Advancing Combat Casualty Care Statistics and Other Battlefield Care Metrics.

Aggregate statistics can provide intra-conflict and inter-conflict mortality comparisons and trends within and between U.S. combat operations. However, capturing individual-level data to evaluate medical and non-medical factors that influence combat casualty mortality has historically proven difficult. The Department of Defense (DoD) Trauma Registry, developed as an integral component of the Joint Trauma System during recent conflicts in Afghanistan and Iraq, has amassed individual-level data that have afforded greater opportunity for a variety of analyses and comparisons. Although aggregate statistics are easily calculated and commonly used across the DoD, other issues that require consideration include the impact of individual medical interventions, non-medical factors, non-battle-injured casualties, and incomplete or missing medical data, especially for prehospital care and forward surgical team care. Needed are novel methods to address these issues in order to provide a clearer interpretation of aggregate statistics and to highlight solutions that will ultimately increase survival and eliminate preventable death on the battlefield. Although many U.S. military combat fatalities sustain injuries deemed non-survivable, survival among these casualties might be improved using primary and secondary prevention strategies that prevent injury or reduce injury severity. The current commentary proposes adjustments to traditional aggregate combat casualty care statistics by integrating statistics from the DoD Military Trauma Mortality Review process as conducted by the Joint Trauma System and Armed Forces Medical Examiner System.

Do No Harm in Global Health Engagement.

This manuscript examines the principle of "Do No Harm" in DoD Global Health Engagement (GHE) efforts. It highlights the potential positive and negative consequences of health investments and explores how unintentional harm is addressed in a global health context. The manuscript also discusses the involvement of the U.S. military in global health and the concept of dual loyalty faced by military GHE practitioners. The goal is to understand the challenges of doing no harm and identify methods to mitigate or avoid unintended negative consequences in DoD GHE activities.

The Walter Reed Project, Kisumu Field Station: Impact of Research on Malaria Policy, Management, and Prevention.

The Walter Reed Project is a collaboration between the Walter Reed Army Institute of Research of the United States Department of Defense and the Kenya Medical Research Institute. The Kisumu field station, comprising four campuses, has until recently been devoted primarily to research on malaria countermeasures. The Kombewa Clinical Research Center is dedicated to conducting regulated clinical trials of therapeutic and vaccine candidates in development. The center's robust population-based surveillance platform, along with an active community engagement strategy, guarantees consistent recruitment and retention of participants in clinical trials. The Malaria Diagnostic Center, backed by WHO-certified microscopists and a large malaria blood film collection, champions high-quality malaria diagnosis and strict quality assurance through standardized microscopy trainings. The Malaria Drug Resistance Laboratory leverages cutting-edge technology such as real-time Polymerase Chain Reaction (qPCR) to conduct comprehensive research on resistance markers and obtain information on drug efficacy. The laboratory has been working on validating artemisinin resistance markers and improving tracking methods for current and future antimalarial compounds. Finally, the Basic Science Laboratory employs advanced genomic technology to examine endpoints such as immunogenicity and genomic fingerprinting for candidate drugs and vaccine efficacy. Herein, we examine the site's significant contributions to malaria policy, management, and prevention practices in Kenya and around the world.

Blood consumption in the Role 2 setting: A Department of Defense Trauma Registry analysis.

BACKGROUND: The Role 2 setting represents the most far-forward military treatment facility with limited surgical and holding capabilities. There are limited data to guide recommendations on blood product utilization at the Role 2. We describe the consumption of blood products in this setting. STUDY DESIGN AND METHODS: We analyzed data from 2007 to 2023 from the Department of Defense Trauma Registry (DODTR) that received care at a Role 2. We used descriptive and inferential statistics to characterize the volumes of blood products consumed in this setting. We also performed a secondary analysis of US military, Coalition, and US contractor personnel. RESULTS: Within our initial cohort analysis of 15,581 encounters, 17% (2636) received at least one unit of PRBCs or whole blood, of which 11% received a submassive transfusion, 4% received a massive transfusion, and 1% received a supermassive transfusion. There were 6402 encounters that met inclusion for our secondary analysis. With this group, 5% received a submassive transfusion, 2% received a massive transfusion, and 1% received a supermassive transfusion. CONCLUSIONS: We described volumes of blood products consumed at the Role 2 during recent conflicts. The maximum number of units consumed among survivors exceeds currently recommended available blood supply. Our findings suggest that rapid resupply and cold-stored chain demands may be higher than anticipated in future conflicts.

The Design and Application of a Health Behavioral Change (HBC) Roadmap.

INTRODUCTION: To assist in addressing medical readiness challenges, the DOD has established various Centers of Excellence to focus efforts to protect, treat, train, and educate service members concerning risks and potential injuries. Using the hearing health domain as a pilot, this effort used DOD methods to evaluate all facets of successful health behavior change (HBC) practices within a military environment and developed a framework and pathway for HBC. METHODS: The DOD uses the Joint Capabilities Integration and Development System (JCIDS) to ensure new DOD capabilities are identified and fielded in a manner that is interoperable, resilient, and supportables. The study sponsor for the Health Behavioral Change Framework study is the Defense Health Agency Deputy Assistant Director for Research and Engineering (R&E). The main objective of this group was to ensure that final products would both meet the requirements as defined by the JCIDS process, as well as be used by the operational force in addressing HBCs that improve readiness of the joint force. RESULTS: The Health Behavior Change Guidebook applies to all organizations across the DOD and military health system that may participate in or support specific tasks related to the design, conduct, and assessment of the HBC campaign. The advantage of the process is the ability to define gaps and solutions at an enterprise level. The HBC framework can be applied to a variety of health domains to include behavioral health. CONCLUSIONS: Use of the "Guidebook for Design, Conduct and Assessment of Health Behavior Change Campaign Within the DOD" and DOTMLPF-P analysis will move Defense Health Agency toward more disciplined use of the JCIDS. The HBC framework allowed the Hearing Center of Excellence to lead the hearing health community to create a capability-based assessment for hearing HBC.

Injury Patterns and Treatment Strategies in Civilian and Military Isolated Abdominal Gunshot Wounds.

BACKGROUND: Combat-related gunshot wounds (GSW) may differ from those found in civilian trauma centers. Missile velocity, resources, logistics, and body armor may affect injury patterns and management strategies. This study compares injury patterns, management, and outcomes in isolated abdominal GSW between military (MIL) and civilian (CIV) populations. METHODS: The Department of Defense Trauma Registry (DoDTR) and TQIP databases were queried for patients with isolated abdominal GSW from 2013 to 2016. MIL patients were propensity score matched 1:3 based on age, sex, and extraabdominal AIS. Injury patterns and in-hospital outcomes were compared. Initial operative management strategies, including selective nonoperative management (SNOM) for isolated solid organ injuries, were also compared. RESULTS: Of the 6435 patients with isolated abdominal GSW, 183 (3%) MIL were identified and matched with 549 CIV patients. The MIL group had more hollow viscus injuries (84% vs. 66%) while the CIV group had more vascular injuries (10% vs. 21%) (p < .05 for both). Operative strategy differed, with more MIL patients undergoing exploratory laparotomy (95% vs. 82%) and colectomy (72% vs. 52%) (p < .05 for both). However, no difference in ostomy creation was appreciated. More SNOM for isolated solid organ injuries was performed in the CIV group (34.1% vs. 12.5%; p < 0.05). In-hospital outcomes, including mortality, were similar between groups. CONCLUSIONS: MIL abdominal GSW lead to higher rates of hollow viscus injuries compared to CIV GSW. MIL GSW are more frequently treated with resection but with similar ostomy creation compared to civilian GSW. SNOM of solid organ injuries is infrequently performed following MIL GSW.

Suicide attempts and mental health diagnoses in combat-injured service members: A retrospective cohort study.

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

After the Trauma: The Role of Rehabilitation Medicine in U.S. DoD Global Health Engagement.

The U.S. Department of Defense (DoD) possesses significant expertise with rehabilitation of combat injured personnel. This is an area of growing interest with Global Health Engagement (GHE), particularly in countries with active conflict such as Ukraine. Effective rehabilitation can contribute to both development and security, and by leveraging its inherent expertise via rehabilitation-based GHE, the DoD can contribute to these strategic objectives.

The Primary Care Management of Headache: Synopsis of the 2020 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

INTRODUCTION: In June of 2020, the U.S. DVA and DoD approved a new joint clinical practice guideline for assessing and managing patients with headache. This guideline provides a framework to evaluate, treat, and longitudinally manage the individual needs and preferences of patients with headache. METHODS: In October of 2018, the DVA/DoD Evidence-Based Practice Work Group convened a guideline development panel that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. RESULTS: The guideline panel developed key questions, systematically searched and evaluated the literature, created a 1-page algorithm, and advanced 42 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. CONCLUSION: This synopsis summarizes the key features of the guideline in three areas: prevention, assessing and treating medication overuse headache, and nonpharmacologic and pharmacologic management of headache.

Synopsis of the 2020 US Department of Veterans Affairs/US Department of Defense Clinical Practice Guideline: The Non-Surgical Management of Hip and Knee Osteoarthritis.

In July 2020, the US Department of Veterans Affairs (VA) and US Department of Defense (DoD) approved a new joint clinical practice guideline for the non-surgical management of hip and knee osteoarthritis. This synopsis highlights some of the recommendations. In February 2019, the VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched (ie, Cochrane Database of Systematic Reviews, EMBASE, MEDLINE PreMEDLINE, PubMed, and the Agency for Healthcare Research and Quality website) and evaluated the literature, created a simple 1-page algorithm, and advanced 19 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. This synopsis summarizes key recommendations in all 6 topics covered in the guideline. These topics are diagnosis, self-management, physical therapy, pharmacotherapy, orthobiologics, and complementary and integrative health.

Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) guidelines for management of dyslipidemia and cardiovascular disease risk reduction: Putting evidence in context.

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in the United States (U.S.) and incurs significant cost to the healthcare system. Management of cholesterol remains central for ASCVD prevention and has been the focus of multiple national guidelines. In this review, we compare the American Heart Association (AHA)/American College of Cardiology (ACC) and the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) Cholesterol guidelines. We review the evidence base that was used to generate recommendations focusing on 4 distinct themes: 1) the threshold of absolute 10-year ASCVD risk to start a clinician-patient discussion for the initiation of statin therapy in primary prevention patients; 2) the utility of coronary artery calcium score to guide clinician-patient risk discussion pertaining to the initiation of statin therapy for primary ASCVD prevention; 3) the use of moderate versus high-intensity statin therapy in patients with established ASCVD; and 4) the utility of ordering lipid panels after initiation or intensification of lipid lowering therapy to document efficacy and monitor adherence to lipid lowering therapy. We discuss why the VA/DoD and AHA/ACC may have reached different conclusions on these key issues.

Comparison of Survival among Colon Cancer Patients in the U.S. Military Health System and Patients in the Surveillance, Epidemiology, and End Results (SEER) Program.

BACKGROUND: Access to health care is associated with cancer survival. The U.S. military health system (MHS) provides universal health care to beneficiaries, reducing barriers to medical care access. However, it is unknown whether the universal care has translated into improved survival among patients with colon cancer. We compared survival of patients with colon cancer in the MHS to that in the U.S. general population and assessed whether stage at diagnosis differed between the two populations and thus could contribute to survival difference. METHODS: The data were from Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR) and the NCI's Surveillance, Epidemiology, and End Results (SEER) program, respectively. The ACTUR (N = 11,907) and SEER patients (N = 23,814) were matched to demographics and diagnosis year with a matching ratio of 1:2. Multivariable Cox regression model was used to estimate all-cause mortality for ACTUR compared with SEER. RESULTS: ACTUR patients exhibited better survival than their SEER counterparts (HR, 0.82; 95% confidence interval, 0.79-0.87) overall and in most subgroups by age, in both men and women, and in whites and blacks. The better survival remained when the comparison was stratified by tumor stage. CONCLUSIONS: Patients with colon cancer in a universal health care system had better survival than patients in the general population. IMPACT: Universal care access is important to improve survival of patients with colon cancer.

Data-driven approaches to care delivery: Actionable informatics in the DoD's primary care behavioral health program.

INTRODUCTION: Transforming administrative health care data into meaningful metrics has been critical to the implementation of the Department of Defense's Primary Care Behavioral Health (PCBH) program. METHODS: Data from clinical encounters with PCBH providers are used to develop metrics of program performance collaboratively. Metrics focus on describing the PCBH program and patients, provider fidelity to the model, and provider performance. These metrics form two key deliverables: a monitoring dashboard for program managers and a training dashboard for expert trainers conducting site visits. RESULTS: Behavioral health consultants (BHCs) conducted nearly 200,000 encounters with more than 100,000 unique patients in fiscal year 2019 at more than 170 locations in 6 countries and 37 states. Administrative data derived from these encounters were used to create a variety of metrics that describe practice and performance at both the provider and program levels. These metrics are delivered through a variety of analytic products to stakeholders who use that information to make data-driven decisions about program direction and provider training. DISCUSSION: We discuss examples of program management decisions and expert trainer actions based on these dashboards, highlighting the benefits of continued collaboration between analysts and program managers. Specifically, excerpts from several dashboards illustrate how penetration and productivity metrics yield specific, tailored action plans to improve care delivery and provider performance. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Barriers to PTSD treatment-seeking by women veterans who experienced military sexual trauma decades ago: The role of institutional betrayal.

BACKGROUND: While some barriers to PTSD treatment engagement among veterans are well-identified, e.g., stigma, little is known about the barriers to VA PTSD treatment-seeking among women veterans who experienced military sexual trauma (MST) decades ago. PURPOSE: To explore the barriers to PTSD treatment-seeking of women veterans with PTSD related to MST experienced prior to 2000. METHOD: Data were collected from women veterans (n = 14) who had experienced MST and sought VA PTSD treatment. Data analyses utilized a constructivist grounded theory approach. FINDINGS: The context of the MST experience, including the military environment at the time, the era in which they experienced MST and the response of others to their reporting or disclosure of MST created decades-long barriers to PTSD treatment-seeking. DISCUSSION: Understanding institutional betrayal as a barrier to PTSD treatment-seeking among women veterans who experienced MST decades ago is necessary to develop effective targeted outreach and programs for this population.

Conducting Virtual Global Health Engagement (GHE) activities in the Midst of the Global COVID-19 Pandemic: Considerations for the Department of Defense GHE Enterprise.

The global COVID-19 pandemic resulted in restriction of non-essential travel across the globe, as seen in the Office of the Under Secretary of Defense Memorandum, "Force Health Protection Guidance (Supplement 4): DoD Guidance for Personnel Traveling During the Novel Coronavirus Outbreak" (11 March 2020). This resulted in the suspension of most, if not all, Department of Defense (DoD) security cooperation (SC) programs, including DoD Global Health Engagement (GHE) activities.1 One such program is the African Peacekeeping Rapid Response Partnership (APRRP), which relies heavily on face-to-face interactions with select African Partner Nations (PNs), and which was significantly impacted by the inability to conduct in-person training with key partners. In light of these restrictions and suspended activities, the Uniformed Services University of the Health Sciences' (USU's) Center for Global Health Engagement (CGHE), in support of the US Africa Command (USAFRICOM) Office of the Command Surgeon, explored virtual means to execute DoD GHE activities to continue engaging its APRRP PNs, pending return to in-country activities.

Influenza Surveillance Trends and Influenza Vaccine Effectiveness Among Department of Defense Beneficiaries During the 2019-2020 Influenza Season.

Laboratory-based influenza surveillance was conducted in the 2019-2020 influenza season among Department of Defense (DoD) beneficiaries through the DoD Global Respiratory Pathogen Surveillance Program (DoDGRS). Sentinel and participating sites submitted 28,176 specimens for clinical diagnostic testing. A total of 5,529 influenza-positive cases were identified. Starting at surveillance week 45 (3-9 November 2019), influenza B was the predominant influenza type, followed by high activity of influenza A(H1N1)pdm09 three weeks thereafter. Both influenza B and influenza A(H1N1)pdm09 were then highly co-circulated through surveillance week 13 (22-28 March 2020). End-of-season influenza vaccine effectiveness (VE) was estimated using a test-negative case-control study design. The adjusted end-of-season VE for all beneficiaries, regardless of influenza type or subtype, was 46% (95% confidence interval: 40%-52%). The influenza vaccine was moderately effective against influenza viruses during the 2019-2020 influenza season.

Personality Disorders as a Basis for Discharge and Denial of Benefits in the Military: Logical or Abusive?

ABSTRACT: The US Department of Defense specifically states that intellectual disability and personality disorders are not diseases for compensation purposes, and disabilities from them may not be service connected absent a superimposed mental disorder. In addition, the diagnosis of a personality disorder led to the discharge of 31,000 troops during the years 2001 to 2010. I review the history of these developments, and how the Diagnostic and Statistical Manual of Mental Disorders enabled these actions. In contrast, the United Kingdom and Canada do not allow such actions. Whether our approach is logical seems highly questionable, especially given the significant problems with the DSM's definitions of personality disorders, definitions at odds with the literature.