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.

[Microbiological challenges in the treatment of war injuries]. / Mikrobiologische Herausforderungen bei der Versorgung von Kriegsverletzungen.

The treatment of war injuries represents a continuing and recurrent challenge in modern reconstructive surgery. Previously, tumor resections and sepsis-related resections were mainly responsible for lengthy bone defects in Germany. In recent years another picture has increasingly emerged, particularly caused by the medical support of Ukraine. Aspects of military surgery are also becoming more important in civil hospitals, especially in the treatment of gunshot and explosion injuries. In Germany, war injuries are currently secondarily treated, as the distribution of patients is carried out according to the cloverleaf principle, weeks or months after the occurrence of the primary injury. In addition to complex bone and soft tissue defects of the extremities following such injuries, which often affect neural and vascular structures, reconstruction is often complicated by an increasing spectrum of multidrug-resistant pathogens. The definition of microbiological terms, such as contamination, colonization, critical colonization, local and systemic infections are important in the clinical routine in order to initiate a targeted treatment, especially in treatment with antibiotics. Wound swabs for determination of the spectrum of pathogens and the optimal testing of resistance are important for selecting the appropriate antibiotic agents. The concept of antibiotic stewardship (ABS) is established in many hospitals to improve the quality of antibiotic treatment and to minimize the formation of resistance. The selection of the method of reconstruction depends on the condition of the patient, the overall clinical constellation and the function to be expected after completion of treatment. The treatment of injuries due to violence and terrorism necessitates clear concepts and an interdisciplinary approach, especially with respect to microbiological challenges and increasing resistance situations.

[Initial in-hospital treatment of patients with penetrating trauma due to violence and war]. / Innerklinische Erstversorgung von Patienten mit penetrierendem Trauma nach Gewalt und Krieg.

BACKGROUND: Current political and social developments have brought the topics of violence, in this context attributable to terrorism and sabotage, and since February 2022 awareness of war in particular has again greatly increased. This article aims to present the contextualized dealing with penetrating injuries in terms of initial in-hospital treatment. OBJECTIVE: The question remains to be answered as to what extent penetrating injuries require special attention and to what extent the treatment priorities, options and strategies as well as surgical treatment require adaptation of the usual approach in routine clinical practice in Germany. MATERIAL AND METHOD: The experience of the authors in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of a comprehensive systematic literature review and current data from a national evaluation on the topic of preparing hospitals in Germany for such scenarios are taken into account. RESULTS AND DISCUSSION: The clinical systems need to be well-prepared for such casualties, especially if they require treatment in large numbers. This is precisely so because the majority of patients are in a relevantly threatening situation (usually in the sense of a hemorrhage), treatment must be very urgently provided and in such scenarios a lack of resources must always be overcome, at least temporarily, especially for example for blood transfusions.

[Challenge of limb care after violence and war with a special focus on imaging procedures]. / Herausforderung der Extremitätenversorgung nach Gewalt und Krieg mit besonderer Betrachtung bildgebender Verfahren.

BACKGROUND: Injury patterns in the area of the extremities following violence and war harbor many special features and require special attention. Destructive and complex defect injuries are often present, which necessitate elaborate and special reconstruction approaches, predominantly as part of a staged and multistaged procedure. RESEARCH QUESTION: In this context, special attention must be paid to the diagnostic options as an essential aspect, as a clear diagnosis means that targeted treatment steps can be planned and implemented. MATERIAL AND METHOD: The authors' experience in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia, as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of interdisciplinary cooperation with radiological and, in particular, nuclear medicine disciplines are taken into account in the daily routine. RESULTS AND DISCUSSION: Extremity injuries in the context of violence and war are accompanied by complex bone and surrounding soft tissue defects due to the high energy impact. The principles of reconstruction familiar from everyday life can only be transferred one-to-one to a limited extent. The treatment pathways are often very long and complex and the questions of infection and tissue vitality must be answered again and again in stages. Interdisciplinary collaboration with the disciplines specialized in imaging procedures, particularly in the field of nuclear medicine, is one of the key building blocks for a successful treatment pathway.

[National challenges for trauma surgery in Germany due to violence and war]. / Nationale Herausforderungen für die Unfallchirurgie in Deutschland bei Gewalt und Krieg.

Due to the war in Ukraine and the treatment of patients with war wounds in the hospitals of the TraumaNetworks of the German Society for Trauma Surgery (TraumaNetzwerke DGU®), injuries from life-threatening mission situations (LebEL), terrorism, violence and war have become a matter of daily professional life. Furthermore, the societal and global feeling of security has fundamentally changed. The much-cited term "turning point in history", the reorientation of the Armed Forces and the investigation of the resilience of the healthcare system with respect to the "fitness for war", approximate to the description of the current challenges for trauma surgery (UCH) in Germany. Based on the developments following the terrorist attacks in Paris in 2015 and in Brussels in 2016, a clarification is given as to which adaptations have already been successful and how quickly an improvement could successfully be achieved. In this context, the concept of tactical care and the course on Terror and Disaster Surgical Care (TDSC), for example, have been game changing. The main challenge currently lies in overcoming the structural alterations in the German healthcare system and professionally in the treatment of war wounded personnel from Ukraine. The knowledge gained from these two national tasks must be analyzed for the future development and adaptation of established treatment structures, e.g., of the TraumaNetzwerke DGU®, under the requirements of the increased resilience against war, terrorism and violence. The aim is to name that which has already been achieved with respect to the national challenges for UCH and at the same time to outline or discuss further necessities for improvements and elimination of possible gaps in capabilities.

[Current mortality from war injuries-A narrative review]. / Aktuelle Mortalität von Kriegsverletzungen ­ eine narrative Übersichtsarbeit.

BACKGROUND: The war in Ukraine has led to a strategic reorientation of the German Armed Forces towards national and alliance defense. This has also raised the need for medical and surgical adaptation to scenarios of conventional warfare. In order to develop appropriate and effective concepts it is necessary to identify those war injuries that are associated with a relevant primary and secondary mortality and that can be influenced by medical measures (potentially survivable injuries). OBJECTIVE: The aim of this selective literature review was to identify war injuries with high primary and secondary mortality. METHODS: A selective literature review was performed in the PubMed® database with the search terms war OR combat AND injury AND mortality from 2001 to 2023. Studies including data of war injuries and associated mortality were included. RESULTS: A total of 33 studies were included in the analysis. Severe traumatic brain injury and thoracoabdominal hemorrhage were the main contributors to primary mortality. Injuries to the trunk, neck, traumatic brain injury, and burns were associated with relevant secondary mortality. Among potentially survivable injuries, thoracoabdominal hemorrhage accounted for the largest proportion. Prehospital blood transfusions and short transport times significantly reduced war-associated mortality. CONCLUSION: Control of thoracoabdominal hemorrhage has the highest potential to reduce mortality in modern warfare. Besides that, treatment of traumatic brain injury, burns and neck injuries has a high relevance in reducing mortality. Hospitals of the German Armed Forces need to focus on these requirements.

Long-term burden of war injuries among civilians in LMICs: case of the July 2006 war in Lebanon.

Introduction: Lebanon, a country located on the eastern shore of the Mediterranean Sea, is one of the world's smaller sovereign states. In the past few decades, Lebanon endured a perpetual political turmoil and several armed conflicts. July 12, 2006, marked the start of a one-month war in Lebanon, which resulted in thousands of casualties. Little is known about the long-term consequences of war injuries inflicted on civilians during the July 2006 war. Methods: The objectives of this paper were to identify and evaluate: 1- civilians' access to healthcare and medicine under conditions of war; 2- the long-term socioeconomic burden on injured civilians; and 3- their quality of life more than a decade post-war. We adopted a mixed-method research design with an emphasis on the qualitative component. We conducted interviews with patients, collected clinical and financial data from hospital medical records, and administered a self-rated health questionnaire, the EQ-5D-5L. Simple descriptive statistics were calculated using Excel. NVivo 12® was used for data management and thematic analysis. Results: We conducted 25 interviews. Injured civilians were mostly males, average age of 27. The most common mechanism of injury was blast injury. Most patients underwent multiple surgeries as well as revision surgeries. The thematic analysis revealed three themes: 1- recall of the time of the incident, the thousand miles journey, and patients' access to services; 2- post-trauma sequelae and services; and 3- long-term impact. Patients described the long-term burden including chronic pain, poor mobility, anxiety or depression, and limited activities of daily living. Discussion: Civilians injured during the July 2006 war described the traumatising events they endured during the war and the limited access to medical care during and post-war. Up until this study was conducted, affected civilians were still experiencing physical, psychological, and financial sequelae. Acknowledging the limitations of this study, which include a small sample size and recall bias, the findings underscore the necessity for the expansion of services catering to civilians injured during wartime.

Targeted metagenomic assessment reflects critical colonization in battlefield injuries.

IMPORTANCE: Microbial contamination in combat wounds can lead to opportunistic infections and adverse outcomes. However, current microbiological detection has a limited ability to capture microbial functional genes. This work describes the application of targeted metagenomic sequencing to profile wound bioburden and capture relevant wound-associated signatures for clinical utility. Ultimately, the ability to detect such signatures will help guide clinical decisions regarding wound care and management and aid in the prediction of wound outcomes.

The relationship between combat-related traumatic amputation and subclinical cardiovascular risk.

BACKGROUND: The relationship between acute combat-related traumatic injury (CRTI) to coronary flow reserve (CFR) and subclinical cardiovascular risk have not been examined and was the primary aim of this study. METHODS AND RESULTS: UK combat veterans from the ADVANCE cohort study (UK-Afghanistan War 2003-14) with traumatic limb amputations were compared to injured non-amputees and to a group of uninjured veterans from the same conflict. Subclinical cardiovascular risk measures included fasted blood atherogenic index of plasma (AIP), triglyceride-glucose index (TyG; insulin resistance), the neutrophil-lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hs-CRP; vascular inflammation), body mass index (BMI) and visceral fat volume (dual-energy X-ray absorptiometry) and 6-min walk distance (6MWD; physical performance). The subendocardial viability ratio (SEVR), to estimate CFR, was calculated using arterial pulse waveform analysis (Vicorder device). In total 1144 adult male combat veterans were investigated, comprising 579 injured (161 amputees, 418 non-amputees) and 565 uninjured men. AIP, TyG, NLR, hs-CRP, BMI, total body fat and visceral fat volume were significantly higher and the SEVR and 6MWD significantly lower in the amputees versus the injured-non-amputees and uninjured groups. The SEVR was lowest in those with above knee and multiple limb amputations. CRTI (ExpB 0.96; 95% CI 0.94-0.98: p < 0.0001) and amputation (ExpB 0.94: 95% CI 0.91-0.97: p < 0.0001) were independently associated with lower SEVR after adjusting for age, rank, ethnicity and time from injury. CONCLUSION: CRTI, traumatic amputation and its worsening physical deficit are associated with lower coronary flow reserve and heightened subclinical cardiovascular risk.

No association between war-related trauma or PTSD symptom severity and epigenome-wide DNA methylation in Burundian refugees.

Background: War-related trauma is associated with varying posttraumatic stress disorder (PTSD) prevalence rates in refugees. In PTSD development, differential DNA methylation (DNAm) levels associated with trauma exposure might be involved in risk versus resilience processes. Studies investigating DNAm profiles related to trauma exposure and PTSD among refugees remain sparse.Objective: The present epigenome-wide association study investigated associations between war-related trauma, PTSD, and altered DNAm patterns in Burundian refugee families with 110 children and their 207 female and male caregivers.Method: War-related trauma load and PTSD symptom severity were assessed in structured clinical interviews with standardised instruments. Epigenome-wide DNAm levels were quantified from buccal epithelia using the Illumina EPIC beadchip.Results: Controlling for biological confounders, no significant epigenome-wide DNAm alterations associated with trauma exposure or PTSD were identified in children or caregivers (FDRs > .05). Co-methylated positions derived as modules from weighted gene correlation network analyses were not significantly associated with either war-related trauma experience in children or caregivers or with PTSD.Conclusions: These results do not provide evidence for altered DNAm patterns associated with exposure to war-related trauma or PTSD.

The study examines an understudied population in epigenome-wide association studies.Burundian refugees' war-trauma, PTSD, and DNA methylation were studied.Epigenome-wide DNA methylation was not significantly associated with war-trauma or PTSD in the conflict-affected sample.

Body image and psychosocial well-being among UK military personnel and veterans who sustained appearance-altering conflict injuries.

A modest but significant number of military personnel sustained injuries during deployments resulting in an altered-appearance (e.g., limb loss and/or scarring). Civilian research indicates that appearance-altering injuries can affect psychosocial wellbeing, yet little is known about the impact of such injuries among injured personnel. This study aimed to understand the psychosocial impact of appearance-altering injuries and possible support needs among UK military personnel and veterans. Semi-structured interviews with 23 military participants who sustained appearance-altering injuries during deployments or training since 1969 were conducted. The interviews were analyzed using reflexive thematic analysis, identifying six master themes. These themes indicate that in the context of broader recovery experiences, military personnel and veterans experience a variety of psychosocial difficulties related to their changed appearance. While some of these are consistent with evidence from civilians, military-related nuances in the challenges, protective experiences, coping approaches, and preferences for support are evident. Personnel and veterans with appearance-altering injuries may require specific support for adjusting to their changed appearance and related difficulties. However, barriers to acknowledging appearance concerns were identified. Implications for support provision and future research are discussed.

Systematic review of the microbiology of osteomyelitis associated with war injuries in the Middle East and North Africa.

Osteomyelitis is a serious complication associated with war-related limb injuries requiring complicated treatment regimens and management. Few reports have been published from the Middle-East and North-Africa regions about the microbial aetiology of osteomyelitis caused by war injuries. The aim of this review is to collect published data about the microbiology of osteomyelitis in war-related injuries in the region and to derive targeted treatment regimens to manage these serious and limb-threatening infections. A thorough literature search was done using six search engines for pertinent articles. Articles with a minimum of five cases of osteomyelitis from war wounds, citation of microbial aetiology and mention of the timing of cultures obtained in relation to injury were included. Nine studies that met the eligibility criteria were included, involving 1644 patients and a total of 2332 cultures. Gram-negative bacteria were isolated from 1184 cultures, and Gram-positive bacteria were identified from 1148 cultures. Antibiotic coverage should be tailored for Gram-negative organisms in the early stages and Gram-positives in the chronic phase, respectively, with broader coverage reserved for critically ill patients. There is a dire need for further and larger studies about osteomyelitis from war injuries for targeted treatment.

War-related traumatic brain injuries during the Syrian armed conflict in Damascus 2014-2017: a cohort study and a literature review.

BACKGROUND: The decade-long Syrian armed conflict killed or injured more than 11% of the Syrian population. Head and neck injuries are the most frequent cause of war-related trauma, about half of which are brain injuries. Reports about Syrian brain trauma victims were published from neighboring countries; However, none are available from Syrian hospitals. This study aims to report war-related traumatic brain injuries from the Syrian capital. METHODS: We conducted a retrospective cohort study between 2014 and 2017 at Damascus Hospital, the largest public hospital in Damascus, Syria. Target patients were the victims of combat-related traumatic brain injuries who arrived alive and were admitted to the neurosurgery department or to another department but followed by the neurosurgery team. The collected data included the mechanism, type, and site of injury based on imaging findings; types of invasive interventions; intensive-care unit (ICU) admissions; as well as neurological status at admission and discharge including several severity scales. RESULTS: Our sample consisted of 195 patients; Ninety-six of them were male young adults, in addition to 40 females and 61 children. Injuries were caused by shrapnel in 127 (65%) cases, and by gunshots in the rest, and most of them (91%) were penetrating. Sixty-eight patients (35%) were admitted to the ICU, and 56 (29%) underwent surgery. Neurological impairment was reported in 49 patients (25%) at discharge, and the mortality rate during hospitalization was 33%. Mortality and neurological impairment associated significantly with higher values on clinical and imaging severity scores. CONCLUSIONS: This study captured the full spectrum of war-related brain injuries of civilians and armed personnel in Syria without the delay required to transport patients to neighboring countries. Although the clinical presentation of injuries at admission was not as severe as that in previous reports, the inadequate resources (i.e., ventilators and operation rooms) and the lack of previous experience with similar injuries might have resulted in the higher mortality rate. Clinical and imaging severity scales can provide a handy tool in identifying cases with low probability of survival especially with the shortage of personal and physical resources.

Molecular surveillance of multidrug-resistant Gram-negative bacteria in Ukrainian patients, Germany, March to June 2022.

BackgroundSince the beginning of the war in Ukraine in February 2022, Ukrainians have been seeking shelter in other European countries.AimWe aimed to investigate the prevalence and the molecular epidemiology of multidrug-resistant Gram-negative (MDRGN) bacteria and meticillin-resistant Staphylococcus aureus (MRSA) in Ukrainian patients at admittance to the University Hospital Frankfurt, Germany.MethodsWe performed screening and observational analysis of all patients from March until June 2022. Genomes of MDRGN isolates were analysed for antimicrobial resistance, virulence genes and phylogenetic relatedness.ResultsWe included 103 patients (median age: 39 ±â€¯23.7 years), 57 of whom were female (55.3%; 95% confidence interval (CI): 45.2-5.1). Patients were most frequently admitted to the Department of Paediatrics (29/103; 28.2%; 95% CI: 19.7-37.9). We found 34 MDRGN isolates in 17 of 103 patients (16.5%; 95% CI: 9.9-25.1). Ten patients carried 21 carbapenem-resistant (CR) bacteria, five of them more than one CR isolate. Four of six patients with war-related injuries carried eight CR isolates. In six of 10 patients, CR isolates caused infections. Genomic characterisation revealed that the CR isolates harboured at least one carbapenemase gene, bla NDM-1 being the most frequent (n = 10). Core genome and plasmid analysis revealed no epidemiological connection between most of these isolates. Hypervirulence marker genes were found in five of six Klebsiella pneumoniae CR isolates. No MRSA was found.ConclusionHospitals should consider infection control strategies to cover the elevated prevalence of MDRGN bacteria in Ukrainian patients with war-related injuries and/or hospital pre-treatment and to prevent the spread of hypervirulent CR isolates.

Adherence to a Balanced Approach to Massive Transfusion in Combat Casualties.

BACKGROUND: Hemorrhage is the most common cause of potentially preventable death on the battlefield. Balanced resuscitation with plasma, platelets, and packed red blood cells (PRBCs) in a 1:1:1 ratio, if whole blood (WB) is not available, is associated with optimal outcomes among patients with hemorrhage. We describe the use of balanced resuscitation among combat casualties undergoing massive transfusion. MATERIALS AND METHODS: We conducted a secondary analysis of data from the Department of Defense Trauma Registry (DODTR) spanning encounters from January 1, 2007, to March 17, 2020. We included all casualties who received at least 10 units of either PRBCs or WB. We categorized casualties as recipients of plasma-balanced resuscitation if the ratio of plasma to PRBC units was 0.8 or greater; similarly, we defined platelet-balanced resuscitation as a ratio of platelets to PRBC units of 0.8 or greater. We portrayed these populations using descriptive statistics and compared characteristics between non-balanced and balanced resuscitation recipients for both plasma and platelets. RESULTS: We identified 28,950 encounters in the DODTR with documentation of prehospital activity. Massive transfusions occurred for 2,414 (8.3%) casualties, among whom 1,593 (66.0%) received a plasma-balanced resuscitation and 1,248 (51.7%) received a platelet-balanced resuscitation. During the study period, 962 (39.8%) of these patients received a fully balanced resuscitation with regard to both the plasma:PRBC and platelet:PRBC ratios. The remaining casualties did not undergo a balanced resuscitation. CONCLUSIONS: While a majority of massive transfusion recipients received a plasma-balanced and/or platelet-balanced resuscitation, fewer patients received a platelet-balanced resuscitation. These findings suggest that more emphasis in training and supply may be necessary to optimize blood product resuscitation ratios.