Relationship between clinician documented blast exposure and pulmonary function: a retrospective chart review from a national specialty clinic.

BACKGROUND: Service member exposure to explosive blast overpressure waves is common with considerable attention to traumatic brain injury (TBI) and neuropsychological sequalae. Less is known about the impacts on the respiratory system, particularly long-term effects, despite vulnerability to overpressure. Using a national registry, we previously observed an independent relationship between self-reported blast exposure and respiratory symptoms; however, the impact on objective measures of pulmonary function is poorly understood. METHODS: 307 Veterans referred to our national specialty center for post-deployment health concerns underwent a comprehensive multi-day evaluation that included complete pulmonary function testing (PFT), occupational and environmental medicine history, neuropsychological or psychological evaluation. We developed an a priori chart abstraction process and template to classify Veterans into blast exposure groups: (1) none, (2) single-mild, or (3) multiple-mild. This template focused primarily on clinician documented notes of blast related TBI that were used as proxy for blast overpressure injury to thorax. PFT variables characterizing flow (FEV1%; %∆FEV1), volume (TLC%), diffusion (DLCO%) and respiratory mechanics (forced oscillometry) were selected for analysis. RESULTS: Veterans (40.5 ± 9.7 years; 16.3% female) were referred 8.6 ± 3.6 years after their last deployment and presented with considerable comorbid conditions and health problems (e.g., 62% post-traumatic stress, 55% dyspnea). After chart abstraction, Veterans were assigned to none (n = 208), single mild (n = 52) and multiple mild (n = 47) blast exposure groups. Among the blast exposed, clinicians documented 73.7% were < 50 m from the blast and 40.4% were physically moved by blast. PFT outcome measures were similar across all groups (p value range: 0.10-0.99). CONCLUSIONS: In this referred sample of deployed Veterans, PFT measures of flow, volume, diffusion, and respiratory mechanics were not associated with clinician documented blast exposure per the retrospective chart abstraction methodology applied. Yet, these clinical findings suggest future research should determine and assess distinction between Veteran recollections of perceived blast experiences versus overpressure wave exposure to the respiratory system.

Multimorbidity and quality of life after blast-related injury among US military personnel: a cluster analysis of retrospective data.

BACKGROUND: Blast injury emerged as a primary source of morbidity among US military personnel during the recent conflicts in Iraq and Afghanistan, and led to an array of adverse health outcomes. Multimorbidity, or the presence of two or more medical conditions in an individual, can complicate treatment strategies. To date, there is minimal research on the impact of multimorbidity on long-term patient-reported outcomes. We aimed to define multimorbidity patterns in a population of blast-injured military personnel, and to examine these patterns in relation to long-term quality of life (QOL). METHODS: A total of 1972 US military personnel who sustained a blast-related injury during military operations in Iraq and Afghanistan were identified from clinical records. Electronic health databases were used to identify medical diagnoses within the first year postinjury, and QOL was measured with a web-based assessment. Hierarchical cluster analysis methods using Ward's minimum variance were employed to identify clusters with related medical diagnosis categories. Duncan's multiple range test was used to group clusters into domains by QOL. RESULTS: Five distinct clusters were identified and grouped into three QOL domains. The lowest QOL domain contained one cluster with a clinical triad reflecting musculoskeletal pain, concussion, and mental health morbidity. The middle QOL domain had two clusters, one with concussion/anxiety predominating and the other with polytrauma. The highest QOL domain had two clusters with little multimorbidity aside from musculoskeletal pain. CONCLUSIONS: The present study described blast-related injury profiles with varying QOL levels that may indicate the need for integrated health services. Implications exist for current multidisciplinary care of wounded active duty and veteran service members, and future research should determine whether multimorbidity denotes distinct post-blast injury syndromes.

Additional Vitamin and Mineral Support for Patients with Severe Burns: A Nationwide Experience from a Catastrophic Color-Dust Explosion Event in Taiwan.

Major burn injuries, which encompass ≥20% of the total body surface area (TBSA), are the most severe form of trauma because of the stress response they provoke, which includes hypermetabolism, muscle wasting, and stress-induced diabetes. In 2015, a color-dust explosion disaster occurred in the Formosa Fun Coast of Taiwan and injured 499 people, who were transferred via a nationwide emergency delivery system. Some recommendations are currently available regarding vitamin and mineral support for wound healing and recovery in severe burns, but there is a lack of evidence to confirm the benefits. Thus, the current study aimed to investigate the effects of additional vitamin and mineral support for patients with severe burn injuries. Sixty-one hospitalized individuals with major burns (full thickness and ≥20% TBSA) were classified into the supplement (n = 30) and control (n = 31) groups, according to whether they received supplementation with additional vitamins, calcium, and magnesium. There were significant differences between the supplement and control groups in the incidence of wound infection (30.0% vs. 77.4%, p < 0.001), sepsis (13.3% vs. 41.9%, p = 0.021), and hospitalization days (51.80 vs. 76.81, p = 0.025). After adjustment, logistic regression analysis revealed that, compared to those in the control group, patients in the supplement group had a lower risk for wound infection (OR 0.11; 95% CI 0.03⁻0.43; p = 0.002) and sepsis (OR 0.09; 95% CI 0.01⁻0.61; p = 0.014). Supplementation of multiple vitamins, calcium, and magnesium reduced the risk of wound infection and sepsis, shortened the time of hospitalization, and can be considered for use in major burns.

Civilian casualties of terror-related explosions: The impact of vascular trauma on treatment and prognosis.

OBJECTIVES: A high prevalence (10%) of vascular trauma (VT) was previously described in terror-related trauma as compared with non-terror-related trauma (1%), in a civilian setting. No data regarding outcome of VT casualties of improvised explosive device (IED) explosions, in civilian settings, are available. The aim of the current study is to present the prognosis of civilian casualties of IED explosions with and without VT. METHODS: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from September 2000 to December 2005 who were victims of explosions were included. These patients were subdivided into patients with VT (n = 109) and non-VT (NVT) (n = 1,152). Both groups were analyzed according to mechanism of trauma, type and severity of injury, and treatment. RESULTS: Of 1,261 explosion casualties, there were 109 VT victims (8.6%). Patients with VT tended to be more complex, with a higher injury severity score (ISS): 17.4% with ISS 16 to 24 as compared with only 10.5%. In the group of critically injured patients (ISS, 25-75), 51.4% had VT compared with only 15.5% of the NVT patients. As such, a heavy share of hospitals' resources were used-trauma bay admission (62.4%), operating rooms (91.7%), and intensive care unit beds (55.1%). The percentage of VT patients who were admitted for more than 15 days was 2.3 times higher than that observed among the NVT patients. Lower-extremity VT injuries were the most prevalent. Although many resources are being invested in treating this group of patients, their mortality rate is approximately five times more than NVT (22.9% vs. 4.9%). CONCLUSIONS: Vascular trauma casualties of IED explosions are more complex and have poorer prognosis. Their higher ISS markedly increases the hospital's resource utilization, and as such, it should be taken into consideration either upon the primary evacuation from the scene or when secondary modulation is needed in order to reduce the burden of the hospitals receiving the casualties. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level V.

Symptoms of post-concussional syndrome are non-specifically related to mild traumatic brain injury in UK Armed Forces personnel on return from deployment in Iraq: an analysis of self-reported data.

BACKGROUND: Mild traumatic brain injury (mTBI) is being claimed as the 'signature' injury of the Iraq war, and is believed to be the cause of long-term symptomatic ill health (post-concussional syndrome; PCS) in an unknown proportion of military personnel. METHOD: We analysed cross-sectional data from a large, randomly selected cohort of UK military personnel deployed to Iraq (n=5869). Two markers of PCS were generated: 'PCS symptoms' (indicating the presence of mTBI-related symptoms: none, 1-2, 3+) and 'PCS symptom severity' (indicating the presence of mTBI-related symptoms at either a moderate or severe level of severity: none, 1-2, 3+). RESULTS: PCS symptoms and PCS symptom severity were associated with self-reported exposure to blast whilst in a combat zone. However, the same symptoms were also associated with other in-theatre exposures such as potential exposure to depleted uranium and aiding the wounded. Strong associations were apparent between having PCS symptoms and other health outcomes, in particular being a post-traumatic stress disorder or General Health Questionnaire case. CONCLUSIONS: PCS symptoms are common and some are related to exposures such as blast injury. However, this association is not specific, and the same symptom complex is also related to numerous other risk factors and exposures. Post-deployment screening for PCS and/or mTBI in the absence of contemporaneous recording of exposure is likely to be fraught with hazards.