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Introduction U.S. military women were at risk of combat exposure and injury from asymmetric warfare during the conflicts in Iraq and Afghanistan. Previous research has yielded mixed results when examining sex differences in PTSD following operational deployment. To date, no study has explored sex differences in PTSD after combat injury. Materials and Methods This retrospective study included U.S. military service men and women who experienced a combat injury in Iraq or Afghanistan (March 2003 to March 2013) and completed a Post-Deployment Health Assessment (PDHA) within 1 year of injury. The PDHA is administered at the end of deployment and includes the 4-item Primary Care PTSD Screen. The prevalence of screening positive for PTSD was evaluated by sex using a chi-square test. Multivariable logistic regression was used to assess the association between sex and PTSD while adjusting for covariates. Results The study sample included 16,215 injured military personnel (666 women and 15,549 men). The average time between injury and PDHA was 132 days (SD  = 91.0). Overall, women had a higher prevalence of screening positive for PTSD than men (48.3% vs. 40.9%, P  < .001). In multivariable regression, women had higher odds than men of screening positive for PTSD (odds ratio, 1.34; 95% confidence interval, 1.14-1.57). Psychiatric history was the strongest predictor of screening positive for PTSD regardless of sex (odds ratio, 1.59; 95% confidence interval, 1.45-1.74). Conclusions In this novel study of military service members, women were more likely to screen positive for PTSD than men after combat injury. Strategies to mitigate PTSD, enhance resiliency, and incorporate psychological care into injury rehabilitation programs for women may be needed for future U.S. military conflicts where they will play a larger role in combat operations. [ABSTRACT FROM AUTHOR]

As reported in the 2022 Biden-Harris National Security Strategy, China is perceived as the primary U.S. competitor with the intent and means to become the world's greatest superpower. China's efforts, which are at odds with America's ambition to maintain its global influence, are complemented by ostensibly harmless "gray zone tactics," defined as coercive geopolitical, economic, military, and cyber activities below the use of kinetic military force. Such tactics may be utilized with seemingly innocuous intentions, but in reality, they can complicate U.S. combat casualty care in the event of an Indo-Pacific conflict. One tactic of particular impact is China's development of artificial islands throughout the South China Sea. By creating these islands, China is expanding its reach beyond its continental borders. These islands, alongside China's well-developed naval and missile capabilities, will cause disruptions to U.S. casualty care staging, medical resupply, and aeromedical evacuations. To mitigate those threats, the USA should implement a robust regional Combatant Command Trauma System, improve global health security cooperation with local partner nations, and implement irregular or guerilla trauma systems that meet medical needs in impromptu, clandestine settings. Operational recommendations based on these efforts could include pre-positioning tactical combat casualty care and damage control resuscitation supplies and developing with nearby host-nation evacuation platforms such as small boat operators. These solutions, among others, require years of training, relationship-building, and capability development to institute successfully. As a result, U.S. Military leaders should act now to incorporate these strategies into their irregular warfare, low-intensity conflict, and large-scale combat operation toolkits. [ABSTRACT FROM AUTHOR]

The world trend of military surgery of last decades is an improvement of treatment outcomes in combat trauma, the reduction of both early and late mortality, which is associated with the training of combatants in providing first aid, self-help, improving medical logistics, implementing the principles of damage control surgery and early resuscitation, staging of assistance. However, in the structure of mortality, especially late, the leading positions, as before, belong to acute lung damage, acute respiratory distress syndrome, multiple organ failure whose pathogenesis is considered in this review. The conceptual tool of this study goes beyond the usual surgical one. However, just as combat trauma requires a multisystem approach, so the solution to the problem of multiple organ failure can be found only with the interaction of various disciplines, and therefore only this level of understanding of this problem opens the prospect of further development.

Background. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used worldwide to stop bleeding in trauma and wounds in patients with hemorrhagic shock. REBOA allows for the hemodynamic stabilization, patient transportation and final bleeding control. The study aims to demonstrate the capabilities of REBOA as a method of bleeding control in the wounded with hemorrhagic shock in the context of war in Ukraine. Materials and methods. Five AFU servicemen who sustained mine-blast wounds in the Eastern Ukraine as a result of shelling by Russian troops were delivered with signs of internal bleeding and hemorrhagic shock to the primary and secondary levels of medical care (Role 1, 2). The REBOA balloon catheter was inserted and inflated by surgeons working in stabilization centers or advanced surgical teams. Upon admission, all patients underwent chest and abdominal ultrasound according to the FAST protocol. We used COBRA-OS 4 Fr and ER-REBOA 7 Fr balloon catheters. The positioning of the balloon in the aorta was performed according to external anatomical landmarks (3 cases) and ultrasound (2 cases). In all clinical cases, the balloon catheter was placed in zone I. In one case, the balloon was moved from zone I to zone III (control of the source of bleeding). The duration of aortic occlusion ranged from 15 to 50 minutes. Immediately after removal of the introducer, manual compression of the puncture site was used (3 cases) or suturing of the arteriotomy (2 cases). Results. The sources of bleeding in our clinical cases were injuries of the iliac vessels (2 cases), the renal artery (1 case), and injuries of the inferior vena cava and liver (2 cases). Four patients were evacuated to a higher level of medical care after the REBOA was installed. In one case, there were complications from vascular access (femoral artery thrombosis). We were unable to save one wounded soldier, most likely due to the delay in evacuation from the previous stage, the severity of injury, and massive blood loss. Conclusions. As our observations have shown, the use of REBOA in combat conditions allows not only to stabilize hemodynamics in the wounded with severe combined trauma and bleeding but also to conduct a successful evacuation to a higher level of medical care to stop bleeding ultimately. REBOA can be successfully used at the prehospital stage. This requires clearly defined indications for the technique’s use, training of medical personnel, and provision of balloon catheters to medical units of the Armed Forces of Ukraine.

Background. A combat gunshot wound is significantly different from a civilian trauma. It is characterized by the prevalence of penetrating injuries, which increases the volume of blood loss at the pre-hospital stage, and the destruction of large masses of muscle tissue (rhabdomyolysis), which leads to acute kidney injury. Moreover, combat trauma occurs in conditions of chronic background stress as a result of severe emotional and physical strain, uncomfortable weather conditions, and deprivation of sleep, drinking and food. So, such a phenomenon as voluntary dehydration is common among soldiers in combat conditions. In wounded, oliguria is often considered a result of acute kidney injury, but it can also be a symptom of severe dehydration. The purpose of our work was to analyze three clinical cases of oliguria caused by dehydration in wounded with combat trauma to better understand the severity of the condition of such victims and to improve medical aid for them. Materials and methods. The article describes three cases of men aged 35, 50 and 44 years with combat gunshot wounds to the extremities, who were admitted to the tertiary care hospital on the second day after the injury with oliguria (0.18–0.19 ml/kg/hr) and high creatinine (333 to 457 μmol/L). Results. All three patients were conscious, breathing spontaneously, had stable hemodynamics, and moderate anemia after pre-hospital blood transfusions. Focused ultrasound study revealed hyperdynamic left ventricle and small inferior vena cava with complete inspiratory collapse, which suggested hypovolemia. Upon further investigation of the medical history, patients admitted not drinking any liquid for one to two days prior to injury. Tissue hydrophilicity test was conducted which showed severe dehydration in all three cases. Infusion volume was calculated using P.I. Shelestiuk nomogram (modified by O.V. Kravets et al.) and amounted to 60 ml/kg of balanced crystalloid solutions. Upon starting rehydration, diuresis was restored within two hours and amounted to 0.7– 2.1 ml/kg/h in all three patients. Creatinine levels normalized in 2–4 days. Patients were transferred to another hospital in a moderate condition in 4–5 days. Conclusions. Oliguria is a frequent complication of combat gunshot injury. Although it is most often associated with acute kidney injury from rhabdomyolysis, it should also be considered that in a combat environment, soldiers’ access to water may be limited and the injury may be accompanied by dehydration. In the cases presented, the differential diagnosis of the causes of oliguria in the wounded made it possible to detect signs of severe dehydration, abstain from the inappropriate use of saluretics, quickly compensate for the fluid deficit, and to avoid the development of kidney damage and the need for renal replacement therapy.

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. [ABSTRACT FROM AUTHOR]

Objective: War participation risks mental disorders. Ukrainian combatants in Anti-Terrorist Operation/Joint Forces Operation since 2014 receive psychiatric care. Some show unique symptoms, not fitting recognized disorders, termed post-combat delayed response (tension) syndrome. The aim of this study was to establish diagnostic criteria and develop a scale of differential diagnosis of post-combat delayed response (tension) syndrome. Methods: This was a clinical retrospective study conducted on the basis of Zaporizhzhia Military Hospital and Zaporizhzhia and State Medical University, Ukraine, in the period from 2015 to 2021. Combatants of Ukraine—members of Anti-Terrorist Operation/Joint Forces Operation were involved in the study. In total, 426 male combatants were surveyed from whom those suffering from post-traumatic stress disorder (n  = 24), neurasthenia (n  = 35), and post-combat delayed response (tension) syndrome (n  = 46) were selected. Results: The key symptoms of post-combat delayed response (tension) syndrome were selected and ranked in order of their differential diagnostic value. The diagnostic scale for post-combat delayed response (tension) syndrome was developed, which consists of 12 points. Conclusions: The received anamnestic information is important for classifying patients at risk of post-combat delayed response (tension) syndrome. [ABSTRACT FROM AUTHOR]

Introduction Between 2011 and 2014, The Combat Casualty Training Consortium research study sought to evaluate all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among U.S. combat fatalities. This study identified a major training gap in critical airway management. To address this gap, the Advanced Joint Airway Management System (AJAMS) was designed and assessed for physical fidelity and educational utility in a population of paramedic instructors. Materials and Methods Paramedic instructors served as participants in this prospective observational pilot study (n  = 12). Participants interacted with three airway management trainers: The AJAMS trainer, the Laerdal Airway Management Trainer, and the TruCorp AirSim Advance Bronchi X Trainer. Participants then completed an evaluation of the trainer using a purpose-built data collection instrument that queried the trainer's realism and educational utility. Within-group differences were analyzed via a 1-way repeated measures ANOVA, with a Bonferroni post hoc analysis. Rank data were analyzed via non-parametric Freidman's test, and Wilcoxon signed-rank test post hoc analysis, corrected using the Bonferroni correction. Results The AJAMS trainer conveys significantly more physical fidelity (visual: P  < .001, ηp2 = 0.977; tactile: P  < .001, ηp2 = 0.983; and behavioral: P  = .001, ηp2 = 0.971) and overall educational utility (χ2(2) = 15.273, P  < .001) than the two commercially available skill trainers. Conclusions These data suggest that physical fidelity is an important attribute in the design of simulators for health care, as perceived by expert instructors. These data illustrate that the AJAMS-integrated simulator demonstrates unparalleled physical fidelity, relative to commercially available airway management skill trainers. [ABSTRACT FROM AUTHOR]

Introduction Simulation-based medical training has been shown to be effective and is widely used in civilian hospitals; however, it is unclear how widely and how effectively simulation is utilized in the U.S. Military Health System (MHS). The current operational state of medical simulation in the MHS is unknown, and there remains a need for a system-wide assessment of whether and how the advances in simulation-based medical training are employed to meet the evolving needs of the present-day warfighter. Understanding the types of skills and methods used within simulation programs across the enterprise is important data for leaders as they plan for the future in terms of curriculum development and the investment of resources. The aim of the present study is to survey MHS simulation programs in order to determine the prevalence of skills taught, the types of learners served, and the most common methodologies employed in this worldwide health care system. Materials and Methods A cross-sectional survey of simulation activities was distributed to the medical directors of all 93 simulation programs in the MHS. The survey was developed by the authors based on lists of critical wartime skills published by the medical departments of the US Army, Navy, and Air Force. Respondents were asked to indicate the types of learners trained at their program, which of the 82 unique skills included in the survey are trained at their site, and for each skill the modalities of simulation used, i.e. mannequin, standardized patients, part task trainers, augmented/virtual reality tools, or cadaver/live tissue. Results Complete survey responses were obtained from 75 of the 93 (80%) MHS medical simulation training programs. Across all skills included in the survey, those most commonly taught belonged predominantly to the categories of medic skills and nursing skills. Across all sites, the most common category of learner was the medic/corpsman (95% of sites), followed by nurses (87%), physicians (83%), non-medical combat lifesavers (59%), and others (28%) that included on-base first responders, law enforcement, fire fighters, and civilians. The skills training offered by programs included most commonly the tasks associated with medics/corpsmen (97%) followed by nursing (81%), advanced provider (77%), and General Medical Officer (GMO) skills (47%). Conclusion The survey demonstrated that the most common skills taught were all related to point of injury combat casualty care and addressed the most common causes of death on the battlefield. The availability of training in medic skills, nursing skills, and advanced provider skills were similar in small, medium, and large programs. However, medium and small programs were less likely to deliver training for advanced providers and GMOs compared to larger programs. Overall, this study found that simulation-based medical training in the MHS is focused on medic and nursing skills, and that large programs are more likely to offer training for advanced providers and GMOs. Potential gaps in the availability of existing training are identified as over 50% of skills included in the nursing, advanced provider, and GMO skill categories are not covered by at least 80% of sites serving those learners. [ABSTRACT FROM AUTHOR]

Introduction Prolonged Casualty Care (PCC) is a military adaptation aimed at providing pre-hospital care in austere settings when evacuation is delayed or even impossible. Current lack of standardized medical equipment and size/weight restrictions of military packs during dismounted operations hinder effective PCC. We sought to design a standardized, practical, and effective prolonged field care kit (PFAK) to enable widespread implementation of PCC. Materials and Methods We reviewed Joint Trauma System Clinical Practice Guidelines to generate a list of potential contents of the PFAK. We obtained Institutional Review Board (IRB) exemption and then conducted stakeholder surveys of combat casualty care experts across the Joint Trauma System using a modified Delphi survey approach. We established a civil–military working group that provided in-depth qualitative feedback on the PFAK contents and provided an initial design of a long-range medical rucksack (LMR) to house it. Responses were analyzed using mean rank scores to help determine initial components of the PFAK. Tactical subject-matter experts tested and evaluated the PFAK and LMR prototype in austere conditions to refine the design. Results Review of the PCC Clinical Practice Guidelines generated 49 medications and 301 potential supplies as potential PFAK contents. The first Delphi survey was sent to 100 stakeholders (overall response rate of 60%). After the first survey, contents were narrowed to a list of the most essential 27 medications and 105 other components. Iterative prototypes of the PFAK and LMR were tested to determine ergonomics, portability, flexibility, and equipment compartmentalization to facilitate use in emergencies. The prototype was optimized to address the clinical, logistical, and tactical requirements of PCC across a variety of platforms and environmental conditions. Conclusions Given the changing battlefield environment, efficient and effective PCC will play an increasingly important role in the management of combat trauma. The PFAK can meet this need by providing a practical and standardized resuscitation kit generated by expert military and trauma personnel consensus, carried conveniently in the LMR. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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

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. [ABSTRACT FROM AUTHOR]

Introduction Women comprise nearly 19% of the U.S. military and now serve in almost all operational roles, increasing their risk of combat trauma and injuries.3 Data from the Joint Trauma Registry during Operation Enduring Freedom shows that battle-injured females had a higher case fatality rate at 36% compared to their male counterparts at 17%.1 The Tactical Combat Casualty Care curriculum is used to prepare battlefield medics to provide immediate care to wounded service members, but fails to address differences in the care of female versus male casualties. The students, who are presented with life-threatening injuries in simulated trauma scenarios, may be slower to assess, identify, and treat injuries in female patients as compared with male patients. Materials and Methods This observational program analysis was reviewed by the Uniformed Services University Human Research Protections Program and approved for execution as an exempt protocol under the provision of 32 CFR 219.104(d)(1). The study assessed the performance of male and female Mexican military personnel during a Tactical Combat Casualty Care course, using standardized trauma scenarios. Anatomically, correct male and female manikins were used to compare response time for different gender patients presenting with the same injuries. Results There was a statistically significant increase in time required to complete an initial blood sweep, identify a gunshot wound to the chest, and call for medical evacuation when treating a female patient compared to a male patient. Conclusions A lack of female representation in trauma training may have contributed to the higher case fatality rate of female soldiers compared to male soldiers during Operation Enduring Freedom. Female live actors and Gender Retrofit Kits can augment trauma casualty assessment and treatment training scenarios and better prepare our forces to respond to life-threatening emergencies. [ABSTRACT FROM AUTHOR]

Background. Chest injuries during combat operations occupy a prominent place and often become the cause of mortality. Before the widespread introduction of imaging methods into clinical practice, the mortality rate for chest combat injuries exceeded 50 %. Objective: a comparative assessment of radiography and ultrasonography options in the diagnosis of pneumothorax that occurred as a result of combat trauma. Materials and methods. A comparative analysis of the radiography and ultrasonography results was carried out in 76 patients with pneumothorax due to chest combat trauma. Results. During X-ray in the supine position, the sensitivity of the method was 58.1 %, specificity — 72.7 %, accuracy — 64.5 %, positive predictive value — 73.5 %, negative predictive value — 57.1 %. The sensitivity of the method in the sitting position of patients was 71.9 %, specificity — 89.5 %, accuracy — 76.3 %, positive predictive value — 95.3 %, negative predictive value — 51.5 %. Ultrasound diagnosis of pneumothorax was based on identifying the “barcode” sign due to the lack of sliding of the visceral pleura during the patient’s inspiration. The sensitivity of ultrasonography in B-mode was 90.8 %, specificity — 81.8 %, accuracy — 89.5 %, positive predictive value — 96.7 %, negative predictive value — 60.0 %, and in combined B + M modes — 94.0, 88.9, 93.4, 98.4, 66.7 %, respectively. In the diagnosis of large pneumothorax, the sensitivity of radiography was 96.8 %, specificity — 100.0 %, accuracy — 96.9 %, positive predictive value — 100.0 %, negative predictive value — 50.0 %, respectively, and of ultrasonography — 96.7, 100.0, 96.9, 100.0, 66.7 %, respectively. Conclusions. Ultrasonography has greater sensitivity for diagnosing small pneumothorax than conventional radiography, especially in bedridden patients. Ultrasonography in combined B + M modes can be both a primary and a clarifying method for diagnosing pneumothorax in combat trauma.

Introduction: Combat ground maneuvers consist of various platforms and have several environmental characteristics, influenced by the terrain, the operational mission, and the force's capabilities. This study assesses data on injuries sustained during urban warfare, aiming to evaluate the relationship between injury characteristics, maneuver platform, and personal protective gear on the battlefield.Materials and Methods: IDF soldiers injured infantry soldiers from the "Cast Lead" and the "Protective Edge" operations in the Gaza Strip (2008-2009 and 2014, respectively) were divided into four groups according to the maneuver platform and the environment: mounted infantry (armored and unarmored vehicle) and dismounted infantry (urban and open area). The primary outcome was the severity of the injury, and the secondary outcome was the injured body part.Results: Overall, 588 casualties were included in the final analysis, of whom 507 were dismounted infantry soldiers (265 in open terrain and 242 in urban area) and 81 were mounted infantry soldiers (20 in unarmored and 61 were injured in armored vehicles). The Injury Severity Score was similar in all subgroups. Open terrain subgroups were found to have fewer head injuries and higher levels of lower extremity injuries, similar to the unarmored vehicle group. More facial injuries were documented in the urban area group.Conclusions: The Injury Severity Score was not influenced by environmental protection. Although we found differences in the injured body parts, further studies on the exact mechanism of injury are needed to elucidate further the relationship and differences between the various platforms used and injuries seen in urban warfare, aiming for tailor-made protection. [ABSTRACT FROM AUTHOR]

Background. The study of the problem of physical and mental health of people who have survived combat trauma is a component of a wide field of research on the problem of stress, which manifests itself at all levels of the organization of the body. Combat injuries, in particular those of the areas of pelvis and genitourinary system, stressful events, lead to the development of erectile dysfunction (ED). In recent decades, a sufficient number of scientific facts have been accumulated, which confirm the significant influence of stress factors on the reduction of sexual desire and sexual activity. Therefore, determination of Ca2+,Mg2+- and Na+,K+-ATPase activity on a convenient model like peripheral blood lymphocytes add complexity to the understanding of the development of the pathophysiological and pathobiochemical mechanisms of the body, the result of which is the development of ED. Materials and methods. The research was conducted on peripheral blood lymphocytes of men injured as a result of combat operations (shrapnel and bullet wounds) in the Russian-Ukrainian war and treated at the Military Medical Clinical Center of the Western Region. The research group of men with combat injuries was divided into two subgroups: men aged 20–39 years (subgroup 1) and men aged 40–53 years (subgroup 2). The control group consisted of 48 practically healthy men without complaints of sexual dysfunction or cardiac, neurological or endocrinological pathology. Among the men of the control group were 30 men aged 20–39 years (subgroup 3) and 18 men aged 40–53 years (subgroup 4). Results. It has been shown that in the peripheral blood lymphocytes of men injured as a result of hostilities, there is a decrease in Na+,K+-ATPase activity and Ca2+,Mg2+-ATPase activity of the plasma membrane and endoplasmic reticulum, which leads to overloading of the cytosol with Na+ and Ca2+ ions, respectively, which is characteristic of pathological processes. Conclusion. Erectile dysfunction due to combat trauma is accompanied by a decrease in both Ca2+,Mg2+-ATPase activity of the plasma membrane and Ca2+,Mg2+-ATPase activity of endoplasmic reticulum of blood lymphocytes. As the age of patients with disorders of sexual function increases, the decrease in Ca2+,Mg2+-ATPase activities becomes more expressed. In men with erectile dysfunction due to combat trauma, the activity of Na+,K+-ATPase is also inhibited. According to the ROC curve, Ca2+,Mg2+-ATPase activity of the endoplasmic reticulum in blood lymphocytes is a potential biomarker of erectile dysfunction.

Background. In recent years, spore-forming bacteria of the Ваcillus species, as the brightest representatives of exogenous microflora, have attracted the attention of researchers. One of the most studied probiotics with proven probiotic activity, high efficiency and safety are Bacillus, species of non-pathogenic spore-forming bacteria. The use of probiotic disinfection in medical institutions is a promising direction for the prevention of antibacterial polyresistance in the fight against nosocomial infection. The goal is to analyze the effectiveness of combinations of Bacillus probiotic cultures in the intensive care patients. Materials and methods. The basis of this study is the analysis of the results of a comprehensive clinical-instrumental and laboratory study of clinical, hemodynamic, biochemical indicators, as well as systemic inflammatory markers in 74 patients with combat trauma within day 1–10 of hospital stay, who were treated in the anesthesiology, resuscitation and intensive care unit and the emergency department of the Military Medical Clinical Center of the Northern Region from May 2022 to May 2023. Results. A statistical analysis of the correspondence of identified pathogens to the options of prescribing antibacterial drugs revealed a tendency to decrease in the number of different pathogens per 1 patient during the 10-day stay in the intensive care unit/emergency department. When carrying out a statistical analysis of the changes in intoxication indices, an increase of LII and LI was detected already on the day 1 of treatment; on the day 3 of the study, an upward trend for both studied indices was noted without statistical probability between the groups; оn day 5 of hospital stay in patients of groups I and II, the average LII and LI had a tendency to gradually increase, 11.4 ± 3.2 c.u. and 8.6 ± 1.1 c.u., 4.2 ± 1.7 c.u. and 3.9 ± 0.8 c.u., accordingly, without statistically probable changes due to the large dispersion of each of these indices in the variation series of indicators in patients of both groups; on the day 7 of the study, this trend persisted and these parameters were 10.7 ± 3.6 c.u. and 8.6 ± 1.1 c.u., 4.9 ± 1.2 c.u. and 3.6 ± 0.7 c.u. in patients of groups I and II, respectively; on the day 10 of observation, the average values of LII and LI almost equaled. It is important to determine a probable (p < 0.05) increase in the LII in patients of group I on the day 5 of treatment compared to the day 1: 11.4 ± 3.2 c.u. and 3.2 ± 0.7 c.u., respectively, and on the day 3: 11.4 ± 3.2 c.u. and 5.2 ± 1.1 c.u., respectively. This trend persisted until the day 7 of hospital stay, when the LII was probably (p < 0.05) higher than the index on the first day of observation: 10.7 ± 3.6 c.u. and 3.2 ± 0.7 c.u., respectively, and on the day 3 of intensive care: 10.7 ± 3.6 c.u. and 5.2 ± 1.1 c.u. The average length of stay in the intensive care unit in group I was 16.2 ± 9.6 days, in group II — 12.4 ± 8.9 days without a probable statistical difference between the groups due to the considerable dispersion of this indicator in the variation series among patients. Identical dynamics was determined when comparing the changes of the Sequential Organ Failure Assessment score. Conclusions. The use of combinations of Bacillus probiotic cultures in intensive care patients during 10 days of hospital stay against the background of the de-escalation principle of prescribing antibacterial drugs contributed to the reduction in the number of drugs with antibacterial properties in the treatment protocol.

Aim. To investigate possible rhythm and conduction disturbances, as well as the blood pressure (BP) profile in young and middle-aged patients with combat wounds. Materials and methods. The cross-sectional study enrolled 102 patients who suffered limb injuries in the period from 13 to 114 days (median 38 days) before admission to the hospital. The age of the patients included in the study ranged from 20 to 59 years, with an average of 35.7±8.5 years. Patients underwent Holter ECG monitoring and 24-hour BP monitoring. The following questionnaires and scales were used: a questionnaire to identify signs of autonomic changes (A. Vein), a scale for assessing the severity of psychophysiological response to stress, an insomnia severity index, the Hamilton scale for assessing anxiety, the Hamilton scale for assessing depression, a questionnaire for PTSD screening, visual analog pain scale. Results. The mean heart rate per day reached 84.6±11.1 per minute, the minimum heart rate was 56.9±10.1, the maximum heart rate was 134.4±18.6 per minute. The group mean duration of tachycardia was 498.1±316 minutes (8 hours 18 minutes). There was an inverse correlation between the age of patients and the duration of tachycardia per day (r=-0.29; p=0.04), maximum heart rate (r=-0.28; p=0.007), minimum heart rate per day (r=-0.23; p=0.02). In patients 20-29 years old, the maximum heart rate reached 141.4±19.4, in patients over 40 years old – 134.3±17.9 (p=0.009). The mean value of the circadian index for the group was 1.17±0.13 (0.68-1.47). In 69.7%, the circadian index was rigid. Heart rate variability was within normal values in 32.2% of the examined patients, in 48.8% it was reduced, and in 19.1% it was sharply reduced. Heart rhythm disturbances were recorded in 65.5% of patients. The most frequently detected sinus arrhythmia (in 76.2% of cases of all arrhythmias), migration of the supraventricular pacemaker (in 27.0%) and atrial rhythm (in 11.1%). Arterial hypertension was detected in 67.7% of the examined patients. The maximum systolic BP (SBP) corresponding to arterial hypertension of the 1st degree was registered in 43.9% of patients, grade 2 – in 19.7%, grade 3 – in 3.0%, high normal BP – in 16.7%, normal BP – in 16.7%. Maximum diastolic BP (DBP) corresponding to grade 1 hypertension was found in 30.8% of patients, grade 2 – in 30.8%, grade 3 – in 15.4%, high normal BP – in 10.8%, normal BP – in 12.3%. The mean daily SBP was 126 mm Hg, DBP was 81 mm Hg. The mean daytime SBP was 128 mm Hg, DBP was 82 mm Hg. The mean nighttime SBP is 118 mm Hg, DBP is 77 mm Hg. The maximum SBP was 148 mm Hg, DBP was 97 mm Hg. When analyzing the types of daily BP curves, the vast majority of patients (44.6%) were classified as “non-dipper” type, both for SBP and DBP. Conclusions. The study results indicate that patients with combat injuries very often have sinus tachycardia, which is recorded over a long period of time. Heart rate is highest in the youngest injured patients and decreases as age increases. Sinus arrhythmia is very common, other rhythm and conduction disorders are much less common. High BP, especially DBP, is often recorded.

Trigger warningThis article deals with combat experiences and their consequences and could be potentially disturbing.IntroductionMoral injury (MI) is a severe form of combat trauma that shatters soldiers’ moral bearings as the result of killing in war. Among the myriad ways that moral injury affects veterans’ reintegration into civilian life, its impact on political and societal reintegration remains largely unstudied but crucial for personal, community, and national health.Methods13 in-depth interviews examine combat soldiers’ exposure to potentially morally injurious events (PMIEs) that include killing enemy combatants, harming civilians, and betrayal by commanders, the military system, and society. Interviewees also described their political activities (e.g., voting, fundraising, advocacy, protest) and social activism (e.g., volunteering, teaching, charitable work). Interviewees also completed the Moral Injury Symptom Scale.ResultsTwo distinct narratives process PMIEs. In a humanitarian narrative, soldiers hold themselves or their in-group morally responsible for perpetrating, witnessing, or failing to prevent a morally transgressive act such as killing or injuring civilians or placing others at unnecessary risk. In contrast, a national security perspective blames an out-group for leaving soldiers with no choice but to act in ways that trigger moral distress. Associated with shame and guilt, the humanitarian perspective triggered amends-making and social activism after discharge. In contrast, a national security perspective associated with anger and frustration fostered protest and intense political activism.DiscussionDespite its harmful health effects, moral trauma and injury can drive intense political and social activism, depending upon the narrative veterans adopt to interpret PMIEs. Aside from moral injury’s personal, familial, and social effects, moral injury drives veterans’ return to the political arena of civil society. As such, veterans play a central role in politics and dramatically affect post-war policy in democratic nations following conflict.

This was a novel pilot study about the relationship between PTSD severity and resource gain and loss using the conservation of resources (COR) model with U.S. Veterans. Higher PTSD severity was predicted to be associated with greater resource loss scores, and lower PTSD scores were predicted to be associated with greater resource gain scores. The sample size was limited (N = 19) due to the COVID-19 outbreak. Veterans completed a demographic questionnaire, the Montreal Cognitive Assessment (MoCA), the Combat Exposure Scale (CES), the PTSD Symptom Scale–Interview (PSS-I), the Conservation of Resources–Evaluation (COR-E), and two additional open-ended questions. A statistically significant negative medium effect size was found between PTSD diagnosis and resource gain (r(17) = −0.42, p = 0.039, one-tailed). A large effect size in resource gain scores between PTSD and non-PTSD groups was also found (t(17) = 1.880, p = 0.077, d = 0.87), with the non-PTSD group reporting more gain of resources than the PTSD group. Post hoc tests revealed that the resource gain score of the mild PTSD group was significantly higher than that of the severe + very severe PTSD group (p = 0.034). Results suggest that resource gain, when compared to resource loss, was the strongest predictor for a non-PTSD diagnosis.

The article discusses the long-term effects of combat trauma as portrayed in Joss Whedon’s Firefly series, focusing on the issues of trust, identity, and belonging. In doing so, it highlights the image of warrior and war in popular culture.

As a result of large-scale war in Ukraine, the frequency of gunshot wounds of the upper extremities has increased dramatically, accompanied by massive damage to soft tissue, neurovascular plexuses, and significant bone deficiency, so their treatment with traditional methods is risky. This leads to the development of new treatment methods, in particular, techniques for shoulder arthrodesis. Objective. To investigate the effectiveness of shoulder arthrodesis using an individual 3D-titanium implant and or a locked compression plate (LCP) with bone autoplasty for the treatment of severe combat trauma of the upper extremity. Methods. In 2022–2023, 19 men aged 36.2 (24–52) years with severe combat trauma of the upper extremity underwent shoulder arthrodesis using individual 3D-titanium implants (n = 9) or LCP with bone autoplasty (n = 10). The follow-up period was 18 months. Individual 3D-implants were created in the CAD program Autodesk Fusion 360 and made of Ti6AI4V alloy by three- dimensional metal 3D-printing. The functional status of the shoulder joint was assessed by the Oxford Shoulder Score, VAS at 6 and 12 months after surgery. Fusion was checked radiographically at 1, 3, 6 and 12 months. Results. The average follow- up period was 12 months. Ankylosis of the shoulder joint was formed in 18 (95 %) patients, and clinical consolidation without final restructuring with a positive tendency to bone fusion was detected in one patient (5 %). Radiologically confirmed fusion in 8.5 months (6–12). After 12 months, a decrease in pain (VAS: 5 to 1 points; p < 0.001) and improvement in the condition of the shoulder (Oxford Shoulder Score: 25 to 40 points, p < 0.001) were found compared with 6 months. Conclusions. Treatment of severe combat trauma of the upper extremity by shoulder arthrodesis allows to eliminate pain and restore sufficient function to perform daily tasks one year after surgery. The combination of shoulder arthrodesis with individual 3D-implants resulted in the restoration of upper limb function in all 9 patients with massive bone and muscle defects. [ABSTRACT FROM AUTHOR]

Objective: To examine time from injury to initiation of surgical care and association with survival in US military casualties. Background: Although the advantage of trauma care within the "golden hour" after an injury is generally accepted, evidence is scarce. Methods: This retrospective, population-based cohort study included US military casualties injured in Afghanistan and Iraq, January 2007 to December 2015, alive at initial request for evacuation with maximum abbreviated injury scale scores ≥2 and documented 30-day survival status after injury. Interventions: (1) handoff alive to the surgical team, and (2) initiation of first surgery were analyzed as time-dependent covariates (elapsed time from injury) using sequential Cox proportional hazards regression to assess how intervention timing might affect mortality. Covariates included age, injury year, and injury severity. Results: Among 5269 patients (median age, 24 years; 97% males; and 68% battle-injured), 728 died within 30 days of injury, 68% within 1 hour, and 90% within 4 hours. Only handoffs within 1 hour of injury and the resultant timely initiation of emergency surgery (adjusted also for prior advanced resuscitative interventions) were significantly associated with reduced 24-hour mortality compared with more delayed surgical care (adjusted hazard ratios: 0.34; 95% CI: 0.14-0.82; P = 0.02; and 0.40; 95% CI: 0.20-0.81; P = 0.01, respectively). In-hospital waits for surgery (mean: 1.1 hours; 95% CI; 1.0-1.2) scarcely contributed (P = 0.67). Conclusions: Rapid handoff to the surgical team within 1 hour of injury may reduce mortality by 66% in US military casualties. In the subgroup of casualties with indications for emergency surgery, rapid handoff with timely surgical intervention may reduce mortality by 60%. To inform future research and trauma system planning, findings are pivotal. [ABSTRACT FROM AUTHOR]

Fracture-related infection following orthopedic surgery, especially in cases of war-related trauma, represents a grave complication. The injuries sustained in war often entail severe damage to soft tissues, including significant impairment of vessels, nerves, tendons, muscles, and result in substantial bone defects. Complicating matters further, these infections often involve multidrug-resistant pathogens, making effective treatment a significant challenge. Optimal management of patients with combat-related trauma and signs of infection necessitates specialized care in dedicated centers. The approach to treatment should be guided by a well-defined algorithm that incorporates appropriate surgical interventions alongside systemic and localized antibiotic administration. In instances where chronic infection manifests after war-related injuries and specific causative agents are not definitively identified, initiating empiric therapy is advisable. A combination of meropenem, colistin, and vancomycin can be a suitable choice for initial treatment. Subsequently, once the causative microbes are identified, targeted treatment can be prescribed based on the susceptibility patterns. This article delves into the primary pathogens commonly found in war-related wounds and provides effective antibiotic regimens based on the specific microorganisms. One promising approach for managing severe war injuries is suppressive antibiotic therapy, which enhances the prospects of successful treatment. The comprehensive strategy outlined here aims to mitigate the serious risks posed by fracture-related infections in the context of war-induced trauma, ultimately improving patient outcomes and prognosis. [ABSTRACT FROM AUTHOR]

The article discusses the significant contributions of the military research community to advancements in medical care in both military and civilian settings. It emphasizes the importance of medical research in maintaining force readiness and addresses the future challenges that the military health system may face. These challenges include the need for medical care to be delivered closer to the field of battle, the importance of addressing mental health challenges, and the necessity of innovative approaches to improve the overall physical health of the warfighter. The article also highlights the role of the Military Health System Research Symposium in fostering collaboration and generating ideas to address these challenges. [Extracted from the article]

Civil War combat trauma remains a subject of interest to scholars studying the social and psychological changes that the war wrought upon American society. The focus has largely been on the South, but if we look northwards we find that combat trauma was too often masked by victory. But soldiers cannot singlehandedly delineate the contours of the emotional landscape of the wartime North. By locating combat trauma within the emotional nexus of non-combatant communities during and after the war, we can better understand the long-term effects of the Civil War on the development of America as a nation. [ABSTRACT FROM AUTHOR]

Existing scales mainly focus on danger-based threats of death and bodily harm to assess exposure to traumatic events in war zone. However, major provocations and transgression of deeply held values and moral beliefs, as well as witnessing the suffering of others can be as traumatic as fear-inducing danger-based events. This raises the need for scales that assess both danger- and nondanger-based events among soldiers operating in modern war zones. Norwegian military personnel deployed to Afghanistan between late 2001 and end of 2020 were invited to participate in a cross-sectional survey with a final sample size of 6,205 (males: n = 5,693; 91.7%; mean age = 41.93 years). We applied data reduction techniques (e.g., exploratory factor analysis, EFA, and exploratory graph analysis, EGA, through a community detection algorithm) to develop a 12-item, three-factor model (personal threat, traumatic witnessing, and moral injury) of the Warzone Stressor Exposure Index (WarZEI). Confirmatory factor analysis showed support for the factor model, with evidence of concurrent, discriminant, and incremental validity. These results indicate the WarZEI is a reliable and valid measure for assessing exposure to warzone stressors that allows for heterogeneity and the multidimensional nature of exposure to warzone stressors. [ABSTRACT FROM AUTHOR]

Background: Infection is a frequent and serious complication after combat-related trauma. The Sequential Organ Failure Assessment (SOFA) score has been shown to have predictive value for outcomes, including sepsis and mortality, among various populations. We evaluated the prognostic ability of SOFA score in a combat-related trauma population. Methods: Combat casualties (2009-2014) admitted to Landstuhl Regional Medical Center (LRMC; Germany) intensive care unit (ICU) within 4 days post-injury followed by transition to ICUs in military hospitals in the United States were included. Multivariate logistic regression was used to determine predictive effect of selected variables and receiver operating characteristic (ROC) curve analysis was used to evaluate overall accuracy of SOFA score for infection prediction. Results: Of the 748 patients who met inclusion criteria, 436 (58%) were diagnosed with an infection (32% bloodstream, 63% skin and soft tissue, and 40% pulmonary) and were predominantly young (median 24 years) males. Penetrating trauma accounted for 95% and 86% of injuries among those with and without infections, respectively (p < 0.001). Median LRMC admission SOFA score was 7 (interquartile range [IQR]: 4-9) in patients with infections versus 4 (IQR: 2-6) in patients without infections (p < 0.001). Thirty-day mortality was 2% in both groups. On multivariate regression, LRMC SOFA score was independently associated with infection development (odds ratio: 1.2; 95% confidence interval: 1.1-1.3). The ROC curve analysis revealed an area under the curve of 0.69 for infection prediction, and 0.80 for mortality prediction. Conclusions: The SOFA scores obtained up to 4 days post-injury predict late onset infection occurrence. This study revealed that for every 1 point increase in LRMC SOFA score, the odds of having an infection increases by a factor of 1.2, controlling for other predictors. The use of SOFA score in admission assessments may assist clinicians with identifying those at higher risk of infection following combat-related trauma. [ABSTRACT FROM AUTHOR]

Tranexamic acid (TXA) lessens surgical bleeding and reduces mortality in patients with traumatic hemorrhage. Hemorrhage is common in combat zones and is one of the most common causes of mortality in a war scenario. The management of hemorrhage involves early arrest/temporization of ongoing bleed and restoration of blood volume to restore physiological stability as soon as possible. TXA by its antifibrinolytic action decreases blood loss, thus circumventing the requirement of massive crystalloid resuscitation, in turn an important causative factor for acute traumatic coagulopathy. Currently, TXA is recommended in acute hemorrhage worldwide; thus, its use in the combat scenario needs to be conceptualized by the primary caregivers. This conceptualization will be discussed in detail in this review article.

This article examines how the Falklands war has been remembered in Britain. By looking at how ideas of the Falklands war reached public audiences, the article traces changing British understandings of the composition of the conflict. In the 1980s, the war was regarded as politically divisive. Since the 1990s, political divisions faded, and the perspectives of veterans, particularly as represented in the memoirs of lower ranked soldiers, became prominent. This has resulted in focus on new themes, such as experiences of combat trauma and relationships with the Falkland Islands and islanders. These changes illustrate shifts in civil–military relations in Britain and encouraged new interpretations of what the Falklands war meant for Britain. In the contexts of the wars in Iraq and Afghanistan, particularly that of Iraq, Britain's engagement in the Falklands came to be seen not only as politically legitimate, but also as the right choice to have made. [ABSTRACT FROM AUTHOR]

Background: The United States Armed Services Blood Program (ASBP) faced complex blood supply challenges during two decades of military operations in the U.S. Central Command (CENTCOM) and through an adaptive, responsive, and agile system, gained valuable insights on blood product usage in combat casualty care. Study Design and Methods: A retrospective review of blood product introduction and utilization trends was compiled from ASBP data collected during CENTCOM operations from 2014 through 2021. Results: During the study period, several blood products were introduced to the CENTCOM area of operations including Low Titer O Whole Blood (LTOWB), Cold‐Stored Platelets (CSP), Liquid Plasma (LP), and French Freeze Dried Plasma (FDP) manufactured from U.S. sourced donor plasma, all while expanding Walking Blood Bank capabilities. There was a gradual substitution of component therapy for whole blood; blood utilization peaked in 2017. Transfusion of Fresh Whole Blood (FWB) from Walking Blood Banks decreased as fully pre‐tested LTOWB was supplied by the ASBP. LTOWB was initially supplied in citrate–phosphate‐dextrose (CPD) anticoagulant (21‐day shelf life) but was largely replaced with LTOWB in citrate–phosphate‐dextrose‐adenine (CPDA‐1) anticoagulant (35‐day shelf life) by 2019. Implementation of prehospital transfusion and expansion of surgical and resuscitation teams led to an increase in the number of sites receiving blood. Discussion: ASBP introduced new products to its inventory in order to meet changing blood product demands driven by changes in the Joint Trauma System Clinical Practice Guidelines and operational demands. These products were adopted into clinical practice with a resultant evolution in transfusion strategies. [ABSTRACT FROM AUTHOR]

Tranexamic acid (TXA) lessens surgical bleeding and reduces mortality in patients with traumatic hemorrhage. Hemorrhage is common in combat zones and is one of the most common causes of mortality in a war scenario. The management of hemorrhage involves early arrest/temporization of ongoing bleed and restoration of blood volume to restore physiological stability as soon as possible. TXA by its antifibrinolytic action decreases blood loss, thus circumventing the requirement of massive crystalloid resuscitation, in turn an important causative factor for acute traumatic coagulopathy. Currently, TXA is recommended in acute hemorrhage worldwide; thus, its use in the combat scenario needs to be conceptualized by the primary caregivers. This conceptualization will be discussed in detail in this review article. [ABSTRACT FROM AUTHOR]

Purpose: To determine the rates and types of open‐globe wounds in soldiers admitted to Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries. Methods: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were patients who suffered open‐globe injuries. Open‐globe injuries were classified by type of wound: corneal, corneo‐scleral or scleral, or type of open‐globe injury: perforating, rupture, penetrating or intraocular foreign body. The primary analysis assessed the effect on final visual acuity (VA) and the risk of enucleation. Results: In this study, 285 (32.02%) open‐globe injuries were recorded in 890 eyes in the data set. Corneal wounds were noted in 127 (44.56%) eyes, corneo‐scleral wounds in 78 (27.37%) and scleral wounds in 129 (45.26%) eyes. The involvement of both the corneal and sclera was associated with poorer visual outcome (BCVA < 20/200) compared to injuries with an injury confined to either the cornea or scleral alone (p = 0.038). At a wound length of greater than approximately 14 mm, patients had 75% chance of having a poor final VA. Enucleation was performed in 64 (22.46%) eyes of patients with wounds. The type of wound was not found to be predictive of enucleation in multivariate analysis, but rather the type of open‐globe injury was predictive. Perforating (OR: 1.58, 95% CI: 1.43–1.72) and globe rupture injuries (OR: 1.49, 95% CI: 1.33–1.66) were more likely to undergo enucleation. Conclusions: Open‐globe injuries occur frequently in combat ocular trauma. Poor final VA was noted most with corneo‐scleral wounds with approximately 50% of patients having a final VA less than 20/200. [ABSTRACT FROM AUTHOR]

Combat trauma experienced in a warzone can hamper the physical, mental, and spiritual health of military service members and Veterans for years afterward. Spiritual care for combat trauma is designed to help service members and Veterans find meaning and purpose in their experiences. One such spiritual care program is REBOOT Combat Recovery, a 12-week, Christian-based course led by trained volunteers across the country. An in-depth investigation of the REBOOT program is needed to advance knowledge of spiritual care for combat trauma and to assess the course in attendees' own words. Semi-structured interviews were conducted with 40 course graduates. Experiences of the course were positive. Interviewees identified the program's emphasis on peer fellowship, spirituality, and the roots of distress as reasons for its effectiveness (RQ1). The most helpful aspects of the program involved the hospitality and family focus; targets for improvement included maintaining fidelity to the curriculum and offering opportunities for continuity upon graduation (RQ2). Interviewees described a variety of ways the course affected their view of self, their relationship with God and others, and their perceptions of combat trauma (RQ3). These findings are valuable for enriching spiritual care, in general, and enhancing the REBOOT Combat Recovery program, in particular. [ABSTRACT FROM AUTHOR]

The actualization of the rehabilitation problem of persons with gunshot wounds of the forearms and hands is associated with a large proportion of gunshot wounds of the upper limbs in the structure of combat trauma, the complexity of their treatment, many complications and a high degree of disability. Purpose. To investigate the impact of rehabilitation program on quality of people's life with forearm or hand gunshots using physiotherapy methods. Approach. The study was involved 76 men with gunshot wounds of the bones of the forearm and hand. The research was conducted on the basis of the military clinical hospital in Kyiv. Patients were randomly divided into 2 groups: the main group (MG, n=38) and the control group (CG, n=38). For the MG, was introduced an algorithm for the application of physical therapy measures, which was developed on the basis of the model of the International Classification of Functioning (ICF), Restriction of Life and Health. For rehabilitation of patients in the CG was used a standard program of the medical institution. In order to assess the effectiveness of rehabilitation interventions, examinations of patients were performed before the application of physical therapy measures and 6 months after the rehabilitation course. The research methods to comprehensively assess to the quality of patients' life: measurement of the functional independence on a scale FIM (Functional Independence Measure), assessment of the capacity of the upper limb on the scale DASH (Disability of the Arm, Shoulder and Hand Outcome Measure); Hamilton's alarm scale (The Hamilton Anxiety Rating Scale (HARS)), depression self-esteem scale PHQ-9 (Patient Health Questionnaire). Results. After the course of rehabilitation, the patients of the MG felt significantly fewer restrictions associated with dysfunction of the upper limbs, compared with the CG, which was reflected in the indicators of the scales FIM and DASH. Increasing activity in everyday life had a positive effect on the mental state of people with gunshot wounds of the upper limbs, in particular under the influence of rehabilitation measures in patients of the MG significantly reduced anxiety symptoms and depressive symptoms. Conclusions. Using of the developed algorithm of physical therapy measures based on the model of the ICF, RLH significantly improved various aspects of quality of patients' life with gunshot wounds of the forearm and hand and was more effective than the standard approach. [ABSTRACT FROM AUTHOR]

Methemoglobinemia, characterized by the conversion of functional hemoglobin to methemoglobin, can significantly impede tissue oxygenation. Prompt diagnosis and treatment of methemoglobinemia are critical to optimizing clinical outcomes. Although the underlying etiology of methemoglobinemia is often attributed to a medication reaction or chemical exposure, its association with battlefield trauma remains underexplored. This case series explores the presence of methemoglobinemia in nine soldiers evacuated from tanks targeted by explosives, shedding new light on screening needs and treatment strategies. Nine combat trauma patients with methemoglobinemia were admitted to Soroka Medical Center over a two-month period. Detailed case descriptions illustrate the diverse presentations and treatment responses. Notably, the administration of methylene blue resulted in rapid methemoglobin reductions and an improvement in oxygenation without any observed side effects. This series highlights an unexpected consequence of an explosion within an armored fighting vehicle and the challenges related to standard pulse oximetry interpretation and accuracy in the presence of methemoglobinemia, emphasizing the need for vigilant monitoring and co-oximetry utilization. Additionally, the coexistence of carboxyhemoglobin further warrants attention due to its synergistic and deleterious effects on oxygen delivery. Collaborative efforts with military authorities should aim to explore the underlying mechanisms associated with trauma and methemoglobinemia and optimize battlefield care. This case series underscores the significance of methemoglobinemia screening in combat trauma patients, and advocates for systematic co-oximetry utilization and methylene blue availability in combat zones. Early detection and intervention of methemoglobinemia in combat soldiers are often difficult in the context of battlefield injuries but are necessary to mitigate the potentially fatal consequences of this condition. [ABSTRACT FROM AUTHOR]

Introduction: Forward surgical centers (FSCs) provide combat medical support to troops in the field. They comprise a surgical team with radiology and laboratory services. Methodology: Two years data from a single FSC located in a counter-insurgency operational zone were recorded and analyzed on several parameters. The admission and discharge registers, operation theater records of surgery and anesthesia, and the fatal case records were used as data sources. Results: About 60% of the trauma cases were penetrating trauma. The most common region of the body that was injured was the extremities mainly upper limbs. The torso injuries were less than expected presumably due to the use of body armor. Majority of the cases were priority 2 cases requiring urgent surgery. Fifty percent of cases required general anesthetic and the remaining were done under neuraxial blockade or regional or local anesthesia. Eight percent of cases required blood transfusion at the FSC. As banked blood was not readily available, the FSC relied on fresh whole blood. Forty-nine percent of the operated cases were discharged from the FSC without needing transfer to the rear. In 85% of the cases, the surgical team was able to perform definitive surgery. Forty-seven percent of cases were transferred to the next level of surgical care. The overall survival of the trauma cases received at the FSC was 97.12% with a mortality of 2.88%. The leading cause of death was head and chest injuries. The results of this study are comparable to the results of the American experience in Iraq and Afghanistan. Conclusion: This study analyzes the data from a FSC to provide an analysis of the surgical case load in a counterinsurgency area. In spite of multiple limitations, the FSC provided definitive surgery to more than 85% of the trauma cases. The remaining 15% received emergency surgery and were later transferred to the next higher medical facility for superspecialty treatment. About half the number of patients were discharged from the FSC, implying that the true picture of combat trauma should be assessed at the level of FSC and not a referral/zonal hospital.

Background: Limbs are most commonly involved in combat trauma. There is insufficient data on limb injuries sustained in the combat zone of Indian Armed Forces. This study aims to analyze limb injuries in 166 cases at a tertiary care center in counter insurgency operational area. Materials and Methods: All casualties with limb injuries who presented to the center from January 2014 to December 2019 were included in the study. Data were obtained from admission and discharge registers, central registry, and operation theater registers. Casualties who were killed in action were excluded from the study. The extremity involved, wounding agent, type of injury, length of hospital stay (LOHS), number of surgical interventions, and type of reconstruction undertaken were recorded. Results: Limb injuries accounted for 61% of all casualties, with a mean age of 30.45% ± 6.72 years. Nearly 67% of all injuries were caused by fragmentation device, 61% were of soft-tissue (ST) type, and 39% were of ST injuries with fractures (STFs). The LOHS and number of surgical interventions for STFs were statistically significantly higher (P < 0.001). There was a moderate correlation between the grades of injuries, LOHS, and number of surgeries. The most common reconstruction undertaken was split skin graft in 32% cases. Conclusion: This study for the first time evaluates limb injuries in combat-related trauma in Indian Armed Forces. It also analyzes the LOHS, and number of surgeries with the type of injuries and their correlation.

Background: Multidrug-resistant infections complicating combat-related trauma necessitate the use of broad-spectrum antimicrobials. Recent literature posits an association between vancomycin (VANC) and piperacillin--tazobactam (VPT) combination therapy and acute kidney injury (AKI). We examined whether therapy with VPT was associated with an increased risk of AKI compared to VANC and other broad-spectrum b-lactam antibiotics (VBL) following combat-related injuries. Methods: Patients within the Trauma Infectious Disease Outcomes Study (TIDOS) who received ≥48 hours concomitant VPT or VBL started within 24 hours of each other were assessed. Exclusion criteria were receipt of renal replacement therapy and baseline creatinine >1.5 mg/dL. Acute kidney injury was defined by meeting any of the Risk, Injury, Failure, Loss, End Stage Renal Disease (RIFLE), AKIN, or VANC consensus guidelines criteria 3 to 7 days after therapy initiation. Variables significantly associated with AKI were used in inverse probability treatment weighting to perform univariate and subsequent logistic regression multivariate modeling to determine significant risk factors for AKI. Results: Sixty-one patients who received VPT and 207 who received VBL were included. Both groups had a median age of 24 years and initial median creatinine of 0.7 mg/dL. The VBL patients were more likely to have sustained blast injuries (P = .001) and received nephrotoxic agents (amphotericin [P = .002] and aminoglycosides [P < .001]). In the VBL group, AKI incidence was 9.7% compared to 13.1% in the VPT group (P = .438). Multivariate analysis identified a relative risk of 1.727 (95% CI: 1.027-2.765) for AKI associated with VPT exposure. Acute kidney injury severity generally met RIFLE Risk criteria and was 1 day in duration. Only 1 patient had persistent renal dysfunction 30 days after therapy completion. Conclusion: In this young and previously healthy, severely ill combat-injured population, VPT was associated with nearly twice the risk of AKI compared to VBL. Nevertheless, AKI was of low severity, short duration, and had high rates of renal recovery. [ABSTRACT FROM AUTHOR]

A Performance Improvement project conducted within Army Behavioral Health identified significant challenges associated with treating service members diagnosed with posttraumatic stress disorder (PTSD) including unavailability of frequent and consistent therapy, a low completion rate of evidence-based treatment, and a high non-response rate. In response to these findings, clinical staff at Brooke Army Medical Center developed an intensive outpatient program for the treatment of PTSD and combined Acceptance and Commitment Therapy with Prolonged Exposure therapy to create an integrative and uniquely tailored intervention. This project included 311 active duty service members who had not made significant progress in individual outpatient therapy for PTSD. Each participant completed pre- and post-treatment measures of symptoms, functioning, and processes related to psychological flexibility. Program evaluation also included participant interviews, survey responses, and clinician reports. Overall, the program was tolerable and reviewed favorably by participants. Preliminary pre-post treatment analyses revealed, on average, large reductions in PTSD symptoms as well as significant changes in the target direction on nine of ten outcome measures. These findings encourage further investigation of process-outcome relationships and future, rigorous implementation studies of ACT and exposure integration and culturally and contextually sensitive treatments for military-related PTSD. • Evaluation of PTSD IOP that treated 311 active duty military service members. • Our protocol combines ACT and exposure therapy for the treatment of PTSD. • Significant reductions in PTSD symptoms found in military IOP. • PCL-5 and PDS-5 scores decreased significantly. • Protocol combining ACT and exposure therapy experienced a drop-out rate of only 3.9%. [ABSTRACT FROM AUTHOR]