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The purpose of this study was to examine subjective cognitive and psychiatric functioning in post-deployed military Veterans who underwent the Veterans Health Administration's Traumatic Brain Injury (TBI) Screening and Evaluation Program and enrolled in the VA's Million Veteran Program (MVP). Veterans (N = 7483) were classified into three groups based on outcomes from the TBI Screening and Evaluation Program: (1) negative TBI screen ('Screen-'), (2) positive TBI screen but no TBI diagnosis ('Screen+/TBI-'), or (3) positive TBI screen and TBI diagnosis ('Screen+/TBI+'). Chi-square analyses revealed significant group differences across all self-reported cognitive and psychiatric health conditions (e.g., memory loss, depression), and ANCOVAs similarly showed a significant association between group and subjective symptom reporting. Specifically, the relationship between TBI group and clinical outcome (i.e., health conditions and symptoms) was such that the Screen+/TBI+ group fared the worst, followed by the Screen+/TBI- group, and finally the Screen- group. However, evaluation of effect sizes suggested that Veterans in the two Screen+ groups (Screen+/TBI+ and Screen+/TBI-) are faring similarly to one another on subjective cognitive and psychiatric functioning, but that both Screen+ groups are faring significantly worse than the Screen- group. Our results have meaningful clinical implications and suggest that Veterans who screen positive for TBI, regardless of ultimate TBI diagnosis, be eligible for similar clinical services so that both groups can benefit from valuable treatments and therapeutics. Finally, this research sets the stage for follow-up work to be conducted within MVP that will address the neurobiological underpinnings of cognitive and psychiatric distress in this population.

ObjectiveDescribe dementia cases identified through International Classification of Diseases (ICD) coding in the Long-term Impact of Military-relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) multicenter prospective longitudinal study (PLS) of mild traumatic brain injury (mTBI).DesignDescriptive case series using cross-sectional data.MethodsVeterans Affairs (VA) health system data including ICD codes were obtained for 1563 PLS participants through the VA Informatics and Computing Infrastructure (VINCI). Demographic, injury, and clinical characteristics of Dementia positive and negative cases are described.ResultsFive cases of dementia were identified, all under 65 years old. The dementia cases all had a history of blast-related mTBI and all had self-reported functional problems and four had PTSD symptomatology at the clinical disorder range. Cognitive testing revealed some deficits especially in the visual memory and verbal learning and memory domains, and that two of the cases might be false positives.ConclusionsICD codes for early dementia in the VA system have specificity concerns, but could be indicative of cognitive performance and self-reported cognitive function. Further research is needed to better determine links to blast exposure, blast-related mTBI, and PTSD to early dementia in the military population.

There is a high comorbidity between symptoms of depression and cannabis and alcohol use in civilian and veteran populations. Prospective studies attempting to clarify the directionality of these comorbidities have yielded mixed results. Further, the relations between these constructs and impulsive personality, particularly negative urgency (NU, the tendency to act rashly when experiencing emotional distress) warrants further attention, as NU relates to symptoms of depression and alcohol and cannabis use. Importantly, NU partially accounts for the association between symptoms of depression and cannabis and alcohol problems in cross-sectional studies. This study examined alternative theories of directionality in order to better understand the longitudinal associations between symptoms of depression, NU, and cannabis or alcohol use. Three semiannual waves of data (baseline, 6-month, and 12-month) were collected in parallel assessments from a sample of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 361). Autoregressive cross-lagged panel models were used to test four alternative theory-driven models about the longitudinal associations between the interaction of symptoms of depression and NU and cannabis or alcohol use. Models revealed unique direction of effects specific to each substance, such that the interaction between symptoms of depression and NU at 6 months postbaseline predicted more alcohol use at 12 months postbaseline, whereas more cannabis use at 6 months postbaseline predicted more severe symptoms of depression at 12 months postbaseline. Results suggests alternate directions of effect for cannabis and alcohol use. Future research should examine these patterns over wider assessment periods in order to see more variability and change over time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

ObjectiveCognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated to treat posttraumatic stress disorder (PTSD) in the Veterans Health Administration (VHA). However, few Iraq and Afghanistan war veterans (Operation Enduring Freedom [OEF], Operation Iraqi Freedom [OIF], Operation New Dawn [OND]) diagnosed with PTSD have received CPT/PE and many initiate CPT/PE after substantial delay. Veterans who do not initiate CPT/PE or initiate CPT/PE after delay may have poorer treatment outcomes. This study aimed to identify predictors of CPT/PE initiation and timing.MethodsParticipants included OEF/OIF/OND veterans diagnosed with PTSD who received psychotherapy between 2001 and 2017 in the VHA (n = 265,566). Logistic regression analysis was utilized to predict initiating CPT/PE (vs. no CPT/PE). Multinomial logistic regression analysis was utilized to predict not initiating or initiating delayed CPT/PE versus "early CPT/PE" (< 1 year after first mental health visit). Analyzed predictors included demographic, military, and clinical complexity variables (e.g., comorbidities, reported military sexual trauma [MST] history).ResultsSeventy-Seven percent of veterans did not initiate CPT/PE, with 7.4% initiating early and 15.4% initiating delayed CPT/PE. Reported MST history (odds ratio [OR] = 1.45, 95% CI [1.39, 1.51]) and history of suicidal ideation/attempt (OR = 1.42, 95% CI [1.38, 1.46]) were strong predictors of CPT/PE initiation versus no CPT/PE. Comorbid pain (relative risk ratio [RRR] = 1.35, 95% CI [1.30, 1.42]) and depressive disorders (RRR = 1.37, 95% CI [1.32, 1.43]) were associated with increased likelihood of delayed versus early CPT/PE.ConclusionsMost veterans in our study did not initiate CPT/PE. Generally, clinical complexity variables increased likelihood of initiating CPT/PE and initiating CPT/PE more than 1 year after first mental health visit. Additional research is needed to understand whether CPT/PE delay results from receipt of alternative intervention due to clinical complexity variables. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Hostility, anger, and aggression are conceptually related but unique constructs found to occur more often among veterans with posttraumatic stress disorder (PTSD) than among civilians or veterans without PTSD. However, the pathways between PTSD, depression, hostility, anger, and aggression have not been comprehensively characterized. Therefore, drawing on a sample of returning Operation Enduring Freedom/Operation Iraqi Freedom combat veterans ( N = 175; 95% male; mean age 30 years), this study sought to examine the direct and indirect relationships among PTSD, depression, hostility, anger, and four types of aggression: verbal, and physical toward self, others, and objects. Functional modeling of direct effects was done using multiple least-squares regression and bootstrapped mediation analyses were carried out to test indirect effects. Results indicate that PTSD is not the overall direct contributor to different forms of aggression, supporting the mediating role of depression and trait anger. Depression symptoms explain part of the relationships between PTSD and verbal aggression, physical aggression toward objects, and physical aggression toward self and trait anger explains part of the relationships between PTSD and verbal aggression, physical aggression toward objects, and physical aggression toward others. Our findings support the importance of assessing for anger, depression, and different types of aggression among veterans presenting for PTSD treatment to develop individualized treatment plans that may benefit from early incorporation of interventions.

ObjectivesSuicidal ideation (SI) is highly prevalent in Iraq/Afghanistan-era veterans with a history of mild traumatic brain injury (mTBI), and multiple mTBIs impart even greater risk for poorer neuropsychological functioning and suicidality. However, little is known about the cognitive mechanisms that may confer increased risk of suicidality in this population. Thus, we examined relationships between neuropsychological functioning and suicidality and specifically whether lifetime mTBI burden would moderate relationships between cognitive functioning and suicidal ideation.MethodsIraq/Afghanistan-era Veterans with a history of mTBI seeking outpatient services (N = 282) completed a clinical neuropsychological assessment and psychiatric and postconcussive symptom questionnaires.ResultsIndividuals who endorsed SI reported more severe post-traumatic stress disorder (PTSD), depression, and postconcussive symptoms and exhibited significantly worse memory performance compared to those who denied SI. Furthermore, mTBI burden interacted with both attention/processing speed and memory, such that poorer performance in these domains was associated with greater likelihood of SI in individuals with a history of three or more mTBIs. The pattern of results remained consistent when controlling for PTSD, depression, and postconcussive symptoms.ConclusionsSlowed processing speed and/or memory difficulties may make it challenging to access and use past experiences to solve current problems and imagine future outcomes, leading to increases in hopelessness and SI in veterans with three or more mTBIs. Results have the potential to better inform treatment decisions for veterans with history of multiple mTBIs. (JINS, 2019, 25, 79-89).

Exposure to potentially morally injurious events has been shown to be associated with posttraumatic stress disorder (PTSD) and depression symptoms in military personnel. Few studies have examined factors that help to explain how potentially morally injurious events may contribute to the development of trauma-related psychopathology. Negative posttrauma cognitions are thought to play a role in the etiology of PTSD and depression following trauma; however, it is unclear whether more global beliefs about the self, others, and world play a role in the development of PTSD and depression due to morally injurious events. Using structural equation modeling, we tested whether morally injurious experiences were indirectly related to trauma-related psychopathology (PTSD and depression) through negative posttrauma cognitions in a sample of veterans seeking treatment for PTSD. An indirect effects only model best fit the data and showed that morally injurious experiences, specifically perceived transgressions by oneself and perceived betrayal, were indirectly associated with trauma-related psychopathology through negative posttrauma cognitions, β = .17; 95% CI [.04, .31] and β = .25; 95% CI [.11, .41], respectively. Our findings suggest that negative posttrauma cognitions may be an important mechanism linking exposure to morally injurious events and trauma-related psychopathology.

The Marine Resiliency Study-II examined changes in symptomatology across a deployment cycle to Afghanistan. U.S. Servicemembers (N = 1041) received clinical testing at two time points either bracketing a deployment (855) or not (186). Factor analyses were used to generate summary and change scores from Time 1 to Time 2. A between-subject design was used to examine changes across the deployment cycle with deployment (low-trauma, high-trauma, and non-deployed) and social support (low vs. high) as the grouping variables. Insomnia increased post-deployment regardless of deployment trauma (std. effect for high-trauma and low-trauma = 0.39 and 0.26, respectively). Only the high-trauma group showed increased PTSD symptoms and non-perspective-taking (std. effect = 0.40 and 0.30, respectively), while low-trauma showed decreased anxiety symptoms after deployment (std. effect = -0.17). These associations also depend on social support, with std. effects ranging from -0.22 to 0.51. When the groups were compared, the high-trauma deployed group showed significantly worse PTSD and non-perspective-taking than all other groups. Similar to studies in other military divisions, increased clinical symptoms were associated with high deployment stress in active duty Servicemembers, and social support shows promise as a moderator of said association.

Objective: We aimed to characterise self-reported military and occupational exposures including Agent Orange, chemical/biological warfare agents, solvents, fuels, pesticides, metals and burn pits among Veterans in the Department of Veterans Affairs Million Veteran Program (MVP)., Methods: MVP is an ongoing longitudinal cohort and mega-biobank of over one million US Veterans. Over 500 000 MVP participants reported military exposures on the baseline survey, and over 300 000 reported occupational exposures on the lifestyle survey. We determined frequencies of selected self-reported occupational exposures by service era, specific deployment operation (1990-1991 Gulf War, Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)), service in a combat zone and occupational categories. We also explored differences in self-reported exposures by sex and race., Results: Agent Orange exposure was mainly reported by Vietnam-era Veterans. Gulf War and OEF/OIF Veterans deployed to a combat zone were more likely to report exposures to burn pits, chemical/biological weapons, anthrax vaccination and pyridostigmine bromide pill intake as compared with non-combat deployers and those not deployed. Occupational categories related to combat (infantry, combat engineer and helicopter pilot) often had the highest percentages of self-reported exposures, whereas those in healthcare-related occupations (dentists, physicians and occupational therapists) tended to report exposures much less often. Self-reported exposures also varied by race and sex., Conclusions: Our results demonstrate that the distribution of self-reported exposures varied by service era, demographics, deployment, combat experience and military occupation in MVP. Overall, the pattern of findings was consistent with previous population-based studies of US military Veterans., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Upper limb (UL) disability in people with UL loss is well reported in the literature, less so for people with lower limb loss. This study aimed to compare UL disability in injured (major trauma) and uninjured UK military personnel, with particular focus on people with upper and lower limb loss., Methods: A volunteer sample of injured (n = 579) and uninjured (n = 566) UK military personnel who served in a combat role in the Afghanistan war were frequency matched on age, sex, service, rank, regiment, role, and deployment period and recruited to the Armed Services Trauma Rehabilitation Outcome (ADVANCE) longitudinal cohort study. Participants completed the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire, scored from 0 (no disability) to 100 (maximum disability) 8 years postinjury. Mann-Whitney U and Kruskal-Wallis tests were used to compared DASH scores between groups. An ordinal model was used to assess the effect of injury and amputation on DASH scores., Results: DASH scores were higher in the Injured group compared to the Uninjured group (3.33 vs 0.00) and higher in people with lower limb loss compared to the Uninjured group (0.83 vs 0.00), although this was not statistically significant. In the adjusted ordinal model, the odds of having a higher DASH score was 1.70 (95% CI = 1.18-2.47) times higher for people with lower limb loss compared to the Uninjured group. DASH score was not significantly different between people with major and partial UL loss (15.42 vs 12.92). The odds of having a higher DASH score was 8.30 (95% CI = 5.07-13.60) times higher for people with UL loss compared to the Uninjured group., Conclusion: People with lower limb loss have increased odds of having more UL disability than the Uninjured population 8 years postinjury. People with major and partial UL loss have similar UL disability. The ADVANCE study will continue to follow this population for the next 20 years., Impact: For the first time, potential for greater long-term UL disability has been shown in people with lower limb loss, likely resulting from daily biomechanical compensations such as weight-bearing, balance, and power generation. This population may benefit from prophylactic upper limb rehabilitation, strength, and technique., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Physical Therapy Association.)

Operation Allies Refuge started in July 2021 with implications for critical care nurses, both military and civilian, serving at the US Army's Landstuhl Regional Medical Center in Landstuhl, Germany. Cultural and logistical concerns and complications were at the forefront of care provided to Afghan evacuees during the operation and were exacerbated by a mass casualty event on August 26, 2021, when a suicide bomber attacked the Abbey Gate of Hamid Karzai International Airport in Kabul, Afghanistan. This article discusses the issues that affected care, including language barriers, supply shortages, cultural differences, mass evacuation during a pandemic, and management of the mass casualty event by the critical care team. The information is compiled into a summary of lessons learned to assist in future management of emergency evacuee care within our military and civilian health care systems., (©2024 American Association of Critical-Care Nurses.)

Background: Combat casualties are frequently injured in austere settings where modern imaging modalities are unavailable. Exploratory laparotomies are often performed in these settings when there is suspicion for intra-abdominal injury. Prior studies of combat casualties reported non-therapeutic laparotomy (NTL) rates as high as 32%. Given improvements in combat casualty care over time, we evaluated NTLs performed during later years of the wars in Iraq and Afghanistan., Methods: Military personnel with combat-related injuries (6/1/2009-12/31/2014) who underwent exploratory laparotomy based on concern for abdominal injury (i.e. not performed for proximal vascular control or fecal diversion) and were evacuated to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals were assessed. An NTL was defined as a negative laparotomy without substantial intra-abdominal injuries requiring repair. Characteristics, indications for laparotomy, operative findings, and outcomes were examined., Results: Among 244 patients who underwent laparotomies, 41 (16.8%) had NTLs and 203 (83.2%) had therapeutic laparotomies (i.e. positive findings). Patients with NTLs had more computed tomography scans concerning for injury (48.8% vs 27.1%; p = 0.006), less penetrating injury mechanisms (43.9% vs 71.9%; p < 0.001), and lower Injury Severity Scores (26 vs 33; p = 0.003) compared to patients with therapeutic laparotomies. Patients with NTLs were also less likely to be admitted to the intensive care unit (70.7 vs 89.2% for patients with therapeutic laparotomies; p = 0.007). No patients with NTLs developed abdominal surgical site infections (SSI) compared to 16.7% of patients with therapeutic laparotomies (p = 0.002). There was no significant difference in mortality between the groups (p = 0.198)., Conclusions: Our proportion of NTLs was lower than reported from earlier years during the wars in Iraq and Afghanistan. No infectious complications from NTLs (i.e. abdominal SSIs) were identified. Nevertheless, surgeons should continue to have a low threshold for exploratory laparotomy in military patients in austere settings with concern for intra-abdominal injury., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Respiration is a crucial determinant of autonomic balance and heart rate variability (HRV). The comparative effect of spontaneous versus paced breathing on HRV has been almost exclusively explored in healthy adults and never been investigated in an injured military cohort., Objective: To examine the effect of spontaneous versus paced breathing on HRV in veterans with combat-related traumatic injury (CRTI)., Design: Observational cohort study., Setting: ArmeD serVices trAuma rehabilitatioN outComE (ADVANCE) study, Stanford Hall, UK., Participants: The sample consisted of 100 randomly selected participants who sustained CRTI (eg, amputation) during their deployment (Afghanistan 2003-2014) and were recruited into the ongoing ADVANCE prospective cohort study., Intervention: Not applicable., Main Outcome Measure: HRV was recorded using a single-lead ECG. HRV data were acquired during a sequential protocol of 5-minute spontaneous breathing followed immediately by 5 minutes of paced breathing (six cycles/minute) among fully rested and supine participants. HRV was reported using time domain (root mean square of successive differences), frequency domain (low frequency and high frequency) and nonlinear (sample entropy) measures. The agreement between HRV during spontaneous versus paced breathing was examined using the Bland-Altman analysis., Results: The mean age of participants was 36.5 ± 4.6 years. Resting respiratory rate was significantly higher with spontaneous versus paced breathing (13.4 ± 3.4 vs. 7.6 ± 2.0 breaths/minute; p < .001), respectively. Resting mean heart rate and root mean square of successive differences were significantly higher with paced breathing than spontaneous breathing (p < .001). Paced breathing significantly increased median low frequency power than spontaneous breathing (p < .001). No significant difference was found in the absolute power of high frequency between the two breathing protocols. The Bland-Altman analysis revealed poor agreement between HRV values during spontaneous and paced breathing conditions with wide limits of agreement., Conclusion: Slow-paced breathing leads to higher HRV than spontaneous breathing and could overestimate resting "natural-state" HRV., (© 2024 The Authors. PM&R published by Wiley Periodicals LLC on behalf of American Academy of Physical Medicine and Rehabilitation.)

Objective: The study investigated the association over time between the rates of anger/hostility and suicidality in post-9/11 veterans as a function of time following separation from the military and combat exposure., Method: Structured clinical interviews were conducted with N = 2,580 Iraq/Afghanistan-era U.S. military veterans serving since 9/11/01. For each participant, a postseparation interval was calculated as the time between military separation and the clinical interview, with a range of up to 9 years. Combat exposure was assessed using a three-level categorical proxy derived from the Combat Exposure Scale indexing levels of none, below, and above median exposure. Three separate estimates measuring anger/hostility and three separate measures of suicidality were modeled variously across separation intervals and levels of combat exposure., Results: In bivariate analyses, higher levels of combat exposure were associated with overall significantly higher levels of both anger/hostility and suicidality. Based on multivariable analyses, rates in measures indexing suicidality among veterans did not decrease as a function of the number of years postseparation. In contrast, rates in measures indexing anger/hostility among veterans endorsing above-median levels of combat exposure decreased significantly with increasing time since separation. Nonetheless, even at longer time points, both suicidality and anger/hostility remained elevated among respondents endorsing above-median combat exposure., Conclusions: These findings illustrate the importance of implementing suicide prevention and anger management programs for postseparation adjustment as well as for the period beyond the immediate postseparation, with particular attention paid to the level of combat exposure experienced. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Background: Military veterans with posttraumatic stress disorder (PTSD) commonly experience posttraumatic guilt. Guilt over commission or omission evolves when responsibility is assumed for an unfortunate outcome (e.g., the death of a fellow combatant). Survivor guilt is a state of intense emotional distress experienced by the weight of knowing that one survived while others did not., Methods: This study of the Translational Research Center for TBI and Stress Disorders (TRACTS) analyzed structural and diffusion-weighted magnetic resonance imaging data from 132 male Iraq/Afghanistan veterans with PTSD. The Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV) was employed to classify guilt. Thirty (22.7 %) veterans experienced guilt over acts of commission or omission, 34 (25.8 %) experienced survivor guilt, and 68 (51.5 %) had no posttraumatic guilt. White matter microstructure (fractional anisotropy, FA), cortical thickness, and cortical volume were compared between veterans with guilt over acts of commission or omission, veterans with survivor guilt, and veterans without guilt., Results: Veterans with survivor guilt had significantly lower white matter FA compared to veterans who did not experience guilt (p < .001), affecting several regions of major white matter fiber bundles. There were no significant differences in white matter FA, cortical thickness, or volumes between veterans with guilt over acts of commission or omission and veterans without guilt (p > .050)., Limitations: This cross-sectional study with exclusively male veterans precludes inferences of causality between the studied variables and generalizability to the larger veteran population that includes women., Conclusion: Survivor guilt may be a particularly impactful form of posttraumatic guilt that requires specific treatment efforts targeting brain health., Competing Interests: Declaration of competing interest The other authors disclose no financial or other biomedical interests or potential conflicts of interest. Disclosure Dr. Koerte is a professor at Ludwig-Maximilians-Universität Munich (paid position). She serves as European Editor at Journal of Neurotrauma (unpaid position) and as Vice President of the European Neurotrauma Organization (unpaid position). She receives research grant funding from the National Institutes of Health, the European Research Council, the German Ministry for Research and Education. She receives funding for a research study on sport-related concussion from Abbott Inc. The Ludwig-Maximilians-University hospital received donations for her research from the Schatt Foundation and from Mary Ann Liebert Inc. She receives royalties for book chapters published by Thieme Publishers. Her spouse is employee at Siemens and she thus holds stock options at Siemens and Siemens Healthineers. Dr. Koerte's in-kind contributions: PhD students working under her supervision receive scholarships from the Villigst Foundation, the Konrad Adenauer Foundation, the Studienstiftung des deutschen Volkes, the China Scholarship Council collaboration with Ludwig-Maximilians-University Munich, the Harvard Munich Club, and Fulbright. Dr. Shenton is Professor of Psychiatry and Radiology at Harvard Medical School and is employed by Brigham and Women's Hospital. She has grant funding from the National Institute of Mental Health and formerly from VA Merit Awards and from the National Institute of Neurological Diseases and Stroke. She serves on the editorial board of several professional journals (unpaid), on NIH study sections (Honoria minimum), and she receives royalties for book chapters and books published by Thieme Publishers, Elsevier, and Cambridge University Press (minimal). She receives funding also for legal cases as a consultant and an expert witness related to mild traumatic brain injury and the use of diffusion tensor imaging in the courtroom. Dr. Shenton's in-kind contributions include PhD, MD, MD-PhD trainees and junior faculty working under her mentorship, many of whom have received K awards and grant support for their research. Dr. Kaufmann received speaker honoraria and financial compensation for travel expenses from Medtronic, UCB, Livanova, and Eisai and has participated in clinical trials for Medtronic, UCB and Precisis, all unrelated to the submitted work. Her research is supported by the Medical Clinical Scientist Program (MCSP). Tim Wiegand receives author royalties from ELSEVIER publishers., (Copyright © 2024 Elsevier B.V. All rights reserved.)

In 2015, the VIRTUS helmet was introduced to UK Armed Forces and will ultimately replace the Mark 7 combat helmet. The VIRTUS helmet has a reduced trimline compared to the Mark 7 helmet and can incorporate attachments such as a visor, mandible guard and nape protection. An anonymous questionnaire was provided to 200 UK Armed Forces personnel deployed to four locations on Operation TORAL in Afghanistan between September and October 2019. This is the first User feedback survey assessing the VIRTUS helmet in an operational environment. Users were measured to ascertain the fit of their helmet and asked to rate perceived helmet mass and comfort using a 5-point Likert scale. Users were also asked whether the VIRTUS helmet was better than previous helmets and about their use of the nape protection. The VIRTUS helmet was perceived to be an improvement over previously issued UK combat helmets in terms of both comfort and mass., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Introduction: Hypothermia increases mortality in trauma populations and frequently occurs in military casualties due to the nature of combat environments. The association between hypothermia and the time of year when injured remains unclear. We sought to determine the association between seasonal changes in temperature and hypothermia among combat casualties., Materials and Methods: This observational study was a secondary analysis of a previously described Department of Defense Trauma Registry dataset which included U.S. military and Coalition casualties who received prehospital care from January 2007 to March 2020 in Afghanistan and Iraq. We tested for associations between hypothermia (<36.2°C) and seasonal ambient temperatures by constructing multivariable logistic regression models. Summer was defined as June through August and winter as December through February. We assumed that the combat operations occurred in the area near the point of first contact with the deployed military treatment facilities. This study was determined to be exempt from Institutional Review Board oversight., Results: There were 5,821 that met inclusion for this study. Within the multivariable logistic regression model, we adjusted for injury severity score, mechanism of injury, and imputed transport time, finding that combat casualties were 2.28 (odds ratio, 95% confidence interval 1.93-2.69) times more likely to develop hypothermia in the winter versus summer. When using temperature as a continuous outcome, casualties had a lower emergency department temperature during the winter (parameter estimate -0.133°C, P < 0.001) after adjusting for confounders. In casualties experiencing hypothermia, mortality was higher (4% versus 1%, P < 0.001), and composite median injury severity score values were higher (10 versus 5, P < 0.001). Among hypothermic casualties, serious injuries were significantly more common (all P < 0.001) to the head (15% versus 7%), thorax (15% versus 7%), abdomen (9% versus 6%), extremities (35% versus 22%), and skin (4% versus 2%)., Conclusions: We found a seasonal variation in the occurrence of hypothermia in a large cohort of trauma casualties. Despite adjustment for multiple known confounders, our findings substantiate probable ambient temperature variations to trauma-induced hypothermia. Furthermore, our findings, when taken in the context of other studies on the efficacy of current hypothermia prevention and treatment strategies, support the need for better methods to mitigate hypothermia in future cold-weather operations., (© 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: Soldiers on the battlefield are affected by heavy body armor and excessive march load. It is well known, but the long-term effects of this extra weight on the musculoskeletal system of military veterans, specifically the lumbar spine, are unclear. In Iraq and Afghanistan, most body armors weighed over 33 pounds (15 kg). These armors were 3 times heavier than those used in Vietnam. Chiropractors at the Fargo VA Hospital are seeing more young veterans with non-traumatic lower back pain. This article presents a perspective on the impact of body armor weight and excessive carry load on lumbosacral disc herniation with radicular pain in military veterans., Materials and Methods: This study is a retrospective case series. We used a convenient sampling method. We selected the first 10 military veterans who came to a Fargo VA chiropractor in late fall 2023. Each veteran filled out a VA Form 10-5345 to give us permission to access their electronic health records. All 10 veterans also completed a survey. The survey asked about their active combat status, the type and weight of their body armor, how long they wore the armor each day, how much weight they carried, and their opinion on the cause of their lower back pain (service related or not). The Fargo VA does not require an institutional review board for a case series., Results: This study found that military veterans experience lower back pain at an average age of 35 years. This is at least 5 years earlier than non-service men. Lower back pain with disc herniation typically occurs at the L4-L5 and L5-S1 disc levels. All 10 veterans in the study believe that their lower back pain is related to their service. Sixty percent of the participants in the study have a service-connected disability because of back pain., Conclusions: For military veterans, onset of lower back pain from a disc herniation at a young age may be linked to carrying heavy body armor and loads. However, the small sample size of this case series limits causal relationship inferences., (© 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: Information from published studies describing dental treatment of nonmilitary personnel in a military theater of operations is sparse. The primary objective of this study is to determine the number of dental emergencies (DEs) and the types of dental treatment rendered on non-U.S. military (civilian) personnel treated by Navy dentists in 2007-2008 in Iraq and 2009 in Afghanistan. The second objective is to compare the type of DE treatment procedures provided to civilian personnel to the type of DE treatment procedures performed on U.S. military personnel., Materials and Methods: Navy Dental Officers documented the diagnoses of unscheduled DEs. All treatment provided was described at the time of treatment using the Current Dental Terminology codes of the American Dental Association. Current Dental Terminology Code A0145 (2007 and earlier) and A0199 (2008 onward) in the patient encounter indicated a DE. This study is limited to DE occurring in (1) patient categories: U.S. civilian employees, other beneficiaries of the U.S. Government, foreign national civilian/dependents, and civilian, no government connection and (2) U.S. military service members. Chi-square analysis was performed to compare the proportion of dental treatment category procedures on civilian patients compared to those on U.S. military patients., Results: During the reporting period, 308 patients were treated for DE in Afghanistan. Civilians treated accounted for 18.5% (n = 57) of all DEs. Nearly 93.0% of civilians who were treated were U.S. (DoD) civilian employees. Of the 57 civilian patients treated for DE, 61.4% of patients (n = 35) received oral surgery. There were 251 U.S. military patient encounters (81.5% of all DEs). Restorative dentistry was the most common dental procedure for military personnel DE. When comparing civilian and military patients, civilian patients are statistically more likely than military patients to receive oral surgery treatment for DE (P < .00001). In Iraq, 3,198 patients were treated for DE during the reporting period. Civilians treated accounted for 18.8% (n = 601) of all DEs. About 56.9% (n = 342) of civilians who were treated were U.S. contract employees. Of the 601 civilian patients treated for DE, 37.1% (n = 223) received oral surgery. There were 2,597 U.S. military patient DE encounters, and restorative dentistry was the most common dental procedure. When comparing civilian and U.S. military patients in Iraq, civilians are statistically less likely to have their DE treated by restorative dentistry (P < .00001) and are more likely have it treated by oral surgery/extractions (P < .00001). It is significantly more likely for civilians to have multiple categories of DE that must be treated (P< .00001)., Conclusions: The primary group of civilians treated for DE in Afghanistan was U.S. civilian employees. The primary group of civilians treated for DE in Iraq were contract employees of the U.S. Government. The primary dental treatment of civilian beneficiaries in both the theaters of operation was oral surgery. This brings into question what dental fitness standards are there for primarily U.S. civilian and contract employees., (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.)

Background: Problematic anger, characterized by excessive frequency, intensity, and duration of anger which causes substantial emotional distress and functional interference, poses a marked challenge in military populations. Despite its importance, research on this topic is limited. This study contributes to the literature by exploring problematic anger in a large sample of Norwegian military personnel who served in NATO missions in Afghanistan., Methods: All Norwegian military personnel who deployed to Afghanistan between 2001 and 2020 were sent a link to a cross-sectional web-based survey by the Joint Medical Services of the Norwegian Armed Forces in 2020. A total of 6205 individuals (response rate: 67.7%) participated. The cross-sectional survey assessed problematic anger, mental and physical health, war zone stressor exposure, and quality of life., Results: Overall, 8.4% of participants reported problematic anger. Mental health disorders, deployment-related shame and guilt, chronic pain, and challenges with the military-to-civilian transition were independently associated with problematic anger. Both staying in service and maintaining a part-time connection with the military as a reservist mitigated the risk of problematic anger after deployment, compared to complete separation from military service., Conclusion: Findings demonstrate a sizeable prevalence of problematic anger among veterans of combat deployments. Given the associations between problematic anger and mental health disorders, chronic pain, and transition challenges, interventions designed to mitigate problematic anger need to be multi-faceted, including the possibility of maintaining an ongoing connection to military service. By reducing the risk of problematic anger, occupational, interpersonal and health outcomes may be improved for service members. Future research should examine the impact of problematic anger on adjustment over time, prevention strategies, and problematic anger in other high-risk occupations., (© 2024. The Author(s).)

Introduction: Sleep-related disorders are associated with pain, fatigue, and deficits in cognitive performance, which may interfere with successful rehabilitation. The study objectives were to (1) quantify outpatient prescriptions for insomnia medications during the first year following combat-related amputations, (2) examine longitudinal changes in prescriptions for insomnia medications, and (3) analyze patient characteristics associated with prescriptions for insomnia medications., Material and Methods: This was a retrospective study of DoD casualty records from the Expeditionary Medical Encounter Dataset and prescriptions for outpatient medications from the Pharmacy Data Transaction Service. Patients were a total of 1,651 U.S. service members who sustained major limb amputations in Operations Iraqi and Enduring Freedom from 2001 through 2017 and had outpatient prescriptions for any medication during the first year postinjury. Prescriptions for medications recommended for insomnia were low-dose antidepressants, anxiolytic sedatives, benzodiazepines, melatonin receptor agonist, and low-dose quetiapine. These prescription medications were analyzed by medication type, postinjury time, and patient characteristics during the first year postinjury., Results: During the first year postinjury, 78% of patients (1,291 of 1,651) had outpatient prescriptions for insomnia medications, primarily anxiolytic sedative drugs (e.g., zolpidem), averaging a total of 86 prescription days (median = 66). The prevalence of these prescriptions declined substantially during the first year, from 57% of patients during the first quarter to 28% during the fourth quarter postinjury. In univariate analyses, multiple patient characteristics, including high Injury Severity Score, continued opioid and non-opioid analgesic prescriptions, and diagnoses of chronic pain, mood disorder, and posttraumatic stress disorder, were significantly associated with higher prevalence and duration of outpatient prescriptions for insomnia medications., Conclusions: The present results indicate a high prevalence of outpatient prescriptions for insomnia medications following combat-related amputations, a prevalence that is substantially higher than previously reported among active duty personnel. These findings can inform DVA/DoD guidelines for amputation care and insomnia among military subpopulations. The results highlight the need for more research on the treatment of insomnia during early postinjury rehabilitation among patients who sustained serious combat injuries., (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.)

Former UK military personnel who were previously deployed to Iraq and Afghanistan in combat roles have exhibited elevated levels of Post-Traumatic Stress Disorder (PTSD) compared to other groups. The present qualitative analyses used semi-structured interviews and a framework analysis to compare the experiences of symptomatic (N=10) and asymptomatic (N=7) former Army and Royal Marine personnel who were exposed to combat. Participants were drawn from a large UK military health and wellbeing cohort study and were sampled based upon probable PTSD status using scores from the PTSD Checklist-Civilian Version (PCL-C). All symptomatic participants attributed the development of post-traumatic stress to deployment events, with one additionally ascribing symptoms to childhood events. Among the participants, post-traumatic stress was temporarily buffered, and held at bay, by the holding function of various military structures, including the military collective; cultural and ethical frameworks that helped to organise traumatic experiences; an operational necessity for psychological compartmentalisation and even the distraction of deployment itself. Leaving the military appeared to elicit a global rupture of these supports. As a result, the military-to-civilian transition led to an intensification of post-traumatic stress, including deployment-related memories, among the symptomatic participants. In contrast, asymptomatic participants tended to report continuity of their holding structures across the lifespan, especially across the military-to-civilian transition. The onset and maintenance of post-traumatic stress may thus be explained by an interplay between the capacity of holding structures and the magnitude of lifetime rupture. Overall, findings might provide an explanation for the widening discrepancies between those with enduring post-traumatic stress and those without and further research is required to determine the fit of our findings for other groups and contexts. This approach further illustrates the need to situate individual experiences of post-traumatic stress in wider structural, ecological, cultural and ethical contexts., Competing Interests: The authors have read the journal’s policy and have the following competing interests: NTF is supported by a grant from the UK MoD, and is a trustee of a charity supporting the wellbeing of military personnel and veterans, outside of the submitted work. SAMS is supported by the National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre at South London, Maudsley NHS Foundation Trust, and the National Institute for Health Research (NIHR Advanced Fellowship, NIHR300592), outside of the submitted work. WB works part-time for the veteran’s mental health charity Combat Stress. AS is a serving regular member of the British Army and was seconded to King’s College London during this work. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Palmer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Poor sleep quality has been associated with changes in brain volume among veterans, particularly those who have experienced mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD). This study sought to investigate (1) whether poor sleep quality is associated with decreased cortical thickness in Iraq and Afghanistan war veterans, and (2) whether these associations differ topographically depending on the presence or absence of mTBI and PTSD., Methods: A sample of 440 post-9/11 era U.S. veterans enrolled in the Translational Research Center for Traumatic Brain Injury and Stress Disorders study at VA Boston, MA from 2010 to 2022 was included in the study. We examined the relationship between sleep quality, as measured by the Pittsburgh Sleep Quality Index (PSQI), and cortical thickness in veterans with mTBI (n = 57), PTSD (n = 110), comorbid mTBI and PTSD (n = 129), and neither PTSD nor mTBI (n = 144). To determine the topographical relationship between subjective sleep quality and cortical thickness in each diagnostic group, we employed a General Linear Model (GLM) at each vertex on the cortical mantle. The extent of topographical overlap between the resulting statistical maps was assessed using Dice coefficients., Results: There were no significant associations between PSQI and cortical thickness in the group without PTSD or mTBI (n = 144) or in the PTSD-only group (n = 110). In the mTBI-only group (n = 57), lower sleep quality was significantly associated with reduced thickness bilaterally in frontal, cingulate, and precuneus regions, as well as in the right parietal and temporal regions (β = -0.0137, P < 0.0005). In the comorbid mTBI and PTSD group (n = 129), significant associations were observed bilaterally in frontal, precentral, and precuneus regions, in the left cingulate and the right parietal regions (β = -0.0094, P < 0.0005). Interaction analysis revealed that there was a stronger relationship between poor sleep quality and decreased cortical thickness in individuals with mTBI (n = 186) compared to those without mTBI (n = 254) specifically in the frontal and cingulate regions (β = -0.0077, P < 0.0005)., Conclusions: This study demonstrates a significant relationship between poor sleep quality and lower cortical thickness primarily within frontal regions among individuals with both isolated mTBI or comorbid diagnoses of mTBI and PTSD. Thus, if directionality is established in longitudinal and interventional studies, it may be crucial to consider addressing sleep in the treatment of veterans who have sustained mTBI., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

In the aftermath of the US withdrawal from Afghanistan, over 100,000 individuals were evacuated to the United States, primarily arriving through Philadelphia International Airport and Dulles International Airport under Operation Allies Welcome. In Philadelphia, evacuees were greeted at the airport by a medical triage unit (MTU) that was rapidly assembled to provide on-site medical care. The MTU triaged emergent medical complaints, handled minor complaints on-site to reduce impact on local health care systems, distributed patients who did require a higher level of care among area hospitals, and ensured appropriate follow-up care for individuals with ongoing needs. Although there are regional and federal entities whose purview is the establishment and coordination of such responses, these entities were not mobilized to respond immediately when planes began to arrive carrying the first wave of evacuees as this event was not a designated disaster. The MTU was a grassroots effort initiated by local health care providers in coordination with the local Medical Reserve Corps and Department of Public Health. This article presents a framework for similar operations, anticipating an ongoing need for planning for sudden arrivals of large numbers of displaced persons, particularly via air travel, in a time of increasing mass displacement events, as well as a rationale for establishing more robust networks of local medical professionals willing to respond in the case of an emergency and involving them in the emergency planning processes to ensure preexisting protocols are practical.

The current war in Ukraine has drawn public attention to the treatment of war injuries. Follow-up treatment in Germany is portrayed the clover leaf of the TraumaNetzwerke DGU, is largely based on the demands of the Federal Ministries for Defence and Health and is intended to enhance resilience in war.The present article presents the special features of the care of severely injured patients during hostilities and should provide insights into the expected results of treatment and the actual procedures. We emphasise the unpredictability of the care of the severely injured during hostilities.On the basis of a search of the literature for the deployment of the German Army in Afghanistan and for the current war in Ukraine, we present the challenges and the typical patterns of injuries. We discuss the factors that can influence the procedures and the quality of the results during hostilities and how these may differ from civil polytrauma care in Germany - which is well established and standardised.Even during deployment of the Federal Army or (as planned) NATO, care of the severely injured is under standardised conditions, as based on the algorithmic ATLS care and which is concentrated on bleeding control. The corresponding equipment and personnel are well established, well prepared and well trained.However, there may be special local conditions or special deployments that make it inevitable that emergency medical care will be more delayed than in the civil system in Germany and can only take place after protracted transport. The objective is always that soldiers in combat should be able to receive medical care that is equivalent to that received by all accident victims in Germany, whatever the time and site of the accident., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient mass-casualty situation (MASCAL)., Methods: The sample included orthopedic (four) and general surgeons (eight) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan, on August 26, 2021. One orthopedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1, expeditionary knowledge (examination score); 2, procedural skills competencies (performance assessment score); and 3, clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases was reviewed and rated (performance score) by the Joint Trauma System's Performance Improvement Branch, a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each predeployment measure and MASCAL surgical care., Results: Predeployment knowledge and clinical activity measures met program benchmarks. Baseline predeployment procedural skills competency scores did not meet program benchmarks; however, those gaps were closed through retraining, ensuring all surgeons met or exceeded the program benchmarks predeployment. There were very large effect sizes (Cohen's d ) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons., Conclusion: The prescribed program measures ensured that all surgeons achieved predeployment performance benchmarks and provided high-quality trauma care to our nation's service members., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "œwork of the United States Government"œ for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

People with depression often underutilize mental health care. This study was conceived as a first step toward a clinical decision support tool that helps identify patients who are at higher risk of underutilizing care. The primary goals were to (a) describe treatment utilization patterns, early termination, and return to care; (b) identify factors associated with early termination of treatment; and (c) evaluate the accuracy of regression models to predict early termination. These goals were evaluated in a retrospective cohort analysis of 108,457 U.S. veterans who received care from the Veterans Health Administration between 2001 and 2021. Our final sample was 16.5% female with an average age of 34.5. Veterans were included if they had a depression diagnosis, a positive depression screen, and received general health care services at least a year before and after their depression diagnosis. Using treatment quality guidelines, the threshold for treatment underutilization was defined as receiving fewer than four psychotherapy sessions or less than 84 days of antidepressants. Over one fifth of veterans (21.6%) received less than the minimally recommended care for depression. The odds of underutilizing treatment increased with lack of Veterans Administration benefits, male gender, racial/ethnic minority status, and having received mental health treatment in the past (adjusted OR > 1.1). Posttraumatic stress disorder comorbidity correlated with increased depression treatment utilization (adjusted OR < .9). Models with demographic and clinical information from medical records performed modestly in classifying patients who underutilized depression treatment (area under the curve = 0.595, 95% CI [0.588, 0.603]). Most veterans in this cohort received at least the minimum recommended treatment for depression. To improve the prediction of underutilization, patient factors associated with treatment underutilization likely need to be supplemented by additional clinical information. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

BackgroundEarly diagnosis and treatment of chronic obstructive pulmonary disease (COPD) can slow disease progression. The Department of Veterans Affairs (VA)/Department of Defense Clinical Practice Guidelines (CPG), established to improve patient outcomes, recommend the use of spirometry in the COPD diagnostic process. The aims of this study were to assess VA health care providers' performance related to CPG-recommended spirometry administration in the evaluation of newly diagnosed COPD among veterans, determine the patient characteristics that may influence the adherence rate, and compare VA concordance rates to those of other health plans.MethodsAdministrative health care data related to Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) veterans was used to identify newly diagnosed COPD cases and the proportion of cases receiving spirometry. Cases were defined as veterans who had their first medical encounter with a coded diagnosis of COPD ≥ 6 months after their initial VA health care evaluation. The relationship between prediagnostic and comorbid conditions and the administration of CPG-concordant spirometry was examined using regression analyses.FindingsAmong the 923,646 OEF/OIF/OND veterans receiving VA health care between January 2002 and December 2014, 32,076 (3%) had a coded diagnosis of COPD. Among those, 22,156 (69%) were identified as newly diagnosed COPD cases; only 6,827 (31%) had CPG-concordant spirometry. Concordant spirometry was more likely to occur in veterans aged ≥40. A pre-existing tobacco use disorder marginally changed the concordance rate.DiscussionVA provider adherence to CPG-concordant spirometry would decrease the prevalence of false-positive COPD cases and lead to more targeted disease treatment. Future research should focus on such cases by assessing the association between COPD diagnosis and bronchodilator responsiveness.

Emerging knowledge suggests that post-traumatic stress disorder (PTSD) pathophysiology is linked to the patients' epigenetic changes, but comprehensive studies examining genome-wide methylation have not been performed. In this study, we examined genome-wide DNA methylation in peripheral whole blood in combat veterans with and without PTSD to ascertain differentially methylated probes. Discovery was initially made in a training sample comprising 48 male Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) veterans with PTSD and 51 age/ethnicity/gender-matched combat-exposed PTSD-negative controls. Agilent whole-genome array detected ~5600 differentially methylated CpG islands (CpGI) annotated to ~2800 differently methylated genes (DMGs). The majority (84.5%) of these CpGIs were hypermethylated in the PTSD cases. Functional analysis was performed using the DMGs encoding the promoter-bound CpGIs to identify networks related to PTSD. The identified networks were further validated by an independent test set comprising 31 PTSD+/29 PTSD- veterans. Targeted bisulfite sequencing was also used to confirm the methylation status of 20 DMGs shown to be highly perturbed in the training set. To improve the statistical power and mitigate the assay bias and batch effects, a union set combining both training and test set was assayed using a different platform from Illumina. The pathways curated from this analysis confirmed 65% of the pool of pathways mined from training and test sets. The results highlight the importance of assay methodology and use of independent samples for discovery and validation of differentially methylated genes mined from whole blood. Nonetheless, the current study demonstrates that several important epigenetically altered networks may distinguish combat-exposed veterans with and without PTSD.

Military service members have an increased risk of developing mental health (MH) problems following deployment to Iraq or Afghanistan, yet only a small percentage seek mental health treatment. The aim of the present study was to explore patterns of MH service utilization within the first 12 months following return from combat deployment. Participants were 169 service members who had returned from war-zone deployment in either Iraq or Afghanistan and had assessments covering a 12-month period following their homecoming. The authors first examined the prevalence of mental health diagnoses and engagement with mental health treatment (e.g., visits to the emergency room, inpatient hospitalization, individual therapy, group therapy, family or couple therapy, medication appointments, and self-help). Regression analyses explored whether distress, functioning, diagnoses, or social support predicted treatment use. Findings indicated that 28 of 50 military service members (56%) who met diagnostic criteria for a mental health disorder accessed services in the year following their return from deployment. Individual treatment was the most common modality, and those with major depressive disorder (MDD) reported the most treatment contacts. Social support was not associated with use of mental health services. Baseline functioning and psychiatric distress predicted entry into treatment whereas only psychiatric distress predicted amount of mental health service use in the 12-month postdeployment period. Findings highlight the need for enhanced strategies to link those reporting psychiatric distress with MH treatment services and increase community connectedness regardless of whether they meet full criteria for a mental health diagnosis. (PsycINFO Database Record

ObjectiveCerebral blood flow (CBF) plays a critical role in the maintenance of neuronal integrity, and CBF alterations have been linked to deleterious white matter changes. Although both CBF and white matter microstructural alterations have been observed within the context of traumatic brain injury (TBI), the degree to which these pathological changes relate to one another and whether this association is altered by time since injury have not been examined. The current study therefore sought to clarify associations between resting CBF and white matter microstructure post-TBI.Methods37 veterans with history of mild or moderate TBI (mmTBI) underwent neuroimaging and completed health and psychiatric symptom questionnaires. Resting CBF was measured with multiphase pseudocontinuous arterial spin labeling (MPPCASL), and white matter microstructural integrity was measured with diffusion tensor imaging (DTI). The cingulate cortex and cingulum bundle were selected as a priori regions of interest for the ASL and DTI data, respectively, given the known vulnerability of these regions to TBI.ResultsRegression analyses controlling for age, sex, and posttraumatic stress disorder (PTSD) symptoms revealed a significant time since injury × resting CBF interaction for the left cingulum (p

Mild traumatic brain injury (mTBI), or concussion, is prevalent in the military. The course of recovery can be highly variable. This study investigates whether deployment-acquired mTBI is associated with subsequent presence and severity of post-concussive symptoms (PCS) and identifies predictors of persistent PCS among US Army personnel who sustained mTBI while deployed to Afghanistan. We used data from a prospective longitudinal survey of soldiers assessed 1-2 months before a 10-month deployment to Afghanistan (T0), on redeployment to the United States (T1), approximately 3 months later (T2), and approximately 9 months later (T3). Outcomes of interest were PCS at T2 and T3. Predictors considered were: sociodemographic factors, number of previous deployments, pre-deployment mental health and TBI history, and mTBI and other military-related stress during the index deployment. The study sample comprised 4518 soldiers, 822 (18.2%) of whom experienced mTBI during the index deployment. After adjusting for demographic, clinical, and deployment-related factors, deployment-acquired mTBI was associated with nearly triple the risk of reporting any PCS and with increased severity of PCS when symptoms were present. Among those who sustained mTBI, severity of PCS at follow-up was associated with history of pre-deployment TBI(s), pre-deployment psychological distress, more severe deployment stress, and loss of consciousness or lapse of memory (versus being "dazed" only) as a result of deployment-acquired mTBI. In summary, we found that sustaining mTBI increases risk for persistent PCS. Previous TBI(s), pre-deployment psychological distress, severe deployment stress, and loss of consciousness or lapse of memory resulting from mTBI(s) are prognostic indicators of persistent PCS after an index mTBI. These observations may have actionable implications for prevention of chronic sequelae of mTBI in the military and other settings.

ObjectiveAlthough posttraumatic stress disorder (PTSD) and chronic pain frequently occur in tandem, the pathophysiological mechanisms mediating this comorbidity are poorly understood. Because excessive inflammation occurs in both conditions, we examined the cerebrospinal fluid (CSF) concentrations of inflammatory response mediators interleukin 1-beta (IL-1β), interleukin 6 (IL-6), interleukin 8 (IL-8), tumor necrosis factor-alpha (TNFα) and interleukin 10 (IL-10) after prolonged suprathreshold pain stimulus in 21 male combat veterans; 10 with PTSD and 11 combat controls (CC).MethodsAfter completing baseline quantitative sensory testing (QST) and psychological profiling, all patients received an injection of capsaicin into the quadriceps muscle. Spontaneously reported pain was measured for 30min after the capsaicin injection. The evoked pain measure of temporal summation was tested between 70 and 110min post capsaicin injection. Inflammatory (IL-1β, IL-6, IL-8 TNFα) and anti-inflammatory (IL-10) CSF cytokines were measured before (baseline) and after capsaicin injection over a time frame of 110min.ResultsFollowing intramuscular capsaicin injection, pro-inflammatory cytokines [TNFα, IL-6, IL-8] significantly increased (percent rise from baseline) in both groups, whereas IL-1β significantly increased in the PTSD group only. The anti-inflammatory cytokine IL-10 showed an immediate (within 10min) increase in the CC group; however, the IL-10 increase in the PTSD group was delayed and not consistently elevated until 70min post injection.ConclusionThese findings show significant central nervous system (CNS) differences in the inflammatory response to a deep pain stimulus in combat veterans with and without PTSD. They support the concept that abnormally elevated neuroinflammatory response to pain stimuli may be one CNS mechanism accounting for the high co-occurrence of PTSD and pain.

Purpose: Combat deployment increases exposure to potentially traumatic events. Perceived social support (PSS) may promote health and recovery from combat trauma. This systematic review and meta-analysis aimed to synthesize studies investigating the level of PSS and associated factors among (ex-)military personnel who served in the Iraq/Afghanistan conflicts., Methods: Five electronic databases were searched in August 2023 and searches were restricted to the beginning of the Iraq/Afghanistan conflicts in 2001. The search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A quality assessment was carried out, and a meta-analysis and narrative synthesis were performed., Results: In total, 35 papers consisting of 19,073 participants were included. Of these, 31 studies were conducted in the United States (US) and 23 were cross-sectional. The pooled mean PSS score was 54.40 (95% CI: 51.78 to 57.01). Samples with probable post-traumatic stress disorder had a lower mean PSS score (44.40, 95% CI: 39.10 to 49.70). Approximately half of the included studies (n = 19) investigated mental health in relation to PSS, whilst only four explored physical health. The most frequently reported risk factors for low PSS included post-traumatic stress disorder, depression and anxiety, whilst post-traumatic growth and unit support were protective factors., Conclusion: Higher levels of PSS were generally associated with more positive psychosocial and mental health-related outcomes following deployment. PSS should be targeted in psychosocial interventions and education programmes. Future research should investigate PSS in (ex-)military personnel across other countries and cultures, based on the lack of studies that focused on PSS in countries outside of the US., (© 2024. The Author(s).)

Background: Mental Health support to military operations is well established as an integral part of military medicine. Unfortunately, Commanders often receive little or no training in how best to use their mental health assets or what their capabilities are. Conversely, members of a Field Mental Health Team frequently have no operational experience and try to merely translate their civilian practice onto the battlefield., Aim: This article describes what mental health professional can, and should do on military deployments and calls for greater training and awareness of both Mental Health professionals and Operational Commanders to foster mutual understanding and use the Field Mental Health Team to best effect., Method: The paper drawson the experience of working in a Field Mental Health Team on six operational deployments in Iraq and Afghanistan., Results: Military mental health professionals work mostly in peacetime and this work ill prepares them for the very different type of work required of them on operations., Conclusion: More training is required to prepare both practitioners and commanders for the mental health issues that confront them on operational deployments.

Background/aims: Suicidal Ideation (SI) is a risk factor for suicide, a leading cause of death amongst young men globally. In this study we assess whether sustaining a serious physical combat injury is associated with SI and whether leaving service mediates this association., Methods: We analysed data from male UK Armed Forces personnel who sustained a combat injury in Afghanistan and a frequency-matched comparison group who did not sustain such an injury (the ADVANCE cohort). SI was measured from the Patient Health Questionnaire-9 item 'thoughts that you would be better off dead or of hurting yourself in some way'., Results: Approximately, 11.9% ( n  = 61) of the uninjured group, 15.3% ( n  = 83) of the overall injured group, 8.5% ( n  = 13) of an Amputation injury (AI) subgroup and 17.6% ( n  = 70) of a Non-Amputation Injury (NAI) subgroup reported SI in the past 2 weeks. The NAI subgroup reported greater likelihood of SI (Relative Risk Ratio (RR) = 1.44, 95% confidence interval (CI) [1.04, 2.00]) compared to the comparison group, whereas the overall injured group (RR = 1.23, 95% CI [0.90, 1.68]) and AI subgroup (RR = 0.65, 95% CI [0.36, 1.18]) did not. Leaving service fully mediated the association between sustaining a NAI and SI (natural direct effect RR = 1.08, 95% CI [0.69, 1.69])., Conclusions: UK military personnel with NAI reported significantly higher rates of SI compared to demographically similar uninjured personnel, while those who sustained AIs reported no significant difference. Leaving service was associated with greater rates of SI for both injured and uninjured personnel and fully mediated the association between sustaining a NAI and SI., Competing Interests: Conflict of interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C. Williamson is currently in receipt of a PhD studentship via the King’s Centre for Military Health Research Health and Wellbeing Study funded by the Office for Veterans’ Affairs, UK Government. N. T. Fear is part funded by a grant from the UK Ministry of Defence and is and an unpaid trustee of a charity supporting the wellbeing of service personnel, veterans and their families. A. Bennett is a serving member of the Royal Air Force. The views expressed are those of the author(s) and not necessarily those of the Office for Veteran’s Affairs or the Ministry of Defence.

We sought to determine whether posttraumatic stress disorder (PTSD) was associated with sexual health in returned warzone-deployed veterans from the recent Iraq and Afghanistan conflicts. We studied 1,581 males and females from the Veterans After-Discharge Longitudinal Registry, a gender-balanced U.S. Department of Veterans Affairs registry of health care-seeking veterans with and without PTSD. Approximately one quarter (25.1%) of males (n = 198) and 12.7% of females (n = 101) had a sexual dysfunction diagnosis and/or prescription treatment for sexual dysfunction. Both genders were more likely to have a sexual dysfunction diagnosis and/or prescription treatment if they had PTSD compared with those without PTSD (male: 27.3% vs. 21.1%, p = .054; female: 14.9% vs. 9.4%, p = .022). Among the 1,557 subjects analyzed here, males with PTSD had similar levels of sexual activity compared to those without PTSD (71.2% vs. 75.4%, p = .22), whereas females with PTSD were less likely to be sexually active compared to females without PTSD (58.7% vs. 72.1%, p < .001). Participants with PTSD were also less likely to report sex-life satisfaction (male: 27.6% vs. 46.0%, p < .001; female: 23.0% vs. 45.7%, p < .001) compared with those without PTSD. Although PTSD was not associated with sexual dysfunction after adjusting for confounding factors, it was significantly negatively associated with sex-life satisfaction in female veterans with a prevalence ratio of .71, 95% confidence interval [.57, .90].

BACKGROUND: Theoretical work posits that drug-related risk behaviour increases during armed conflict; however, few studies have been conducted in conflict settings. The objective of this analysis is to determine whether conflict or local displacement impact risk behaviours among people who inject drugs (PWID) in Kabul, Afghanistan. METHODS: Consenting PWIDs aged ≥18 years completed interviews at 3, 6, 9, 12, 18, and 24 months of follow-up. Quarters with peak conflict or local displacement exposure were defined and associations with injecting drug use and sexual risk behaviours analysed with generalized estimating equations. RESULTS: Of 483 PWID enrolled, 385 completed ≥1 follow-up visit (483.8 person-years) between 2007 and 2009. All participants were male, with 35% initiating injecting as a refugee. Sharing syringes (Odds Ratio (OR))=8.53, 95% Confidence Interval (CI): 2.58 – 28.2) and sexually transmitted infection (STI) symptoms (OR=1.72, 95% CI: 1.00 – 2.96) increased significantly during peak conflict quarters, while odds of STI symptoms (OR=0.06, 95% CI: 0.02 – 0.20) and arrest (OR=0.61, 95% CI: 0.40 – 0.93) were significantly lower during periods of displacement. CONCLUSION: Syringe sharing significantly increased during peak conflict periods amongst PWID in Kabul. Programming should include instruction for coping with conflict and prepare clients for harm reduction needs during conflict.

BackgroundPervasive use of improvised explosive devices (IEDs), rocket-propelled grenades, and land mines in the recent conflicts in Iraq and Afghanistan has brought traumatic brain injury (TBI) and its impact on health outcomes into public awareness. Blast injuries have been deemed signature wounds of these wars. War-related TBI is not new, having become prevalent during WWI and remaining medically relevant in WWII and beyond. Medicine's past attempts to accurately diagnose and disentangle the pathophysiology of war-related TBI parallels current lines of inquiry and highlights limitations in methodology and attribution of symptom etiology, be it organic, psychological, or behavioral. New approaches and biomarkers are needed.PreclinicalSerological biomarkers and biomarkers of injury obtained with imaging techniques represent cornerstones in the translation between experimental data and clinical observations. Experimental models for blast related TBI and PTSD can generate critical data on injury threshold, for example for white matter injury from acceleration. Carefully verified and validated models can be evaluated with gene expression arrays and proteomics to identify new candidates for serological biomarkers. Such models can also be analyzed with diffusion MRI and microscopy in order to identify criteria for detection of diffuse white matter injuries, such as DAI (diffuse axonal injury). The experimental models can also be analyzed with focus on injury outcome in brain stem regions, such as locus coeruleus or nucleus raphe magnus that can be involved in response to anxiety changes.ClinicalMild (and some moderate) TBI can be difficult to diagnose because the injuries are often not detectable on conventional MRI or CT. There is accumulating evidence that injured brain tissues in TBI patients generate abnormal low-frequency magnetic activity (ALFMA, peaked at 1-4Hz) that can be measured and localized by magnetoencephalography (MEG). MEG imaging detects TBI abnormalities at the rates of 87% for the mild TBI, group (blast-induced plus non-blast causes) and 100% for the moderate group. Among the mild TBI patients, the rates of abnormalities are 96% and 77% for the blast and non-blast TBI groups, respectively. There is emerging evidence based on fMRI and MEG studies showing hyper-activity in the amygdala and hypo-activity in pre-frontal cortex in individuals with PTSD. MEG signal may serve as a sensitive imaging marker for mTBI, distinguishable from abnormalities generated in association with PTSD. More work is needed to fully describe physiological mechanisms of post-concussive symptoms.

A comprehensive evaluation, including the assessment of neurobehavioral symptoms, has been instituted at the Department of Veterans Affairs (VA) healthcare system to address the large number of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans returning with mild traumatic brain injuries (mTBIs). The Validity-10 is measure of symptom overreporting embedded within the Neurobehavioral Symptom Inventory, a component of the comprehensive evaluation that assesses postconcussive symptom severity. The Validity-10 is composed of 10 unlikely/low-frequency items and a validated cutoff score to identify postconcussive symptom overreporting. We examined the items and cutoff used in the initial development and validation study of the Validity-10 through retrospective chart reviews of 331 treatment-seeking Veterans who sustained an mTBI. The Validity-10 exhibited significant relationships with psychiatric variables, VA service connection, and neuropsychological performance validity (all p < 0.01), but nonsignificant relationships with demographic and injury variables (all p > 0.05). Furthermore, the Validity-10 modestly predicted neuropsychological performance validity test failure over and above psychiatric comorbidities and VA service connection. The present study supports the use of the Validity-10 to assess symptom validity in treatment-seeking OIF/OEF Veterans with a history of mTBI.

BackgroundArmed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan.MethodsConsenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007-December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models.ResultsOf 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9-125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3-44.6) and 1.5/100 p-y (95 % CI 0.6-3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31-0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01-1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01-100.3) independently predicted HIV infection.ConclusionThere is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support.

Comorbidity of posttraumatic stress disorder (PTSD) and history of traumatic brain injury (TBI) is high among Veterans of Operation Iraqi Freedom/Enduring Freedom/New Dawn (OIF/OEF/OND). Cognitive processing therapy (CPT) is empirically supported for the treatment of PTSD, but it is not specifically designed to accommodate the memory, attention, or problem solving deficits that are experienced by many Veterans with comorbid PTSD and TBI. Compensatory cognitive rehabilitation, including cognitive symptom management and rehabilitation therapy (CogSMART), is effective for cognitive deficits stemming from a variety of etiologies, including TBI. We have integrated components of CogSMART into CPT in order to address the unique challenges faced by Veterans with ongoing cognitive complaints related to PTSD and a history of mild TBI. Here we describe an ongoing randomized controlled trial investigating the efficacy of our novel hybrid treatment, SMART-CPT, as compared to standard CPT, for OIF/OEF/OND Veterans with PTSD and a history of mild to moderate TBI. We describe the development of this hybrid treatment as well as implementation of the randomized controlled trial.

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.)

The concept of resilience is embedded within military culture and professional identity. To date, temporal changes in individuals' perceptions of their own resilience have not been systematically assessed in highstakes occupational contexts, like the military. The current study examined change in selfreported resilience over time by: (1) examining the longitudinal measurement invariance of the Brief Resilience Scale (BRS); (2) assessing the longitudinal pattern of resilience across a combat deployment cycle; and (3) examining predictors of postdeployment resilience and change in resilience scores across time. U.S. Army soldiers assigned to a combat brigade completed a survey at four time points over the course of a deployment cycle: (a) prior to deployment to Afghanistan; (b) during deployment; (c) immediately following return to home station; and (d) approximately 2-3 months thereafter. The longitudinal measurement invariance of the BRS was established. Growth curve modeling indicated that, on average, self-reported resilience decreased across the deployment cycle, but there was considerable individual variation in the rate of change. Of note, loneliness, as measured during deployment, predicted the rate of change in self-reported resilience over time. Results have implications for the longitudinal analysis of resilience and for the development of interventions with military personnel.

Introduction: Respiratory diseases such as chronic rhinosinusitis and asthma are observed at increased rates in active duty and veteran military members, and they are especially prevalent in individuals who have been deployed in Southwest Asia during Operation Iraqi Freedom and Operation Enduring Freedom. Particulate matter, specifically the fine-grain desert sand found in the Middle East, may be a key source of this pathology because of deleterious effects on mucociliary clearance., Materials and Methods: With IRB approval, human sinonasal tissue was grown at an air-liquid interface and cultures were exposed to different types and sizes of particulate matter, including sand from Afghanistan and Kuwait. Ciliary dynamic responses to mechanical stimulation and ATP application were assessed following particulate exposure., Results: Particle size of the commercial sand was substantially larger than that of the sand of Afghan or Kuwaiti origin. Following exposure to particulate matter, normal dynamic ciliary responses to mechanical stimulation and ATP application were significantly decreased (P < .01), with corresponding decreases in ATP-induced calcium flux (P < .05). These changes were partially reversible with apical washing after a 16-h period of exposure. After 36 h of exposure to Middle Eastern sand, ciliary responses to purinergic stimulation were completely abolished., Conclusions: There is a neutralization of the dynamic ciliary response following chronic particulate matter exposure, similar to ciliary pathologies observed in patients with chronic rhinosinusitis. Aerosolized particulate matter endured by military personnel in the Southwest Asia may cause dysfunctional mucociliary clearance; these data help to explain the increased prevalence of respiratory pathology in individuals who are or have been deployed in this region., (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.)

Blast is the most common injury mechanism in conflicts of this century due to the widespread use of explosives, confirmed by recent conflicts such as in Ukraine. Data from conflicts in the last century such as Northern Ireland, the Falklands, and Vietnam up to the present day show that between 16% and 21% of personnel suffered a traumatic brain injury. Typical features of fatal brain injury to those outside of a vehicle (hereafter referred to as dismounted) due to blast include the presence of hemorrhagic brain injury alongside skull fractures rather than isolated penetrating injuries more typical of traditional ballistic head injuries. The heterogeneity of dismounted blast has meant that analysis from databases is limited and therefore a detailed look at the radiological aspects of injury is needed to understand the mechanism and pathology of dismounted blast brain injury. The aim of this study was to identify the head and spinal injuries in fatalities due to dismounted blast. All UK military fatalities from dismounted blast who suffered a head injury from 2007-2013 in the Iraq and Afghanistan conflicts were identified retrospectively. Postmortem computerized tomography images (CTPMs) were interrogated for injuries to the head, neck, and spine. All injuries were documented and classified using a radiology brain injury classification (BIC) tool. Chi-squared ( χ 2 ) and Fisher's exact tests were used to investigate correlations between injuries, along with odds ratios for determining the direction of correlation. The correlations were clustered. There were 71 fatalities from dismounted blast with an associated head injury with a CTPM or initial CT available for analysis. The results showed the heterogeneity of injury from dismounted blast but also some potential identifiable injury constellations. These were: intracranial haemorrhage, intracranial deep haemorrhage, spinal injury, and facial injury. These identified injury patterns can now be investigated to consider injury mechanisms and so develop mitigation strategies or clinical treatments. Level of Evidence: Observational. Study type: cohort observational.

Exertional dyspnea has been documented in US military personnel after deployment to Iraq and Afghanistan. We studied whether continued exertional dyspnea in this patient population is associated with pulmonary vascular disease (PVD). We performed detailed histomorphometry of pulmonary vasculature in 52 Veterans with biopsy-proven post-deployment respiratory syndrome (PDRS) and then recruited five of these same Veterans with continued exertional dyspnea to undergo a follow-up clinical evaluation, including symptom questionnaire, pulmonary function testing, surface echocardiography, and right heart catheterization (RHC). Morphometric evaluation of pulmonary arteries showed significantly increased intima and media thicknesses, along with collagen deposition (fibrosis), in Veterans with PDRS compared to non-diseased (ND) controls. In addition, pulmonary veins in PDRS showed increased intima and adventitia thicknesses with prominent collagen deposition compared to controls. Of the five Veterans involved in our clinical follow-up study, three had borderline or overt right ventricle (RV) enlargement by echocardiography and evidence of pulmonary hypertension (PH) on RHC. Together, our studies suggest that PVD with predominant venular fibrosis is common in PDRS and development of PH may explain exertional dyspnea and exercise limitation in some Veterans with PDRS., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Blast-related mild traumatic brain injury (mTBI) is recognized as the "signature injury" of the Iraq and Afghanistan wars. Sleep disruption, mTBI, and neuroinflammation have been individually linked to cerebral perivascular space (PVS) dilatation. Dilated PVSs are putative markers of impaired cerebrospinal fluid (CSF) and interstitial fluid exchange, which plays an important role in removing cerebral waste. The aim of this cross-sectional, retrospective study was to define associations between biomarkers of inflammation and MRI-visible PVS (MV-PVS) burden in Veterans after blast-related mTBI (blast-mTBI) and controls. The CSF and plasma inflammatory biomarker concentrations were compared between blast-mTBI and control groups and correlated with MV-PVS volume and number per white matter cm 3 . Multiple regression analyses were performed with inflammatory biomarkers as predictors and MV-PVS burden as the outcome. Correction for multiple comparisons was performed using the Banjamini-Hochberg method with a false discovery rate of 0.05. There were no group-wise differences in MV-PVS burden between Veterans with blast-mTBI and controls. Greater MV-PVS burden was significantly associated with higher concentrations of several proinflammatory biomarkers from CSF (i.e., eotaxin, MCP-1, IL-6, IL-8) and plasma (i.e., MCP-4, IL-13) in the blast-mTBI group only. After controlling for sleep time and symptoms of post-traumatic stress disorder, temporal MV-PVS burden remained significantly associated with higher CSF markers of inflammation in the blast-mTBI group only. These data support an association between central, rather than peripheral, neuroinflammation and MV-PVS burden in Veterans with blast-mTBI independent of sleep. Future studies should continue to explore the role of blast-mTBI related central inflammation in MV-PVS development, as well as investigate the impact of subclinical exposures on MV-PVS burden.

Objective: The majority of traumatic brain injuries (TBIs) are classified as mild and occur in young individuals. The course of recovery varies but can result in chronic or troubling outcomes. The impact of age on TBI outcomes in young adults before complete brain maturation is not well studied., Methods: In this study, we compared the effects of mild TBI on cognitive performance and self-reported TBI symptoms and posttraumatic stress disorder (PTSD) in 903 soldiers in 3 different age groups: 24 years or younger, 25 to 27 years, and 28 to 40 years. The soldiers had returned from war zones in Iraq and were screened for TBI within a few days of return. Cognitive performance was measured with the Automated Neuropsychological Assessment Metrics of Military TBI Version 4 (ANAM4). Symptoms associated with mild TBI were self-reported on the Neurobehavioral Symptom Inventory, and the PTSD Checklist-Civilian Version (PCL-C)., Results: Soldiers with TBI in every age group had significantly higher prevalence of most symptoms than those with no TBI. Soldiers with TBI also reported more chronic pain sites, regardless of age. Soldiers aged 28 to 40 years with TBI had the lowest cognitive performance scores (ANAM) across several subtests, both unadjusted and adjusted. The Global Deficit Score was significantly higher for soldiers aged 28 to 40 years and 25 to 27 years with TBI than for soldiers younger than 24 years with no TBI. After adjusting for PTSD symptoms, education, and number of lifetime TBIs, the overall test battery mean for soldiers aged 28 to 40 years with TBI was significantly lower than for soldiers younger than 24 years with no TBI., Conclusion: Soldiers with mild TBI in the younger age group show more symptoms associated to frontal lobe function while soldiers in the older group suffer more cognitive impairment. This may warrant further study as it may indicate a propensity to later cognitive decline among soldiers who were older at the time of injury., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)