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Introduction: Blood is critical to expeditionary casualty care. Currently, low-titer O whole blood is the preferred product, because it serves as a universal blood product, but demand is higher than supply. Type-specific whole blood (TSWB) has the potential to address this shortfall and provide an identical clinical benefit to specific patient populations. This study estimates the benefit of TSWB to the expeditionary blood supply., Materials and Methods: Potential TSWB demand was estimated based on the product demand during the US involvement in Afghanistan (2001-2021). Potential production yield increases were based on blood production at the Keesler AFB Blood Distribution Center (FY2016-FY2023)., Results: Including type A TSWB is estimated to increase whole blood production 11.1% monthly. Type-specific whole blood, if available, is expected to be utilized in 20.7% to 35.6% of U.S. Military casualties requiring blood transfusion. Seasonality was found in production (P < .001)., Conclusions: Incorporating TSWB is anticipated to meaningfully expand whole blood availability to meet current shortfalls and future expeditionary casualty needs., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

In expeditionary environments, the consistent availability of blood for casualty care is imperative yet challenging. Responding to evidence and the specific needs of its expeditionary context, the US Central Command (USCENTCOM) prioritized supplying stored low titer O whole blood (LTOWB) to its units from March, 2023 onward. A strategy was devised to set minimal LTOWB on-hand supply benchmarks, determined by the number of operating beds and point of injury teams. This transition led to a 54% reduction in orders for packed red blood cells. As a countermove, the Armed Services Blood Program (ASBP) enhanced LTOWB production at a conversion rate 2:1 from packed red blood cell to LTOWB. Consequently, there was a decline in expired blood products, and fulfillment rates for blood requests are projected to reach 100% consistently. This paper delves into the intricacies of the expeditionary blood supply, the rationale behind the LTOWB transition, the devised allocation strategy, and the subsequent impacts of this change., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The medical entry standards for the United States Central Command (USCENTCOM) restrict individuals with various medical conditions from entering the deployed environment. The impact of this program is unknown., Materials and Methods: The total number of army personnel deployed to USCENTCOM, the number of individuals with a medical entry waiver adjudicated by United States Army Central (USARCENT), and the evacuation number for each population were compared for calendar year 2023 (CY2023)., Results: A total estimated population of 20,519 U.S. Army personnel were deployed to USCENTCOM. A population of 1,918 received a medical entry waiver due to a disqualifying medical condition. The evacuation rate for the general population was 2.4% compared to the 1.4% evacuation rate of the population with a medical entry waiver (P = .0027)., Conclusion: The medical entry standards, as written and adjudicated in 2023, resulted in a relatively reduced evacuation rate for individuals with otherwise prohibited medical conditions compared to the general deployed population., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Organizational proficiency increases with experience, which is known as a learning curve. A theoretical peacetime effect occurs when knowledge and skills degrade during peacetime. In this study, the intertheater evacuation system was examined for evidence of a military learning curve and peacetime effect., Materials and Methods: Data on medical evacuations from U.S. Central Command occurring between January 1, 2003, and December 31, 2022, were acquired from the TRANSCOM Regulating and Command & Control Evacuation System. Priority mission evacuation time corresponding to peak periods of activity in Iraq and Afghanistan and minimal activity in Afghanistan was analyzed. Any reduction or increase in the delivery time of casualties would be considered a change in proficiency., Results: There was a marginal monthly decline of 0.019 days (27.4 min) to perform a priority evacuation from Iraq (95% confidence interval [CI], 0.009 to 0.028 days, P < .001) and a decline of 0.010 days (14.4 min) from Afghanistan (95% CI, 0.003 to 0.016 days, P = .004) over 40 months from peak monthly average times. There was a monthly marginal increase in priority evacuation average time from Afghanistan of 0.008 days (11.5 min) (95% CI, 0.005 to 0.011, P < .001) between January 2013 and December 2020. The number of monthly evacuations estimated to maintain or improve monthly average evacuation time is approximately 50., Conclusions: An intertheater aeromedical evacuation system increased in proficiency during periods of conflict and declined during relative peacetime. There is evidence of a peacetime effect on intertheater aeromedical evacuation., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Behavioral 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 Methods: Data 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., Results: The 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%., Conclusions: There 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., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Response 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 Methods: A 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., Results: Genotyping 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., Conclusions: Pharmacogenetic 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., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Medical readiness to deploy is an increasingly important issue within the military. Musculoskeletal back pain is one of the most common medical problems that affects service members. This study demonstrates the associations between risk factors and the prevalence of musculoskeletal back pain among active duty sailors and Marines within the Department of the Navy (DoN)., Materials and Methods: Utilizing the Military Health System Data Repository, we conducted a retrospective cross-sectional review of administrative healthcare claim data for all active duty DoN personnel with at least one medical encounter during fiscal years 2009-2015. For each fiscal year, we identified all claims with an ICD-9 code for back pain and calculated prevalence. We compared those with and without back pain across all variables (age, gender, rank, race, body mass index, tobacco use, occupation, and branch of service) using chi-square analysis. Unadjusted and adjusted log-binomial regressions were used to calculate prevalence ratios and examine associated risk factors for back pain., Results: The number of active duty subjects per fiscal year ranged from 424,460 to 437,053. The prevalence of back pain showed an upward trend, ranging from 9.99% in 2009 to 12.09% in 2015. Personnel aged 35 years and older had the strongest adjusted prevalence ration (APR) for back pain (APR 2.59; 95% CI, 2.53-2.66). There were also strong associations with obese body mass index (APR 1.76; 95% CI, 1.66-1.86), overweight body mass index (APR 1.29; 95% CI, 1.27-1.32), and tobacco use (APR 1.39; 95% CI, 1.36-1.42). Females were more likely to have back pain than males (APR 1.43; 95% CI, 1.40-1.47) and Marines more likely than sailors (APR 1.39; 95% CI, 1.36-1.42). The occupation with the highest prevalence ratio was healthcare (APR 1.34; 95% CI, 1.29-1.40) when compared to the reference group of combat specialists., Conclusions: There was an increasing prevalence of back pain across the DoN from 2009 to 2015. Different occupational categories demonstrate different prevalence of back pain. Surprisingly, combat occupations and aviators were among the groups with the lowest prevalence. Lifestyle factors such as excess body weight and use of tobacco products are clearly associated with increased prevalence. These results could inform military leaders with regard to setting policies that could increase medical readiness., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The U.S. Army medics are often the first responders in the care of sick and injured soldiers on the battlefield, sick call in a Role 2 aid station and garrison clinics. Sick call medics are required to utilize the Algorithm Directed Troop Medical Care (ADTMC) to care for and then render a disposition for these soldiers. The current ADTMC manual is a thick, heavy paper manual. A desktop and smartphone application has been developed that contains the entire ADTMC manual algorithm-based content. Our goal is to enhance the medics' clinical learning and critical thinking skills while improving their evaluation, disposition, and documentation during patient encounters., Materials and Methods: The application was field-tested with the 173rd IBCT (A) while attending a field exercise at Grafenwoehr, Germany. At the unit's Role 2 tent setup, the use of the paper manual to the utilization of the same material via the ADTMC application was compared by observing the medics' workflows directly while they were caring for ill and injured soldiers., Results: Medics, while examining patients, would demonstrate 50% faster exam time using the application compared to medics using only the manual. Moreover, a 50% decrease in document processing time as a result of digitization of the paper documentation process was confirmed. The application ("app") enabled the medics to continue their screening assessments and patient disposition duties on a desktop computer or a smartphone without the need to refer to the paper manual., Conclusion: Medics, by adopting this tool, will become quicker, more efficient, and develop critical thinking skills. In other words, the ability to objectively evaluate patients in order to form a proper disposition of sick and injured soldiers during training, in the field, as well as in garrison. When utilized properly, the ADTMC application ensures that soldiers reporting to sick call are expeditiously routed to the appropriate level of care, and is a vehicle for further training for medics in the care of soldiers., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The U.S. Preventive Services Task Force (USPSTF) modified their screening guidelines for breast cancer in November 2009. Previous studies evaluated the impact of these guideline changes among privately and Medicare insured populations. Women in the military form a unique population exposed to many social, environmental, and occupational hazards that may increase breast cancer incidence. By evaluating mammography screening rates among women in the military before and after the USPSTF guideline changes, this study evaluated the impact of the USPSTF breast cancer guideline change on screening mammography use within the military population and determined whether current guidelines were followed for this high-risk population with universal health care access., Materials and Methods: This study evaluated the impact of the 2009 guideline changes among the population of universally insured military servicewomen, comparing the proportion of active duty women aged 40 to 64 receiving mammograms from fiscal years 2006 to 2015 using an interrupted time series analysis. Stratified analyses evaluated differences by age (aged 40-49, 50-64), race, military branch, and rank. This research is considered exempt by the Uniformed Services University Institutional Review Board., Results: The proportion of insured military servicewomen receiving mammograms increased from October 2005 through September 2009. A significant decrease occurred in the first quarter of 2010 following the publication of the screening guideline update. From this new baseline, the proportion of women screened increased again through September 2015. Comparative analyses showed more pronounced effects both immediately and over time among the women aged 50 to 64 compared to those aged 40 to 49 years and among older enlisted women compared with their officer counterparts. The patterns were near identical in all subgroups; however, no changes in rate were evident among Air Force and black servicewomen aged 50 to 64 and Army and Navy/Marine Corps servicewomen aged 40 to 49 years. No racial disparities in screening or impact were noted., Conclusions: The USPSTF guidelines had differential impacts among some subpopulations. While older women, aged 50 to 64 years, had a greater temporary reduction immediately after the guideline change, younger women aged 40 to 49 years had a longer-term reduction in screening following the guideline changes. No racial disparities in the proportion screened or in the impact of the guideline change were noted in this population with universal health coverage. The lack of Department of Defense standard breast cancer screening guidelines was evident from the different patterns of mammography utilization observed among military branches. To completely understand the impact of the updated screening guidelines, future studies must incorporate research focusing on changes in breast cancer morbidity and mortality as well as updated cost-benefit analyses., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Within the Military Health System (MHS), facilities have struggled to meet minimum recommended volume thresholds for certain procedures. Understanding variations in complication rates and cost can help policymakers tailor policy to target improvement. Our objective was to quantify the variation in bariatric surgery complication rates and costs across a sample of military hospitals., Materials and Methods: We study a retrospective cohort of 38 military surgeons practicing in 21 military treatment facilities from 2007 to 2014 who performed 1,277 bariatric surgeries. Data from the Centralized Credentials and Quality Assurance System, which provides education and training characteristics of physicians, were linked to patient encounter data from the MHS Data Repository. Physicians were included if they performed at least five bariatric surgeries over the study period. Patients were included if they had a diagnosis of obesity (body mass index > 30) and underwent a bariatric weight loss surgery. We calculated and summarized inpatient costs and complication rates across both surgeons and facilities using multivariable mixed-effects linear or logistic models. We used these models to calculate adjusted complication rates and average costs across both providers and hospitals to characterize variation in bariatric outcomes within the MHS. This study was considered exempt by the Uniformed Services University Institutional Review Board., Results: We find evidence of large variations in both complication rates and costs per admission. Overall, we found a 15.5% complication rate across the sample. When comparing averages across facilities, we find large variation in complications (49.4% coefficient of variation [CV]) and procedure costs (25.9% CV). Controlling for patient comorbidities, BMI, and year attenuates much of the variation (12.6% CV complications, 4.4% CV cost), but cannot completely explain differences across facilities. Our model suggests that complications cost 32% more than complication-free surgeries on average suggesting that quality improvement efforts could potentially yield large savings., Conclusions: We find large variations in complication rates even after controlling for patient health. Furthermore, surgical complications are a significant determinant of cost. Policymakers should target efforts to improve surgical quality across facilities and physicians. Surgical quality improvement initiatives could produce savings to the MHS through reduced complications and improved surgical readiness., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: There is a widespread and long-held belief in the submarine community that submariners father more daughters than the general population. The U.S. Sex Ratio at birth (males/females) has remained around 1.05 since the early 2000s. Limited evidence exists that certain environmental exposures including chemicals, heavy metals, radiation and g-forces may influence sex ratio at birth. A reduction in male births in a population has been associated with lower male fertility. A 1970 single site study showed a higher ratio of female offspring in personnel serving aboard U.S. Navy nuclear submarines than the general population. A 2004 study concluded that this was probably not true. However, this study was small, and did not evaluate the difference between children conceived during sea duty versus shore duty. They did note a higher chance of female offspring correlated with a longer time in the community, as well as an increased ratio in sonar technicians. These findings warrant further investigation., Methods: An electronic survey was e-mailed to submariners, after receiving required IRB and Navy approvals. Participants were asked birth year, year they entered submarine service, and how many children they had. For each child they were asked sex, child's birth year, mother's birth year, and whether they were on sea duty or shore duty at the time of conception. Those who were on sea duty at the time of conception were asked what their job was, where they were stationed and what type of submarine they were on. Those who were on shore duty at the time of conception were asked whether they were in contact with submarines on a regular basis, whether they were officer or enlisted, and what region they were stationed in for shore duty., Results: Four thousand eight hundred responses were received with a total of 6,958 children included in the analysis. Respondents had a SR of 0.95 compared to 1.05 U.S. population in 2015 (p < 0.0001). Submariners on sea duty had a SR of 0.88 compared to 1.02 on shore duty (p = 0.007). Those who had regular submarine contact on shore duty had a SR of 0.72 compared to 1.17 in those who did not (p < 0.001). Geographical location during shore duty did show differences that were statistically significant (p = 0.018). Geographical location during sea duty did not show significant differences. No significant differences were seen for paternal age, maternal age, job during sea duty, type of submarine assigned to or time in community., Conclusion: The submariners surveyed reported greater numbers of daughters than the general population, especially when on sea duty or in regular contact with submarines during shore duty. Further study should be done to confirm results and explore possible etiologies of differences in sex ratio., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.)

Introduction: Physically active providers are more likely to prescribe exercise. Unfortunately, many become sedentary during their training. We examined pedometry as an incentive to promote physical activity in a cohort of medical students., Methods: This was a prospective, unblinded clinical trial of pedometry. 107 preclinical medical students volunteered. 50 students received Fitbit pedometers and 57 served as controls. All students ran 1.5- or 2-mile timed runs before pedometer issue, and again 1 year after. Change in run times were the primary outcome measure. Step counts, body composition, and exercise frequency were secondary outcomes., Results: 76% of students with pedometers reported increased motivation to exercise and 57% reported changing daily routines as a result of pedometry. Active pedometry participants declined from 48/50 initially to 22/50 over 13 months. Run times slowed an average of 5.0 seconds for pedometry users vs. 12.3 seconds for the control group. This difference was not statistically significant (p = 0.48)., Conclusions: A subset of future physicians reported increased motivation to exercise after a trial of pedometry. However, adherence over the long term was poor and it seems to have a limited impact on aerobic exercise performance in this population., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Introduction: Finding ways to improve communication and self-reflection skills is an important element of medical education and continuing professional development. This study examines the relationship between self-reflection and educational outcomes., Methods: We correlate performance in a preclinical course that focuses on self-reflection as it relates to contextual elements of patient care (Human Context of Health Care), with educational measures such as overall grade point average, clinical clerkship scores, and Medical College Admission Test (MCAT) scores., Results: Student performance in Human Context of Health Care correlated with MCAT-Verbal scores, MCAT-writing sample scores, clerkship grades, and overall medical school grade point average (R = 0.3; p < 0.001)., Conclusion: Writing and self-reflection skills are often neglected in undergraduate medical curricula. Our findings suggest that these skills are important and correlate with recognized long-term educational outcomes.

Background: Foot friction blisters in military personnel lessen a soldier's mobility, concentration, and critical decision-making skills., Objective: To determine the prevalence of and factors associated with friction blisters during deployment in all military personnel who nonurgently presented to the 28th Combat Support Hospital., Methods: A cross-sectional survey was performed at the 28th Combat Support Hospital. Statistical tests used included descriptive statistics, chi-square tests, and logistic regression for nominal data., Results: The response rate was 97% with 872 surveys completed. Blister prevalence was 33% (95% confidence interval [CI] = 30.0-36.4). Eleven percent of these sought treatment (p < 0.001). Factors increasing the risk of developing blisters include female sex (prevalence ratio [PR] = 1.55, 95% CI = 1.27-1.91), wearing boots not broken in (PR = 1.52, CI = 1.26-1.85), longer than 6 months in theater (PR = 1.33, CI = 1.09-1.63), and history of prior blisters (PR = 2.08, CI = 1.69-2.56)., Conclusions: The prevalence of foot friction blisters was 33% during a 12-month block of Operation Iraqi Freedom I. Of these, 11% required medical care. The group most likely to develop blisters is women, ages 26 to 34, who are unable to break in their boots and have a past history of blisters.