Combating the "Peacetime Effect" in Military Plastic Surgery: Implications for Mission Readiness.

Military treatment facility-assigned surgeons face numerous challenges in maintaining critical wartime skills, including the "peacetime effect" and the "dual mission." Using the field of plastic surgery to illustrate these issues, we contrast plastic surgeons' contributions to combat casualty care with primary data describing plastic surgeons' clinical practice in many military hospitals. Then, we outline the current administrative mechanisms being promoted at the enterprise-level for surgeons to gain a more mission-focused, clinical practice, while also examining significant shortcomings in these policies. Finally, we conclude with a call to action for the military surgical community to accelerate change in the development of more robust clinical practices for our surgeons, or potentially lose our ability to field a ready surgical force.

Initial Surgical Treatment for Breast Cancer and the Distance Traveled for Care.

BACKGROUND: Geography may influence the operative decision-making in breast cancer treatment. This study evaluates the relationship between distance to treating facility and the initial breast cancer surgery selected, identifying the characteristics of women who travel for surgery. METHODS: Utilizing Florida state inpatient and ambulatory surgery databases, we identified female breast cancer patients who underwent surgical treatment from January 1 to December 31, 2013. Patients were subgrouped by distance to treatment facility. The primary outcome was the initial surgical treatment choice. Regression models were used to identify factors associated with greater distance to initial treatment. RESULTS: The final sample included 12 786 patients who underwent lumpectomy, mastectomy alone, or mastectomy with reconstruction. Compared to women who traveled < 4.0 miles, women who traveled > 14.0 miles were younger (P < .001), more often identified as white with private insurance (P < .001) and were less likely to have three or more medical comorbidities (P < .001). With increased travel to treatment, the frequency of lumpectomy decreased (P < .001), while the frequency of mastectomy with reconstruction increased (P < .001). Increasing age in years (adjusted odds ratio (AOR) = .98 [95% CI = .98-.99]) and identifying as nonwhite with private (AOR = .70 [.61-.80]) or public insurance (AOR = .64 [.56-.73]) was associated with less frequently travelling for initial breast cancer surgery. DISCUSSION: The relationship between the initial surgical treatment for breast cancer and the distance traveled for care highlights a disparity between those who can and cannot travel for treatment.

Plastic Surgery at War: A Scoping Review of Current Conflicts.

INTRODUCTION: The scope of military plastic surgery and location where care is provided has evolved with each major conflict. To help inform plastic surgeon utilization in future conflicts, we conducted a review of military plastic surgery-related studies to characterize plastic surgeon contributions during recent military operations. MATERIALS AND METHODS: Using a scoping review design, we searched electronic databases to identify articles published since September 1, 2001 related to military plastic surgery according to a defined search criterion. Next, we screened all abstracts for appropriateness based on pre-established inclusion/exclusion criteria. Finally, we reviewed the remaining full-text articles to describe the nature of care provided and the operational level at which care was delivered. RESULTS: The final sample included 55 studies with most originating in the United States (54.5%) between 2005 and 2019 and were either retrospective cohort studies (81.8%) or case series (10.9%). The breadth of care included management of significant upper/lower extremity injuries (40%), general reconstructive and wound care (36.4%), and craniofacial surgery (16.4%). Microsurgical reconstruction was a primary focus in 40.0% of published articles. When specified, most care was described at Role 3 (25.5%) or Roles 4/5 facilities (62.8%) with temporizing measures more common at Role 3 and definite reconstruction at Roles 4/5. Several lessons learned were identified that held commonality across plastic surgery domain. CONCLUSIONS: Plastic surgeons continue to play a critical role in the management of wounded service members, particularly for complex extremity reconstruction, craniofacial trauma, and general expertise on wound management. Future efforts should evaluate mechanisms to maintain these skill sets among military plastic surgeons.

Asia-wide phylogeography of wild boar (Sus scrofa) based on mitochondrial DNA and Y-chromosome: Revising the migration routes of wild boar in Asia.

Genetics of pigs has been well studied in Europe and Asia, but most of previous studies of molecular phylogeny of Sus scrofa have been based on sequences of both wild and domestic forms. In this study we analysed genetic traits of Sus scrofa from 13 regions in Asia (including previously undisclosed Eastern Caucasus and Trans-Baikal regions) using purely wild boar samples. Mitochondrial control region and Y-chromosome genes (AMELY & USP9Y) were employed to resolve phylogeographic relationships. We discussed spatio-temporal dynamics of wild boar distribution and compared molecular data to morphological and cytogenetic data on wild boar variability and taxonomy. A total of 51 haplotypes were detected in mtDNA control region and five haplotypes were found in combined sequences of Y-chromosome genes. The phylogeography of Asia-wide wild boars supported a hypothesis of migration from South-East Asia to South Asia, followed by migration to East and West Asia. We present a hypothesis about independent dispersal of wild boars into West Asia from South and North-East Asia. Mitochondrial DNA phylogeny generally fits the morphologically based intraspecies taxonomy. Distribution of chromosomal variants of wild boar presently does not show clear correlation with mtDNA clades.

Cannabis Abuse or Dependence and Post-operative Outcomes After Appendectomy and Cholecystectomy.

BACKGROUND: Though cannabis is gaining broader acceptance among society and a noted increase in legalization, little is known regarding its impact on post-operative outcomes. We conducted this study to quantify the relationship between cannabis abuse or dependence (CbAD) on post-operative outcomes after cholecystectomy and appendectomy. METHODS: Using the 2013-2015 Nationwide Readmissions Database, we identified discharges associated with cholecystectomy or appendectomy from January 2013-August 2015. Patients were grouped by CbAD history. The primary outcomes were length of stay, serious adverse events, home discharge, and 30-day readmission. Propensity-score matching was used to account for differences between groups and all statistics accounted for the matched sample. RESULTS: The final sample included 3288 patients with a CbAD history matched 1:1 to patients without a CbAD history (total sample = 6576). After matching, acceptable balance was achieved in clinical characteristics between groups. In the cholecystectomy cohort (n = 1707 pairs), CbAD patients had longer hospitalizations (3.5 versus 3.2 d, P 0.003) and similar rates of serious adverse events (6.1 versus 4.8, P 0.092), home discharge (96.1 vs 96.2, P 0.855), and readmission (8.3 versus 6.9, P 0.137). In the appendectomy cohort (n = 1581 pairs), CbAD patients had longer hospital stays (2.7 versus 2.5 d, P 0.024); more frequent serious adverse events (5.0 versus 3.5, P 0.041); and similar home discharge (96.8 vs 97.3, P 0.404) and readmission (5.4 versus 5.1, P 0.639) rates. CONCLUSIONS: Patients with a history of CbAD in the cholecystectomy and appendectomy cohorts had slightly longer hospital stays, and patients with a history of CbAD in the appendectomy group displayed a slight increase in adverse events, but otherwise similar clinical outcomes without clinically significant increases in complications compared to patients without this history.

Maternal genomic variability of the wild boar (Sus scrofa) reveals the uniqueness of East-Caucasian and Central Italian populations.

The phylogeography of the European wild boar was mainly determined by postglacial recolonization patterns from Mediterranean refugia after the last ice age. Here we present the first analysis of SNP polymorphism within the complete mtDNA genome of West Russian (n = 8), European (n = 64), and North African (n = 5) wild boar. Our analyses provided evidence of unique lineages in the East-Caucasian (Dagestan) region and in Central Italy. A phylogenetic analysis revealed that these lineages are basal to the other European mtDNA sequences. We also show close connection between the Western Siberian and Eastern European populations. Also, the North African samples were clustered with the Iberian population. Phylogenetic trees and migration modeling revealed a high proximity of Dagestan sequences to those of Central Italy and suggested possible gene flow between Western Asia and Southern Europe which was not directly related to Northern and Central European lineages. Our results support the presence of old maternal lineages in two Southern glacial refugia (i.e., Caucasus and the Italian peninsula), as a legacy of an ancient wave of colonization of Southern Europe from an Eastern origin.

Where winter rules: Modeling wild boar distribution in its north-eastern range.

Wild boars are distributed almost all over the Earth. Though, Northern Asia remained not inhabited by the species until the end of the 20th century. In the last two decades slowly but surely the wild boar has expanded the northeastern edge of its range to the northern border of the taiga. Investigating environmental factors that underlie range expansions is crucial for understanding its mechanism and predict future changes in species distribution and biodiversity. Here we investigated the distribution of wild boar in its northeastern range, comparing the role of habitat and climate variables at three spatial scales: the permanently occupied area, the area of potential expansion and the total area. We have shown that along the gradient of wild boar occupancy (from permanently to sporadically occupied to presently unoccupied) the importance of habitat variables decreases while importance of climatic variables increases. Our analysis suggests that the potential range increase of the species results from the combined effect of habitat and climatic variables. A possibility for future expansion, however, is rather related to climate change (particularly to the increase of temperature at high latitudes) than to the alteration of habitat or shifts in resource use.

Innovations in the Plastic Surgery Care Pathway: Using Telemedicine for Clinical Efficiency and Patient Satisfaction.

BACKGROUND: Telemedicine delivers clinical information and permits discussion between providers and patients at a distance. Postoperative visits may be a burden to patients-many of whom travel long distances and miss work opportunities. By implementing a telehealth opportunity, the authors sought to develop a process that optimizes efficiency and provides optimal patient satisfaction. METHODS: Using quality improvement methods that have been highly effective in the business sector, we developed a testable workflow for patients in the postoperative telehealth setting. Seventy-two patients were enrolled and surveyed. A preoperative survey sought to determine travel distance, comfort with technology, access to the Internet and video-enabled devices, and the patient's interest in telehealth. A postoperative survey focused on patient satisfaction with the experience. RESULTS: Using the Lean Six Sigma methodology, the authors developed a telehealth workflow to optimize clinical efficiency. Preoperative surveys revealed that the majority (73 percent) of patients preferred in-person follow-up visits in the clinic. However, the postoperative survey distributed after the telehealth encounter found that nearly 100 percent of patients were satisfied with the telehealth experience. Ninety-six percent of patients said that their questions were answered, and 97 percent of patients stated that they would use telehealth again in the future. CONCLUSIONS: Telehealth encounters enable real-time clinical decision-making by providing patients and visiting nurses access to providers and decreasing patient transportation needs and wait times. Although initially hesitant to opt for a telehealth encounter in lieu of a traditional visit, the great majority of patients voiced satisfaction with the telehealth experience. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complication Profiles by Mastectomy Indication in Tissue Expander Breast Reconstruction.

BACKGROUND: Two-stage implant breast reconstruction is the most commonly performed breast reconstruction procedure. Limited data exist regarding reconstruction complication rates examined by mastectomy indication. METHODS: Patients who underwent two-stage implant breast reconstruction at Yale New Haven Hospital from 2011 to 2017 were included in the study. Perioperative complications were compared. Chi-square analysis, t tests, and Fisher's exact tests were used to determine significant associations. A binary logistic regression was used to determine variables with a significant impact on the likelihood of mastectomy flap necrosis. RESULTS: Between 2011 and 2017, complete perioperative records were available for 141 patients who underwent 226 mastectomies followed by two-stage tissue expander/permanent implant reconstruction. Of the 226 mastectomies, 134 were therapeutic and 92 were prophylactic. On regression analysis, there were no significant differences in demographics, comorbidities, or mastectomy and reconstructive details between the two breast groups except for there being more modified radical mastectomies in therapeutic breasts (p = 0.003). When comparing complications, there was a significantly higher risk of mastectomy flap necrosis in the therapeutic group (p = 0.017). Therapeutic mastectomies had a 9.5 times higher risk of mastectomy flap necrosis than prophylactic mastectomies when adjusted for confounding variables. There were no significant differences in other reconstructive complications between the two groups. CONCLUSIONS: Patients undergoing therapeutic mastectomies have a significantly higher risk of mastectomy flap necrosis than those undergoing prophylactic mastectomies. Although the underlying cause still needs to be determined, differences in technique may be related to mastectomy flap necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A Predictive Model for Determining Permanent Implant Size During 2-Stage Implant Breast Reconstruction.

BACKGROUND: Two-stage tissue expander (TE)/permanent implant (PI) breast reconstruction remains the most commonly performed technique in breast reconstruction. Predictions for the PI size preoperatively impact on the number and range of implants made available at TE exchange. This study aims to identify critical preoperative variables and create a predictive model for PI size. METHODS: Patients who underwent 2-stage implant breast reconstruction from 2011 to 2017 were included in the study. Linear and multivariate regression analyses were used to identify significant preoperative variables for PI volume. RESULTS: During the study period, 826 patients underwent 2-stage TE/PI breast reconstruction. Complete records were available for 226 breasts. Initial TE fill ranged from 0% to 102% with a mean final fill of 100.6% of TE volume. The majority of PIs were smooth round (98.2%), silicone (90%) implants. In a multivariate analysis, significant variables for predicting PI size were TE final fill volume (P < 0.0001), TE size (P = 0.03), and a history of preoperative radiation (P = 0.001). Relationships between these 3 variables were utilized to form a predictive model with a regression coefficient of R2 = 0.914. CONCLUSIONS: Significant variables for predicting PI volume were TE final fill volume, TE size, and a history of preoperative radiation. The ability to more accurately predict the PI volume can improve surgical planning, reduce consignment inventory, and simplify operating room workflow.

Genetic diversity and phylogeography of Siberian roe deer, Caproulus pygargus, in central and peripheral populations.

Current understanding of phylogeographical structure and genetic diversity of Siberian roe deer remains limited mainly due to small sample size and/or low geographical coverage in previous studies. Published data suggest at least two phylogroups: western (Ural Mountains and Western Siberia) and eastern (east from lake Baikal, including the Korean peninsula), but their phylogenetic relationship remains unclear. Combined sequences of cytochrome b (1140 bp) and the mtDNA control region (963 bp) were analyzed from 219 Siberian roe deer from 12 locations in Russia, Mongolia, and South Korea, which cover a large part of its range, to assess genetic diversity and phylogeographical status. Special emphasis was placed on the demographic history and genetic features of central, peripheral, and isolated populations. Results of median-joining network and phylogenetic tree analyses indicate that Siberian roe deer from the Urals to the Pacific Ocean are genetically diverse and that geographical distribution and composition of haplogroups coincide with previously described ranges of the subspecies Capreolus pygargus pygargus and Capreolus pygargus tianschanicus. We found that peripheral populations in the northwestern parts of the species range (Urals), as well as the isolated population from Jeju Island, are genetically distinct from those in the core part of the range, both in terms of genetic diversity and quantitative composition of haplogroups. We also found that northwestern (Urals) and northern (Yakutia) peripheral populations share the same haplogroup and fall into the same phylogenetic clade with the isolated population from Jeju Island. This finding sheds light on the taxonomic status of the Jeju Island population and leads to hypotheses about the discordance of morphological and genetic evolution in isolated populations and specific genetic features of peripheral populations.

Genetic diversity and genetic structure of the Siberian roe deer (Capreolus pygargus) populations from Asia.

BACKGROUND: The roe deer, Capreolus sp., is one of the most widespread meso-mammals of Palearctic distribution, and includes two species, the European roe deer, C. capreolus inhabiting mainly Europe, and the Siberian roe deer, C. pygargus, distributed throughout continental Asia. Although there are a number of genetic studies concerning European roe deer, the Siberian roe deer has been studied less, and none of these studies use microsatellite markers. Natural processes have led to genetic structuring in wild populations. To understand how these factors have affected genetic structure and connectivity of Siberian roe deer, we investigated variability at 12 microsatellite loci for Siberian roe deer from ten localities in Asia. RESULTS: Moderate levels of genetic diversity (H(E) = 0.522 to 0.628) were found in all populations except in Jeju Island, South Korea, where the diversity was lowest (H(E) = 0.386). Western populations showed relatively low genetic diversity and higher degrees of genetic differentiation compared with eastern populations (mean Ar = 3.54 (east), 2.81 (west), mean F(ST) = 0.122). Bayesian-based clustering analysis revealed the existence of three genetically distinct groups (clusters) for Siberian roe deer, which comprise of the Southeastern group (Mainland Korea, Russian Far East, Trans-Baikal region and Northern part of Mongolia), Northwestern group (Western Siberia and Ural in Russia) and Jeju Island population. Genetic analyses including AMOVA (F(RT) = 0.200), Barrier and PCA also supported genetic differentiation among regions separated primarily by major mountain ridges, suggesting that mountains played a role in the genetic differentiation of Siberian roe deer. On the other hand, genetic evidence also suggests an ongoing migration that may facilitate genetic admixture at the border areas between two groups. CONCLUSIONS: Our results reveal an apparent pattern of genetic differentiation among populations inhabiting Asia, showing moderate levels of genetic diversity with an east-west gradient. The results suggest at least three distinct management units of roe deer in continental Asia, although genetic admixture is evident in some border areas. The insights obtained from this study shed light on management of Siberian roe deer in Asia and may be applied in conservation of local populations of Siberian roe deer.

Prophylactic fasciotomy in a porcine model of extremity trauma.

BACKGROUND: Extremity injury, with concomitant hemorrhagic shock, can result in ischemia-reperfusion injury and the formation of compartment syndrome requiring fasciotomy. As the benefit of prophylactic fasciotomy is unclear, the objective of this study is to determine the functional recovery of an ischemic limb with hemorrhagic shock after prophylactic fasciotomy. MATERIAL AND METHODS: Yorkshire swine underwent 35% blood volume hemorrhage, followed by 1, 3, and 6 h of ischemia (n = 17; 1HR, 3HR, and 6HR) via iliac artery occlusion followed by repair and reperfusion. A second cohort (n = 18) underwent fasciotomy of the anterior compartment of the hind limb following vascular repair (1HR-F, 3HR-F, and 6HR-F). Compartment pressures, measures of electromyographic (EMG) recovery, and a validated gait score (modified Tarlov) were performed throughout a 14-d survival period. RESULTS: Increasing ischemic intervals resulted in incremental increases in compartment pressure (P < 0.05), although the mean did not exceed 30 mm Hg. EMG studies did not show a significant improvement comparing the 3HR with 6HR groups. There was a significant improvement in the EMG studies within the 3HR-F, when compared with 6HR-F. There was a trend toward sensory improvement between the 3HR-F and 3HR groups. However, this did not translate to a difference in functional outcome as measured by the Tarlov gait score. CONCLUSIONS: Within this swine model of hemorrhagic shock and hind limb ischemia, the use of prophylactic fasciotomies did not improve functional outcome.

Wild boar populations up, numbers of hunters down? A review of trends and implications for Europe.

Across Europe, wild boar numbers increased in the 1960s-1970s but stabilised in the 1980s; recent evidence suggests that the numbers and impact of wild boar has grown steadily since the 1980s. As hunting is the main cause of mortality for this species, we reviewed wild boar hunting bags and hunter population trends in 18 European countries from 1982 to 2012. Hunting statistics and numbers of hunters were used as indicators of animal numbers and hunting pressure. The results confirmed that wild boar increased consistently throughout Europe, while the number of hunters remained relatively stable or declined in most countries. We conclude that recreational hunting is insufficient to limit wild boar population growth and that the relative impact of hunting on wild boar mortality had decreased. Other factors, such as mild winters, reforestation, intensification of crop production, supplementary feeding and compensatory population responses of wild boar to hunting pressure might also explain population growth. As populations continue to grow, more human-wild boar conflicts are expected unless this trend is reversed. New interdisciplinary approaches are urgently required to mitigate human-wild boar conflicts, which are otherwise destined to grow further.

Genetic structure of wild boar (Sus scrofa) populations from East Asia based on microsatellite loci analyses.

BACKGROUND: Wild boar, Sus scrofa, is an extant wild ancestor of the domestic pig as an agro-economically important mammal. Wild boar has a worldwide distribution with its geographic origin in Southeast Asia, but genetic diversity and genetic structure of wild boar in East Asia are poorly understood. To characterize the pattern and amount of genetic variation and population structure of wild boar in East Asia, we genotyped and analyzed microsatellite loci for a total of 238 wild boar specimens from ten locations across six countries in East and Southeast Asia. RESULTS: Our data indicated that wild boar populations in East Asia are genetically diverse and structured, showing a significant correlation of genetic distance with geographic distance and implying a low level of gene flow at a regional scale. Bayesian-based clustering analysis was indicative of seven inferred genetic clusters in which wild boars in East Asia are geographically structured. The level of genetic diversity was relatively high in wild boars from Southeast Asia, compared with those from Northeast Asia. This gradient pattern of genetic diversity is consistent with an assumed ancestral population of wild boar in Southeast Asia. Genetic evidences from a relationship tree and structure analysis suggest that wild boar in Jeju Island, South Korea have a distinct genetic background from those in mainland Korea. CONCLUSIONS: Our results reveal a diverse pattern of genetic diversity and the existence of genetic differentiation among wild boar populations inhabiting East Asia. This study highlights the potential contribution of genetic variation of wild boar to the high genetic diversity of local domestic pigs during domestication in East Asia.

The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a hemorrhage control and resuscitative adjunct that has been demonstrated to improve central perfusion during hemorrhagic shock. The aim of this study was to characterize the systemic inflammatory response associated and cardiopulmonary sequelae with 30, 60, and 90 min of balloon occlusion and shock on the release of interleukin 6 (IL-6) and tumor necrosis factor alpha. MATERIALS AND METHODS: Anesthetized female Yorkshire swine (Sus scrofa, weight 70-90 kg) underwent a 35% blood volume-controlled hemorrhage followed by thoracic aortic balloon occlusion of 30 (30-REBOA, n = 6), 60 (60-REBOA, n = 8), and 90 min (90-REBOA, n = 6). This was followed by resuscitation with whole blood and crystalloid over 6 h. Animals then underwent 48 h of critical care with sedation, fluid, and vasopressor support. RESULTS: All animals were successfully induced into hemorrhagic shock without mortality. All groups responded to aortic occlusion with a rise in blood pressure above baseline values. IL-6, as measured (picogram per milliliter) at 8 h, was significantly elevated from baseline values in the 60-REBOA and 90-REBOA groups: 289 ± 258 versus 10 ± 5; P = 0.018 and 630 ± 348; P = 0.007, respectively. There was a trend toward greater vasopressor use (P = 0.183) and increased incidence of acute respiratory distress syndrome (P = 0.052) across the groups. CONCLUSIONS: REBOA is a useful adjunct in supporting central perfusion during hemorrhagic shock; however, increasing occlusion time and shock results in a greater IL-6 release. Clinicians must anticipate inflammation-mediated organ failure in post-REBOA use patients.

Physiologic tolerance of descending thoracic aortic balloon occlusion in a swine model of hemorrhagic shock.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging technique in trauma; however, the physiologic sequelae have not been well quantified. The objectives of this study were to characterize the burden of reperfusion and organ dysfunction of REBOA incurred during 30 or 90 min of class IV shock in a survivable porcine model of hemorrhage. METHODS: After induction of shock, animals were randomized into 4 groups (n = 6): 30 min of shock alone (30-Shock) or with REBOA (30-REBOA) and 90 min of shock alone (90-Shock) or with REBOA (90-REBOA). Cardiovascular homeostasis was then restored with blood, fluid, and vasopressors for 48 h. Outcomes included mean central aortic pressure (MCAP), lactate concentration, organ dysfunction, histologic evaluation, and resuscitation requirements. RESULTS: Both REBOA groups had greater MCAPs throughout their shock phase compared to controls (P < .05) but accumulated a significantly greater serum lactate burden, which returned to control levels by 150 min in the 30-REBOA groups and 320 min in the 90-REBOA group. There was a greater level of renal dysfunction and evidence of liver necrosis seen in the 90-REBOA group compared to the 90-Shock group. There was no evidence of cerebral or spinal cord necrosis in any group. The 90-REBOA group required more fluid resuscitation than the 90-Shock group (P = .05). CONCLUSION: REBOA in shock improves MCAP and is associated with a greater lactate burden; however, this lactate burden returned to control levels within the study period. Ultimately, prolonged REBOA is a survivable and potentially life-saving intervention in the setting of hemorrhagic shock and cardiovascular collapse in the pig.

Anatomic distribution and mortality of arterial injury in the wars in Afghanistan and Iraq with comparison to a civilian benchmark.

OBJECTIVE: The purpose of this study was to examine the anatomic distribution and associated mortality of combat-related vascular injuries comparing them to a contemporary civilian standard. DESIGN: The Joint Trauma Theater Registry (JTTR) was queried to identify patients with major compressible arterial injury (CAI) and noncompressible arterial injury (NCAI) sites, and their outcomes, among casualties in Iraq and Afghanistan from 2003 to 2006. The National Trauma Data Bank (NTDB) was then queried over the same time frame to identify civilian trauma patients with similar arterial injuries. Propensity score-based matching was used to create matched patient cohorts from both populations for analysis. RESULTS: Registry queries identified 380 patients from the JTTR and 7020 patients from the NTDB who met inclusion criteria. Propensity score matching for age, elevated Injury Severity Score (ISS; >15), and hypotension on arrival (systolic blood pressure [SBP] <90) resulted in 167 matched patients from each registry. The predominating mechanism of injury among matched JTTR patients was explosive events (73.1%), whereas penetrating injury was more common in the NTDB group (61.7%). In the matched cohorts, the incidence of NCAI did not differ (22.2% JTTR vs 26.6% NTDB; P = .372), but the NTDB patients had a higher incidence of CAI (73.7% vs 59.3%; P = .005). The JTTR cohort was also found to have a higher incidence of associated venous injury (57.5% vs 23.4%; P < .001). Overall, the matched JTTR cohort had a lower mortality than NTDB counterparts (4.2% vs 12.6%; P = .006), a finding that was also noted among patients with NCAI (10.8% vs 36.4%; P = .008). There was no difference in mortality between matched JTTR and NTDB patients with CAI overall (2.0% vs 4.1%; P = .465), or among those presenting with Glasgow Coma Scale (GCS) <8 (28.6% vs 40.0%; P = 1.00) or shock (SBP <90; 10.5% vs 7.7%; P = 1.00). The JTTR mortality rate among patients with CAI was, however, lower among patients with ISS >15 compared with civilian matched counterparts (10.7% vs 42.4%; P = .006). CONCLUSIONS: Mortality of injured service personnel who reach a medical treatment facility after major arterial injury compares favorably to a matched civilian standard. Acceptable mortality rates within the military cohort are related to key aspects of an organized Joint Trauma System, including prehospital tactical combat casualty care, rapid medical evacuation to forward surgical capability, and implementation of clinical practice guidelines. Aspects of this comprehensive combat casualty care strategy may translate and be of value to management of arterial injury in the civilian sector.