Effectiveness of In-Theater Mental Health Assessments.

INTRODUCTION: The leading cause for medical evacuation from the U.S. Central Command area of responsibility is because of mental health conditions. The In-Theater Mental Health Assessment (ITMHA) is a DoD-required screening of deployed personnel. It is vital to examine the efficacy of ITMHA's potential to significantly impact the mental health outcomes of service members. MATERIALS AND METHODS: All ITMHA results of individuals in 2 deployed Army battalions along with a brigade headquarters deployed to U.S. Central Command between October 2022 and October 2023 were collected and analyzed. Descriptive statistics were used to characterize the results of the ITMHA. RESULTS: Of 670 deployed service members, 157 (23%) scored positive on ITMHA. Ten service members were referred for additional mental health evaluation. The remaining 147 (22%) service members who scored positive were not referred because of a lack of significant impairment or were already engaged in mental health services. One service member in the study was evacuated because of a mental health condition. The most common major life stressors identified were family/relationship issues, sleep problems, and mental health concerns. CONCLUSIONS: The number of deployed personnel identified through the ITMHA as requiring mental health care was modest. The ITMHA has multiple limitations that, if addressed, will improve its utility to mitigate mental health decline in the expeditionary environment.

Declining Military Surgical Cases and the Impact on Military Surgical Graduate Medical Education.

BACKGROUND: Several studies have indicated a decline in the number, types, and complexity of surgical procedures within military treatment facilities (MTFs). This study aims to determine what effect, if any, these downward trends have had on the relationship between the military health system (MHS) and surgical graduate medical education. METHODS: Graduating chief resident final ACGME case logs from 4 of thirteen military general surgery programs were evaluated from 2015 to 2020. The proportion of total cases performed by residents at military institutions were compared on a year over year basis. RESULTS: The proportion of cases performed within the military hospitals declined 3.27% each year between 2015 and 2020 (P < .0001) in 4 MTFs. All individual hospitals had significant declines in case volume except one (William Beaumont Army Medical Center) which increased 6.05% with each year, but also increased the number of MTF partnerships within its program (P < .0001). CONCLUSIONS: There has been a statistically significant decline over time in the proportion of cases logged by residents within the studied military treatment facilities. Investment into military hospitals to increase case numbers, case diversity, and complexity and/or acceptance of this gradual decline with greater shifting of educational workload onto civilian hospitals is required.

The Impact of the Maritime Deployment Cycle on the Surgeon's Knowledge, Skills, and Abilities.

INTRODUCTION: The U.S. Navy routinely deploys aircraft carriers and amphibious assault ships throughout the world in support of U.S. strategic interests, each with an embarked single surgeon team. Surgeons and their teams are required to participate in lengthy pre-deployment shipboard certifications before each deployment. Given the well-established relationship of surgeon volume to patient outcome, we aim to compare the impact of land vs. maritime deployments on Navy general surgeon practice patterns. MATERIALS AND METHODS: Case logs and pre-deployment training initiation of land-based (n = 8) vs. maritime-based (n = 7) U.S. Navy general surgeons over a 3-year period (2017-2020) were compared. Average cases per week were plotted over 26 weeks before deployment. Student's t-test was utilized for all comparisons. RESULTS: Cases declined for both groups in the weeks before deployment. At 6 months (26 weeks) before deployment, land-based surgeons performed significantly more cases than their maritime colleagues (50.3 vs. 14.0, P = .009). This difference persisted at 16 weeks (13.1 vs. 1.9, P = .011) and 12 weeks (13.1 vs. 1.9, P = .011). Overall, surgeon operative volume fell off earlier for maritime surgeons (16 weeks) than land-based surgeons (8 weeks). Within 8 weeks of deployment, both groups performed a similarly low number of cases as they completed final deployment preparations. CONCLUSIONS: Surgeons are a critical component of combat causality care teams. In this analysis, we have demonstrated that both land- and maritime-based U.S. Navy surgeons have prolonged periods away from clinical care before and during deployments; for shipboard surgeons, this deficit is large and may negatively impact patient outcomes in the deployed maritime environment. The authors describe this discrepancy and provide practical doctrinal solutions to close this readiness gap.

Tactical Combat Casualty Care Maritime Scenario: Shipboard Missile Strike.

The types of injuries seen in combat action on a naval surface ship may be similar in many respects to the injuries seen in ground combat, and the principles of care for those injuries remain in large part the same. However, some contradistinctions in the care of combat casualties on a ship at sea must be highlighted, since this care may entail a number of unique challenges and different wounding patterns. This paper presents a scenario in which a guided missile destroyer is struck by a missile fired from an unmanned aerial vehicle operated by an undetermined hostile entity. Despite the presence of casualties who require care, the primary focus of a naval vessel that has just been damaged by hostile action is to prevent the ship from sinking and to conserve the fighting force on board the ship to the greatest extent possible. The casualties in this scenario include sailors injured by both blast and burns, as well as a casualty with a non-fatal drowning episode. Several of the casualties have also suffered the effects of a nearby underwater explosion while immersed. Challenges in the care of these casualties include delays in evacuation, the logistics of obtaining whole blood for transfusion while at sea, and transporting the casualties to the next higher level of care aboard a Casualty Receiving and Treatment Ship. As the National Defense Strategy pivots to a focus on the potential for maritime combat, the medical community must continue to maintain readiness by preparing fo.

Committee on Surgical Combat Casualty Care position statement on the use of single surgeon teams and invited commentaries.

BACKGROUND: Over the last 20 years of war, there has been an operational need for far forward surgical teams near the point of injury. Over time, the medical footprint of these teams has decreased and the utilization of mobile single surgeon teams (SSTs) by the Services has increased. The increased use of SSTs is because of a tactical mobility requirement and not because of proven noninferiority of clinical outcomes. Through an iterative process, the Committee on Surgical Combat Casualty Care (CoSCCC) reviewed the utilization of SSTs and developed an expert-opinion consensus statement addressing the risks of SST utilization and proposed mitigation strategies. METHODS: A small triservice working group of surgeons with deployment experience, to include SST deployments, developed a statement regarding the risks and benefits of SST utilization. The draft statement was reviewed by a working group at the CoSCCC meeting November 2021 and further refined. This was followed by an extensive iterative review process, which was conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. The final draft was voted on by the entire CoSCCC membership. To inform the civilian trauma community, commentaries were solicited from civilian trauma leaders to help put this practice into context and to further the discussion in both military and civilian trauma communities. RESULTS: After multiple revisions, the SST statement was finalized in January 2022 and distributed to the CoSCCC membership for a vote. Of 42 voting members, there were three nonconcur votes. The SST statement underwent further revisions to address CoSCCC voting membership comments. Statement commentaries from the President of the American Association for the Surgery for Trauma, the chair of the Committee on Trauma, the Medical Director of the Military Health System Strategic Partnership with the American College of Surgeons and a recently retired military surgeon we included to put this military relevant statement into a civilian context and further delineate the risks and benefits of including the trauma care paradigm in the Department of Defense (DoD) deployed trauma system. CONCLUSION: The use of SSTs has a role in the operational environment; however, operational commanders must understand the tradeoff between tactical mobility and clinical capabilities. As SST tactical mobility increases, the ability of teams to care for multiple casualty incidents or provide sustained clinical operations decreases. The SST position statement is a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.

US Central Command military blood utilization practices 2011 to 2020.

BACKGROUND: Military involvement in Afghanistan ended in 2021, and while low-intensity troop engagements continue globally, casualty numbers are dwindling. To understand the clinical and operational connections between blood utilization and clinical paradigm shifts in resuscitation strategies, a review of blood product utilization and the changes in the last decade was conducted within the US Central Command area of responsibility. The intent of this review was to assess patterns of blood use during the last decade of the United States' involvement in the most recent major conflicts to potentially inform future blood requirements. METHODS: Blood product and types transfused between January 1, 2011, and December 31, 2020, were acquired from the Medical Situational Awareness in Theater blood reports. All reported blood usage data in the US Central Command area of responsibility were queried. RESULTS: Packed red blood cells and fresh frozen plasma (FFP) usage showed no statistically significant change over time ( τb = 0.24, p = 0.3252; τb = -0.47, p = 0.0603). Fresh and stored whole blood (SWB) use increased overtime ( τb = 0.69, p = 0.0056; τb = 0.83, p = 0.0015). A strong inverse relationship was found between SWB and FFP usage ( r = -0.68, p = 0.0309) and liquid plasma and FFP usage ( r = -0.65, p = 0.0407) over time. CONCLUSION: Whole blood usage increased significantly over time with a preference for SWB. Component therapy is anticipated to remain a critical element of resuscitation in the event of large-scale combat operations secondary to supply chain and longer storage times. LEVEL OF EVIDENCE: Therapeutic/care management; Level III.

How did absentee voting affect the 2020 U.S. election?

The 2020 U.S. election saw a record turnout, saw a huge increase in absentee voting, and brought unified national Democratic control­yet these facts alone do not imply that vote-by-mail increased turnout or benefited Democrats. Using new microdata on millions of individual voters and aggregated turnout data across all 50 states, this paper offers a causal analysis of the impact of absentee vote-by-mail during the COVID-19 (coronavirus disease 2019) pandemic. Focusing on natural experiments in Texas and Indiana, we find that 65-year-olds voted at nearly the same rate as 64-year-olds, despite the fact that only 65-year-olds could vote absentee without an excuse. Being just old enough to vote no-excuse absentee did not substantially increase Democratic turnout relative to Republican turnout. Voter interest appeared to be more important in driving turnout across vote modes, neutralizing the electoral impact of Democrats voting by mail at higher rates during the historic pandemic.

Timeline of Psychological and Physiological Effects Occurring During Military Deployment on a Medical Team.

BACKGROUND: The negative effects of deployment on military mental health is a topic of major interest. Predeployment and postdeployment assessments are common, but to date there has been little to no intradeployment assessment of military members. This study attempts to determine the physiological and psychiatric effects on Servicemembers over the course of deployment, to provide a baseline data set and to allow for better prediction, prevention, and intervention on these negative effects. METHODS: A retrospective analysis was performed on physiological and psychiatric data collected on a single deployed medical team between 16 January 2020 and 12 July 2020. Patient health screening questionnaires (PHQ-9) and physiological measurements were completed serially twice weekly on five active-duty military volunteers for the entirety of a scheduled 6-month deployment. RESULTS: Depression symptom development followed a linear trend (p = .0149) and severity followed a quadratic trend (p < .001) over a length of a deployment. Weight (p = .435) and pulse (p = .416) were not statistically altered. Mean arterial pressure (MAP) had a statistically significant reduction (p < .001). CONCLUSION: In this specific population, there was a linear relationship between time deployed and depression symptoms and severity. Depression symptom severity decreases toward the end of deployment but does not return to baseline before deployment's end.

Clinical utilization of deployed military surgeons.

BACKGROUND: Combat casualty care has been shaped by the prolonged conflicts in Southwest Asia, namely Afghanistan, Iraq, and Syria. The utilization of surgeons in austere locations outside of Southwest Asia and its implication on skill retention and value have not been examined. This study hypothesizes that surgeon utilization is low in the African theater. This lack of activity is potentially damaging to surgical skill retention and patient care. METHODS: Military case logs of surgeons deployed to Africa under command of Special Operations Command Africa between January 1, 2016, and January 1, 2020, were examined. Cases were organized based on population served, general type of procedure, current procedural terminology codes, and location. RESULTS: Twenty deployment caseloads representing 74% of the deployments during the period were analyzed. In 3,294 days, 101 operations were performed, which included 45 on combat/terrorism related injuries and 19 on US personnel. East and West African deployments, combat, and noncombat zones, respectively, were compared. East Africa averaged 4.1 ± 3.8 operations per deployment, and West Africa, 7.3 ± 8.0 (p = 0.2434). In East Africa, 56.1% of total operations were related to combat/terrorism, compared with 29.6% of total operations in West Africa (p = 0.0077). West Africa had a significantly higher proportion of elective (p = 0.0002) and humanitarian cases (p = <0.0001). CONCLUSION: Surgical cases for military surgeons were uncommon in Africa. The low volumes have implications for skill retention, morale, and sustainability of military surgical end strength. Reduction in deployment lengths, deployment location adjustments, and/or skill retention strategies are required to ensure clinical peak performance and operational readiness. Failure to implement changes to current practices to optimize surgeon experience will likely decrease surgical readiness and could contribute to decreased retention of deployable military surgeons to support global operations. LEVEL OF EVIDENCE: Economic/decision, level III.

Isolating Populations to Control Pandemic Spread in an Austere Military Environment.

BACKGROUND: The COVID-19 pandemic has been a struggle for medical systems throughout the world. In austere locations in which testing, resupply, and evacuation have been limited or impossible, unique challenges exist. This case series demonstrates the importance of population isolation in preventing disease from overwhelming medical assets. METHODS: This is a case series describing the outbreak of COVID-19 in an isolated population in Africa. The population consists of a main population with a Role 2 capability, with several supported satellite populations with a Role 1 capability. Outbreaks in five satellite population centers occurred over the course of the COVID-19 pandemic from its start on approximately 1 March 2020 until 28 April 2020, when a more robust medical asset became available at the central evacuation hub within the main population. RESULTS: Population movement controls and the use of telehealth prevented the spread within the main population at risk and enabled the setup of medical assets to prepare for anticipated widespread disease. CONCLUSION: Isolation of disease in the satellite populations and treating in place, rather than immediately moving to the larger population center's medical facilities, prevented widespread exposure. Isolation also protected critical patient transport capabilities for use for high-risk patients. In addition, this strategy provided time and resources to develop infrastructure to handle anticipated larger outbreaks.

Current challenges in military trauma readiness: Insufficient relevant surgical case volumes in military treatment facilities.

BACKGROUND: The management of battlefield trauma requires a specific skill set, which is optimized by regular trauma experience. As military casualties from the prolonged conflicts in the Middle East decrease, challenges exist to maintain battlefield trauma readiness. Military surgeons must therefore depend on the Military Health System. The purpose of the study was to evaluate the frequency of surgical cases relevant to deployed combat casualty care performed at military treatment facilities (MTFs). METHODS: Combat casualty care relevant cases (CCC-RCs) were defined as emergent, open surgical cases in which the patient required a blood transfusion. Case logs from four military treatment centers with surgical residency training programs were used. Twenty-four months of case records between January 1, 2017, and January 1, 2019, were included to determine total numbers of CCC-RCs at each institution. The results were compared with San Antonio Military Medical Center's, the Department of Defense's only American College of Surgeons-verified level 1 trauma center. RESULTS: Fifty-one trauma/general surgeons and six vascular surgeons case logs were examined. Thirty (0.3%) of 10,529 cases performed by trauma/general and vascular surgeons over the 2-year study period were considered CCC-RCs. These results were in contrast to San Antonio Military Medical Center, which had a significantly higher proportion of CCC-RCs (113 of 320 cases, 35.3%, p < 0.0001). CONCLUSION: A cross-section of MTF surgical case complexity demonstrates a lack of cases considered to be CCC-RCs. At the MTFs evaluated, surgical case surrogates for combat trauma and combat casualty care is close to zero. These data are potentially representative of other military treatment centers, which focus on beneficiary care. For readiness purposes, MTFs that care primarily for Tricare beneficiaries without a significant trauma population should not be considered meaningful sources of CCC-RCs for trauma/general and vascular surgeons. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

Ketamine Use for Prolonged Field Care Reduces Supply Use.

This case describes the prolonged treatment of a 38-year-old man with a transpelvic gunshot wound requiring a diverting ostomy and cystostomy for damage control procedures with a comminuted acetabular and femoral head fracture. The team used a ketamine drip for prolonged field care over 48 hours. The benefit of using a ketamine drip included low supply requirement, excellent analgesia, and ease of administration, but side-effects included somnolence and atelectasis necessitating oxygen supplementation before evacuation.

Universal vote-by-mail has no impact on partisan turnout or vote share.

In response to coronavirus disease 2019 (COVID-19), many scholars and policy makers are urging the United States to expand voting-by-mail programs to safeguard the electoral process. What are the effects of vote-by-mail? In this paper, we provide a comprehensive design-based analysis of the effect of universal vote-by-mail-a policy under which every voter is mailed a ballot in advance of the election-on electoral outcomes. We collect data from 1996 to 2018 on all three US states that implemented universal vote-by-mail in a staggered fashion across counties, allowing us to use a difference-in-differences design at the county level to estimate causal effects. We find that 1) universal vote-by-mail does not appear to affect either party's share of turnout, 2) universal vote-by-mail does not appear to increase either party's vote share, and 3) universal vote-by-mail modestly increases overall average turnout rates, in line with previous estimates. All three conclusions support the conventional wisdom of election administration experts and contradict many popular claims in the media.

Advanced Trauma Life Support Time Standards.

INTRODUCTION: Trauma readiness is critical to military medicine. Without medical centers that include persistent volumes of trauma, simulation has become the means to maintain and practice those skills. To create those simulations, standards for both design and metrics to evaluate practitioners are required. MATERIALS AND METHODS: Forty-four traumas were monitored and times to completion of the various steps of Advanced Trauma Life Support were recorded and tabulated. The times recorded for level 1 and level 2 traumas were compared without statistical differences identified. RESULTS: Normative times for various portions of the Advanced Trauma Life Support protocol were provided. These include time to airway assessment, breathing assessment, circulation assessment, establishment of intravenous, completion of primary survey, chest X-ray, first set of vitals, and focused assessment with sonography for trauma scan. CONCLUSIONS: Using these mean times, simulations can be created to best replicate traumas and evaluate the capabilities of practitioners.

Objective comparison of animal training versus artificial simulation for initial cricothyroidotomy training.

This manuscript aims to determine if there is a difference in performance outcomes after initial training with either animals or simulators. Volunteers without prior experience performing emergency procedures were randomly assigned to receive training in cricothyroidotomy on either a pig model or on an artificial simulator. Volunteers were given identical lectures and trained to proficiency. Two weeks after training, trainees were tested using human cadavers as to their performance with time, incision size, incision start location, initial placement attempt, and final accuracy. Overall success rate of the animal-trained group was 64 per cent and in the artificial simulator group, 73 per cent (P = 0.431). Median time to completion in the animal group and artificial simulator group was 143 s and 105 s (P = 0.482), and incision lengths 4.0 cm and 3.2 cm (P = 0.173), respectively. Accuracy of initially attempted incision placement and final cricothyroidotomy tube placement was also compared. Initially attempted site accuracy in the animal-trained group was 93 per cent and correct final position 79 per cent, and in the artificial group, 100 per cent (P = 0.452) and 88 per cent (P = 0.782), respectively. There was no statistically significant, objective difference in any metric between animal- and simulator-trained groups after cricothyroidotomy training. For initial training, there is no objective benefit of animal training.

Mosquito genomics. Highly evolvable malaria vectors: the genomes of 16 Anopheles mosquitoes.

Variation in vectorial capacity for human malaria among Anopheles mosquito species is determined by many factors, including behavior, immunity, and life history. To investigate the genomic basis of vectorial capacity and explore new avenues for vector control, we sequenced the genomes of 16 anopheline mosquito species from diverse locations spanning ~100 million years of evolution. Comparative analyses show faster rates of gene gain and loss, elevated gene shuffling on the X chromosome, and more intron losses, relative to Drosophila. Some determinants of vectorial capacity, such as chemosensory genes, do not show elevated turnover but instead diversify through protein-sequence changes. This dynamism of anopheline genes and genomes may contribute to their flexible capacity to take advantage of new ecological niches, including adapting to humans as primary hosts.

Mosquito genomics. Extensive introgression in a malaria vector species complex revealed by phylogenomics.

Introgressive hybridization is now recognized as a widespread phenomenon, but its role in evolution remains contested. Here, we use newly available reference genome assemblies to investigate phylogenetic relationships and introgression in a medically important group of Afrotropical mosquito sibling species. We have identified the correct species branching order to resolve a contentious phylogeny and show that lineages leading to the principal vectors of human malaria were among the first to split. Pervasive autosomal introgression between these malaria vectors means that only a small fraction of the genome, mainly on the X chromosome, has not crossed species boundaries. Our results suggest that traits enhancing vectorial capacity may be gained through interspecific gene flow, including between nonsister species.

Comparison of self-efficacy and its improvement after artificial simulator or live animal model emergency procedure training.

The objective of this study is to compare post-training self-efficacy between artificial simulators and live animal training for the performance of emergency medical procedures. Volunteer airmen of the 81st Medical Group, without prior medical procedure training, were randomly assigned to two experimental arms consisting of identical lectures and training of diagnostic peritoneal lavage, thoracostomy (chest tube), and cricothyroidotomy on either the TraumaMan (Simulab Corp., Seattle, Washington) artificial simulator or a live pig (Sus scrofa domestica) model. Volunteers were given a postlecture and postskills training assessment of self-efficacy. Twenty-seven volunteers that initially performed artificial simulator training subsequently underwent live animal training and provided assessments comparing both modalities. The results were first, postskills training self-efficacy scores were significantly higher than postlecture scores for either training mode and for all procedures (p < 0.0001). Second, post-training self-efficacy scores were not statistically different between live animal and artificial simulator training for diagnostic peritoneal lavage (p = 0.555), chest tube (p = 0.486), and cricothyroidotomy (p = 0.329). Finally, volunteers undergoing both training modalities indicated preference for live animal training (p < 0.0001). We conclude that artificial simulator and live animal training produce equivalent levels of self-efficacy after initial training, but there is a preference in using a live animal model to achieve those skills.