A prediction model for differential resilience to the effects of combat-related stressors in US army soldiers.

OBJECTIVES: To develop a composite score for differential resilience to effects of combat-related stressors (CRS) on persistent DSM-IV post-traumatic stress disorder (PTSD) among US Army combat arms soldiers using survey data collected before deployment. METHODS: A sample of n = 2542 US Army combat arms soldiers completed a survey shortly before deployment to Afghanistan and then again two to three and 8-9 months after redeployment. Retrospective self-reports were obtained about CRS. Precision treatment methods were used to determine whether differential resilience to persistent PTSD in the follow-up surveys could be developed from pre-deployment survey data in a 60% training sample and validated in a 40% test sample. RESULTS: 40.8% of respondents experienced high CRS and 5.4% developed persistent PTSD. Significant test sample heterogeneity was found in resilience (t = 2.1, p = 0.032), with average treatment effect (ATE) of high CRS in the 20% least resilient soldiers of 17.1% (SE = 5.5%) compared to ATE = 3.8% (SE = 1.2%) in the remaining 80%. The most important predictors involved recent and lifetime pre-deployment distress disorders. CONCLUSIONS: A reliable pre-deployment resilience score can be constructed to predict variation in the effects of high CRS on persistent PTSD among combat arms soldiers. Such a score could be used to target preventive interventions to reduce PTSD or other resilience-related outcomes.

Military and occupational exposures among Veterans in the Million Veteran Program by survey self-report: a descriptive study.

OBJECTIVE: We aimed to characterise self-reported military and occupational exposures including Agent Orange, chemical/biological warfare agents, solvents, fuels, pesticides, metals and burn pits among Veterans in the Department of Veterans Affairs Million Veteran Program (MVP). METHODS: MVP is an ongoing longitudinal cohort and mega-biobank of over one million US Veterans. Over 500 000 MVP participants reported military exposures on the baseline survey, and over 300 000 reported occupational exposures on the lifestyle survey. We determined frequencies of selected self-reported occupational exposures by service era, specific deployment operation (1990-1991 Gulf War, Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)), service in a combat zone and occupational categories. We also explored differences in self-reported exposures by sex and race. RESULTS: Agent Orange exposure was mainly reported by Vietnam-era Veterans. Gulf War and OEF/OIF Veterans deployed to a combat zone were more likely to report exposures to burn pits, chemical/biological weapons, anthrax vaccination and pyridostigmine bromide pill intake as compared with non-combat deployers and those not deployed. Occupational categories related to combat (infantry, combat engineer and helicopter pilot) often had the highest percentages of self-reported exposures, whereas those in healthcare-related occupations (dentists, physicians and occupational therapists) tended to report exposures much less often. Self-reported exposures also varied by race and sex. CONCLUSIONS: Our results demonstrate that the distribution of self-reported exposures varied by service era, demographics, deployment, combat experience and military occupation in MVP. Overall, the pattern of findings was consistent with previous population-based studies of US military Veterans.

Critical Care Nursing and Mass Casualty Response During Operation Allies Refuge.

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

Non-therapeutic laparotomies in military trauma (2009-2014).

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.

Outpatient Prescriptions for Insomnia Medications During the First Year Following Combat-Related Amputations.

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.

Poor sleep and decreased cortical thickness in veterans with mild traumatic brain injury and post-traumatic stress disorder.

BACKGROUND: Poor sleep quality has been associated with changes in brain volume among veterans, particularly those who have experienced mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD). This study sought to investigate (1) whether poor sleep quality is associated with decreased cortical thickness in Iraq and Afghanistan war veterans, and (2) whether these associations differ topographically depending on the presence or absence of mTBI and PTSD. METHODS: A sample of 440 post-9/11 era U.S. veterans enrolled in the Translational Research Center for Traumatic Brain Injury and Stress Disorders study at VA Boston, MA from 2010 to 2022 was included in the study. We examined the relationship between sleep quality, as measured by the Pittsburgh Sleep Quality Index (PSQI), and cortical thickness in veterans with mTBI (n = 57), PTSD (n = 110), comorbid mTBI and PTSD (n = 129), and neither PTSD nor mTBI (n = 144). To determine the topographical relationship between subjective sleep quality and cortical thickness in each diagnostic group, we employed a General Linear Model (GLM) at each vertex on the cortical mantle. The extent of topographical overlap between the resulting statistical maps was assessed using Dice coefficients. RESULTS: There were no significant associations between PSQI and cortical thickness in the group without PTSD or mTBI (n = 144) or in the PTSD-only group (n = 110). In the mTBI-only group (n = 57), lower sleep quality was significantly associated with reduced thickness bilaterally in frontal, cingulate, and precuneus regions, as well as in the right parietal and temporal regions (ß = -0.0137, P < 0.0005). In the comorbid mTBI and PTSD group (n = 129), significant associations were observed bilaterally in frontal, precentral, and precuneus regions, in the left cingulate and the right parietal regions (ß = -0.0094, P < 0.0005). Interaction analysis revealed that there was a stronger relationship between poor sleep quality and decreased cortical thickness in individuals with mTBI (n = 186) compared to those without mTBI (n = 254) specifically in the frontal and cingulate regions (ß = -0.0077, P < 0.0005). CONCLUSIONS: This study demonstrates a significant relationship between poor sleep quality and lower cortical thickness primarily within frontal regions among individuals with both isolated mTBI or comorbid diagnoses of mTBI and PTSD. Thus, if directionality is established in longitudinal and interventional studies, it may be crucial to consider addressing sleep in the treatment of veterans who have sustained mTBI.

[Care for Seriously Injured People in Military Conflicts]. / Schwerstverletztenversorgung in kriegerischen Auseinandersetzungen.

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

Holding and rupture: Describing post-traumatic stress among former UK Army and Royal Marine personnel deployed to Iraq and Afghanistan.

Former UK military personnel who were previously deployed to Iraq and Afghanistan in combat roles have exhibited elevated levels of Post-Traumatic Stress Disorder (PTSD) compared to other groups. The present qualitative analyses used semi-structured interviews and a framework analysis to compare the experiences of symptomatic (N=10) and asymptomatic (N=7) former Army and Royal Marine personnel who were exposed to combat. Participants were drawn from a large UK military health and wellbeing cohort study and were sampled based upon probable PTSD status using scores from the PTSD Checklist-Civilian Version (PCL-C). All symptomatic participants attributed the development of post-traumatic stress to deployment events, with one additionally ascribing symptoms to childhood events. Among the participants, post-traumatic stress was temporarily buffered, and held at bay, by the holding function of various military structures, including the military collective; cultural and ethical frameworks that helped to organise traumatic experiences; an operational necessity for psychological compartmentalisation and even the distraction of deployment itself. Leaving the military appeared to elicit a global rupture of these supports. As a result, the military-to-civilian transition led to an intensification of post-traumatic stress, including deployment-related memories, among the symptomatic participants. In contrast, asymptomatic participants tended to report continuity of their holding structures across the lifespan, especially across the military-to-civilian transition. The onset and maintenance of post-traumatic stress may thus be explained by an interplay between the capacity of holding structures and the magnitude of lifetime rupture. Overall, findings might provide an explanation for the widening discrepancies between those with enduring post-traumatic stress and those without and further research is required to determine the fit of our findings for other groups and contexts. This approach further illustrates the need to situate individual experiences of post-traumatic stress in wider structural, ecological, cultural and ethical contexts.

Problematic anger among military personnel after combat deployment: prevalence and risk factors.

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

Upper Limb Function in People With Upper and Lower Limb Loss 8 Years Postinjury: The Armed Services Trauma Outcome Study (ADVANCE) Cohort Study.

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

Suicidal ideation in male UK military personnel who sustained a physical combat injury in Afghanistan and the mediating role of leaving service: The ADVANCE cohort study.

BACKGROUND/AIMS: Suicidal Ideation (SI) is a risk factor for suicide, a leading cause of death amongst young men globally. In this study we assess whether sustaining a serious physical combat injury is associated with SI and whether leaving service mediates this association. METHODS: We analysed data from male UK Armed Forces personnel who sustained a combat injury in Afghanistan and a frequency-matched comparison group who did not sustain such an injury (the ADVANCE cohort). SI was measured from the Patient Health Questionnaire-9 item 'thoughts that you would be better off dead or of hurting yourself in some way'. RESULTS: Approximately, 11.9% (n = 61) of the uninjured group, 15.3% (n = 83) of the overall injured group, 8.5% (n = 13) of an Amputation injury (AI) subgroup and 17.6% (n = 70) of a Non-Amputation Injury (NAI) subgroup reported SI in the past 2 weeks. The NAI subgroup reported greater likelihood of SI (Relative Risk Ratio (RR) = 1.44, 95% confidence interval (CI) [1.04, 2.00]) compared to the comparison group, whereas the overall injured group (RR = 1.23, 95% CI [0.90, 1.68]) and AI subgroup (RR = 0.65, 95% CI [0.36, 1.18]) did not. Leaving service fully mediated the association between sustaining a NAI and SI (natural direct effect RR = 1.08, 95% CI [0.69, 1.69]). CONCLUSIONS: UK military personnel with NAI reported significantly higher rates of SI compared to demographically similar uninjured personnel, while those who sustained AIs reported no significant difference. Leaving service was associated with greater rates of SI for both injured and uninjured personnel and fully mediated the association between sustaining a NAI and SI.

Operational mental health. . .what practitioners and commanders should know.

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

Operation Allies Welcome Medical Response Unit at Philadelphia International Airport: A Framework for Medical Triage of High Volume of Displaced Persons Arriving by Air.

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

Posttraumatic survivor guilt is associated with white matter microstructure alterations.

BACKGROUND: Military veterans with posttraumatic stress disorder (PTSD) commonly experience posttraumatic guilt. Guilt over commission or omission evolves when responsibility is assumed for an unfortunate outcome (e.g., the death of a fellow combatant). Survivor guilt is a state of intense emotional distress experienced by the weight of knowing that one survived while others did not. METHODS: This study of the Translational Research Center for TBI and Stress Disorders (TRACTS) analyzed structural and diffusion-weighted magnetic resonance imaging data from 132 male Iraq/Afghanistan veterans with PTSD. The Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV) was employed to classify guilt. Thirty (22.7 %) veterans experienced guilt over acts of commission or omission, 34 (25.8 %) experienced survivor guilt, and 68 (51.5 %) had no posttraumatic guilt. White matter microstructure (fractional anisotropy, FA), cortical thickness, and cortical volume were compared between veterans with guilt over acts of commission or omission, veterans with survivor guilt, and veterans without guilt. RESULTS: Veterans with survivor guilt had significantly lower white matter FA compared to veterans who did not experience guilt (p < .001), affecting several regions of major white matter fiber bundles. There were no significant differences in white matter FA, cortical thickness, or volumes between veterans with guilt over acts of commission or omission and veterans without guilt (p > .050). LIMITATIONS: This cross-sectional study with exclusively male veterans precludes inferences of causality between the studied variables and generalizability to the larger veteran population that includes women. CONCLUSION: Survivor guilt may be a particularly impactful form of posttraumatic guilt that requires specific treatment efforts targeting brain health.

The UK VIRTUS helmet: User feedback from Operation TORAL in Afghanistan.

In 2015, the VIRTUS helmet was introduced to UK Armed Forces and will ultimately replace the Mark 7 combat helmet. The VIRTUS helmet has a reduced trimline compared to the Mark 7 helmet and can incorporate attachments such as a visor, mandible guard and nape protection. An anonymous questionnaire was provided to 200 UK Armed Forces personnel deployed to four locations on Operation TORAL in Afghanistan between September and October 2019. This is the first User feedback survey assessing the VIRTUS helmet in an operational environment. Users were measured to ascertain the fit of their helmet and asked to rate perceived helmet mass and comfort using a 5-point Likert scale. Users were also asked whether the VIRTUS helmet was better than previous helmets and about their use of the nape protection. The VIRTUS helmet was perceived to be an improvement over previously issued UK combat helmets in terms of both comfort and mass.

Longitudinal measurement invariance and growth curve modeling of psychological resilience across the deployment cycle.

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

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.

Prevalence and Correlates of VA-Purchased Community Care Use Among Post-9/11-Era Veterans With Traumatic Brain Injury.

OBJECTIVE: Post-9/11-era veterans with traumatic brain injury (TBI) have greater health-related complexity than veterans overall, and may require coordinated care from TBI specialists such as those within the Department of Veterans Affairs (VA) healthcare system. With passage of the Choice and MISSION Acts, more veterans are using VA-purchased care delivered by community providers who may lack TBI training. We explored prevalence and correlates of VA-purchased care use among post-9/11 veterans with TBI. SETTING: Nationwide VA-purchased care from 2016 through 2019. PARTICIPANTS: Post-9/11-era veterans with clinician-confirmed TBI based on VA's Comprehensive TBI Evaluation (N = 65 144). DESIGN: This was a retrospective, observational study. MAIN MEASURES: Proportions of veterans who used VA-purchased care and both VA-purchased and VA-delivered outpatient care, overall and by study year. We employed multivariable logistic regression to assess associations between veterans' sociodemographic, military history, and clinical characteristics and their likelihood of using VA-purchased care from 2016 through 2019. RESULTS: Overall, 51% of veterans with TBI used VA-purchased care during the study period. Nearly all who used VA-purchased care (99%) also used VA-delivered outpatient care. Veterans' sociodemographic, military, and clinical characteristics were associated with their likelihood of using VA-purchased care. Notably, in adjusted analyses, veterans with moderate/severe TBI (vs mild), those with higher health risk scores, and those diagnosed with posttraumatic stress disorder, depression, anxiety, substance use disorders, or pain-related conditions had increased odds of using VA-purchased care. Additionally, those flagged as high risk for suicide also had higher odds of VA-purchased care use. CONCLUSIONS: Veterans with TBI with greater health-related complexity were more likely to use VA-purchased care than their less complex counterparts. The risks of potential care fragmentation across providers versus the benefits of increased access to care are unknown. Research is needed to examine health and functional outcomes among these veterans.

Level of perceived social support, and associated factors, in combat-exposed (ex-)military personnel: a systematic review and meta-analysis.

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

Putting the ready in readiness: A post hoc analysis of surgeon performance during a military mass casualty situation in Afghanistan.

BACKGROUND: All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient mass-casualty situation (MASCAL). METHODS: The sample included orthopedic (four) and general surgeons (eight) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan, on August 26, 2021. One orthopedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1, expeditionary knowledge (examination score); 2, procedural skills competencies (performance assessment score); and 3, clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases was reviewed and rated (performance score) by the Joint Trauma System's Performance Improvement Branch, a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each predeployment measure and MASCAL surgical care. RESULTS: Predeployment knowledge and clinical activity measures met program benchmarks. Baseline predeployment procedural skills competency scores did not meet program benchmarks; however, those gaps were closed through retraining, ensuring all surgeons met or exceeded the program benchmarks predeployment. There were very large effect sizes (Cohen's d ) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons. CONCLUSION: The prescribed program measures ensured that all surgeons achieved predeployment performance benchmarks and provided high-quality trauma care to our nation's service members. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.