along each thematic axis; (2) Clustering—semi-supervised clustering, informed by the manually annotated sample, was applied to the proposals to produce document clusters; (3) Evaluation and Selection—quantitative and qualitative means were used to evaluate and select an optimal cluster solution. The results of the clustering were then summarized and presented descriptively.ResultsThe results of the clustering process identified 24 unique PS and 20 unique SS. The most prevalent PS were Musculoskeletal Injury (12%), Traumatic Injury (11%), and Healthcare Systems Optimization (11%). The most prevalent SS were Sensing and Imaging Technology (27%), Virtual Health (23%), and Physical and Virtual Simulation (11.5%). The most common problem-solution pair was Healthcare Systems Optimization—Virtual Health, followed by Musculoskeletal Injury—Sensing and Imaging Technology. The analysis revealed that problem-solution-set co-occurrences were well distributed throughout the domain space, demonstrating the variety of research conducted in this research domain.ConclusionsA semi-supervised document clustering approach was applied to a repository of proposals to partially automate the process of document annotation. By applying this process, we successfully extracted thematic content from the proposals related to problems to be addressed and proposed technological solutions. This analysis provides a snapshot of the research supply in the domain of military medicine over the last 12 years. Future work should seek to replicate and improve the document clustering process used. Future efforts should also be made to compare these results to actual published work in the domain of military medicine, revealing differences in demand for research as determined by funding and publishing decision-makers and supply by researchers.
      PubDate: Tue, 08 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad314
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Transition of Resuscitative Endovascular Balloon Occlusion of the Aorta
           from Zone 3 to Zone 1 to Treat Hemodynamic Collapse during Continued
           Hemorrhage

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      Pages: e285 - e290
      Abstract: ABSTRACTIntroductionNoncompressible torso hemorrhage (NCTH) accounts for most potentially survivable deaths on the battlefield. Treatment of NCTH is challenging, especially in far-forward environments with limited capabilities. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has shown promise in the care of patients with NCTH. REBOA involves introducing a balloon catheter into the descending aorta in a specific occlusion region (zones 1, 2, or 3) and acts as a hemorrhage control adjunct with resuscitative support. The balloon is placed in zone 3 in the infrarenal aorta for high junctional or pelvic injuries and in zone 1 proximal to the diaphragm for torso hemorrhage. Zone 1 REBOA provides more resuscitative support than zone 3; however, the potential for ischemia and reperfusion injuries is greater with zone 1 than with zone 3 REBOA placement. This study aims to determine the possible benefit of transitioning the REBOA balloon from zone 3 to zone 1 to rescue a patient with ongoing venous bleeding and impending cardiovascular collapse.Materials and MethodsYorkshire male swine (70–90 kg, n = 6 per group) underwent injury to the femoral artery, which was allowed to bleed freely for 60 s, along with a simultaneous controlled venous hemorrhage. After 60 s, the arterial bleed was controlled with hemostatic gauze and zone 3 REBOA was inflated. Five hundred milliliters of Hextend was used for initial fluid resuscitation. The controlled venous bleed continued until a mean arterial pressure (MAP) of 30 mmHg was reached to create an impending cardiovascular collapse. The animals were then randomized into either continued zone 3 REBOA or transition from zone 3 to zone 1 REBOA. Following 30 min, a “hospital phase” was initiated, consisting of cessation of the venous hemorrhage, deflation of the REBOA balloon, and transfusion of one unit of whole blood administered along with saline and norepinephrine to maintain a MAP of 60 mmHg or higher. The animals then underwent a 2-h observation period. Survival, hemodynamics, and blood chemistries were compared between groups.ResultsNo significant differences between groups were observed in hemodynamic or laboratory values at baseline, postinitial injury, or when MAP reached 30 mmHg. Survival was significantly longer in animals that transitioned into zone 1 REBOA (log-rank analysis, P = .012). The average time of survival was 14 ± 10 min for zone 3 animals vs. 65 ± 59 min for zone 1 animals (P = .064). No animals in the zone 3 group survived to the hospital phase. Zone 1–treated animals showed immediate hemodynamic improvement after transition, with maximum blood pressure reaching near baseline values compared to those in the zone 3 group.ConclusionsIn this swine model of NCTH, hemodynamics and survival were improved when the REBOA balloon was transitioned from zone 3 to zone 1 during an impending cardiovascular collapse. Furthermore, these improved outcome data support the pursuit of additional research into mitigating ischemia–reperfusion insult to the abdominal viscera while still providing excellent resuscitative support, such as intermittent or partial REBOA.
      PubDate: Tue, 08 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad313
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Relative Risk of All-Cause Medical Evacuation for Behavioral Health
           Conditions in U.S. Central Command

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      Pages: e279 - e284
      Abstract: ABSTRACTIntroductionBehavioral health disorders are the leading category of evacuations from the U.S. Central Command (USCENTCOM) area of responsibility. Understanding the relative risk of behavioral health conditions associated with all-cause evacuation is important for the allocation of resources to reduce the evacuation burden.Materials and MethodsData from the USTRANSCOM Regulating and Command & Control Evacuation System and Theater Medical Data Store covering personnel deployed to the USCENTCOM area of responsibility between January 1, 2017 and December 31, 2021 were collected and analyzed. All individuals who were diagnosed with a behavioral health–specific ICD-9 (290–316) or ICD-10 (F00–F99) code during the period were included. Using the earliest medical encounter, the number of individuals diagnosed with a particular code and the frequency individuals were evacuated being diagnosed with any code were calculated.ResultsThe mean monthly USCENTCOM population during this period was 62,535. A total of 22,870 individuals were diagnosed with a behavioral health–related disorder during the study period. Of this population, 1,414 individuals required an evacuation. The relative risk of the top 30 diagnosis codes used during the initial visit of individuals during the study period was calculated. Within this group of initial diagnoses, F32.9 ‘Major depressive disorder, single episode, unspecified’ had the highest proportion evacuated at 15.9%.ConclusionsThere is a broad array of behavioral health–specific diagnoses used initially in the care of behavioral health disorders with a great variation in their association with evacuation risk. Variations of diagnoses associated with anxiety, depressive, and adjustment disorders are most associated with eventual evacuation.
      PubDate: Mon, 07 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad306
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Selection, Initiation, Continuation, and Efficacy of Reversible
           Contraception Among Enlisted U.S. Service Women in Their First Term
           of Service From 2012 to 2020

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      Pages: e227 - e234
      Abstract: ABSTRACTBackgroundPregnancy is the second most common cause of limited duty days among active duty service members in the U.S. Military. Pregnancy accounts for 10% of all days on restricted duty, despite impacting a minority of active duty service members. One out of five service women will experience an unintended pregnancy every year despite the availability of no-cost contraception and reproductive healthcare. Young, single, junior enlisted service women experience the highest rate of unintentional pregnancy. Previous studies have demonstrated service branch-based variability in selection, initiation, and continuation of specific contraceptive methods related to service branch culture and access to contraception during basic training. It is unclear if these differences impact overall contraception use or fertility rates among junior enlisted service women in their first term of enlistment. This study examines rates of contraceptive selection, initiation, continuation, and efficacy among junior enlisted service women in their first 4-year enlistment period, and the service branch specific variability in these outcomes.MethodsThis study is a secondary analysis of Military Healthcare Data Repository records from women who began basic training between 2012 and 2020 and remained on active duty for at least 12 months. We used Kaplan–Meier analyses to examine the effect of age and military branch on contraceptive continuation and efficacy. We used binomial regression for interval censored data, to assess the association of service branch with rates of contraceptive initiation, contraception use, births, and childbirth-related duty restrictions.ResultsWe identified 147,594 women who began basic training between 2012 and 2020. The mean age of these women at the beginning of basic training was 20.4 ± 3.1 years. Women in the marines and navy had higher contraceptive initiation rates than women in the army or air force. Among women initiating a contraceptive pill, patch, or ring (short-acting reversible contraception), 58.3% were still using some form of hormonal contraception 3 months later. Among women initiating depot-medroxyprogesterone (DMPA), 38.8% were still using any form of hormonal contraception 14 weeks later. Long-acting reversible contraceptive methods, such as intrauterine or subdermal contraceptives, had higher continuation rates and less service-based variability in continuation and failure rates than short-acting reversible contraception or depot-medroxyprogesterone. The proportion of days on any form of prescription contraception during the first 4 years on active duty varied from 23.3% in the army to 38.6% in the navy. The birth rate varied from 34.8 births/1,000 woman-years in the air force up to 62.7 births/1,000 woman-years in the army. Compared with women in the air force, women in the army experienced 2,191 additional days of postpartum leave and 13,908 days on deployment restrictions per 1,000 woman-years.DiscussionService branch specific variability in contraceptive use is associated with differences in days of pregnancy-related duty restrictions during first 4 years on active duty among junior enlisted females. Robust implementation of best practices in contraceptive care across the military health system to improve contraceptive initiation and continuation appears to offer an opportunity to improve military readiness and promote the health and well-being of active duty service women, particularly in the army.
      PubDate: Sat, 05 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad308
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Standing Tall: Do Height-Based Accountability Incentives Predict
           Artificial Increases in Measured Height Among Sailors in the U.S.
           Military'

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      Pages: e259 - e266
      Abstract: ABSTRACTIntroductionThe objective of this study was to investigate the changes in men’s and women’s measured height in response to weight gain above standards for the U.S. Navy and to quantify associated distortions in body mass index (BMI). We expected that some servicemembers would manipulate their measured height to comply with service standards.Materials and MethodsThe study was a retrospective observational study. The data were housed in the Person-Event Data Environment, an individual-level administrative registry from the United States Department of Defense. All participants were active-duty U.S. Navy sailors aged 21–50 during the years 2010–2019. The main outcomes were height and weight as recorded during twice-yearly physical fitness assessments and BMI calculated as: height in pounds × 703/(height in inches)2. We assessed whether weight gain above standards was associated with an increase in height at the subsequent height–weight assessment.ResultsAmong the 489,020 sailors, individuals were nearly 1.5 times as likely to measure taller when they gained weight that put them above military height–weight standards as compared to those who continued to remain within standards. Men were more often out of standards and therefore their measured height increased during subsequent assessments more often than women. Increases in height depressed measures of BMI slightly.ConclusionsAmong U.S. sailors, taller height was correlated with surpassing height-based weight limits, where taller individuals were allowed to weigh more and still meet professional weight standards. Results underscore that current height–weight accountability standards may distort behavior, leading servicemembers to manipulate measurements rather than improve job-relevant fitness. Instead, greater reliance on fitness-based measures of health, such as fitness tests, may hold promise for upholding servicemember readiness. Our results highlight that when stakes are attached to a measure, individuals may work to raise their performance using strategies that are misaligned with the policy intent.
      PubDate: Fri, 04 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad302
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Acute Renal Failure with Severe Loin Pain and Patchy Renal Ischemia after
           Anaerobic Exercise in Active Duty Marines

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      Pages: e429 - e432
      Abstract: ABSTRACTAcute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise (ALPE) is a rare cause of exertional acute kidney injury. The proposed mechanism of injury in ALPE is renovascular spasm, in the setting of oxidative stress and muscular damage, which creates a characteristic wedge-shaped infarction pattern on delayed imaging. Patients present with nausea, vomiting, loin or abdominal pain, and fatigue within 1-2 days of anaerobic exercise, associated with an acute rise in serum creatinine, which generally plateaus within 3 days. This process is likely exacerbated by dehydration, analgesic usage, and lower baseline fitness levels. This disease process is distinct from rhabdomyolysis, in that creatine kinase levels are not significantly elevated, myoglobinuria is not seen, and aggressive fluid resuscitation is not beneficial. We present three cases of ALPE following participation in the Marine Combat Fitness Test (CFT), an anaerobic evolution. Medical workup demonstrated no additional etiology for acute renal failure. The average peak creatinine in these patients was 2.9 mg/dL, and all demonstrated return to normal renal function, without hemodialysis. One patient experienced recurrent ALPE, after short-interval CFT participation. Military medical providers should be aware of this diagnosis when evaluating service members with acute renal injury after exercise. The clinical course is benign, and affected service members are at increased risk of recurrence, with subsequent intense exercise. Service members should engage in a graduated exercise program, before intense exercise activities, and should be monitored closely for recurrent renal injury.
      PubDate: Thu, 03 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad258
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Custom Iris Prosthesis for Subtotal Traumatic Aniridia From Combat
           Ocular Trauma

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      Pages: e443 - e447
      Abstract: ABSTRACTTraumatic aniridia from combat ocular trauma can cause visual disability. A 41-year-old male Army Veteran was referred for evaluation of light sensitivity and glare secondary to subtotal traumatic aniridia of his left eye from an improvised explosive device blast. A custom-made artificial iris prosthesis was implanted in the ciliary sulcus and secured using Gore-Tex sutures. After surgery, the patient reported improvement of his light sensitivity and quality of life. The custom iris prosthesis is a surgical option for visual disability resulting from traumatic aniridia from combat ocular trauma.
      PubDate: Thu, 03 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad278
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Diagnosis of Resistance to Thyroid Hormone due to a Rare Mutation
           in the Thyroid Hormone Receptor Beta Gene in a Patient Previously
           Presumed to Have Graves’ Disease

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      Pages: e439 - e442
      Abstract: ABSTRACTClinicians may confuse an impaired sensitivity to thyroid hormone with hyperthyroidism and offer an inappropriate treatment. We report a diagnosis of resistance to thyroid hormone (RTH) caused by a rare mutation in the thyroid hormone receptor beta gene in a patient previously presumed to have Graves’ disease. We have found only one published case of a novel point mutation, c.749T>C (p.Ile250Thr variant) associated with 50% reduction in thyroid hormone receptor binding affinity for triiodothyronine in the I250T mutant; it was found in this patient. A 66-year-old male veteran, with a history of non-ischemic cardiomyopathy and arrhythmias, was referred by a cardiologist with concerns for a possible thyrotropin (TSH) adenoma on account of elevated TSH and free thyroxine (FT4) levels. Pituitary imaging was negative. He was previously treated with radioiodine for presumptive Graves’ disease in the civilian sector. Examination revealed a goiter with no nodules. Repeat TSH and FT4 levels were elevated and also free triiodothyronine (FT3) and reverse triiodothyronine. These findings and other test results were consistent with RTH, which was confirmed by genetic testing. Mutation analysis showed the patient to be heterozygous for the p.Ile250Thr variant. He later developed hypothyroidism. Resistance to thyroid hormone can be misdiagnosed as hyperthyroidism with consequent inappropriate treatment. Treatment is not needed in most RTH-beta patients. Thyroid ablation should generally be avoided. Clinicians must be cautious whenever they encounter concurrent elevation of TSH, FT4, and FT3. This RTH-beta patient has a rare I250T mutant of the thyroid hormone receptor beta gene, the second reported case in the literature.
      PubDate: Wed, 02 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad283
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Healthcare Utilization Following Hemipelvectomy or Hip Disarticulation
           in the Military Health System

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      Pages: e235 - e241
      Abstract: ABSTRACTIntroductionAmputations at the hip and pelvic level are often performed secondary to high-energy trauma or pelvic neoplasms and are frequently associated with a prolonged postoperative rehabilitation course that involves a multitude of health care providers. The purpose of this study was to examine the health care utilization of patients with hip- and pelvic-level amputations that received care in the U.S. Military Health System.Materials and MethodsWe performed a retrospective review of all patients who underwent a hip- or pelvic-level amputation in the Military Health System between 2001 and 2017. We compiled and reviewed all inpatient and outpatient encounters during three time points: (1) 3 months pre-amputation to 1 day pre-amputation, (2) the day of amputation through 12 months post-amputation, and (3) 13-24 months post-amputation. Health care utilization was defined as the average number of encounter days/admissions for each patient. Concomitant diagnoses following amputation including post-traumatic stress disorder, traumatic brain injury, anxiety, depression, and chronic pain were also recorded.ResultsA total of 106 individuals with hip- and pelvic-level amputations were analyzed (69 unilateral hip disarticulation, 6 bilateral hip disarticulations, 27 unilateral hemipelvectomy, 2 bilateral hemipelvectomies, and 2 patients with a hemipelvectomy and contralateral hip disarticulation). Combat trauma contributed to 61.3% (n = 65) of all amputations. During the time period of 3 months pre-amputation, patients had an average of 3.8 encounter days. Following amputation, health care utilization increased in both the year following amputation and the time period of 13-24 months post-amputation, averaging 170.8 and 77.4 encounter days, respectively. Patients with trauma-related amputations averaged more total encounter days compared to patients with disease-related amputations in the time period of 12 months following amputation (203.8 vs.106.7, P < .001) and the time period of 13-24 months post-amputation (92.0 vs. 49.0, P = .005). PTSD (P = .02) and traumatic brain injuries (P < .001) were more common following combat-related amputations.ConclusionsThis study highlights the increased health care resource demand following hip- and pelvic-level amputations in a military population, particularly for those patients who sustained combat-related trauma. Additionally, patients with combat-related amputations had significantly higher rates of concomitant PTSD and traumatic brain injury. Understanding the extensive needs of this unique patient population helps inform providers and policymakers on the requirements for providing high-quality care to combat casualties.
      PubDate: Sat, 29 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad295
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • The Functional Movement Screen and Self-reported Injury
           in Senior Military College Cadets

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      Pages: e242 - e249
      Abstract: ABSTRACTIntroductionSecular trend of increasing musculoskeletal injuries (MSKIs) across all branches of the U.S. Military is a critical limiting factor in the effective and efficient process of preparing military personnel for combat. The need to evaluate functional capacity beyond current physical fitness test (PFT) standards is the key in understanding an individual’s risk of noncombat-related injury. The purpose of this study is to evaluate the relationship between Functional Movement ScreenTM (FMS) scores, incidence of musculoskeletal injuries, and standardized PFT scores among freshman Cadets during their first 10 weeks of enrollment at a senior military college.Materials and MethodsEighty-two participants (72 male and 10 female participants; mage: 18.2 years) completed the FMS, an institution-specific PFT (2-min maximum pushups, 2-min maximum abdominal crunches, and 1.5 mile timed run), and an Incidence of Injury and Incidence of Pain Questionnaire. Independent t-tests, Spearman’s rank correlation coefficients logistic regression analysis, and Receiver Operator Curves were performed to evaluate relationships between the study variables.ResultsFMS composite and PFT sex-normed total scores were higher in females (16.4, 236.1) than in males (15.0, 204.9). Ninety percent of all females reported injury or pain during the 10-week survey period compared to 48% of males.ConclusionsNo significant difference between FMS scores and injury and pain was found within both sex groups. Therefore, use of the composite FMS score as an indicator for risk of injury or to predetermine PFT performance is not recommended for this study’s population. The rate of incidence of injury or pain in Cadets during a 10-week enrolment period is high. Females outperformed males in the FMS and PFT and reported higher rates of injury and pain. The utility of the FMS may be limited when substantially scaled for implementation across entire military populations. Future research should evaluate performance associations of the FMS with Army Combat Fitness Test components in a population of equally distributed sex and race.
      PubDate: Fri, 28 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad285
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • A Case of Whipple’s Disease With Concomitant Esophageal
           Candidiasis

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      Pages: e405 - e409
      Abstract: ABSTRACTWhipple’s Disease (WD) is a rare disease caused by the infection of Tropheryma whipplei. It can lead to immunosuppression and a multitude of effects on different organ systems, resulting in a constellation of seemingly unrelated findings. Although treatment may appear straightforward, T. whipplei can be difficult to eradicate. We present the case of a 36-year-old male with months of progressively worsening watery diarrhea, migratory arthralgias, and weight loss. He had undergone an extensive evaluation for rheumatologic, oncologic, and infectious disorders without positive findings. Esophagogastroduodenoscopy and colonoscopy revealed esophageal candidiasis, Helicobacter pylori infection, and foamy macrophages in the lamina propria of the duodenum and ileum with positive polymerase chain reaction for T. whipplei. There were no other risk factors for esophageal candidiasis. He received treatment for his esophageal candidiasis and H. pylori infection and was treated for WD with ceftriaxone for 2 weeks, followed by hydroxychloroquine and doxycycline for 1 year. Symptoms resolved after 3 months of therapy. One year later, repeat bidirectional endoscopy was performed. Biopsies were negative for T. whipplei, although there were persistent foamy macrophages. There have been previously reported cases of patients with WD with concomitant esophageal candidiasis, and this association implies a likely state of relative immunosuppression associated with WD, which is thought to be the result of impaired T helper cell 1 activity. This impairment likely contributes to the high rate of relapse. Having a low threshold for repeat evaluation is advisable for recurrent symptoms, but long-term surveillance strategies are not clearly defined.
      PubDate: Wed, 26 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad246
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Spontaneous Pneumomediastinum Secondary to Undiagnosed Asthma
           in Military Adult

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      Pages: e433 - e438
      Abstract: ABSTRACTSpontaneous pneumomediastinum (SPM) is a rare but described complication of exercise-induced bronchoconstriction (EIB), more commonly observed in children with asthma. We present a 23-year-old active duty military male and avid distance runner who developed progressive radiating retrosternal chest pain preceded by wheezing and coughing paroxysm. A chest computed tomography revealed extensive pneumomediastinum. SPM results from increased intrathoracic pressure with alveolar rupture and subsequent tracking of air between fascial planes. Like most cases of SPM, our patient remained hemodynamically stable and responded well to conservative therapies with complete resolution. After thorough evaluation, undiagnosed asthma was determined to be the inciting etiology. The patient is now well controlled and symptom free on a daily low-dose inhaled corticosteroid without SPM reoccurrence. In young adult patients presenting with SPM, EIB and asthma should be considered on the differential diagnosis as appropriate medical therapy will improve symptoms and reduce risk of reoccurrence.
      PubDate: Mon, 24 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad263
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • A Pilot Replication Study of Implementing an Equine-Assisted Services
           Program Within a VA Residential Substance Use Disorder Treatment Program

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      Pages: e220 - e226
      Abstract: ABSTRACTIntroductionVeterans have high rates of substance use disorders and other mental health conditions including post-traumatic stress disorder. Effective treatments for these conditions exist; however, high attrition rates and residual symptoms after completing treatment are common. Complementary treatment approaches could enhance treatment engagement and/or response among this population. We previously reported a study of one such intervention, an equine-assisted learning, and psychotherapy incorporating horses intervention provided to veterans admitted to a Veterans Health Care Administration residential substance abuse treatment program. The first aim of this study was to replicate the previous study assessing the safety, feasibility, and preliminary outcomes of this intervention. The second aim was to examine the effect of participants attending multiple intervention sessions.Materials and MethodsParticipants were 94 veterans who participated in one to six sessions of a 3–4-hour program consisting of both equine-assisted learning and psychotherapy incorporating horses. Pre- and post-session administration of the Positive and Negative Affect Scale, State-Trait Anxiety Inventory, and Craving Experience Questionnaire was utilized to assess changes in affect, anxiety, and craving. Wilcoxon signed-rank or paired two-tailed t-tests were utilized for pre- to post-session comparisons of the outcome measures for sessions 1–4. Generalized linear mixed-effects (GLME) models were constructed to determine the impact of dosage. GLME models were constructed to determine the impact of dosage.ResultsAs with our previous study, the intervention was safe and feasible to utilize for this population. There were statistically significant pre- to post-session improvements, with medium-to-large effect sizes, for sessions 1–3 for negative affect and sessions 1 and 2 for positive affect, anxiety, and craving. The GLME models revealed no statistical significance for any of the predictors.ConclusionsTaken together, this study and our previous investigation of this equine-assisted services intervention suggest that it is safe and feasible to utilize for veterans admitted to a residential substance abuse treatment program and we have now found short-term benefits in two separate studies. Thus, a randomized controlled trial of this intervention is warranted to demonstrate cause and effect and determine whether longer-term benefits are associated with the intervention. The finding that there was no additional benefit from attendance at more than two intervention sessions suggests that dose–response relationship studies of equine-assisted services interventions for veterans are needed.
      PubDate: Mon, 24 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad274
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Handheld Magnetometer-Assisted Localization and Removal of a Foreign
           Body From the Chest Wall

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      Pages: e420 - e423
      Abstract: ABSTRACTForeign bodies fully embedded in soft tissues present a unique challenge to surgeons attempting excision. Small fragments can be nonpalpable, and many prove difficult to visualize intra-operatively by means of classic radiologic techniques. A 35-year-old active duty soldier presented requesting excision of ballistic fragment embedded in his chest wall that had previously failed a previous attempt at removal. The metallic foreign body was successfully localized intra-operatively using a handheld magnetometer probe and removed without complication. This case demonstrates the utility and cost-effectiveness of the handheld magnetometry for intra-operative localization of metallic foreign bodies. Metallic foreign bodies may be localized intra-operatively using inexpensive and reusable equipment that does not require radiation or bulky radiographic imaging equipment.
      PubDate: Wed, 12 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad255
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Assessing Clinical Utility of Pharmacogenetic Testing in the
           Military Health System

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      Pages: e198 - e204
      Abstract: ABSTRACTIntroductionResponse to medications can differ widely among individual patients. Adverse drug reactions can lead to serious morbidity and mortality. Pharmacogenetic (PGx) testing can predict responses to medications and increased risks of adverse events where the genetic basis is understood. Several published manuscripts suggest positive impacts of systematic preemptive PGx testing. However, few studies have been conducted on PGx implementation in the Military Health System (MHS).Material and MethodsA cross-sectional study of adult beneficiaries in a primary care clinic at a large military treatment facility was conducted in 2022. Participants underwent PGx genotyping of CYP2C19 and CYP2D6 genes at the Defense Health Agency Genetics Reference Laboratory. Participant medication lists were compared to the current Clinical Pharmacogenetic Implementation Consortium (CPIC) PGx gene–drug guidelines to assess potential actionability of these results.ResultsGenotyping of CYP2C19 and CYP2D6 in 165 MHS beneficiaries (mean age: 65 years) revealed that 81.2% of participants had at least one abnormal PGx finding. Among those with an abnormal PGx result, 65% were taking a medication listed on the CPIC website with an association with the particular gene in which the finding was identified. In addition, 78% of all of the participants in the study were taking at least one medication that is metabolized by CYP2C19 or CYP2D6 with associated CPIC guidelines.ConclusionsPharmacogenetic testing for CYP2C19 and CYP2D6 identified a substantial proportion of MHS patients at a single center who could benefit from evaluation of current medication regimens based on the CPIC guidelines. Individualized medical management may be warranted to a greater degree than previously recognized based on the findings given possible differences in medication metabolism. Many MHS beneficiaries already take medications metabolized by CYP2C19 and CYP2D6, and a substantial proportion may be at risk for preventable adverse events for medications metabolized by these enzymes. While preliminary, a large number of actionable polymorphisms among a relatively small set of individuals taking at-risk medications suggest that implementing PGx testing in clinical practice may be beneficial in the MHS with appropriate clinical infrastructure.
      PubDate: Wed, 12 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad254
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • The Influence of Advanced Hyperbaric Medical Training
           on Arterial Gas Embolism Treatment

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      Pages: e401 - e404
      Abstract: ABSTRACT3d Reconnaissance Battalion, a forward-deployed Marine Corps unit in Okinawa, Japan, frequently performs diving operations. Often throughout the year, several reconnaissance teams are diving simultaneously in different locations for training. We present a case of an otherwise healthy 30-year-old-male Reconnaissance Marine who surfaced from a dive with abnormal symptoms and received prompt care from exercise participants who were nonmedical personnel. Studies have demonstrated improved morbidity outcomes in decompression illness patients with shorter times to hyperbaric treatment following the onset of symptoms. High-risk military exercises with diving components have a mandatory safety structure that includes recompression chamber support. All United States Marine Corps Reconnaissance, Marine Corps Special Operations Command, and U.S. Navy dive operations are required to have at least one diving supervisor. To expand the diving capabilities of the unit, Marines are encouraged to attend training and qualify as diving supervisors. This case study demonstrates the efficacy and importance of training Recon Marines to recognize decompression illness as diving supervisors.
      PubDate: Wed, 12 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad260
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • An Atypical Cause of Hoarseness in a Patient With Thyroid
           Nodules

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      Pages: e414 - e416
      Abstract: ABSTRACTHoarseness due to vocal fold paresis (VFP) has a multitude of etiologies including systemic lupus erythematosus (SLE). During a clinical evaluation of a 58-year-old woman with long-standing hoarseness, an incidental finding of thyroid nodules was found to have VFP. Direct laryngoscopy and vocal fold biopsy confirmed the source was an inflammatory process involving the cricoarytenoid joint of the right hemilarynx. A presumptive diagnosis of SLE was made 3 years before meeting the clinical criteria of overt SLE. The VFP debut of SLE is extremely rare, and a literature review includes a handful of case reports (4 of a total of 37) since 1959. Only partial recovery of laryngeal function using glucocorticoids and Plaquenil was accomplished in the current case.
      PubDate: Wed, 05 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad234
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • The Experience of Living With Polycystic Ovary Syndrome in the
           Military

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      Pages: e188 - e197
      Abstract: ABSTRACTIntroductionPolycystic ovary syndrome (PCOS) is the most prevalent reproductive endocrinopathy in women, ranging from 5% to 26% depending on diagnostic criteria applied. Common manifestations of PCOS include overweight and obesity, abnormal menstrual cycles, pelvic pain, increased facial and body hair, acne, and infertility. These abnormalities and associated complications have significant military operational and readiness implications. There is a large gap in research regarding active duty servicewomen (ADW) with PCOS. Therefore, the purpose of this study is to describe ADW’s experience of living with PCOS and to describe the service-branch-specific differences among these women.Materials and MethodsModerator’s guide, audiotapes, transcripts, and field notes. This was a qualitative descriptive study using focus groups and individual interviews. The David Grant Medical Center Institutional Review Board at Travis AFB, CA, USA, approved the study protocol. Women with PCOS were recruited from U.S. Air Force, Army, and Navy locations. Data were analyzed using constant comparative content analysis.ResultsTwenty-three servicewomen from 19 occupations across the Army, Navy, Air Force, and Marine Corps participated. Three overarching categories emerged: (1) challenges managing PCOS symptoms, (2) navigating the military health care system, and (3) navigating PCOS as a service member.ConclusionsServicewomen may have significant career consequences related to PCOS sequelae, such as overweight, obesity, uncontrolled menstrual cycle, and pain. Managing the myriad of symptoms can distract women while deployed, in austere conditions, or at their home stations. As one of the most common cardiometabolic, reproductive endocrinologic conditions in women, PCOS has not received the attention, awareness, education, or research necessary to sufficiently support ADW with this condition. It is imperative that evidence-based strategies are developed to inform relevant and high-quality care for these warfighters. Future qualitative studies are needed to further describe specific stressors and needs of ADW with PCOS. Future intervention studies are also needed to evaluate effective management options for ADW with PCOS.
      PubDate: Wed, 05 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad241
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Vitamin D Abuse in Pursuit of “Gains” Resulting
           in Acute Kidney Injury

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      Pages: e417 - e419
      Abstract: ABSTRACTVitamin toxicity represents an increasingly frequent clinical diagnosis and can be difficult to initially recognize given the plethora of over-the-counter supplements available. The young, active, and heavily male population of the military is especially susceptible to such supplementation pitfalls. Here we present the case of acute renal failure with hypercalcemia that was found to be secondary to unrecognized high-dose over-the-counter vitamin supplementation and subsequent vitamin D hypervitaminosis initiated by the patient in the hope of boosting testosterone production. This clinical scenario demonstrates the dangers of easily accessible, often seemingly benign supplements and the need for greater education and awareness of supplementation use.
      PubDate: Tue, 04 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad237
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Diagnostic and Therapeutic Challenges in a Military Recruit Training
           Center of the Hellenic Navy: A Retrospective Analysis of the Poros
           Registry Serving as a Quality Improvement Project for Medical Officers

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      Pages: e166 - e175
      Abstract: ABSTRACTIntroductionBasic military training (BMT) has been associated with increased morbidity burden. Nevertheless, the exact epidemiology of the encountered cases in the BMT of Greek recruits has never been assessed. The aim of this quality improvement project was to investigate for the first time the clinical patterns, rates, and severity of symptoms leading recruits to visit the infirmary of a recruit training center and use this knowledge to provide a practical guidance for the physicians in charge.Materials and MethodsAll medical cases which were consecutively examined for the time range from November 2021 to September 2022 at the infirmary of the Hellenic Naval recruit training center in Poros, Greece, were retrospectively analyzed. Logistic regression analyses were performed to identify independent predictors of “severe clinical status” (i.e., overnight sick bay confinement and/or transfer to a tertiary hospital within 24 h) and absence from BMT for at least 1 day.ResultsA total of 2,623 medical cases were examined during four recruit seasons from November 2021 to September 2022. Upper respiratory tract infections (URTIs) and musculoskeletal injuries were the most frequent reasons for a recruit’s visit to the infirmary (33.9% and 30.2%, respectively). 6.7% of the total cases were identified as having “severe clinical status.” Specifically, in psychiatric, urological, and cardiovascular cases, febrile events were all independently associated with increased risk of “severe clinical status.” There was a positive association between training week and absence from BMT, while febrile events and spring recruit season were also independently linked with increased probability of absence from BMT for at least 1 day.ConclusionsURTIs and musculoskeletal complaints were the primary reasons for recruits’ presentation at the infirmary of a Greek recruit training center, leading to severe rates of attrition. Further registries and quality improvement projects are warranted to reach specific conclusions and reduce BMT-related morbidity and its subsequent implications.
      PubDate: Mon, 03 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad243
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Prevalence of Neck Pain in Soldiers as a Result of Mild Traumatic Brain
           Injury–Associated Trauma

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      Pages: e182 - e187
      Abstract: ABSTRACTIntroductionMany of the injury mechanisms that cause mild traumatic brain injury (mTBI) also create forces commonly associated with whiplash, resulting in cervical pain injury. The prevalence of associated neck pain with mTBI is not well established. There is a strong indication that injury to the cervical spine may aggravate, cause, and/or impact recovery of symptoms and impairments associated with the concussive event and its primary effect on the brain. The purpose of this study is to help identify the prevalence of ensuing cervical pain within 90 days of a previously documented mTBI and to examine the role of neck pain during concurrent concussive symptoms, in a military population stationed at a large military installation.Materials and MethodsThis retrospective design utilized a de-identified dataset using predetermined search and filter criteria, which included male active duty service members (SMs), 20 to 45 years of age, who received medical care at any clinic on Fort Liberty (Fort Bragg, NC) during fiscal year (FY) 2012 to FY 2019, with documented cervicalgia and mTBI (via the International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes), verified using electronic medical records. The final dataset served as the basis for subject sampling and was analyzed to determine the total number of documented cervicalgia and mTBI diagnoses. Results are presented as descriptive statistics. Approval for this study was received from the Andrews University Office of Research (18-097) and the Womack Army Medical Center Human Protections Office.ResultsBetween FY 2012 and FY 2019, 14,352 unique SMs accessed a Fort Bragg, NC health care facility, at least once (Table I). Overall, 52% of SMs diagnosed with cervicalgia were found to have a previously diagnosed mTBI during the 90 days before the cervicalgia diagnosis. In contrast, the prevalence of same-day cervicalgia and mTBI diagnosis was <1% (Table IV). The prevalence of isolated cervicalgia diagnosis at any time during the reporting period was 3%, whereas isolated mTBI diagnosis was 1% (Table III).TABLE I.Unique Active Duty Service Members (ADSMS) Seeking Care Over FY 2012–2019 (6.6 Years)Fiscal year (FY)aa,bbTotal number of unique patients201220131,19920141,095201588020162,66520171,47520181,95420191,231Cumulative FY 2012–201914,352aTotal patients with at least one appointment in an FY = 10,499.bTotal patients with multiple-year appointments = 3,853.ConclusionsOver 50% of SMs diagnosed with cervicalgia had sustained a documented mTBI within 90 days prior, whereas less than 1% were diagnosed with cervicalgia at the time of initial primary care or emergency room encounter following the mTBI event. This finding suggests that the close anatomical and neurophysiological connections between the head and the cervical spine are both likely to be impacted through the same mechanism of injury. Delayed evaluation (and treatment) of the cervical spine may contribute to lingering post-concussive symptoms. Limitations of this retrospective review include the inability to assess the causality of the relationship between neck pain and mTBI, as only the existence and strength of the prevalence relationship can be identified. The outcome data are exploratory and intended to identify relationships and trends that may suggest further study across installations and across mTBI populations.
      PubDate: Thu, 29 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad228
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • A Case Series of Ocular Syphilis Cases at Military Treatment Facility
           From 2020 to 2021

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      Pages: e410 - e413
      Abstract: ABSTRACTSyphilis is a sexually transmitted infection, caused by the spirochete Treponema pallidum, that can lead to multi-organ involvement. In 2020, over 138,000 cases were reported in the United States equating to a case report of 40.8 per 100,000 people. Ocular syphilis is a rare manifestation and is defined as the clinical presentation of ocular disease in a person with laboratory-confirmed syphilis infection of any stage, with estimated incidence of 0.6–2% of all cases. Syphilis is known as “The Great Imitator,” and can present as nearly any form of ocular disease, though the most common manifestations are posterior uveitis and panuveitis. The highly variable clinical presentation of ocular syphilis often leads to delayed diagnosis allowing the potential for poor, often preventable outcomes. This highlights the need for providers to have a high level of clinical suspicion and awareness of ocular manifestations of syphilis, especially in high risk populations. We present a case series of five patients diagnosed with ocular syphilis at a military treatment facility. Each patient had different presenting symptoms as well as different ocular manifestations.
      PubDate: Tue, 27 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad238
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Developing a Program for Advanced Physical Therapist Practice
           in Amputation Care

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      Pages: e176 - e181
      Abstract: ABSTRACTIntroductionOver the past 20 years, military medicine made great strides in the medical management of traumatically injured patients. Significant advancements were made in the treatment and rehabilitation after limb loss. These advancements can be attributed to the large number of complex patients presenting to military treatment facilities and the demand for medical professionals to provide care to patients with complex injuries and multiple traumatic amputations. The concern now is to maintain the skills needed to be prepared for the next conflict. To meet this demand, the Extremity Trauma and Amputation Center of Excellence (EACE) initiated the documentation of knowledge, skills, and abilities (KSAs) to ensure that the skill sets needed to treat this unique population are not lost. The EACE developed KSAs to sustain advanced clinical practice for physical therapists, occupational therapists, and prosthetists and is in the process of developing KSAs for orthotists and physical medicine physicians. The learning objectives [terminal and enabling learning objectives (TLOs and ELOs)] derived from each set of KSAs will drive curricula development for enduring education, residencies, and fellowships. This article describes the KSAs and learning objectives for advanced physical therapist competencies in amputation care.MethodsClinical subject matter experts (SMEs) convened from the Department of Defense (DoD) Advanced Rehabilitation Centers (ARCs) to draft the initial KSAs. All experts had specific expertise in treating individuals with highly complex lower and upper limb amputation. In a quasi-Delphi methodology, the initial draft KSAs underwent five cycles of review and comment by an additional 15 DoD, Veterans Affairs, and civilian institution experts from clinical practice, education, and research. The consensus KSAs were then transcribed into learning objectives with collaboration between clinical subject matter experts and doctoral-level educators.ResultsThe final program document has 21 instructional modules with 30 TLOs and 157 ELOs.ConclusionThe KSAs and the learning objectives describe the skills expected of an advanced practice physical therapist treating patients with traumatic limb loss. Weaknesses of this document include the focus on traumatic amputation and military specific needs. However, many of the central advanced practices are universal to all physical therapists working in amputation. Thus, this document should serve as a starting point and can evolve to include dysvascular, oncology, and other etiologies. To our knowledge, this is the first paper to describe the KSAs for the advanced practice physical therapist working with traumatic limb loss population. This work will form the framework for physical therapist advanced practice training programs.
      PubDate: Mon, 26 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad231
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Early Repolarization Syndrome Leading to Recurrent Cardiac Arrest in a
           Young Active Duty Patient

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      Pages: e396 - e400
      Abstract: ABSTRACTA previously healthy, active duty 37-year-old male experienced recurrent cardiac arrests because of ventricular fibrillation and polymorphic ventricular tachycardia. Initial evaluation did not reveal a clear ischemic, structural, toxic, or metabolic cause. Close monitoring of telemetry before his third cardiac arrest revealed the cause to be early repolarization syndrome (ERS). In this case, we review the diagnosis, epidemiology, and prognostic significance of early repolarization pattern as it relates to ERS. We also discuss acute and long-term treatment strategies for patients with ERS.
      PubDate: Mon, 26 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad229
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Depression and Differential Oral Health Status Among U.S. Adults With
           and Without Prior Active Duty Service in the U.S. Military, National
           Health and Nutrition Examination Survey 2011-2018

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      Pages: e157 - e165
      Abstract: ABSTRACTIntroductionVeterans suffer from lower overall well-being than non-veterans because of their unique life course. This study aims to compare the impact of depression on oral health for veteran and non-veteran populations.Materials and MethodsData from 11,693 adults (18+) participating in the National Health and Nutrition Examination Survey (2011-2018) were analyzed. The outcome variables were dichotomous (at/above mean) decayed, missing, and filled teeth due to caries (DMFT), as well as the components, namely, missing teeth, filled teeth (FT), and decayed teeth (DT). The primary predictor variable combined depression screening outcome and veteran status (veteran/depressed, veteran/not depressed, non-veteran/depressed, and non-veteran/not depressed). Covariates included socioeconomic factors, demographics, wellness factors, and oral health–related habits. Associations between outcome and predictor variables were assessed with a fully adjusted logistic regression analysis.ResultsVeterans, regardless of depression status, had more DMFT, FT, missing teeth, and DT compared to non-veterans. After controlling for covariates, veterans suffering from depression had higher odds of DT (1.5, 95% CI, 1.0-2.4) compared to non-veterans without depression. In general, veterans who screened negative for depression had better oral health compared to all groups, with lower odds of DT (0.7, 95% CI, 0.6-0.9) and higher odds of FT (1.4, 95% CI, 1.1-1.7) compared to non-veterans with and without depression.ConclusionsThis study found that not only veterans have higher odds of overall caries experience, but also veterans suffering from depression have higher odds of active caries compared to non-depressed veterans. Most veterans lack Veterans Health Administration dental benefits and face challenges maintaining oral health on top of medical and mental health burdens. Our results add further urgency to increasing dental care access for this vulnerable population because of the exacerbation of unmet oral health care needs attributable to the additional mental health challenges veterans face.
      PubDate: Sat, 10 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad217
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • The Effect of Body Armor on Pulmonary Function Using
           Plethysmography

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      Pages: e136 - e140
      Abstract: ABSTRACTMilitary tactical athletes face the unique task of performing physically demanding occupational duties, often while wearing body armor. Forced vital capacity and forced expiratory volume measured using spirometry have been shown to decrease, while wearing plate-carrier style body armor, little is known about the comprehensive effects of wearing body armor on pulmonary function, including lung capacities. Further, the effects of loaded body armor vs. unloaded on pulmonary function are also unknown. Therefore, this study examined how loaded and unloaded body armor affects pulmonary function. Twelve college-aged males performed spirometry and plethysmography under three conditions (basic athletic attire [CNTL], unloaded plate carrier [UNL], and loaded plate carrier [LOAD]). Compared to CNTL, LOAD and UNL conditions significantly reduced functional residual capacity by 14% and 17%, respectively. Compared with CNTL, LOAD condition also showed a small but statistically significant lowered forced vital capacity (P = .02, d = 0.3), a 6% lower total lung capacity (P < .01, d = 0.5), and lowered maximal voluntary ventilation (P = .04, d = 0.4). A loaded plate-carrier style body armor exerts a restrictive effect on total lung capacity, and both loaded and unloaded body armor affects functional residual capacity, which could impact breathing mechanics during exercise. Resulting endurance performance decreases may need to be factored based on the style and loading of body armor, especially for longer-duration operations.
      PubDate: Wed, 07 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad203
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • The Effect of Concussion Mechanism of Injury on Sleep Problems
           in Active Duty Service Members Following Deployment

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      Pages: e141 - e147
      Abstract: ABSTRACTIntroductionSleep disruption is pervasive in the military and is generally exacerbated during deployment, partially due to increases in operational tempo and exposure to stressors and/or trauma. In particular, sleep disruption is a commonly reported symptom following deployment-related traumatic brain injury (TBI), though less is known about the prevalence of sleep disturbance as a function of whether the TBI was induced by high-level blast (HLB) or direct impact to the head. TBI assessment, treatment, and prognosis are further complicated by comorbidity with posttraumatic stress disorder (PTSD), depression, and alcohol misuse. Here, we examine whether concussion mechanism of injury is associated with differences in the prevalence of self-reported sleep disturbance following deployment in a large sample of U.S. Marines while accounting for probable PTSD, depression, and alcohol misuse.Materials and MethodsThis was a retrospective cohort study of active duty enlisted Marines with a probable concussion (N = 5757) who completed the Post-Deployment Health Assessment between 2008 and 2012. Probable concussion was defined as endorsement of a potentially concussive event with corresponding loss or alteration of consciousness. The presence of concussion-related sleep problems was assessed with a dichotomous item. Probable PTSD, depression, and alcohol misuse were assessed using the Primary Care PTSD Screen, the Patient Health Questionnaire-2, and the Alcohol Use Identification Test-Concise, respectively. Logistic regression models investigated the effects of mechanism of injury (HLB vs. impact), PTSD, depression, and alcohol misuse on the presence of sleep problems, adjusting for sex and pay grade. The study was approved by the Naval Health Research Center Institutional Review Board.ResultsApproximately 41% of individuals with a probable deployment-related concussion reported sleep problems following the event; 79% of concussed individuals reporting both HLB and probable PTSD reported sleep problems. All main effects were significantly associated with sleep disturbance in adjusted models. PTSD showed the strongest association with sleep disturbance (adjusted odds ratio [AOR] = 2.84), followed by depression (AOR = 2.43), HLB exposure (AOR = 2.00), female sex (AOR = 1.63), alcohol misuse (AOR = 1.14), and pay grade (AOR = 1.10). A significant HLB × PTSD interaction emerged (AOR = 1.58), which suggests that sleep disturbance was elevated among those with both HLB-induced (vs. impact-induced) concussions and presence (vs. absence) of PTSD. No other significant interactions emerged.ConclusionTo our knowledge, this is the first study to examine the prevalence of concussion-related sleep complaints following deployment as a function of the mechanism of injury in individuals with and without probable PTSD and depression. Individuals with HLB-induced concussion were twice as likely to report sleep problems as those with an impact-induced concussion. Future work should examine these effects longitudinally with validated measures that assess greater precision of exposure and outcome assessment (e.g., blast intensity and type of sleep disturbance).
      PubDate: Sat, 03 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad197
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • A Market Assessment of Introducer Technology to Aid With Endotracheal
           Intubation

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      Pages: e54 - e57
      Abstract: ABSTRACTIntroductionEndotracheal intubation is a potentially lifesaving procedure. Previously, data demonstrated that intubation remains the most performed airway intervention in the Role 1 setting. Additionally, deployed data demonstrate that casualties intubated in the prehospital setting have worse survival than those intubated in the emergency department setting. Technological solutions may improve intubation success in this setting. Certain intubation practices, including the use of endotracheal tube introducer bougies, facilitate intubation success especially in patients with difficult airways. We sought to determine the current state of the market for introducer devices.Materials and MethodsThis market review utilized Google searches to find products for intubation. The search criteria aimed to identify any device ideal for intubation in the emergency setting. Device data retrieved included manufacturer, device, cost, and design descriptions.ResultsWe identified 12 introducer-variants on the market. Devices varied with regards to composition (latex, silicone, polyethylene, combination of several materials, etc.), tip shape, special features for ease of intubation (markings for depth and visibility, size, etc.), disposability/reuse capability, measurements, and prices. The cost of each device ranged from approximately $5 to $100.ConclusionsWe identified 12 introducer-variants on the market. Clinical studies are necessary to determine which devices may improve patient outcomes in the Role 1 setting.
      PubDate: Sat, 03 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad186
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Connection Between Sleep and Psychological Well-Being in U.S. Army
           Soldiers

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      Pages: e40 - e48
      Abstract: ABSTRACTIntroductionThe goal of this exploratory study was to examine the relationships between sleep consistency and workplace resilience among soldiers stationed in a challenging Arctic environment.Materials and MethodsA total of 862 soldiers (67 females) on an Army base in Anchorage, AK, were provided WHOOP 3.0, a validated sleep biometric capture device and were surveyed at onboarding and at the conclusion of the study. Soldiers joined the study from early January to early March 2021 and completed the study in July 2021 (650 soldiers completed the onboarding survey and 210 completed the exit survey, with 151 soldiers completing both). Three comparative analyses were conducted. First, soldiers’ sleep and cardiac metrics were compared against the general WHOOP population and a WHOOP sample living in AK. Second, seasonal trends (summer versus winter) in soldiers’ sleep metrics (time in bed, hours of sleep, wake duration during sleep, time of sleep onset/offset, and disturbances) were analyzed, and these seasonal trends were compared with the general WHOOP population and the WHOOP sample living in AK. Third, soldiers’ exertion, sleep duration, and sleep consistency were correlated with their self-reported psychological functioning. All analyses were conducted with parametric and non-parametric statistics. This study was approved by The University of Queensland Human Research Ethics Committee (Brisbane, Australia) Institutional Review Board.ResultsBecause of the exploratory nature of the study, the critical significance value was set at P < .001. Results revealed that: (1) Arctic soldiers had poorer sleep consistency and sleep duration than the general WHOOP sample and the Alaskan WHOOP sample, (2) Arctic soldiers showed a decrease in sleep consistency and sleep duration in the summer compared to that in the winter, (3) Arctic soldiers were less able to control their bedroom environment in the summer than in the winter, and (4) sleep consistency but not sleep duration correlated positively with self-report measures of workplace resilience and healthy social networks and negatively with homesickness.ConclusionsThe study highlights the relationship between seasonality, sleep consistency, and psychological well-being. The results indicate the potential importance of sleep consistency in psychological functioning, suggesting that future work should manipulate factors known to increase sleep consistency to assess whether improved sleep consistency can enhance the well-being of soldiers. Such efforts would be of particular value in an Arctic environment, where seasonality effects are large and sleep consistency is difficult to maintain.
      PubDate: Fri, 02 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad187
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Consensus and Equipose in the Management of Military Trainee Femoral Neck
           Stress Fractures: A Survey of Military Surgeons

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      Pages: e82 - e89
      Abstract: ABSTRACTBackgroundFemoral neck stress fractures (FNSFs) are a unique injury pattern not commonly treated in the civilian trauma population; however, it is particularly high with military trainees engaged in basic combat training. To date, no study has surveyed a population of military orthopedic surgeons on treatment preferences for military service members (SMs) with FNSF.QuestionsWe aim to evaluate the extent of clinical equipoise that exists in the management of these injuries, hypothesizing that there would be consensus in the factors dictating surgical and non-surgical intervention for FNSF.Patients and MethodsA 27-question survey was created and sent to U.S. military orthopedic surgeon members of the Society of Military Orthopaedic Surgeons. The survey was designed in order to gather the experience among surgeons in treating FNSF and identifying variables that play a role in the treatment algorithm for these patients. In addition, seven detailed, clinical vignettes were presented to further inquire on surgeon treatment preferences. Binomial distribution analysis was used to evaluate for common trends within the surgeon’s treatment preferences.ResultsSeventy orthopedic surgeons completed the survey, the majority of whom were on active duty status in the U.S. Military (82.86%) and having under 5 years of experience (61.43%). Majority of surgeons elected for a multiple screw construct (92.86%), however the orientation of the multiple screws was dependent on whether the fracture was open or closed. Management for compression-sided FNSF involving ≥50% of the femoral neck width, tension-sided FNSF, and stress fractures demonstrating fracture line progression had consensus for operative management. Respondents agreed upon prophylactic fixation of the contralateral hip if the following factors were involved: Complete fracture (98.57%), compression-sided fracture line >75% (88.57%), compression-sided fracture line >50-75% with hip effusion (88.57%), contralateral tension–sided fracture (87.14%), and compression-sided fracture line >50-75% (84.29%). An FNSF < 50% on the contralateral femoral neck or a hip effusion was indeterminate in surgeons indicating need for prophylactic fixation. Majority of surgeons (77.1%) utilized restricted toe-touch weight-bearing for postoperative mobility restrictions.ConclusionsConsensus exists for surgical and non-surgical management of FNSF by U.S. military orthopedic surgeons, despite the preponderance of surgeons reporting a low annual volume of FNSF cases treated. However, there are certain aspects in the operative and non-operative management of FNSF that are unanimously adhered to. Specifically, our results demonstrate that there is no clear indication on the management of FNSF when an associated hip effusion is involved. Additionally, the indications for surgically treating contralateral FNSF are unclear.Level of evidenceIV.
      PubDate: Thu, 01 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usac426
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Correlates of the Veterans Visiting Emergency Departments in Taiwan: A
           Comparison Before and After the Coronavirus Disease 2019 Pandemic

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      Pages: e148 - e156
      Abstract: ABSTRACTBackgroundTaiwan has a substantial number of veterans, but knowledge regarding their emergency department (ED) visits during the coronavirus disease 2019 (COVID-19) pandemic remains limited. This study examined the characteristics of veterans’ ED visits during Taiwan’s COVID-19 epidemic.MethodsThis was a cross-sectional study conducted at the ED of a large veteran medical center located in Taipei, Taiwan, from May 2018 to October 2021. We analyzed the numbers and features of visits in summer and autumn according to the first wave of the COVID-19 epidemic in Taiwan in 2021.ResultsMedical institutions were positively associated with veteran status. Emergency department complaints of trauma (adjusted odds ratio [AOR] = 1.15, 95% CI: 1.06-1.25; summer P < .01) and chest pain/tightness (AOR = 1.65, 95% CI: 1.45-1.87; summer P < .01; AOR = 1.4, 95% CI: 1.26-1.55; P < .01) were associated with increased odds of being a veteran. Triage levels above 2 were positively associated with veteran status in the autumn model (AOR = 1.14, 95% CI: 1.07-1.22; P < .01). Patients hospitalized after ED visits were associated with reduced odds of veteran status (P < .01). Those who spent a long time in the ED were more likely to be veterans than those who spent a shorter time in the ED (P < .01). Veterans were less likely to visit the ED regardless of the time frame of the study period (P < .01), except during the COVID-19 outbreak in the autumn (2019-2020).ConclusionsThe distinctions in ED visits highlighted the individuality of veterans’ medical needs. Our findings suggest that the veteran medical system can add to the focus on improving senior-friendly care, fall prevention, quality of life of institutionalized veterans, access for homeless veterans, and care for ambulatory care–sensitive conditions.
      PubDate: Wed, 31 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad198
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Association of Traumatic Brain Injury and Glioblastoma Multiforme: A Case
           Series

    • Free pre-print version: Loading...

      Pages: e391 - e395
      Abstract: ABSTRACTGlioblastoma multiforme (GBM) is an aggressive variant of central nervous system gliomas that carries a dismal prognosis. Although GBM is the most frequently occurring and malignant type of glioma accounting for more than 60% of all brain tumors in adults, its overall incidence is rare, occurring at a rate of 3.21 per 100,000 persons. Little is known about the etiology of GBM, but one proposed theory is that GBM pathogenesis may be linked to a chronic inflammatory course initiated by traumatic injury to the brain. Limited case reports have suggested an association between GBMs and traumatic brain injury (TBI), but larger case–control and epidemiologic studies have been inconclusive. We present three service members (two active duty and one retired) who developed GBM near the original site of prior head trauma. Each service member’s military occupation was in the special operations community and shared a common theme of TBI following head trauma/injury. The current research on the association between TBI and GBM is limited and conflicting, predominantly due to the low incidence of the disease in the general population. Evidence has indicated that TBI should be considered a chronic disease with long-term health impacts, including long-term disability, dementia, epilepsy, mental health conditions, and cardiovascular diseases. With the addition of our patients, as well as a recently published study proposing a molecular association between trauma and GBM, further research is needed to better understand the potential relationship.
      PubDate: Wed, 24 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad162
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • National Guard Deployment in Support of COVID-19: Psychological and
           Behavioral Health

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      Pages: e127 - e135
      Abstract: ABSTRACTIntroductionThe National Guard (NG) served as a critical component of the USA’s response to the Coronavirus Disease 2019 (COVID-19) pandemic, while concurrently managing their personal responses to the pandemic. Determining whether the activation of NG service members in response to the COVID-19 pandemic was associated with a greater psychological strain can identify NG’s needs for mental health support.Materials and MethodsWe surveyed 3993 NG unit (NGU) service members (75% Army NG, 79% enlisted, 52% 30-49 years old, and 81% males) during the COVID-19 pandemic, with surveys administered between August and November 2020. Almost half (46%) of NGU service members reported being activated in response to COVID-19 (mean activation length = 18.6 weeks). Activated service members completed the survey approximately 2 to 3 months post-activation. Surveys assessed demographics, service-related characteristics, unit cohesion and positive leadership skills (leadership), and COVID-19 activation, and outcomes including probable post-traumatic stress disorder (PTSD), clinically significant anxiety and depression, and anger. Descriptive and logistic regression analyses were conducted. The study was approved by the Institutional Review Board of the Uniformed Services University of the Health Sciences in Bethesda, MD.ResultsIn all, 9.7% met the criteria for probable PTSD, 7.6% reported clinically significant anxiety and depression, and 13.2% reported feeling angry/anger outbursts. Multivariate logistic regression analyses, adjusting for demographic and service-related characteristics, indicated that COVID-19 activation was not associated with a greater risk of PTSD, anxiety and depression, or anger. Regardless of activation status, NGU service members with low levels of unit cohesion and leadership were more likely to report PTSD and anger, and low levels of unit cohesion were associated with clinically significant anxiety and depression.ConclusionsCOVID-19 activation did not increase the risk of mental health difficulties among NGU service members. However, low levels of unit cohesion were associated with the risk of PTSD, anxiety and depression, and anger, and low levels of leadership were associated with the risk of PTSD and anger. The results suggest a resilient psychological response to COVID-19 activation and the potential for strengthening all NG service members through enhancing unit cohesion and leadership support. Future research on specific activation exposures, including the type of work tasks in which service members are engaged, particularly those associated with high-stress work conditions, is needed to help better understand their activation experience and how it may influence post-activation responses.
      PubDate: Sat, 20 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad177
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Myotonometry is Capable of Reliably Obtaining Trunk and Thigh Muscle
           Stiffness Measures in Military Cadets During Standing and Squatting
           Postures

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      Pages: e213 - e219
      Abstract: ABSTRACTIntroductionLow back and lower extremity injuries are responsible for the highest percentage of musculoskeletal injuries in U.S. Army soldiers. Execution of common soldier tasks as well as army combat fitness test events such as the three-repetition maximum deadlift depends on healthy functioning trunk and lower extremity musculature to minimize the risk of injury. To assist with appropriate return to duty decisions following an injury, reliable and valid tests and measures must be applied by military health care providers. Myotonometry is a noninvasive method to assess muscle stiffness, which has demonstrated significant associations with physical performance and musculoskeletal injury. The aim of this study is to determine the test–retest reliability of myotonometry in lumbar spine and thigh musculature across postures (standing and squatting) that are relevant to common soldier tasks and the maximum deadlift.Materials and MethodsRepeat muscle stiffness measures were collected in 30 Baylor University Army Cadets with 1 week between each measurement. Measures were collected in the vastus lateralis (VL), biceps femoris (BF), lumbar multifidus (LM), and longissimus thoracis (LT) muscles with participants in standing and squatting positions. Intraclass correlation coefficients (ICCs3,2) were estimated, and their 95% CIs were calculated based on a mean rating, mixed-effects model.ResultsThe test–retest reliability (ICC3,2) of the stiffness measures was good to excellent in all muscles across the standing position (ICCs: VL = 0.94 [0.87–0.97], BF = 0.97 [0.93–0.98], LM = 0.96 [0.91–0.98], LT = 0.81 [0.59–0.91]) and was excellent in all muscles across the squatting position (ICCs: VL = 0.95 [0.89–0.98], BF = 0.94 [0.87–0.97], LM = 0.96 [0.92–0.98], LT = 0.93 [0.86–0.97]).ConclusionMyotonometry can reliably acquire stiffness measures in trunk and lower extremity muscles of healthy individuals in standing and squatting postures. These results may expand the research and clinical applications of myotonometry to identify muscular deficits and track intervention effectiveness. Myotonometry should be used in future studies to investigate muscle stiffness in these body positions in populations with musculoskeletal injuries and in research investigating the performance and rehabilitative intervention effectiveness.
      PubDate: Fri, 19 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad179
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Disparate Risk Factors Among Pregnant Veterans Using Veterans
           Administration Health Benefits for Community-Based Obstetrical Care

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      Pages: e49 - e53
      Abstract: ABSTRACTIntroductionVeterans using the Veterans Administration Health Care System (VAHCS) for obstetrical care experience disparate pregnancy-related risks and health outcomes when compared to their pregnant counterparts. This study examined the prevalence of risk factors associated with pregnancy-related comorbidities among U.S. Veterans receiving obstetrical care using VAHCS benefits in Birmingham, Alabama.Materials and MethodsA retrospective chart review was conducted of pregnant Veterans receiving care at a large Veterans Administration facility from 2018 to 2021. Using one-sample t-tests, the data from the study charts were compared to the Alabama overall prevalence of tobacco and alcohol use, pregnancy-related hypertension/preeclampsia, and gestational diabetes and, when the Alabama data were unavailable, the U.S. national average prevalence of overweight, obesity, pre-pregnancy hypertension, posttraumatic stress disorder, depression, and anxiety among patients receiving obstetrical care. The institutional review board at the Birmingham VAHCS approved the study, with an exemption for human subjects research.ResultsThe study sample (N = 210) experienced higher levels of obesity (42.3% vs. 24.3%, P < .001), tobacco (21.9% vs. 10.8%, P < .001) and alcohol (19.5% vs. 5.4%, P < .001) use, pre-pregnancy hypertension (10.5% vs. 2.1%, P < .001), posttraumatic stress disorder (33.8% vs. 3.3%, P < .001), anxiety (66.7% vs. 15.2%, P < .001), and depression (66.7% vs. 15.0, P < .001). Fewer patients in the study sample were classified as overweight (16.7% vs. 25.5%, P < .001), developed pregnancy-related hypertension/preeclampsia (7.6% vs. 14.4%, P < .001), or were diagnosed with gestational diabetes (7.1% vs. 10.2%, P < .001). The results did not vary by race or age.ConclusionThe findings highlight the need for further examination of social factors that may be driving disparities among pregnant Veterans, who may benefit from supplemental services to address modifiable comorbidities. Additionally, the implementation of a centralized database to track pregnancy-related outcomes for Veterans would allow these comorbidities to be more closely monitored and addressed. Heightened awareness of a patient’s Veteran status and associated increased risks can alert providers to screen for depression and anxiety more frequently and to familiarize themselves with additional services the VAHCS may offer to patients. These steps could improve referrals to counseling and/or targeted exercise interventions.
      PubDate: Wed, 17 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad172
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Traumatic Transradial Forearm Amputation Temporized With Extracorporeal
           Membrane Oxygenation: A Brief Report

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      Pages: e27 - e33
      Abstract: ABSTRACTIntroductionExtracorporeal membrane oxygenation (ECMO) is typically used to provide mechanical perfusion and gas exchange to critically ill patients with cardiopulmonary failure. We present a case of a traumatic high transradial amputation in which the amputated limb was placed on ECMO to allow for limb perfusion during bony fixation and preparations and coordination of orthopedic and vascular soft tissue reconstructions.Materials and MethodsThis is a descriptive single case report which underwent managment at a level 1 trauma center. Instutional review board (IRB) approval was obtained.ResultsThis case highlights many important factors of limb salvage. First, complex limb salvage requires a well-organized, pre-planned multi-disciplinary approach to optimize patient outcomes. Second, advancements in trauma resuscitation and reconstructive techniques over the past 20 years have drastically expanded the ability of treating surgeons to preserve limbs that would have otherwise been indicated for amputation. Lastly, which will be the focus of further discussion, ECMO and EP have a role in the limb salvage algorithm to extend current timing limitations for ischemia, allow for multidisciplinary planning, and prevent reperfusion injury with increasing literature to support its use.ConclusionsECMO is an emerging technology that may have clinical utility for traumatic amputations, limb salvage, and free flap cases. In particular, it may extend current limitations of ischemia time and reduce the incidence of ischemia reperfusion injury in proximal amputation, thus expanding the current indications for proximal limb replantation. It is clear that developing a multi-disciplinary limb salvage team with standardized treatment protocols is paramount to optimize patient outcomes and allows limb salvage to be pursued in increasingly complex cases.
      PubDate: Tue, 16 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad148
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • A Review of Electrolyte, Mineral, and Vitamin Changes After Traumatic
           Brain Injury

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      Pages: e101 - e109
      Abstract: ABSTRACTIntroductionDespite the prevalence of traumatic brain injury (TBI) in both civilian and military populations, the management guidelines developed by the Joint Trauma System involve minimal recommendations for electrolyte physiology optimization during the acute phase of TBI recovery. This narrative review aims to assess the current state of the science for electrolyte and mineral derangements found after TBI.Materials and MethodsWe used Google Scholar and PubMed to identify literature on electrolyte derangements caused by TBI and supplements that may mitigate secondary injuries after TBI between 1991 and 2022.ResultsWe screened 94 sources, of which 26 met all inclusion criteria. Most were retrospective studies (n = 9), followed by clinical trials (n = 7), observational studies (n = 7), and case reports (n = 2). Of those, 29% covered the use of some type of supplement to support recovery after TBI, 28% covered electrolyte or mineral derangements after TBI, 16% covered the mechanisms of secondary injury after TBI and how they are related to mineral and electrolyte derangements, 14% covered current management of TBI, and 13% covered the potential toxic effects of the supplements during TBI recovery.ConclusionsKnowledge of mechanisms and subsequent derangements of electrolyte, mineral, and vitamin physiology after TBI remains incomplete. Sodium and potassium tended to be the most well-studied derangements after TBI. Overall, data involving human subjects were limited and mostly involved observational studies. The data on vitamin and mineral effects were limited, and targeted research is needed before further recommendations can be made. Data on electrolyte derangements were stronger, but interventional studies are needed to assess causation.
      PubDate: Tue, 16 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad112
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Practices and Policies That Support Breastfeeding Among Military Women: A
           Systematic Review

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      Pages: e119 - e126
      Abstract: ABSTRACTBackgroundPrevious and limited assessments of breastfeeding in women serving on active duty in the U.S. military demonstrate varied and conflicting data regarding breastfeeding outcomes. Disparities exist within the military where enlisted service members have consistently lower rates of breastfeeding duration compared to officers. Yet, little is known about successful care practices and military policies that promote breastfeeding in military women. The aim of this systematic review is to examine care practices and military policies associated with increased breastfeeding initiation and duration among women serving in the U.S. military.Materials and MethodsWe searched Cochrane Database, Cumulative Index of Nursing and Allied Health Literature, PubMed, and PsycInfo for studies published from 2000 to 2022 that included U.S. military personnel and that focused on care practices and military policies that support breastfeeding. Our search terms included (breastfeeding OR breastfeed AND military) and (lactation OR lactating AND military). We included randomized controlled trials, quasi-experimental, cohort, cross-sectional, and other observational designs. We evaluated potential bias in studies using the Evidence Project Risk of Bias Tool and synthesized the overall evidence using the Johns Hopkins Nursing Evidence-Based Practice Synthesis and Recommendations Tool.ResultsWe included 14 studies that were independently reviewed by two authors. Breastfeeding initiation rates among military women were between 66% and 98%, and breastfeeding duration rates at 6 months ranged from 13% to 62%. In these studies, researchers examined various inpatient care practices (skin-to-skin care, timing of circumcision, and infant baths) (n = 3), care delivered by different types of providers (n = 3), group versus individual prenatal care (n = 2), breastfeeding education (n = 2), length of maternity leave (n = 2), and workplace support (n = 2). Skin-to-skin contact following delivery was positively associated with breastfeeding outcomes. There is insufficient evidence to determine if care by different types of medical providers, different types of prenatal care and education, timing of circumcision or baths, length of maternity leave, and workplace support influence breastfeeding outcomes.ConclusionCertain perinatal practices designed to encourage early skin-to-skin contact appear to improve breastfeeding initiation and duration among women serving in the U.S. military. However, there is an overall lack of quality evidence supporting effective practices and policies associated with increased breastfeeding initiation and duration in this population. Given the recent movement toward policy changes that support pregnant and postpartum service members across services, more research is needed to determine the impact of these and other practices and policies on breastfeeding rates, specifically among enlisted service members who have demonstrated lower breastfeeding rates than officers.
      PubDate: Thu, 11 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad128
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Seasonality and Climatic Factors Associated With Human
           Rhinovirus/Enterovirus Nasopharyngeal Sample Positivity on Oahu,
           Hawai’i, 2016-2019

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      Pages: e34 - e39
      Abstract: ABSTRACTIntroductionGlobally, human rhinoviruses/enteroviruses (HRVs/ENTs), indistinguishable on many widely available molecular platforms, are among the leading causes of the common cold. Geographic and climatic factors impact the peak activity of these viruses. In temperate climates, the peak activity of HRV occurs during autumn and spring whereas that of ENT occurs during autumn and summer. Both viruses are thought to peak during the rainy season in tropical climates like Hawai’i; however, data remain limited. We describe HRV/ENT seasonality and evaluate the climatic factors associated with peak activity among respiratory viral samples processed on Oahu, Hawai’i.Materials and MethodsWe conducted a retrospective analysis of all respiratory specimens submitted to Tripler Army Medical Center for multiplex polymerase chain reaction testing between May 2016 and May 2019. Among HRV/ENT-positive samples, we recorded the month and year of positivity. Summative monthly positive detection was calculated with peak months above the mean. Associations between temperature, precipitation levels, relative humidity, and wind speed by week and the number of positive samples for HRV/ENT were evaluated using Poisson regression. This analysis was conducted via IRB exempt protocol number 19R18.ResultsDuring our study period, there were 7,143 nasopharyngeal respiratory samples sent for multiplex polymerase chain reaction testing, with 1,572 positive for HRV/ENT (22%). Nineteen percent of respiratory samples positive for HRV/ENT were additionally positive for one or more respiratory pathogens. The majority of HRV/ENT-positive samples arose from children < 5 years of age (n = 959, 61%). Peak months were February, March, May, August, November, and December. After controlling for lagged count and year, average wind speed was the only climatic factor significantly associated with HRV/ENT sample positivity.ConclusionsThe peak monthly activity of HRV/ENT was similar to temperate climates with the exception of peak activity in February. Unlike other tropical climates, lower wind speed was associated with increased weekly HRV/ENT positivity and should be further explored as a transmission factor. Our study contributes to understanding the annual variability of HRV/ENT activity in tropical environments, which can inform clinician expectations regarding respiratory viral symptomatology in this region.
      PubDate: Mon, 08 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad125
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Arming Hospital Ships of the Future: Hybrid Wars Require a Major Change

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      Pages: e110 - e118
      Abstract: ABSTRACTIntroductionIt is time to provide heavier defense systems to U.S. Navy hospital ships. They serve vital functions in both the military and emergency management spaces. They provide medical support for combat operations and can also convey the empathy and generosity of the American people when used in humanitarian assistance and disaster relief response. Hospital ships are often key to success in scenarios that require the international deployment of resources and medical expertise. Hospital ships serve a dual purpose and hence are subject to regulations that do not address all wartime mission requirements and necessary defensive capabilities. The current U.S. Navy’s interpretation of the Geneva Conventions regarding the visibility, lack of defensive capabilities, and inability to use encrypted communications needlessly endangers medical platforms and personnel in the modern environment.MethodsThe authors (including senior author F.M.B.—a recognized (International Health Law expert) reviewed relevant literature and have evaluated the policies of belligerent parties in past and current conflicts. These increasingly appear to target civilian infrastructure including medical facilities and may increase the risk to hospital ships. This demonstrable current hybrid warfare appears to include purposeful attacks on health care facilities and as such hospital ships should have additional defensive measures.ResultsHybrid warfare and its focus on civilian infrastructure and health care targets are highly visible in the acts of both state and non-state actors and may encourage others to purposefully target health care facilities and personnel. Evidence of this is seen in the current Russian invasion of Ukraine, where since the invasion a year ago 1,218 Ukrainian health facilities have been damaged, including 540 damaged hospitals, 173 of which were totally destroyed and turned into “piles of stones.”ConclusionsIn today’s conflicted global environment, the clear identification of hospital ships leaving them relatively undefended and denying encrypted communication is the folly of a bygone era. Hospital ships may be targeted because they are brightly lit soft targets that can deliver a large payoff by their destruction. It is time to adapt to the global reality and move on from the tradition of painting hospital ships white, adorning them with red crosses, keeping them unarmed, maintaining open communications, and illuminating them at night. The increasing threats from hybrid warfare and unprincipled adversaries to medical platforms and providers of health care demonstrate that hospital ships must be capable of self-defense. The U.S. Navy is designing new platforms for medical missions and the debate, no matter how uncomfortable, must now occur among major decision-makers to make them more tactical and defensible.
      PubDate: Thu, 27 Apr 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad118
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Pressure Injury Mitigation in Prolonged Care: A Randomized Noninferiority
           and Superiority Trial

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      Pages: e205 - e212
      Abstract: ABSTRACTIntroductionCombat casualties are at increased risk for pressure injuries (PIs) during prolonged casualty care. There is limited research on operational PI risk mitigation strategies. The purpose of this study was to (1) compare a prototype mattress (AirSupport) designed for operational conditions versus the foldable Talon litter and Warrior Evacuation Litter Pad (WELP) on PI risk factors and (2) determine whether the Talon + AirSupport pad was noninferior and superior to the Talon + WELP on skin interface pressure.Materials and MethodsHealthy adults (N = 85; 20 men and 65 women), aged 18 to 55 years, were stratified based on body fat percentage and randomized into three groups: Talon (n = 15), Talon + AirSupport (n = 35), and Talon + WELP (n = 35). The participants were asked to lie in a supine position for 1 hour. The outcomes included skin interface pressure (body surface areas: Sacrum, buttocks, occiput, and heels), sacral and buttock skin temperature and moisture, and discomfort and pressure. The study was approved by the University of Washington Institutional Review Board.ResultsAim 1: The Talon had significantly higher peak skin interface pressure versus the AirSupport and WELP on the sacrum, buttocks, occiput, and heels. Skin temperature increase over the 1-hour loaded period was significantly lower on Talon versus AirSupport or WELP, reflecting a lower temperature–induced ischemic load. There was no significant difference in skin moisture changes or discomfort between the surfaces. Aim 2: The upper confidence limits for the difference in skin interface pressure (all body surface areas) for AirSupport versus WELP were below 25 mm Hg, establishing noninferiority of the AirSupport to the WELP. AirSupport was also superior to WELP for the peak interface pressure on the sacrum, occiput, and heels but not on the buttocks. Skin temperature changes (sacrum or buttocks) were not significantly different between the AirSupport and WELP.ConclusionsThe Talon litter presents a PI risk because of increased skin interface pressure, and hence, immediate action is warranted. The decreased PI risk associated with the lower skin interface pressures on the AirSupport and WELP was offset by the higher skin temperature, which may add the equivalent of 20 to 30 mm Hg pressure to the ischemic burden. Thus, any pressure redistribution intervention must be evaluated with a consideration for skin interface pressure, temperature, and moisture. Data from this study were applied to a predictive model for skin damage. Under operational conditions where resources and the environment may limit patient repositioning, it would be expected that casualties would suffer skin damage within 2 to 5 hours, with the occiput as the highest risk area. The severity of predicted skin damage is lowest on the AirSupport, which is consistent with the noninferiority and superiority of the AirSupport mattress compared to the WELP and Talon. Operational utility: The AirSupport and WELP, which were both superior to the Talon, are operationally feasible solutions to mitigate PI risk. The smaller size of the Talon (2.7 kgs compressible) versus the WELP (5 kgs noncompressible) may make them appropriate for different levels of the operational setting.
      PubDate: Sat, 22 Apr 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad121
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Effect of Fatigue on Movement Patterns During a Loaded Ruck March

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      Pages: e15 - e20
      Abstract: ABSTRACTIntroductionLoaded ruck marching is a common training and operational task for many members of the military. It is known to cause fatigue, affect soldier readiness, and can lead to traumatic and overuse injuries. Quantifying the gait changes that occur over the course of a loaded ruck march may provide a better understanding of injury mechanisms and potentially allow for development of individualized injury-prevention training programs. This study examined the change in soldiers’ gait patterns over the course of a loaded ruck march in order to examine the correlation between fatigue and kinematic parameters. Fatigue is a subjective term that may encompass factors such as energy expenditure, muscle exhaustion, and cognitive engagement. Since it can be difficult to quantify, the current study makes the broad assumption that fatigue increases in some (potentially nonlinear) fashion during a loaded ruck march.MethodThree platoons of soldiers participated in a field training exercise with inertial measurement sensors placed on their chests and ankles to record gait parameters throughout a 7-mile ruck march. The effects of fatigue on stride length, stride width, ankle yaw, and torso lean (anterior-posterior [AP] and side-to-side [SS]) were compared using one-way repeated measure analyses of variance.ResultsIn comparing the first and last quarters of the ruck march, stride length decreased, stride width increased, stride width variability increased, AP torso lean variability increased, and SS torso lean variability increased.ConclusionAlthough they do not describe a direct relationship to injury, these results can inform enhanced approaches to quantify and predict soldier fatigue and more reliably prevent future injury.
      PubDate: Thu, 20 Apr 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad086
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Striking up a Conversation: Exploring Advising in Graduate Programs in
           Health Professions Education

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      Pages: e21 - e26
      Abstract: ABSTRACTIntroductionAdvising is happening across the medical education continuum, within non-medical graduate education programs, and is central to the advancement of said learners. This suggests that advising should play a role in graduate health progressions education (HPE) programs.Materials and MethodsTo explore advising curricula among HPE programs, we conducted a website review of all published HPE programs on the Foundation for Advancement of International Medical Education and Research’s website.ResultsWe recognized the lack of information published on advisory roles in graduate HPE programs. This prompted a literature review, which revealed a similar gap.ConclusionsAdvising serves to benefit a student, advisor, and program thus carrying importance and need for discussion. This article is intended to kick-start a scholarly discussion about advising within graduate HPE programs.
      PubDate: Wed, 19 Apr 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad116
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Efficacy of Conservative Interventions for Musculoskeletal Conditions on
           Pain and Disability in Active Serving Military Personnel—A Systematic
           Review

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      Pages: e66 - e75
      Abstract: ABSTRACTIntroductionMusculoskeletal (MSK) injuries and associated pain disorders are one of the leading causes for soldiers not being medically fit for deployment, impacting force capability and readiness. Musculoskeletal pain continues to be a leading cause of disability within military services and is associated with a substantial financial burden. A better understanding of the effectiveness of MSK pain management strategies is required. This review was designed to determine the efficacy of nonsurgical interventions, such as physiotherapy, exercise, pharmacology, and multidisciplinary programs, to manage MSK conditions in active serving military populations.Materials and MethodsMEDLINE, Embase, CINAHL, and SPORTDiscus were searched to identify relevant randomized clinical trials. Recommended methods were used for article identification, selection, and data extraction. The Cochrane Risk of Bias tool and the Grade of Recommendation, Assessment, Development, and Evaluation were used to appraise the studies. Where possible, meta-analyses were performed. The review was conducted according to the PRISMA guidelines.ResultsNineteen articles (1,408 participants) met the eligibility criteria. Low back pain (LBP) was the most frequently investigated condition, followed by knee pain, neck pain, and shoulder pain. Early physiotherapy, exercise and adjunct chiropractic manipulation (for LBP), and multidisciplinary pain programs (physiotherapy, occupational therapy, and psychology) (for chronic MSK pain) improved pain (standardized mean difference ranged from −0.39 to −1.34; low strength of evidence). Participation in multidisciplinary pain programs, adjunct chiropractic manipulation, and early physiotherapy improved disability (for LBP) (standardized mean difference ranged from −0.45 to −0.86; low to very low strength of evidence). No studies evaluated pain medication. Dietary supplements (glucosamine, chondroitin sulfate, and manganese ascorbate), electrotherapy, isolated lumbar muscle exercises, home cervical traction, or training in virtual reality showed no benefit. The studies had a high risk of bias, were typically underpowered, and demonstrated high clinical heterogeneity.ConclusionsCurrently available randomized clinical trials do not provide sufficient evidence to guide military organizations or health care professionals in making appropriate treatment decisions to manage MSK pain in active serving military personnel. Future research is essential to enable evidence-based recommendations for the effective management of MSK pain conditions in this unique population.
      PubDate: Tue, 31 Jan 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usac409
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Scoping Review of Postvention for Mental Health Providers Following
           Patient Suicide

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      Pages: e90 - e100
      Abstract: ABSTRACTIntroductionAs suicides among military personnel continue to climb, we sought to determine best practices for supporting military mental health clinicians following patient suicide loss (i.e., postvention).Materials and MethodsWe conducted a scoping review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Our initial search of academic databases generated 2,374 studies, of which 122 were included in our final review. We categorized postvention recommendations based on the socioecological model (i.e., recommendations at the individual provider, supervisory/managerial, organizational, and discipline levels) and analyzed them using a narrative synthesizing approach.ResultsExtracted recommendations (N = 358) comprised those at the provider (n = 94), supervisory/managerial (n = 90), organization (n = 105), and discipline (n = 69) levels.ConclusionsThe literature converges on the need for formal postvention protocols that prioritize (1) training and education and (2) emotional and instrumental support for the clinician. Based on the scoped literature, we propose a simple postvention model for military mental health clinicians and recommend a controlled trial testing of its effectiveness.
      PubDate: Fri, 20 Jan 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usac433
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • A Review of Verbal and Written Patient Handoffs Applicable to the U.S.
           Military’s Expeditionary Care System

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      Pages: e76 - e81
      Abstract: ABSTRACTIntroductionLong considered a danger point in patient care, handoffs and patient care transitions contribute to medical errors and adverse events. Without standardization of patient handoffs, communication breakdowns arise and critical patient information is lost. Minimal training and informal learning have led to a lack of understanding the process involved in this vital aspect of patient care. In 2017, the U.S. Army commissioned a report to study the process of patient handoffs and identify training gaps. Our report summarizes that process and makes recommendations for implementation.Materials and MethodsScoping literature review of 139 articles published between 1999 and 2017 using PubMed, CINAHL, Cochrane, and Medline databases. Verbal tools for handoffs were evaluated against 12 criteria including patient ID, history, current situation, contingency planning, ability to ask questions, ownership, and read back. Written tools were evaluated against a matrix of 126 casualty/treatment attributes.ResultsAmong verbal communication protocols, the highest scoring handoff mnemonics were HAND ME AN ISOBAR, IPASS the BATON, and I-SBARQ. Among written handoff tools, the highest scoring documents were the Special Operations Forces (SOF) Mechanism, Injuries, Signs, and Treatment (MIST) Casualty Treatment Card and the Department of Defense (DD) Form 1380 Tactical Combat Casualty Care (TCCC) Card. Four critical process elements for patient handoffs and transfers were identified: (1) interactive communications, (2) limited interruptions, (3) a process for verification, and (4) an opportunity to review any relevant historical data.ConclusionsThe findings in this review highlight the need for standardized tools and techniques for patient handoffs in the U.S. Military’s expeditionary care system. Future research is needed to trial verbal and nonverbal handoffs under field conditions to gather observational data to assess effectiveness. The results of our gap analyses may provide researchers insight for determining which handoffs to study. If standardized handoffs are utilized, training programs should incorporate the four critical elements into their curricula.
      PubDate: Sat, 07 Jan 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usac418
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Letter From the Executive Director Dr. John Cho

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      Pages: 1 - 4
      PubDate: Fri, 24 Nov 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad440
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Wartime Endovascular Therapy: A Historical View

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      Pages: 5 - 7
      Abstract: AbstractEndovascular techniques for managing vascular trauma have become increasingly more common. However, these techniques have had limited application in recent conflicts. Using lessons from 20th century conflicts, the present study aims to highlight how advances made in the past may provide a roadmap to improving surgical capabilities in the future.
      PubDate: Fri, 28 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad293
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • “I Hope You Know I Still Think About You”: Medical Student 55-Word
           Story Reflections of Initial Clerkship Experiences

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      Pages: 8 - 9
      PubDate: Wed, 15 Nov 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad439
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Health Facility Planning: A Key Global Health Engagement Capability

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      Pages: 10 - 12
      Abstract: ABSTRACTHealth facility planning is a key global health engagement capability that assesses the health needs of a population and identifies the combination of services, equipment, facilities, and infrastructure necessary to support them. Collaboration with local health care and building professionals is essential to achieving local buy-in and sustainable solutions.
      PubDate: Wed, 24 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad188
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Optimizing Care for Military Women: The Value of the Dual-Certified Family
           and Women’s Health Nurse Practitioner

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      Pages: 13 - 16
      Abstract: ABSTRACTThe number of women in the military has more than tripled over the past 50 years, increasing from 5% in the 1970s to 17% in 2023, making them essential for global health engagement and military operations. Provider competence and confidence are barriers to the consistent availability of preventive, gynecologic, and reproductive services for women across service locations and duty platforms. The Defense Health Board recommends standardizing services and improving the availability and scope of services for women at every point of care. In direct conflict with these recommendations, however, is a congressional call for a drawdown of medical forces, which creates a need for operationally trained clinicians with a broad skill set including comprehensive care for women. Advanced practice registered nurses, such as family and women’s health nurse practitioners, are key assets to fill this gap on military medical health-care teams. At the request of the U.S. Air Force, the Graduate School of Nursing at the Uniformed Services University began offering a Women’s Health Nurse Practitioner (WHNP) program in 2014. The WHNP curriculum was layered onto the existing Family Nurse Practitioner program so that Family Nurse Practitioner students receive enhanced education in women’s health and WHNP students are prepared to meet the holistic, primary care needs of patients across the lifespan in addition to caring for women with obstetric and urogenital health concerns. This article highlights the value of dual-certified Family Nurse Practitioners and WHNPs in the military health-care system. These Uniformed Services University alumni are uniquely prepared to provide comprehensive primary and specialty care for female warfighters across the lifecycle from stable, well-resourced duty stations to austere, operational settings or deployment platforms.
      PubDate: Wed, 17 May 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad140
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Prehospital Lessons From the War in Ukraine: Damage Control Resuscitation
           and Surgery Experiences From Point of Injury to Role 2

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      Pages: 17 - 29
      Abstract: ABSTRACTThe ongoing war in Ukraine presents unique challenges to prehospital medical care for wounded combatants and civilians. The purpose of this article is to identify, describe, and address gaps in prehospital care, casualty evacuation, and medical evacuation throughout Ukraine to share lessons for other providers. Observations and experiences of medical personnel were collected and analyzed, focusing on pain management, antibiotic use, patient assessment, mass casualty triage, blood loss, hypothermia, transport immobilization, and clinical governance. Gaps identified include limited access to pain management, lack of antibiotic guidance, inadequate patient assessment and triage, access to damage control resuscitation and blood, challenged transport immobilization practices, and challenges with clinical governance for both local and foreign providers. Improved prehospital care and casualty and medical evacuation in Ukraine are required, through increased use of empiric pain management, focused antibiotic guidance, enhanced patient assessment and triage in the form of training, access to prehospital blood, and better transport immobilization practices. A robust and active lessons learned program, trauma data capture, and quality improvement process is needed to reduce preventable morbidity and mortality in the war zone. The recommendations presented in this article serve as a starting point for improvements in prehospital care in Ukraine with potential to change prehospital training for the NATO alliance and other organizations operating in similar areas of conflict.Graphical Abstract
      PubDate: Wed, 30 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad253
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Cigarette Smoking Among Veterans at High Risk for Suicide: Challenges
           and Opportunities for Intervention

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      Pages: 30 - 32
      Abstract: ABSTRACTPreventing suicide remains a top clinical priority of the Department of Veterans Affairs (VA). In 2019, U.S. military veterans experienced a suicide rate of 52.3% higher than non-Veteran U.S. adults. Cigarette smoking has been found to be independently associated with an elevated risk of suicidal ideation, attempts, plans, and deaths among veterans and non-veterans. However, tobacco use is frequently overlooked in suicide risk assessment and mitigation and is not yet a target for intervention in VA suicide prevention protocols. In this commentary, we recommend that cigarette smoking be considered in suicide risk assessment protocols and that tobacco cessation interventions be considered as a potential beneficial treatment intervention to reduce the risk of suicide. Given the public health threat of suicide among veterans, it is essential to elucidate promising areas of intervention for those at high risk of suicide. Cigarette smoking is a modifiable target, associated with suicide risk, for which there are evidence-based interventions. Therefore, tobacco use disorder identification and treatment should be considered for inclusion in VA suicide risk protocols.
      PubDate: Mon, 24 Jul 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad269
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Surgical Casualty Care in Contested Distributed Maritime Operations:
           Lessons Learned From the Falklands War

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      Pages: 33 - 37
      Abstract: ABSTRACTThe Falklands Campaign was fought a significant distance from the home base of the British Fleet. The planning and delivery of medical care during this campaign can provide significant lessons for strategic medical planning in other far spread geographic locations, including the Indo-Pacific region. Consideration of doctrine, including Role 1-4 facilities and the golden hour, may need to be reconsidered in light of changing scenarios. New concepts such as the “90-in-90” and “3-in-3” are also discussed as a framework for future planning in the U.S. Indo-Pacific Command area of responsibility.
      PubDate: Fri, 04 Aug 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad304
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Case Report: Vision-Threatening Fungal Keratitis in a Service Member
           Stationed at Guantanamo Bay

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      Pages: 379 - 383
      Abstract: ABSTRACTFungal keratitis is a major cause of corneal blindness worldwide. Compared to other types of infectious keratitis, fungal keratitis has a relatively poor prognosis because of various factors such as delayed patient presentation and diagnosis. Although associated in earlier studies with poverty and low socioeconomic status, military personnel stationed in tropical and subtropical climates, in low-resource settings, are at risk. Here, we report a case of a 20-year-old active duty contact lens–wearing military service member stationed at Guantanamo Bay who developed a severe vision-threatening fungal keratitis in her left eye. Enhancing health and safety precautions in at-risk settings, maintaining vigilance, and leveraging new imaging modalities will be important to ensure early recognition and treatment.
      PubDate: Sat, 17 Jun 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad222
      Issue No: Vol. 189, No. 1-2 (2023)
       
  • Foot Strike Run Retraining for Patients With Patellofemoral Chondral
           Defects: A Case Series

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      Pages: 384 - 390
      Abstract: ABSTRACTMilitary service members (SMs) demonstrate high rates of patellofemoral chondral defects (PFCDs) that are difficult to diagnosis and, if untreated, result in a cascade of events eventually leading to osteoarthritis. Running is an essential occupational task for SMs; however, there is little evidence regarding techniques to maintain running ability in individuals with cartilage defects. The purpose of this case series was to assess the clinical application of foot strike run retraining in patients with PFCDs. This case series included two active duty U.S. Marine Corps SMs who presented to outpatient physical therapy with PFCD, diagnosed via MRI. Both patients attended eight foot strike run retraining sessions. Running mechanics and patient-reported outcomes were recorded pre-training, post-training, and at a 1-month follow-up visit. Both patients successfully converted their strike pattern from a rearfoot to a non-rearfoot strike pattern with training and retained this strategy at 1-month follow-up. Post-intervention, both patients demonstrated increased running tolerance, and improvements in Numeric Pain Rating Scale and Lower Extremity Functional Scale scores. Biomechanical analysis showed that both patients demonstrated a 63% to 70% reduction in average and peak vertical ground reaction force loading rates post-treatment. Modification of foot strike pattern from rear to non-rearfoot strike during running for individuals with PFCD can reduce the magnitude of impact loading, which potentially limits disease progression. These findings suggest that foot strike run retraining may be a feasible strategy to reduce pain and improve function in SMs with PFCD who are required to run for occupational responsibilities.
      PubDate: Tue, 31 Oct 2023 00:00:00 GMT
      DOI: 10.1093/milmed/usad413
      Issue No: Vol. 189, No. 1-2 (2023)
       
 
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School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
Email: journaltocs@hw.ac.uk
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