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Introduction: Disease and non-battle injury (DNBI) has historically been the leading casualty type among service members in warfare and a leading health problem confronting military personnel, resulting in significant loss of manpower. Studies show a significant increase in disease burden for DNBI when compared to combat-related injuries. Understanding the causes of and trends in DNBI may help guide efforts to develop preventive measures and help increase medical readiness and resiliency. However, despite its significant disease burden within the military population, DNBI remains less studied than battle injury. In this review, we aimed to evaluate the recently published literature on DNBI and to describe the characteristics of these recently published studies., Materials and Methods: This systematic review is reported in the Prospective Register of Systematic Reviews database. The systematic search for published articles was conducted through July 21, 2022, in Cumulative Index of Nursing and Allied Health, Cochrane Library, Defense Technical Information Center, Embase, and PubMed. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses, the investigators independently screened the reference lists on the Covidence website (covidence.org). An article was excluded if it met any of the following criteria: (1) Published not in English; (2) published before 2010; (3) data used before 2001; (4) case reports, commentaries, and editorial letters; (5) systematic reviews or narrative reviews; (6) used animal models; (7) mechanical or biomechanical studies; (8) outcome was combat injury or non-specified; (9) sample was veterans, DoD civilians, contractors, local nationals, foreign military, and others; (10) sample was U.S. Military academy; (11) sample was non-deployed; (12) bioterrorism study; (13) qualitative study. The full-text review of 2 independent investigators reached 96% overall agreement (166 of 173 articles; κ = 0.89). Disagreements were resolved by a third reviewer. Study characteristics and outcomes were extracted from each article. Risk of bias was assessed using the Newcastle-Ottawa Scale. Meta-analysis of pooled estimates of incidence rates for disease (D), non-battle injury (NBI), and combined DNBI was created using random-effects models., Results: Of the 3,401 articles, 173 were included for the full review and 29 (16.8%) met all inclusion criteria. Of the 29 studies included, 21 (72.4%) were retrospective designs, 5 (17.2%) were prospective designs, and 3 (10.3%) were surveys. Across all studies, the median number of total cases reported was 1,626 (interquartile range: 619.5-10,203). The results of meta-analyses for 8 studies with reported incidence rates (per 1,000 person-years) for D (n = 3), NBI (n = 7), and DNBI (n = 5) showed pooled incidence rates of 22.18 per 1,000 person-years for D, 19.86 per 1,000 person-years for NBI, and 50.97 per 1,000 person-years for combined DNBI. Among 3 studies with incidence rates for D, NBI, and battle injury, the incidence rates were 20.32 per 1,000 person-years for D, 6.88 per 1,000 person-years for NBI, and 6.83 per 1,000 person-years for battle injury., Conclusions: DNBI remains the leading cause of morbidity in conflicts involving the U.S. Military over the last 20 years. More research with stronger designs and consistent measurement is needed to improve medical readiness and maintain force lethality., Level of Evidence: Systematic Review and Meta-Analysis, Level III., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Introduction: The 75th Ranger Regiment is an elite U.S. military special operations unit that conducted over 20 years of sustained combat operations. The Regiment has a history of providing novel and cutting-edge prehospital trauma care, advancing and translating medical initiatives, and documenting and reporting casualty care performance improvement efforts., Materials and Methods: A retrospective case fatality rate (CFR) review, mortality review, and descriptive analysis of fatalities were conducted for battle-injured personnel assigned or attached to the 75th Ranger Regiment from 2001 to 2021 during combat operations primarily in Afghanistan and Iraq. Fatalities were evaluated for population characteristics, cause of death, mechanism of death, injury severity, injury survivability, and death preventability., Results: A total of 813 battle injury casualties, including 62 fatalities, were incurred over 20 years and 1 month of continuous combat operations. The Regiment maintained a zero rate of prehospital preventable combat death. Additionally, no fatalities had a mechanism of death because of isolated extremity hemorrhage, tension pneumothorax, or airway obstruction. When comparing the CFR of the Regiment to the U.S. military population as a whole, the Regiment had a significantly greater reduction in the cumulative CFR as measured by the difference in average annual percentage change., Conclusions: Documentation and analysis of casualties and care, mortality and casualty reviews, and other performance improvement efforts can guide combatant commanders, medical directors, and fighting forces to reduce preventable combat deaths and the CFR. Early hemorrhage control, blood product resuscitation, and other lifesaving interventions should be established and maintained as a standard prehospital practice to mitigate fatalities with potentially survivable injuries., (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.)

Background: Military operations provide a unified action and strategic approach to achieve national goals and objectives. Mortality reviews from military operations can guide injury prevention and casualty care efforts., Methods: A retrospective study was conducted on all U.S. military fatalities from Operation Inherent Resolve (OIR) in Iraq (2014-2021) and Operation Freedom's Sentinel (OFS) in Afghanistan (2015-2021). Data were obtained from autopsy reports and other existing records. Fatalities were evaluated for population characteristics; manner, cause, and location of death; and underlying atherosclerosis. Non-suicide trauma fatalities were also evaluated for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement., Results: Of 213 U.S. military fatalities (median age, 29 years; male, 93.0%; prehospital, 89.2%), 49.8% were from OIR, and 50.2% were from OFS. More OIR fatalities were Reserve and National Guard forces (OIR 22.6%; OFS 5.6%), conventional forces (OIR 82.1%; OFS 65.4%), and support personnel (OIR 61.3%; OFS 33.6%). More OIR fatalities also resulted from disease and non-battle injury (OIR 83.0%; OFS 28.0%). The leading cause of death was injury (OIR 81.1%; OFS 98.1%). Manner of death differed as more homicides (OIR 18.9%; OFS 72.9%) were seen in OFS, and more deaths from natural causes (OIR 18.9%; OFS 1.9%) and suicides (OIR 29.2%; OFS 6.5%) were seen in OIR. The prevalence of underlying atherosclerosis was 14.2% in OIR and 18.7% in OFS. Of 146 non-suicide trauma fatalities, most multiple/blunt force injury deaths (62.2%) occurred in OIR, and most blast injury deaths (77.8%) and gunshot wound deaths (76.6%) occurred in OFS. The leading mechanism of death was catastrophic tissue destruction (80.8%). Most fatalities had non-survivable injuries (80.8%) and non-preventable deaths (97.3%)., Conclusions: Comprehensive mortality reviews should routinely be conducted for all military operation deaths. Understanding death from both injury and disease can guide preemptive and responsive efforts to reduce death among military forces., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Examinations of risk factors for suicide attempt in United States service members at high risk of mental health diagnoses, such as those with combat injuries, are essential to guiding prevention and intervention efforts., Methods: Retrospective cohort study of 8727 combat-injured patients matched to deployed, non-injured patients utilizing Department of Defense and Veterans Affairs administrative records., Results: Combat injury was positively associated with suicide attempt in the univariate model (HR = 1.75, 95% CI 1.5-2.1), but lost significance after adjustment for mental health diagnoses. Utilizing Latent Transition Analysis in the combat-injured group, we identified five mental/behavioral health profiles: (1) Few mental health diagnoses, (2) PTSD and depressive disorders, (3) Adjustment disorder, (4) Multiple mental health comorbidities, and (5) Multiple mental health comorbidities with alcohol use disorder (AUD). Multiple mental health comorbidities with AUD had the highest suicide attempt rate throughout the study and more than four times that of Multiple mental health comorbidities in the first study year (23.4 vs. 5.1 per 1000 person years, respectively)., Conclusion: Findings indicate that (1) combat injury's impact on suicide attempt is attenuated by mental health and (2) AUD with multiple mental health comorbidities confers heightened suicide attempt risk in combat-injured service members., (© 2022 American Association of Suicidology. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Introduction: Previous studies have identified combat exposure and combat traumatic experience as problematic drinking risk factors. Increasing evidence suggests that opioid use increases the risk of alcohol use disorder. This study investigated the association between opioid prescription use after injury and (1) alcohol use disorder and (2) severity of alcohol use disorder among deployed military servicemembers., Methods: Deidentified health records data of 9,029 deployed servicemembers from a retrospective cohort study were analyzed. Data were randomly selected from the Department of Defense Trauma Registry and included servicemembers with combat injuries during deployment in Iraq or Afghanistan (2002-2016). Pharmacy records and International Classification of Diseases, Ninth and Tenth Revision diagnosis codes were used. Three groups were identified (no opioid prescription use, nonpersistent opioid prescription use, and persistent opioid prescription use) and were compared on the basis of alcohol use disorder risk using Cox proportional hazard models. Data analyses were performed in 2021., Results: Of the 9,029 servicemembers with combat injury, 2,262 developed alcohol use disorder (1,322 developed severe alcohol use disorder). Compared with no opioid prescription use, increased alcohol use disorder risk was associated with persistent opioid prescription use, with a hazard ratio of 1.13 (95% CI=1.02, 1.26). After covariate adjustment, increased risk remained statistically significant (hazards ratio=1.24; 95% CI=1.10, 1.39). There was no significant difference in alcohol use disorder risk between no opioid prescription use and nonpersistent opioid prescription use. The risk of severe alcohol use disorder did not vary by opioid use among servicemembers with alcohol use disorder diagnosis., Conclusions: The findings of the study suggest that the incidence of alcohol use disorder was higher among injured servicemembers with persistent opioid prescription use than among those without opioid use. If replicated in prospective studies, the findings highlight the need for clinicians to consider the current and history of alcohol use of patients in initiating treatment involving opioids., (Published by Elsevier Inc.)

Introduction: Although retrospective analyses have found that combat-injured service members are at high risk for mental and physical health outcomes following injury, relatively little is known about the long-term health of injured service members. To better understand long-term health outcomes after combat injury, a large, prospective observational cohort collecting both subjective and objective health data is needed. Given that a study of this nature would be costly and face many logistical challenges, we first conducted a pilot to assess the feasibility of a larger, definitive study., Materials and Methods: We ran a prospective, observational pilot study of 119 combat-injured service members and veterans who completed (1) at least one set of laboratory measurements (blood and urine sample collection and vitals measurements) at Clinical Laboratory Improvement Amendment of 1988 compliant laboratory locations and (2) at least one online assessment for the Wounded Warrior Recovery Project (WWRP), a 15-year examination of patient-reported outcomes among service members injured on combat deployment. We recruited the pilot study cohort from WWRP participants who met eligibility criteria and indicated interest in additional research opportunities. We collected laboratory values and patient-reported outcomes at baseline and again 1 year later, and obtained demographic, injury, and military service data from the Expeditionary Medical Encounter Database. The David Grant USAF Medical Center Institution Review Board (IRB) and the Naval Health Research Center IRB reviewed and approved the study protocols., Results: During recruitment for the pilot study, 624 study candidates were identified from WWRP. Of the 397 candidates we contacted about the pilot study, 179 (45.1%) enrolled and 119 (66.4%) of those who enrolled completed the first year of participation. The second study year was suspended due to the coronavirus disease-2019 pandemic. At the time of suspension, 72 (60.5%) participants completed follow-up laboratory appointments, and 111 (93.3%) completed second-year WWRP assessments. Participants in the pilot study were predominately male (95.0%) and non-Hispanic White (55.5%), with a median (interquartile range) age of 38.3 (34.1-45.4) years., Conclusions: Collection of patient-reported outcomes and laboratory samples in a geographically dispersed cohort of combat-injured service members is possible. While significant challenges exist, our pilot study results indicate that a larger, longitudinal, cohort study is feasible., (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.)

Study Objectives: Obstructive sleep apnea is prevalent among military members despite fewer traditional risk factors. We sought to determine the incidence and longitudinal predictors of obstructive sleep apnea in a large population of survivors of combat-related traumatic injury and a matched control group., Methods: Retrospective cohort study of military service members deployed to conflict zones from 2002-2016 with longitudinal follow-up in the Veterans Affairs and Military Health Systems. Two cohorts of service members were developed: (1) those who sustained combat injuries and (2) matched, uninjured participants., Results: 17,570 service members were retrospectively analyzed for a median of 8.4 years. After adjustment, traumatic brain injury (hazard ratio [HR] 1.39, 95% confidence interval [CI] 1.20-1.60), posttraumatic stress disorder (HR 1.24, 95% CI 1.05-1.46), depression (HR 1.52, 95% CI 1.30-1.79), anxiety (HR 1.40, 95% CI 1.21-1.62), insomnia (HR 1.71, 95% CI 1.44-2.02), and obesity (HR 2.40, 95% CI 2.09-2.74) were associated with development of obstructive sleep apnea. While combat injury was associated with obstructive sleep apnea in the univariate analysis (HR 1.25, 95% CI 1.17-1.33), the direction of this association was reversed in the multivariable model (HR 0.74, 95% CI 0.65-0.84). In a nested analysis, this was determined to be due to the effect of mental health diagnoses., Conclusions: The incidence of obstructive sleep apnea is higher among injured service members (29.1 per 1,000 person-years) compared to uninjured service members (23.9 per 1,000 person-years). This association appears to be driven by traumatic brain injury and the long-term mental health sequelae of injury., Citation: Haynes ZA, Stewart IJ, Poltavskiy EA, et al. Obstructive sleep apnea among survivors of combat-related traumatic injury: a retrospective cohort study. J Clin Sleep Med . 2022;18(1):171-179., (© 2022 American Academy of Sleep Medicine.)

Objective: To determine whether persistent opioid use after injury is associated with subsequent long-term development of clinically recognized opioid abuse., Summary Background Data: Opioid abuse is an epidemic in the United States and trauma can initiate persistent use; however, it remains unclear whether persistent opioid use contributes to the subsequent development of opioid abuse. The care of combat casualties by the Departments of Defense and Veterans Affairs uniquely allows investigation of this long-term outcome., Methods: This retrospective cohort study randomly selected 10,000 battle-injured United States military personnel. We excluded patients who died during initial hospitalization or within 180 days of discharge, had a preinjury opioid abuse diagnosis, or had missing data in a preselected variable. We defined persistent opioid use as filling an opioid prescription 3 to 6 months after discharge and recorded clinically recognized opioid abuse using relevant diagnosis codes., Results: After exclusion, 9284 subjects were analyzed, 2167 (23.3%) of whom developed persistent opioid use. During a median follow-up time of 8 years, 631 (6.8%) patients developed clinically recognized opioid abuse with a median time to diagnosis of 3 years. Injury severity and discharge opioid prescription amount were associated with persistent opioid use after trauma. After adjusting for patient and injury-specific factors, persistent opioid use was associated with the long-term development of clinically recognized opioid abuse (adjusted hazard ratio, 2.39; 95% confidence interval, 1.99-2.86)., Conclusions: Nearly a quarter of patients filled an opioid prescription 3 to 6 months after discharge, and this persistent use was associated with long-term development of opioid abuse., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Study Objectives: Insomnia is a diagnosis with broad health and economic implications that has been increasingly recognized in military service members. This trend was concurrent with an increase in traumatic wartime injuries. Accordingly, we sought to determine longitudinal predictors of persistent insomnia in combat veterans who sustained traumatic injuries., Methods: Retrospective cohort study of service members deployed to conflict zones from 2002 to 2016, with longitudinal follow-up in the Veterans Affairs and Military Health Systems. Two cohorts were derived: (1) service members who sustained traumatic injuries and (2) an age-, sex-, and service component-matched cohort of uninjured service members who deployed to a combat zone. Insomnia was defined using International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision-Clinical Modification codes., Results: The final population of 17,374 service members was followed from date of injury (or date of matched participant's injury) for a median of 8.4 (interquartile range, 5.3-10.7) years. Service members with traumatic injury were at significantly greater risk of developing insomnia than uninjured service members (hazard ratio = 1.43; 95% confidence interval, 1.30-1.58) after adjustment. Traumatic brain injury was associated with insomnia compared with patients without traumatic brain injury in the multivariable model: mild/unclassified traumatic brain injury (hazard ratio = 2.07; 95% confidence interval, 1.82-2.35) and moderate/severe/ penetrating traumatic brain injury (hazard ratio = 2.43; 95% confidence interval, 2.06-2.86). Additionally, burn injury (hazard ratio = 1.95; 95% confidence interval, 1.47-2.59) and amputation (hazard ratio = 1.61; 95% confidence interval, 1.26-2.06) significantly increased the risk of a diagnosis., Conclusions: Traumatic injuries significantly predicted a diagnosis of insomnia after controlling for mental health disorders. Our findings strongly suggest the need for long-term surveillance of sleep disorders in trauma survivors., Citation: Haynes ZA, Collen JF, Poltavskiy EA, et al. Risk factors of persistent insomnia among survivors of traumatic injury: a retrospective cohort study. J Clin Sleep Med. 2021;17(9):1831-1840., (© 2021 American Academy of Sleep Medicine.)

Background: Military operations vary by scope, purpose, and intensity, each having unique forces and actions to execute a mission. Evaluation of military operation fatalities guides current and future casualty care., Methods: A retrospective study was conducted of all US military fatalities from Operation New Dawn in Iraq, 2010 to 2011. Data were obtained from autopsies and other records. Population characteristics, manner of death, cause of death, and location of death were analyzed. All fatalities were evaluated for concomitant evidence of underlying atherosclerosis. Nonsuicide trauma fatalities were also reviewed for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement., Results: Of 74 US military Operation New Dawn fatalities (median age, 26 years; male, 98.6%; conventional forces, 100%; prehospital, 82.4%) the leading cause of death was injury (86.5%). The manner of death was primarily homicide (55.4%), followed by suicide (17.6%), natural (13.5%), and accident (9.5%). Fatalities were divided near evenly between combatants (52.7%) and support personnel (47.3%), and between battle injury (51.4%) and disease and nonbattle injury (48.6%). Natural and suicide death was higher (p < 0.01, 0.02) among support personnel who were older (p = 0.05) with more reserve/national guard personnel (p = 0.01). Total population prevalence of underlying atherosclerosis was 18.9%, with more among support personnel (64.3%). Of 46 nonsuicide trauma fatalities, most died of blast injury (67.4%) followed by gunshot wound (26.1%) and multiple/blunt force injury (6.5%). The leading mechanism of death was catastrophic tissue destruction (82.6%). Most had nonsurvivable injuries (82.6%) and nonpreventable deaths (93.5%)., Conclusion: Operation New Dawn fatalities were exclusively conventional forces divided between combatants and support personnel, the former succumbing more to battle injury and the latter to disease and nonbattle injury including self-inflicted injury. For nonsuicide trauma fatalities, none died from a survivable injury, and 17.4% died from potentially survivable injuries. Opportunities for improvement included providing earlier blood products and surgery., Level of Evidence: Therapeutic, level V and epidemiological, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Autopsy studies of trauma fatalities have provided evidence for the pervasiveness of atherosclerosis in young and middle-aged adults. The objective of this study was to determine the prevalence of atherosclerosis in elite US military forces., Methods: We conducted a retrospective study of all US Special Operations Command (USSOCOM) fatalities from 2001 to 2020 who died from battle injuries. Autopsies were evaluated from Afghanistan- and Iraq-centric combat operations for evidence of coronary and/or aortic atherosclerosis and categorized as minimal (fatty streaking only), moderate (10-49% narrowing of ≥1 vessel), and severe (≥50% narrowing of ≥1 vessel). Prevalence of atherosclerosis was determined for the total population and by subgroup characteristics of age, sex, race/ethnicity, combat operation, service command, occupation, rank, cause of death, manner of death, and body mass index (BMI)., Results: From the total of 388 USSOCOM battle injury fatalities, 356 were included in the analysis. The mean age was 31 years (range, 19-57 years), and 98.6% were male. The overall prevalence of coronary and/or aortic atherosclerosis was 17.4%. The prevalence of coronary atherosclerosis alone was 13.8%. Coronary atherosclerosis was categorized as minimal in 1.1%, moderate in 7.6%, and severe in 5.1%. Of those with atherosclerosis, 24.2% were <30 years old, 88.7% were from enlisted ranks, and 95.2% had combatant occupations. When BMI could be calculated, 73.5% of fatalities with atherosclerosis had a BMI =25., Conclusions: Autopsy-determined atherosclerosis is prevalent in elite US military Special Operations Forces despite young age and positive lifestyle benefits of service in an elite military unit., (2021.)

Background: The relationship between traumatic injury and subsequent mental health diagnoses is not well understood and may have significant implications for patient screening and clinical intervention. We sought to determine the adjusted association between traumatic injury and the subsequent development of post-traumatic stress disorder (PTSD), depression, and anxiety., Methods: Using Department of Defense and Veterans Affairs datasets between February 2002 and June 2016, we conducted a retrospective cohort study of 7,787 combat-injured United States service members matched 1:1 to combat-deployed, uninjured service members. The primary exposure was combat injury versus no combat injury. Outcomes were diagnoses of PTSD, depression, and anxiety, defined by International Classification of Diseases 9th and 10th Revision Clinical Modification codes., Results: Compared to noninjured service members, injured service members had higher observed incidence rates per 100 person-years for PTSD (17.1 vs. 5.8), depression (10.4 vs. 5.7), and anxiety (9.1 vs. 4.9). After adjustment, combat-injured patients were at increased risk of development of PTSD (HR 2.92, 95%CI 2.68-3.17), depression (HR 1.47, 95%CI 1.36-1.58), and anxiety (HR 1.34, 95%CI 1.24-1.45)., Conclusions: Traumatic injury is associated with subsequent development of PTSD, depression, and anxiety. These findings highlight the importance of increased screening, prevention, and intervention in patients with exposure to physical trauma., (© 2021 The McConnell Group, Inc. Brain and Behavior published by Wiley Periodicals LLC. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Background: A better understanding of the long-term health effects of combat injury is important for the management of veterans' health in the Department of Defense (DoD) and Veterans Affairs (VA) health care systems and may have implications for primary care management of civilian trauma patients., Objective: To determine the impact of traumatic injury on the subsequent development of hypertension (HTN), diabetes mellitus (DM), and coronary artery disease (CAD) after adjustment for sociodemographic, health behavior, and mental health factors., Design: Retrospective cohort study of current and former US military personnel with data obtained from both the DoD and VA health care systems., Participants: Combat injured (n = 8727) service members between 1 February 2002 and 14 June 2016 randomly selected from the DoD Trauma Registry matched 1:1 based on year of birth, sex, and branch of service to subjects that deployed to a combat zone but were not injured., Main Measures: Traumatic injury, stratified by severity, compared with no documented injury. Diagnoses of HTN, DM, and CAD defined by International Classification of Diseases 9th or 10th Revision Clinical Modification codes., Key Results: After adjustment, severe traumatic injury was significantly associated with HTN (HR 2.78, 95% CI 2.18-3.55), DM (HR 4.45, 95% CI 2.15-9.18), and CAD (HR 4.87, 95% CI 2.11-11.25), compared with no injury. Less severe injury was associated with HTN (HR 1.14, 95% CI 1.05-1.24) and CAD (HR 1.62, 95% CI 1.11-2.37)., Conclusions: Severe traumatic injury is associated with the subsequent development of HTN, DM, and CAD. These findings have profound implications for the primary care of injured service members in both the DoD/VA health systems and may be applicable to civilian trauma patients as well. Further exploration of pathophysiologic, health behavior, and mental health changes after trauma is warranted to guide future intervention strategies.

Under direction from the Defense Health Agency, subject matter experts (SMEs) from the Joint Trauma System, Armed Forces Medical Examiner System, and civilian sector established the Military Trauma Mortality Review process. To establish the most empirically robust process, these SMEs used both qualitative and quantitative methods published in a series of peer-reviewed articles over the last 3 years. Most recently, the Military Mortality Review process was implemented for the first time on all battle-injured service members attached to the United States Special Operations Command from 2001 to 2018. The current Military Mortality Review process builds on the strengths and limitations of important previous work from both the military and civilian sector. To prospectively improve the trauma care system and drive preventable death to the lowest level possible, we present the main misconceptions and lessons learned from our 3-year effort to establish a reliable and sustainable Military Trauma Mortality Review process. These lessons include the following: (1) requirement to use standardized and appropriate lexicon, definitions, and criteria; (2) requirement to use a combination of objective injury scoring systems, forensic information, and thorough SME case review to make injury survivability and death preventability determinations; (3) requirement to use nonmedical information to make reliable death preventability determinations and a comprehensive list of opportunities for improvement to reduce preventable deaths within the trauma care system; and (4) acknowledgment that the military health system still has gaps in current infrastructure that must be addressed to globally and continuously implement the process outlined in the Military Trauma Mortality Review process in the future. LEVEL OF EVIDENCE: Level III.

Background: Death from injury occurs predominantly in prehospital settings. Injury prevention and prehospital care of military forces is the responsibility of combatant commanders. Medical examiner and trauma systems should routinely study fatalities and inform commanders of mortality trends., Methods: Data reported on US Special Operations Command (USSOCOM) fatalities who died while performing duties from September 11, 2001, to September 10, 2018, were reevaluated to compare subcommands, units, and trends. Injury was assessed by mechanism, severity, operational posture, and survivability. Death was assessed by manner, cause, classification, mechanism, and preventability., Results: Of 614 USSOCOM fatalities (median age, 30 years; male, 98.5%), 67.6% occurred in the Army command, of which 49.2% occurred in the Special Forces command. Battle injury accounted for 60.1% of USSOCOM fatalities. Most battle-injured fatalities in each subcommand had nonsurvivable injuries and nonpreventable deaths. For each subcommand except Marine Corps, fatalities with nonsurvivable injuries sustained injuries primarily while mounted. By subcommand, the primary cause of death for fatalities with nonsurvivable injuries was blast for Army (57.6%), multiple/blunt force for Navy (60.0%), gunshot wound for Air Force (55.6%), and split between blast (50.0%) and gunshot wound (50.0%) for Marine Corps. For each subcommand except Air Force, fatalities with potentially survivable-survivable injuries sustained injuries primarily while dismounted, and the mechanism of death was primarily hemorrhage plus other mechanism or hemorrhage alone. Hemorrhage only mechanism of death was surpassed over time by complex multimechanism death. Potential for injury survivability and death preventability was greatest during early and later years of conflict., Conclusion: Organizational differences in mortality characteristics and trends were identified from which commanders can refine efforts to prevent and treat injury and improve survival. Fatality analyses inform operational risk matrices and advance casualty prevention and response efforts. Prevention, assessment, and treatment strategies must evolve to reduce death from hemorrhage plus coexisting mechanisms., Level of Evidence: Performance Improvement and Epidemiological, level IV.

Background: Although the long-term effects of combat injury are not well understood, there is emerging concern that exposure to combat environments and subsequent injury may increase the risk of hypertension through changes in inflammatory responses, psychological stress and mental health, and health behaviors., Methods: Data from the Millennium Cohort Study and the Department of Defense Trauma Registry were used to identify combat-exposed and combat-injured participants. Incident hypertension diagnoses were ascertained from the Millennium Cohort survey. The associations between combat exposure/injury and hypertension risk was estimated using multivariable complementary log-log survival models., Results: The final analysis sample consisted of 38 734 participants. Of these, 50.8% deployed but were not exposed to combat, 48.6% deployed and were exposed to combat, and 0.6% had combat injury. Overall prevalence of hypertension was 7.6%. Compared with participants who deployed but did not experience combat (mild exposure), elevated odds of hypertension were observed among those who experienced combat but not wounded (moderate exposure; AOR, 1.28; 95% CI, 1.19-1.38) and those wounded in combat (high exposure; AOR, 1.46; 95% CI, 1.07-2.00). Sleep duration of less than 4 h (AOR, 1.21; 95% CI, 1.03-1.43), sleep duration of 4-6 h (AOR, 1.16; 95% CI, 1.05-1.29), posttraumatic stress disorder (AOR, 1.54; 95% CI, 1.26-1.87), and overweight (AOR, 1.77; 95% CI, 1.61-1.95) and obese (AOR, 2.77; 95% CI, 2.45-3.12) status were also associated with higher odds of hypertension., Conclusion: Results support the hypotheses that combat exposure increases hypertension risk and that combat injury exacerbates this risk.

Background: Comprehensive analyses of battle-injured fatalities, incorporating a multidisciplinary process with a standardized lexicon, is necessary to elucidate opportunities for improvement (OFIs) to increase survivability., Methods: A mortality review was conducted on United States Special Operations Command battle-injured fatalities who died from September 11, 2001, to September 10, 2018. Fatalities were analyzed by demographics, operational posture, mechanism of injury, cause of death, mechanism of death (MOD), classification of death, and injury severity. Injury survivability was determined by a subject matter expert panel and compared with injury patterns among Department of Defense Trauma Registry survivors. Death preventability and OFI were determined for fatalities with potentially survivable or survivable (PS-S) injuries using tactical data and documented medical interventions., Results: Of 369 United States Special Operations Command battle-injured fatalities (median age, 29 years; male, 98.6%), most were killed in action (89.4%) and more than half died from injuries sustained during mounted operations (52.3%). The cause of death was blast injury (45.0%), gunshot wound (39.8%), and multiple/blunt force injury (15.2%). The leading MOD was catastrophic tissue destruction (73.7%). Most fatalities sustained nonsurvivable injuries (74.3%). For fatalities with PS-S injuries, most had hemorrhage as a component of MOD (88.4%); however, the MOD was multifactorial in the majority of these fatalities (58.9%). Only 5.4% of all fatalities and 21.1% of fatalities with PS-S injuries had comparable injury patterns among survivors. Accounting for tactical situation, a minority of deaths were potentially preventable (5.7%) and a few preventable (1.1%). Time to surgery (93.7%) and prehospital blood transfusion (89.5%) were the leading OFI for PS-S fatalities. Most fatalities with PS-S injuries requiring blood (83.5%) also had an additional prehospital OFI., Conclusion: Comprehensive mortality reviews of battlefield fatalities can identify OFI in combat casualty care and prevention. Standardized lexicon is essential for translation to civilian trauma systems., Level of Evidence: Epidemiological, level IV.

Introduction: We explore disparities in awarding post-traumatic stress disorder (PTSD) service-connected disability benefits (SCDB) to veterans based on gender, race/ethnicity, and misconduct separation., Methods: Department of Defense data on service members who separated from October 1, 2001 to May 2017 were linked to Veterans Administration (VA) administrative data. Using adjusted logistic regression models, we determined the odds of receiving a PTSD SCDB conditional on a VA diagnosis of PTSD., Results: A total of 1,558,449 (79% of separating service members) had at least one encounter in VA during the study period (12% female, 4.5% misconduct separations). Females (OR 0.72) and Blacks (OR 0.93) were less likely to receive a PTSD award and were nearly equally likely to receive a PTSD diagnosis (OR 0.97, 1.01). Other racial/ethnic minorities were more likely to receive an award and diagnosis, as were those with misconduct separations (award OR 1.3, diagnosis 2.17)., Conclusions: Despite being diagnosed with PTSD at similar rates to their referent categories, females and Black veterans are less likely to receive PTSD disability awards. Other racial/ethnic minorities and those with misconduct separations were more likely to receive PTSD diagnoses and awards. Further study is merited to explore variation in awarding SCDB., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Musculoskeletal (MSK) conditions are commonly seen among military service members (SM) and Veterans. We explored correlates of award of MSK-related service-connected disability benefits (SCDB) among SM seeking care in Veterans Affairs (VA) hospitals., Materials and Methods: Department of Defense data on SM who separated from October 1, 2001 to May 2017 were linked to VA administrative data. Using adjusted logistic regression models, we determined the odds of receiving MSK SCDB., Results: A total of 1,558,449 (79% of separating SM) had at least one encounter in VA during the study period (7.8% disability separations). Overall, 51% of this cohort had at least one MSK SCDB (88% among disability separations, 48% among normal). Those with disability separations (as compared to normal separations) were significantly more likely to receive MSK SCDB (odds ratio 2.37) as were females (compared to males, odds ratio 1.15)., Conclusions: Although active duty SM with disability separations were more likely to receive MSK-related service-connected disability ratings in the VA, those with normal separations also received such awards. Identifying those at highest risk for MSK-related disability could lead to improved surveillance and prevention strategies in the Department of Defense and VA health care systems to prevent further damage and disability., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Studies of fatalities from injury and disease guide prevention and treatment efforts for populations at risk. Findings can inform leadership and direct clinical practice guidelines, research, and personnel, training, and equipment requirements., Methods: A retrospective review and descriptive analysis was conducted of United States Special Operations Command (USSOCOM) fatalities who died while performing duties from September 11, 2001, to September 10, 2018. Characteristics analyzed included subcommand, military activity, operational posture, and manner of death., Results: Of 614 USSOCOM fatalities (median age, 30 years; male, 98.5%) the leading cause of death was injury (97.7%); specifically, multiple/blunt force injury (34.5%), blast injury (30.7%), gunshot wound (GSW; 30.3%), and other (4.5%). Most died outside the United States (87.1%), during combat operations (85.3%), in the prehospital environment (91.5%), and the same day of insult (90.4%). Most fatalities were with the US Army Special Operations Command (67.6%), followed by the Naval Special Warfare Command (16.0%), Air Force Special Operations Command (9.3%), and Marine Corps Forces Special Operations Command (7.2%). Of 54.6% who died of injuries incurred during mounted operations, most were on ground vehicles (53.7%), followed by rotary-wing (37.3%) and fixed-wing (9.0%) aircrafts. The manner of death was primarily homicide (66.0%) and accident (30.5%), followed by natural (2.1%), suicide (0.8%), and undetermined (0.7%). Specific homicide causes of death were GSW (43.7%), blast injury (42.2%), multiple/blunt force injury (13.8%), and other (0.2%). Specific accident causes of death were multiple/blunt force injury (80.7%), blast injury (6.4%), GSW (0.5%), and other (12.3%). Of accident fatalities with multiple/blunt force injury, the mechanism was mostly aircraft mishaps (62.9%), particularly rotary wing (68.4%)., Conclusion: Most USSOCOM fatalities died abroad from injury in the prehospital setting. To improve survival from military activities worldwide, leaders must continue to optimize prehospital capability and develop strategies that rapidly connect patients to advanced resuscitative and surgical care., Level of Evidence: Epidemiological, level IV; Therapeutic level IV.

Objective: To determine: 1) rates of cardiovascular disease (CVD) among individuals with and without prior US military service; and 2) variation in CVD outcomes by race/ethnicity., Methods: We performed a cross-sectional study of the 2011-2016 Behavioral Risk Factor Surveillance System during 2018-2019. Groups with (n=369,844) and without (n=2,491,784) prior service were compared overall, and by race/ethnicity. CVD odds were compared using logistic regression. Rate-difference decomposition was used to estimate relative contributions of covariates to differences in CVD prevalence., Results: CVD was associated with military service (OR=1.34; P<.001). Among non-Hispanic Blacks, prior service was associated with a lower odds of CVD (OR=.69; P<.001), fully attenuating the net difference in CVD between individuals with and without prior service. Non-Hispanic Whites who served had the highest odds of CVD, while Hispanics with prior service had the same odds of CVD as non-Hispanic Whites without prior service. After age, smoking and body mass index status were the largest contributors to CVD differences by race/ethnicity., Conclusions: Results from this study support an association between prior military service and CVD and highlight differences in this association by race/ethnicity. Knowledge of modifiable health behaviors that contribute to differences in CVD outcomes could be used to guide prevention efforts., Competing Interests: Competing Interests: None declared.

Importance: Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict., Objectives: To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred., Design, Setting, and Participants: Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes., Main Outcomes and Measures: Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR., Results: In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times., Conclusions and Relevance: Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care.

Background: The ability to rapidly administer whole blood (WB) at the point of injury is an important intervention to save lives. This can be accomplished using low titer group O WB donors. Titers of immunoglobulin M anti-A and anti-B might change over time. This study describes titer testing in a large series of donors., Study Design and Methods: Data were collected retrospectively from the Armed Services Blood Program and the Theater Medical Data Store. Soldiers assigned to the 75th Ranger Regiment were screened and titered upon completion of training or before deployment or during periodic unit readiness activities. A Ranger group O low-titer (ROLO) donor was defined as having titers of both anti-A and -B of less than 256 by immediate spin testing., Results: Between May 2015 and January 2017, of a total of 2237 participating soldiers, 1892 (84.5%) soldiers underwent antibody titering once, while 266 (11.9%) were titered twice, 62 (2.8%) were titered three times, and 17 (0.8%) were titered at least four times. The mean age was 26.5 ± 6.5, and 2197 (98.2%) were male. A total of 69.5% of donors met ROLO donor criteria on the first test. The percentage of donors meeting universal-donor criteria increased to 83.5% on the second test, 91.1% on the third test, and 100% on the fourth and fifth tests., Conclusions: With successive titer testing, it appears that individuals display a tendency toward lower titers. This may indicate that titer testing may not be required after the second test if donors have been identified initially as low titer., (© 2019 AABB.)

Background: The injury severity score considers burn size and inhalation injury in estimating overall anatomical injury severity. Models that adjust for injury severity score in addition to total burn size and inhalation injury may therefore be double counting the risk from these individual burn characteristics, and obscuring (or overemphasizing) the contribution of risk from each source. The primary aim of this study was to compare differences in the estimated mortality risk of burn trauma using the traditional injury severity score (ISS) calculation and the non-burn injury severity score (NBISS) to examine how separating out the risk attributable to the burn injury versus other trauma changes the interpretation and clinical assessment., Methods: Among U.S. casualties sustaining burns during combat operations in Iraq and Afghanistan from March 2003 to October 2013, we performed a retrospective cohort study. Unadjusted, adjusted, and weighted Cox proportional hazards models were performed to estimate the risk of age, burn injury severity, and non-burn injury severity on mortality. Weighted hazard ratios and adjusted survival curves were performed using non-parametric inverse probability weighting., Results: Our final sample consisted of 902 service members with a mortality proportion of 5.7% (n=51). Adjusting for non-burn trauma with traditional ISS attenuated the risk of percent total body surface area burned (%TBSA) by 20% when modeled continuously [HR (95% CI): 1.27 (1.10-1.32) vs. 1.07 (0.99-1.15]. However, the adjusted model using NBISS only attenuated the associated mortality risk of burn size by 5% [HR (95% CI): 1.22 (1.12-1.34)] and had a similar model fit (AIC: 484.2 vs. 478.6). For the weighted Cox proportional hazards models, the risk from a large burn (%TBSA≥60) was also attenuated when adjusting for ISS [HR (95% CI): 2.80 (1.18-6.64)] compared to the model adjusting for NBISS [HR (95% CI): 5.63 (2.79-11.35)]., Conclusion: Our analysis comparing the use of traditional ISS and NBISS to measure comorbid non-burn trauma resulted in different interpretations for the effect of %TBSA on subsequent mortality. Our results suggest that the association of %TBSA with death can be obscured by the inclusion of traditional ISS. Therefore, we recommend using NBISS when constructing statistical models in this patient population., (Published by Elsevier Ltd.)

The associations between injury severity, posttraumatic stress disorder (PTSD), and development of chronic diseases, such as hypertension, among military service members are not understood. We sought to (1) estimate the prevalence and incidence of PTSD within a severely injured military cohort, (2) assess the association between the presence and chronicity of PTSD and hypertension, and (3) determine whether or not initial injury severity score and PTSD are independent risk factors for hypertension. Administrative and clinical databases were used to conduct a retrospective cohort study of 3846 US military casualties injured in the Iraq and Afghanistan conflicts between February 1, 2002, and February 1, 2011. Development of PTSD and hypertension after combat injury were determined using the International Classification of Diseases, Ninth Revision codes. Multivariable competing risk regression models were used to assess associations between injury severity score, PTSD, and hypertension, while controlling for covariates. Overall prevalence of PTSD was 42.4%, and prevalence of hypertension was 14.3%. Unadjusted risk of hypertension increased significantly with chronicity of PTSD (1-15 diagnoses: hazard ratio, 1.77; 95% confidence interval, 1.46-2.14; P <0.001; >15 diagnoses: hazard ratio, 2.29; 95% confidence interval, 1.85-2.84; P <0.001) compared with patients never diagnosed with PTSD. The association between injury severity score (hazard ratio, 1.06 per 5-U increment; 95% confidence interval, 1.03-1.10; P <0.001) and hypertension was significant, with little change in effect in the multivariable model (hazard ratio, 1.05 per 5-U increment; 95% confidence interval, 1.01-1.09; P =0.03). In a cohort of service members injured in combat, we found that chronicity of PTSD diagnoses and injury severity were independent risk factors for hypertension., (© 2018 American Heart Association, Inc.)

Introduction: The effect of presenting hypertension is poorly studied in combat casualties. We hypothesized that elevated mean arterial pressure (MAP) on presentation to combat hospitals would be associated with poor outcomes., Methods: Data was obtained from the Department of Defense Trauma Registry and the Armed Forces Medical Examiner System. Variables analyzed included presenting vital signs to Role II-III military theater hospital, demographic variables, injury severity score (ISS), location and mechanism of injury, presence of traumatic brain injury (TBI), acute kidney injury (AKI), and mortality. Patients were stratified by decile of MAP and logistic regression analysis was employed to adjust for confounders., Results: A total of 4072 subjects injured from February 2002 to February 2011 were identified. Compared to patients in the middle deciles of presenting MAP, patients in the highest and lowest MAP deciles were the only groups that demonstrated a higher mortality on univariate analysis (OR 2.06, 95% CI 1.16-2.31 and OR 2.86, 95% CI 1.76-4.67, respectively), and this relationship persisted after adjustment for ISS, HR, temperature, presence of burn injury, TBI, and AKI. Burn injury was associated with mortality in the full multivariate analysis. However, further analysis limited to patients without burn injury did not demonstrate an association between high MAP and mortality (OR 0.84, 95% CI 0.36-1.99; p=0.70). Conversely, when limited to patients with burn injury, high MAP was associated with mortality (OR 3.78, 95% CI 1.74-8.20; p=0.001)., Conclusion: The relationship between mortality and presenting MAP appears to be U-shaped, demonstrating increased mortality in the lowest and highest deciles. However, mortality in the highest MAP decile appears to be limited to casualties with associated burn injury, even after adjustment for TBI, AKI, and ISS, which takes into account the severity of the burn injury. Physicians should recognize that burn patients presenting with an elevated MAP are at an increased risk for poor outcomes., Level of Evidence: III., (Published by Elsevier Ltd.)

Importance: Prehospital blood product transfusion in trauma care remains controversial due to poor-quality evidence and cost. Sequential expansion of blood transfusion capability after 2012 to deployed military medical evacuation (MEDEVAC) units enabled a concurrent cohort study to focus on the timing as well as the location of the initial transfusion., Objective: To examine the association of prehospital transfusion and time to initial transfusion with injury survival., Design, Setting, and Participants: Retrospective cohort study of US military combat casualties in Afghanistan between April 1, 2012, and August 7, 2015. Eligible patients were rescued alive by MEDEVAC from point of injury with either (1) a traumatic limb amputation at or above the knee or elbow or (2) shock defined as a systolic blood pressure of less than 90 mm Hg or a heart rate greater than 120 beats per minute., Exposures: Initiation of prehospital transfusion and time from MEDEVAC rescue to first transfusion, regardless of location (ie, prior to or during hospitalization). Transfusion recipients were compared with nonrecipients (unexposed) for whom transfusion was delayed or not given., Main Outcomes and Measures: Mortality at 24 hours and 30 days after MEDEVAC rescue were coprimary outcomes. To balance injury severity, nonrecipients of prehospital transfusion were frequency matched to recipients by mechanism of injury, prehospital shock, severity of limb amputation, head injury, and torso hemorrhage. Cox regression was stratified by matched groups and also adjusted for age, injury year, transport team, tourniquet use, and time to MEDEVAC rescue., Results: Of 502 patients (median age, 25 years [interquartile range, 22 to 29 years]; 98% male), 3 of 55 prehospital transfusion recipients (5%) and 85 of 447 nonrecipients (19%) died within 24 hours of MEDEVAC rescue (between-group difference, -14% [95% CI, -21% to -6%]; P = .01). By day 30, 6 recipients (11%) and 102 nonrecipients (23%) died (between-group difference, -12% [95% CI, -21% to -2%]; P = .04). For the 386 patients without missing covariate data among the 400 patients within the matched groups, the adjusted hazard ratio for mortality associated with prehospital transfusion was 0.26 (95% CI, 0.08 to 0.84, P = .02) over 24 hours (3 deaths among 54 recipients vs 67 deaths among 332 matched nonrecipients) and 0.39 (95% CI, 0.16 to 0.92, P = .03) over 30 days (6 vs 76 deaths, respectively). Time to initial transfusion, regardless of location (prehospital or during hospitalization), was associated with reduced 24-hour mortality only up to 15 minutes after MEDEVAC rescue (median, 36 minutes after injury; adjusted hazard ratio, 0.17 [95% CI, 0.04 to 0.73], P = .02; there were 2 deaths among 62 recipients vs 68 deaths among 324 delayed transfusion recipients or nonrecipients)., Conclusions and Relevance: Among medically evacuated US military combat causalities in Afghanistan, blood product transfusion prehospital or within minutes of injury was associated with greater 24-hour and 30-day survival than delayed transfusion or no transfusion. The findings support prehospital transfusion in this setting.

Background: The long-term health effects of burn are poorly understood. We sought to evaluate the relationship between burn and the subsequent development of hypertension., Methods: Retrospective cohort study of patients admitted to our burn center from 2003 to 2010. Data collected included demographic variables, burn size, injury severity score, presence of inhalation injury, serum creatinine, need for renal replacement therapy, as well as days spent in the hospital, in the intensive care unit and on mechanical ventilation. Data for the subsequent diagnosis of hypertension was obtained from medical records. Cox proportional hazard regression models were performed to determine what factors were associated with hypertension., Results: Of the 711 patients identified, 670 were included for analysis after exclusions. After adjustment, only age (HR 1.06 per one year increase, 95% confidence interval 1.03-1.08; p<0.001), percentage of total body surface area burned (HR 1.11 per 5% increase, 95% confidence interval 1.04-1.19; p=0.002) and acute kidney injury (HR 1.68, 95% confidence interval 1.05-2.69; p=0.03) were associated with hypertension., Conclusion: Burn size is independently associated with the subsequent risk of hypertension in combat casualties. Clinical support for primary prevention techniques to reduce the incidence of hypertension specific to burn patients may be warranted., (Published by Elsevier Ltd.)

Background: Acute kidney injury (AKI) has been associated with mortality after traumatic injury. However, there is a paucity of data for military service members with injuries received in combat. We sought to identify risk factors for AKI after combat trauma and evaluate whether AKI is a predictor of mortality., Study Design: Retrospective observational study., Settings & Participants: US service members who were critically wounded in Iraq or Afghanistan from February 1, 2002, to February 1, 2011, and survived until evacuation to Landstuhl Regional Medical Center, Germany., Predictors: Demographic variables, vital signs, injury severity score, presence of burn injury, and mechanism of injury as defined at the time of initial injury, as well as the presence of AKI ascertained within the first 7 days using KDIGO (Kidney Disease: Improving Global Outcomes) serum creatinine criteria., Outcomes: Logistic regression models were used to identify risk factors for both AKI and death., Results: Of 6,011 records, 3,807 were included for analysis after excluding patients with missing data. AKI occurred in 474 (12.5%) patients and 112 (2.9%) died. More patients with versus without AKI died (n=62 [13.1%] vs n=50 [1.5%]; P<0.001). After adjustment, AKI was a predictor of mortality (OR, 5.14; 95% CI, 3.33-7.93; P<0.001). Predictors of AKI were age, African American race, injury severity score, amputations, burns, and presenting vital signs., Limitations: AKI diagnoses limited to creatinine-based definitions., Conclusions: AKI predicted mortality in combat veterans injured in the wars in Iraq and Afghanistan., (Published by Elsevier Inc.)

Importance: The term golden hour was coined to encourage urgency of trauma care. In 2009, Secretary of Defense Robert M. Gates mandated prehospital helicopter transport of critically injured combat casualties in 60 minutes or less., Objectives: To compare morbidity and mortality outcomes for casualties before vs after the mandate and for those who underwent prehospital helicopter transport in 60 minutes or less vs more than 60 minutes., Design, Setting, and Participants: A retrospective descriptive analysis of battlefield data examined 21,089 US military casualties that occurred during the Afghanistan conflict from September 11, 2001, to March 31, 2014. Analysis was conducted from September 1, 2014, to January 21, 2015., Main Outcomes and Measures: Data for all casualties were analyzed according to whether they occurred before or after the mandate. Detailed data for those who underwent prehospital helicopter transport were analyzed according to whether they occurred before or after the mandate and whether they occurred in 60 minutes or less vs more than 60 minutes. Casualties with minor wounds were excluded. Mortality and morbidity outcomes and treatment capability-related variables were compared., Results: For the total casualty population, the percentage killed in action (16.0% [386 of 2411] vs 9.9% [964 of 9755]; P < .001) and the case fatality rate ([CFR] 13.7 [469 of 3429] vs 7.6 [1344 of 17,660]; P < .001) were higher before vs after the mandate, while the percentage died of wounds (4.1% [83 of 2025] vs 4.3% [380 of 8791]; P = .71) remained unchanged. Decline in CFR after the mandate was associated with an increasing percentage of casualties transported in 60 minutes or less (regression coefficient, -0.141; P < .001), with projected vs actual CFR equating to 359 lives saved. Among 4542 casualties (mean injury severity score, 17.3; mortality, 10.1% [457 of 4542]) with detailed data, there was a decrease in median transport time after the mandate (90 min vs 43 min; P < .001) and an increase in missions achieving prehospital helicopter transport in 60 minutes or less (24.8% [181 of 731] vs 75.2% [2867 of 3811]; P < .001). When adjusted for injury severity score and time period, the percentage killed in action was lower for those critically injured who received a blood transfusion (6.8% [40 of 589] vs 51.0% [249 of 488]; P < .001) and were transported in 60 minutes or less (25.7% [205 of 799] vs 30.2% [84 of 278]; P < .01), while the percentage died of wounds was lower among those critically injured initially treated by combat support hospitals (9.1% [48 of 530] vs 15.7% [86 of 547]; P < .01). Acute morbidity was higher among those critically injured who were transported in 60 minutes or less (36.9% [295 of 799] vs 27.3% [76 of 278]; P < .01), those severely and critically injured initially treated at combat support hospitals (severely injured, 51.1% [161 of 315] vs 33.1% [104 of 314]; P < .001; and critically injured, 39.8% [211 of 530] vs 29.3% [160 of 547]; P < .001), and casualties who received a blood transfusion (50.2% [618 of 1231] vs 3.7% [121 of 3311]; P < .001), emphasizing the need for timely advanced treatment., Conclusions and Relevance: A mandate made in 2009 by Secretary of Defense Gates reduced the time between combat injury and receiving definitive care. Prehospital transport time and treatment capability are important factors for casualty survival on the battlefield.

Introduction: Traditional risk scoring prediction models for trauma use either anatomically based estimations of injury or presenting vital signs. Markers of organ dysfunction may provide additional prognostic capability to these models. The objective of this study was to evaluate if urinary biomarkers are associated with poor outcomes, including death and the need for renal replacement therapy., Methods: We conducted a prospective, observational study in United States Military personnel with traumatic injury admitted to the intensive care unit at a combat support hospital in Afghanistan., Results: Eighty nine patients with urine samples drawn at admission to the intensive care unit were studied. Twelve patients subsequently died or needed renal replacement therapy. Median admission levels of urinary cystatin C (CyC), interleukin 18 (IL-18), L-type fatty acid binding protein (LFABP) and neutrophil gelatinase-associated lipocalin (NGAL) were significantly higher in patients that developed the combined outcome of death or need for renal replacement therapy. Median admission levels of kidney injury molecule-1 were not associated with the combined outcome. The area under the receiver operating characteristic curves for the combined outcome were 0.815, 0.682, 0.842 and 0.820 for CyC, IL-18, LFABP and NGAL, respectively. Multivariable regression adjusted for injury severity score, revealed CyC (OR 1.97, 95 % confidence interval 1.26-3.10, p = 0.003), LFABP (OR 1.92, 95 % confidence interval 1.24-2.99, p = 0.004) and NGAL (OR 1.80, 95 % confidence interval 1.21-2.66, p = 0.004) to be significantly associated with the composite outcome., Conclusions: Urinary biomarker levels at the time of admission are associated with death or need for renal replacement therapy. Larger multicenter studies will be required to determine how urinary biomarkers can best be used in future prediction models.

Background: As US military combat operations draw down in Afghanistan, the military health system will shift focus to garrison- and hospital-based care. Maintaining combat medical skills while performing routine healthcare in military hospitals and clinics is a critical challenge for Combat medics. Current regulations allow for a wide latitude of Combat medic functions. The Surgeon General considers combat casualty care a top priority. Combat medics are expected to provide sophisticated care under the extreme circumstances of a hostile battlefield. Yet, in the relatively safe and highly supervised setting of contiguous US-based military hospitals, medics are rarely allowed to perform the procedures or administer medications they are expected to use in combat. This study sought to determine patients? opinions on the use of combat medics in their healthcare., Methods: Patients in hospital emergency department (EDs) were offered anonymous surveys. Examples of Combat medic skills were provided. Participants expressed agreement using the Likert scale (LS), with scores ranging from "strongly agree" (LS score, 1) to "strongly disagree" (LS score, 5). The study took place in the ED at Bayne-Jones Army Community Hospital, Fort Polk, Louisiana. Surveys were offered to adult patients when they checked into the ED or to adults with other patients., Results: A total of 280 surveys were completed and available for analysis. Subjects agreed that Combat medic skills are important for deployment (LS score, 1.4). Subjects agreed that Combat medics should be allowed to perform procedures (LS score, 1.6) and administer medications (LS score, 1.6). Subjects would allow Combat medics to perform procedures (LS score, 1.7) and administer medications (LS score, 1.7) to them or their families. Subjects agreed that Combat medic activities should be a core mission for military treatment facilities (MTFs) (LS score, 1.6)., Conclusion: Patients support the use of Combat medics during clinical care. Patients agree that Combat medic use should be a core mission for MTFs. Further research is needed to optimize Combat medic integration into patient healthcare., (2015.)

Background: Servicemembers injured in combat often experience moderate to severe acute pain. Early and effective pain control in the prehospital setting has been shown to reduce the sequelae of untreated pain. Current data suggest that lack of point-of-injury (POI) analgesia has significant, downstream effects on healthcare quality and associated costs., Methods: This was a process improvement project to determine the current rate of adherence to existing prehospital pain management guidelines. The records of patients who had sustained a major injury and met current Tactical Combat Casualty Care (TCCC) criteria for POI analgesia from July 2013 through March 2014 were reviewed to determine if pain medication was given in accordance with existing guidelines, including medication administration and routes. On 31 October 2013, the new TCCC guidelines were released. The "before" period was from July 2013 through October 2013. The "after" period was from November 2013 through March 2014., Results: During the project period, there were 185 records available for review, with 135 meeting TCCC criteria for POI analgesia (68 pre-, 66 postintervention). Prior to 31 October 2013, 17% of study patients received analgesia within guidelines at the POI compared with 35% in the after period. The most common medication administered pre-and post-release was oral transmucosal fentanyl citrate. Special Operations Forces had higher adherence rates to TCCC analgesia guidelines than conventional forces, but these still were low., Conclusion: Less than half of all eligible combat casualties receive any analgesia at the POI. Further research is needed to determine the etiology of such poor adherence to current TCCC guidelines., (2015.)

Introduction: Over the last two decades, the conflicts in Iraq and Afghanistan have cost the United States significantly in terms of lives lost, disabling injuries, and budgetary expenditures. This manuscript calculates the differences in costs between veterans with combat injuries vs veterans without combat injuries. This work could be used to project future costs in subsequent studies. Materials and Methods: In this retrospective cohort study, we randomly selected 7,984 combat-injured veterans between February 1, 2002, and June 14, 2016, from Veterans Affairs Health System administrative data. We matched injured veterans 1:1 to noninjured veterans on year of birth (± 1 year), sex, and first service branch. We observed patients for a maximum of 10 years. This research protocol was reviewed and approved by the David Grant USAF Medical Center institutional review board (IRB), the University of Utah IRB, and the Research Review Committee of the VA Salt Lake City Health Care System in accordance with all applicable Federal regulations. Results: Patients were primarily male (98.1% in both groups) and White (76.4% for injured patients, 72.3% for noninjured patients), with a mean (SD) age of 26.8 (6.6) years for the injured group and 27.7 (7.0) years for noninjured subjects. Average total costs for combat-injured service members were higher for each year studied. The difference was highest in the first year ($16,050 compared to $4,135 for noninjured). These differences remained significant after adjustment. Although this difference was greatest in the first year (marginal effect $12,386, 95% confidence interval $9,736-$15,036; P < 0.001), total costs continued to be elevated in years 2-10, with marginal effects ranging from $1,766 to $2,597 (P < 0.001 for all years). More severe injuries tended to increase costs in all categories. Conclusions: Combat injured patients have significantly higher long-term health care costs compared to their noninjured counterparts. If this random sample is extrapolated to the 53,251 total of combat wounded service members, it implies a total excess cost of $1.6 billion to date after adjustment for covariates and a median follow-up time of 10 years. These costs are likely to increase as injured veterans age and develop additional chronic conditions. [ABSTRACT FROM AUTHOR]

Background: During the conflicts in Iraq and Afghanistan, 52,087 service members have been wounded in combat. The long-term sequelae of these injuries have not been carefully examined. We sought to determine the relation between markers of injury severity and the subsequent development of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease.Methods and Results: Retrospective cohort study of critically injured US military personnel wounded in Iraq or Afghanistan from February 1, 2002 to February 1, 2011. Patients were then followed until January 18, 2013. Chronic disease outcomes were assessed by International Classification of Diseases, 9th edition codes and causes of death were confirmed by autopsy. From 6011 admissions, records were excluded because of missing data or if they were for an individual's second admission. Patients with a disease diagnosis of interest before the injury date were also excluded, yielding a cohort of 3846 subjects for analysis. After adjustment for other factors, each 5-point increment in the injury severity score was associated with a 6%, 13%, 13%, and 15% increase in incidence rates of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease, respectively. Acute kidney injury was associated with a 66% increase in rates of hypertension and nearly 5-fold increase in rates of chronic kidney disease.Conclusions: In Iraq and Afghanistan veterans, the severity of combat injury was associated with the subsequent development of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease. [ABSTRACT FROM AUTHOR]

Objective: Fixed facilities and rapid global evacuation ensured that delayed complications of trauma, such as hyperkalemia, occurred late in the evacuation chain where renal replacement therapies were available. However, future conflicts or humanitarian disasters may involve prolonged evacuation times. We sought to quantify one potential risk of delayed evacuation by assessing hyperkalemia in combat casualties.Methods: Retrospective study of military members admitted to intensive care units in Iraq and Afghanistan from February 1, 2002, to February 1, 2011. This study was approved by the U.S. Army Medical Research and Materiel Command Institutional Review Board. Demographics, injury severity score, burn injury, mechanism of injury, vital signs, creatinine, and potassium were collected. Logistic regression models were used to identify incidence and risk factors for hyperkalemia.Results: Of 6,011 patient records, 1,472 had sufficient data to be included for analysis. Hyperkalemia occurred in 5.8% of patients. Those with hyperkalemia had higher injury severity scores, higher shock index, were more likely to have acute kidney injury, and were more likely to die. On multivariate analysis, acute kidney injury and shock index were significantly associated with the development of hyperkalemia. In a subgroup of patients with data on creatine kinase, rhabdomyolysis was associated with hyperkalemia in the univariate model, but was not significant after adjustment.Conclusion: Hyperkalemia occurred in 5.8% of patients in our cohort of critically injured combat casualties. The development of hyperkalemia was independently associated with acute kidney injury and shock index. In future conflicts, with prolonged evacuation times, mitigation strategies should be developed to treat hyperkalemia in casualties before arrival at definitive care. [ABSTRACT FROM AUTHOR]