The military gear microbiome: risk factors surrounding the warfighter.

Combat extremity wounds are highly susceptible to contamination from surrounding environmental material. This bioburden could be partially transferred from materials in immediate proximity to the wound, including fragments of the uniform and gear. However, the assessment of the microbial bioburden present on military gear during operational conditions of deployment or training is relatively unexplored. Opportunistic pathogens that can survive on gear represent risk factors for infection following injury, especially following combat blasts, where fibers and other materials are embedded in wounded tissue. We utilized 16S rRNA sequencing to assess the microbiome composition of different military gear types (boot, trouser, coat, and canteen) from two operational environments (training in Hawai'i and deployed in Indonesia) across time (days 0 and 14). We found that microbiome diversity, stability, and composition were dependent on gear type, training location, and sampling timepoint. At day 14, species diversity was significantly higher in Hawai'i samples compared to Indonesia samples for boot, coat, and trouser swabs. In addition, we observed the presence of potential microbial risk factors, as opportunistic pathogenic species, such as Acinetobacter, Pseudomonas, and Staphylococcus, were found to be present in all sample types and in both study sites. These study outcomes will be used to guide the design of antimicrobial materials and uniforms and for infection control efforts following combat blasts and other injuries, thereby improving treatment guidance during military training and deployment.IMPORTANCECombat extremity wounds are vulnerable to contamination from environments of proximity to the warfighter, leading to potential detrimental outcomes such as infection and delayed wound healing. Therefore, microbial surveillance of such environments is necessary to aid the advancement of military safety and preparedness through clinical diagnostics, treatment protocols, and uniform material design.

The impact of simulation-based training on medical students' whole blood transfusion abilities.

BACKGROUND: Whole blood transfusion has been found to increase the likelihood of patient survival within both military and civilian medicine contexts. However, no whole blood transfusion training curriculum currently exists within undergraduate or graduate medical education in the United States. The purpose of our study was to: (1) determine the impact of simulation-based training on medical students' abilities to conduct whole blood transfusions; and (2) determine the impact of simulation-based training on medical students' confidence in conducting whole blood transfusions. STUDY DESIGN AND METHODS: We assessed 157 third-year military medical students' ability to conduct whole blood transfusion before and after Operation Gunpowder, a 2-day high-fidelity prolonged casualty care simulation. We conducted a paired samples t-test to compare the students' pre- and post-simulation performance scores as well as self-reported confidence and stress ratings. RESULTS: There was a significant difference in students' scores at the beginning of the course (M = 20.469, SD 6.40675) compared to their scores at the end of the course (M = 30.361, SD = 2.10053); t(155) = -18.833, p < .001. The effect size for this analysis (d = 6.56) was large. There was a significant difference (p < .001) between the pre- and post-ratings for all self-reported confidence and stress survey items. DISCUSSION: Our results suggest that simulation-based training is an effective means of training medical students to conduct whole blood transfusiontraining in a limited resource simulated environment where blood inventories may be limited.

Combat-related peripheral nerve injuries.

Active-duty service members (ADSM) and military Veterans represent a population with increased occupational risk for nerve injuries sustained both during training operations and wartime. Mechanisms of war-related nerve injuries have evolved over time, from the musket ball-related traumas described by S.W. Mitchell to complex blast injuries and toxic exposures sustained during Middle East conflicts in the 21st century. Commonly encountered nerve injury etiologies in this population currently include compression, direct trauma, nutritional deficits, traumatic limb amputation, toxic chemical exposures, or blast-related injuries. Expeditious identification and comprehensive, interdisciplinary treatment of combat-associated neuropathies, as well as prevention of these injuries whenever possible is critical to reduce chronic morbidity and disability for service members and to maintain a well-prepared military. However, diagnosis of a combat-associated nerve injury may be particularly challenging due to comorbid battlefield injuries or delayed presentation of neuropathy from military toxic exposures. Advances in imaging for nerve injury, including MRI and ultrasound, provide useful tools to compliment EMG in establishing a diagnosis of combat-associated nerve injury, particularly in the setting of anatomic disruption or edema. Surgical techniques can improve pain control or restoration of function. In all cases, comprehensive interdisciplinary rehabilitation provides the best framework for optimization of recovery. Further work is needed to prevent combat-associated nerve injuries and promote nerve recovery following injury.

Creative Arts Therapies in Rehabilitation.

Appreciation for the utility of creative arts therapy in rehabilitation is on the rise. The limitations of conventional approaches to address posttraumatic stress disorder and co-occurring traumatic brain injury is spurring the development and increased use of creative arts therapies, especially in US military health care systems. However, emerging applications of creative arts therapies in rehabilitation extend well beyond posttraumatic stress disorder/traumatic brain injury and military populations to span the continuum of care, from the intensive care unit, postoperative recovery unit, acute inpatient medical and surgical wards, outpatient clinics, and home health, as well as in traditional long-term care and psychiatric settings. Critical steps to more fully integrating creative arts therapies in rehabilitation include the following: (1) incorporation of education about creative arts therapies into the curricula across rehabilitation disciplines; (2) alteration of national and state policies to promote greater inclusion of creative arts therapies as reimbursable treatments for a wide array of clinical diagnoses and conditions; and (3) significant expansion of creative arts therapies' evidence base. This can be achieved by increasing funding levels to encourage rigorously designed and controlled studies to determine the efficacy, populations, diagnoses and conditions, cofactors, and the mechanisms of action of creative arts therapies. The time has come for a concentrated effort from the community of rehabilitation professional associations, advocacy organizations, and practitioners to promote the advancement and inclusion of creative arts therapies into appropriate clinical settings to optimize outcomes for patients.

Assessing mid-career female physician burnout in the military health system: finding joy in practice after the COVID-19 pandemic.

BACKGROUND: Rates of physician burnout increased during the COVID-19 pandemic and are expected to continue to rise. Mid-career physicians, female physicians, and military physicians have all been identified as potentially vulnerable populations to experience burnout. We examine factors associated with physician burnout among this intersectional group through a qualitative key informant interview study. METHODS: We developed a semi-structured interview guide using the Institute for Healthcare Improvement's Improving Joy in Work Framework and recruited military, mid-career female physicians who worked in the Military Health System(MHS) during the COVID-19 pandemic, (March 2020 -December 2021). Notes were collated and deductive thematic analysis was conducted. RESULTS: We interviewed a total of 22 mid-career female physician participants. Participants were between 30 and 44 years of age and 7 were mothers during the pandemic. Most were White and served in the Army. All participants discussed the importance of building rapport and having a good relationship with coworkers. All participants also described their discontentment with the new MHS GENESIS electronic health record system. An emerging theme was military pride as most participants were proud to serve in and support the military population. Additionally, participants discussed the negative impact from not feeling supported and not feeling heard by leadership. CONCLUSIONS: Much like providers in other health systems during the pandemic, MHS physicians experienced burnout. This study allowed us to gather key insights to improve policies for active duty service mid-career female military physicians. Provider inclusion, autonomy, and work culture play critical roles in future systems improvement and workforce retention.

BMI changes among U.S. Navy and Marine Corps active-duty service members during the COVID-19 pandemic, 2019-2021.

BACKGROUND: The COVID-19 pandemic disrupted the daily life and routines of Americans across the United States (U.S.), including those of our active-duty service members (ADSMs). Limited movement orders enacted during this time to promote social distancing prohibited access to fitness and dining facilities for ADSMs. This study aims to expand on previous work identifying changes in body mass index (BMI) among U.S. Army service members by identifying changes in body mass index (BMI) among active-duty service members from both the Navy and Marine Corps during the same time period. METHODS: We conducted a retrospective cohort study of active-duty service members from the Navy and Marine Corps using data from the Military Health System Data Repository. BMI was calculated and categorized according to CDC guidelines both before (February 2019 - January 2020) and during the pandemic (September 2020 - June 2021). Women who were pregnant or delivered during and one year prior to the study periods were excluded. Statistical analyses included paired t-tests evaluating mean BMI, percent change, and the Stuart-Maxwell test for marginal homogeneity. RESULTS: We identified 98,330 active-duty Sailors and 55,298 active-duty Marines for inclusion in this study. During the pandemic period the percentage of Sailors with Underweight decreased by 11%, Healthy weight decreased by 11.1%, Overweight increased by 2.1%, and the percentage of Sailors with Obesity increased by 16.5%. During this same time period, Marines with Underweight decreased by 1%, Healthy weight decreased by 16%, Overweight increased by 3.0%, and Marines with Obesity increased by 51%. The largest increases in service members with overweight and obesity observed among both cohorts were among female service members, service members under age 20, and service members with a Junior Enlisted rank. CONCLUSIONS: Significant increases in obesity were observed amongst active-duty United States Navy and Marine Corps service members during DoD pandemic mitigation efforts. Increased rates of obesity likely effected fitness and force readiness. Future interventions should be targeted at younger, Junior-Enlisted Marines and Sailors to promote healthy lifestyles and provide education on nutrition, appropriate exercise, sleep hygiene, and stress management.

The response of the Military Health System (MHS) to the COVID-19 pandemic: a summary of findings from MHS reviews.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic caused major disruptions to the US Military Health System (MHS). In this study, we evaluated the MHS response to the pandemic to understand the impact of the pandemic response in a large, national, integrated healthcare system providing care for ~ 9 million beneficiaries. METHODS: We performed a narrative literature review of 16 internal Department of Defense (DoD) reports, including reviews mandated by the US Congress in response to the pandemic. We categorized the findings using the Doctrine, Organization, Training, Materiel, Leadership, Personnel, Facilities, and Policy (DOTMLPF-P) framework developed by the DoD to assess system efficiency and effectiveness. RESULTS: The majority of the findings were in the policy, organization, and personnel categories. Key findings showed that the MHS structure to address surge situations was beneficial during the pandemic response, and the rapid growth of telehealth created the potential impact for improved access to routine and specialized care. However, organizational transition contributed to miscommunication and uneven implementation of policies; disruptions affected clinical training, upskilling, and the supply chain; and staffing shortages contributed to burnout among healthcare workers. CONCLUSION: Given its highly integrated, vertical structure, the MHS was in a better position than many civilian healthcare networks to respond efficiently to the pandemic. However, similar to the US civilian sector, the MHS also experienced delays in care, staffing and materiel challenges, and a rapid switch to telehealth. Lessons regarding the importance of communication and preparation for future public health emergency responses are relevant to civilian healthcare systems responding to COVID-19 and other similar public health crises.

Analysis of Telehealth Equity Within the Military Health System During the COVID-19 Pandemic.

Background: Telehealth care expanded during the COVID-19 pandemic, although previous studies show racial, gender, and socioeconomic inequalities in its usage. Racial disparities are known to be mitigated in the Military Health System (MHS), whose 9.6 million beneficiaries are universally insured and nationally representative. This study investigated whether known disparities in telehealth usage were mitigated in the MHS. Methods: This study performed a retrospective cross-sectional study of TRICARE telehealth claims data from January 2020 to December 2021. Beneficiaries aged 0 to 64 years were identified with Common Procedural Terminology code modifiers 95, GT, and GQ, which indicated procedures that were delivered through either synchronous or asynchronous telecommunication services. Visits were defined as one encounter per patient per day. Analyses included descriptive statistics of patient demographics, number of telehealth visits, and differences between military-provided and private sector care (PSC). Military rank was used as a proxy for socioeconomic status (SES), generally combining income, education, and occupation type. Results: A total of 917,922 beneficiaries received telehealth visits during the study period: 25% in direct care, 80% in PSC, and 4% in both care settings. The majority of visits were received by females (57%) and associated with a Senior Enlisted rank (66%). The visits by racial category were proportional to the percentage of each category in the population. The lowest number of visits was for those older than 60 years, potentially receiving Medicare instead, and those associated with Junior Enlisted rank, a potential disparity that may also reflect access to leave or smaller family size. Conclusions and Relevance: Within the MHS, telehealth visits were equitable by race, in line with previous findings, but not by gender, SES, or age. Findings by gender are reflected in the greater U.S. population. Further research is needed to assess and address potential disparities associated with Junior Enlisted rank as proxy for low SES.

Understanding How Contingency Staffing Programs Can Support Mental Health Services in the Veterans Health Administration.

Introduction: Beginning in 2019, the Department of Veterans Affairs (VA) prioritized improving access to care nationally to deliver virtual care and implemented 18 regionally based Clinical Resource Hubs (CRHs) to meet this priority. This observational study describes the quantity and types of care delivered by CRH Mental Health teams, and the professions of those hired to deliver it. Methods: A retrospective cohort study, based on national VA CRH mental health care utilization data and CRH staffing data for CRH's first 3 years, was conducted. Results: CRH Mental Health teams primarily used Telemental Health (TMH) to provide care (98.1% of all CRH MH encounters). The most common disorders treated included depression, post-traumatic stress disorder, and anxiety disorders. The amount of care delivered overtime steadily increased as did the racial and ethnic diversity of Veterans served. Psychologists accounted for the largest share of CRH staffing, followed by psychiatrists. Conclusions: CRH TMH delivered from a regional hub appears to be a feasible and acceptable visit modality, based on the continuously increasing CRH TMH visit rates. Our results showed that CRH TMH was predominantly used to address common mental health diagnoses, rather than serious mental illnesses. Traditionally marginalized patient populations increased over the 3-year window, suggesting that CRH TMH resources were accessible to many of these patients. Future research should assess barriers and facilitators for accessing CRH TMH, especially for difficult-to-service patient populations, and should consider whether similar results to ours occur when regional TMH is delivered to non-VA patient populations.

Psychological first aid in operation for military healthcare providers : a study on pre-deployment training.

INTRODUCTION: During operational missions, while the management of physical injuries in the field remains the priority, the identification of operational incapacity of psychological origin is necessary as it is equally crucial for the safety of the individual, the group and the mission. The French Military Health Service has developed a Psychological First Aid Training in Operation (PFATO) course based on relational simulations, for military service members. The aim is to identify the early signs of psychological distress in a comrade and to adopt an adapted and protective attitude. PFATO training is also offered to healthcare providers. METHODS: We conducted a descriptive cross-sectional study using a self-administered online questionnaire which was sent after deployment to all physicians or nurses trained in PFATO between July 2019 and July 2021 (n=80). The main objective of our work was to evaluate the relevance of this awareness training among physicians and nurses and to identify specific complementary expectations in operational psychiatry for this population. RESULTS: We obtained a response rate of 55%. Significantly, 21.62% of participants used PFATO during their last deployment and another 20% observed a team member using PFATO. The circumstances of use as reported by participants included acute stress related to combat, conflict with hierarchy or comrades, and suicidal crisis. Among those who used PFATO, the training helped 87.5% of them to identify signs of psychological distress and 100% of them to assist combatants . All respondents stressed the added value of practical simulations during PFATO education. Moreover, this study also makes it possible to identify adaptations needed to optimize this module for healthcare providers. CONCLUSION: The results suggest the value for healthcare provider of training in first-response psychological care using relational simulation based on the model of raising awareness about PFATO.

[The review of the monograph "Ambroise Paré. The first surgeon of the Kingdom" by E. E. Berger].

The review considers the approach placing famous French surgeon A. Paré into more general European context of European Renaissance of XVI century and into local context of intellectual life of Paris of this period. The refutation of widespread in history of medicine opinion about strict separation of university medicine from artisan surgery in Medieval Europe is discussed.

Opioid prescribing and use in the Military Health System: a framework synthesis, FY2016-FY2021.

BACKGROUND: Opioid misuse is a nationwide issue and is of particular concern with regard to military readiness. The 2017 National Defense Authorization Act charges the Military Health System with greater oversight of opioid use and mitigation of misuse. METHODS: We synthesized published articles using secondary analysis of TRICARE claims data, a nationally representative database of 9.6 million beneficiaries. We screened 106 articles for inclusion and identified 17 studies for data abstraction. Framework analysis was conducted, which assessed prescribing practices, patient use, and optimum length of opioid prescriptions after surgery, trauma, and common procedures, as well as factors leading to sustained prescription opioid use. RESULTS: Across the studies, sustained prescription opioid use after surgery was low overall, with <1% of opioid-naïve patients still receiving opioids more than 1 year after spinal surgery or trauma. In opioid-exposed patients who had undergone spine surgery, sustained use was slightly lower than 10%. Higher rates of sustained use were associated with more severe trauma and depression, as well as with prior use and initial opioid prescriptions for low back pain or other undefined conditions. Black patients were more likely to discontinue opioid use than were White patients. CONCLUSIONS: Prescribing practices are well correlated with degree of injury or intensity of intervention. Sustained prescription opioid use beyond 1 year is rare and is associated with diagnoses for which opioids are not the standard of care. More efficient coding, increased attention to clinical practice guidelines, and use of tools to predict risk of sustained prescription opioid use are recommended.

A cohort study of BMI changes among U.S. Army soldiers during the COVID-19 Pandemic.

BACKGROUND: The increasing number of individuals with obesity is a healthcare concern in the United States (U.S.) population; the men and women who serve in the Army are no exception, with 17.3% of soldiers categorized with a body mass index (BMI) of Obesity in 2017. The COVID-19 pandemic profoundly disrupted life around the globe. During the pandemic, restrictions to soldier movement and activity were put in place to limit COVID-19 transmission. We strive to assess what effects these changes may have had on the BMIs of soldiers. METHODS: We conducted a retrospective cohort study of active duty U.S. Army soldiers using data from the Military Health System Data Repository. BMI was calculated and categorized before (February 2019 - January 2020) and during the pandemic (September 2020 - June 2021). Women who were pregnant or delivered during and one year prior to the study periods were excluded. Statistical analyses included paired t-tests evaluating mean BMI, percent change, and the Stuart-Maxwell test for marginal homogeneity. RESULTS: 191,894 soldiers were included in the cohort. During the pandemic, 50.5% of soldiers in the cohort were classified as Overweight and 23.2% were classified as Obesity. T-test and Stuart-Maxwell test indicated significant differences and changes in BMI categories between the pre-pandemic and pandemic periods, particularly the Obesity category, which experienced a 5% growth and 27% change. Significant absolute changes were observed during the pandemic; 26.7% of soldiers classified as Healthy weight in the pre-pandemic period shifted to Overweight in the pandemic period and 15.6% shifted from Overweight in the pre-pandemic period to Obesity in the pandemic period. Absolute increases were observed across every demographic category in soldiers with obesity; the categories that saw the highest increases were female, ages 20-24, White, and Junior Enlisted soldiers. CONCLUSIONS: Higher rates of obesity may result in decreased health of the force. The specific needs of younger and Junior Enlisted soldiers need to be further addressed, with focus on special intervention programs by the U.S. Army.

"Man Who Won the War": Myth and Reality of Aldo Castellani's Role in Preserving the Health of Troops During the Italo-Ethiopian War 1935-1936.

The invasion of the ancient Ethiopian empire perpetrated by the Italian fascist regime in 1935-1936 deserves all the blame due to a war of aggression, a belated colonial enterprise and a bullying act of a totalitarian regime. Yet there is one aspect of that war that aroused universal admiration among contemporaries and which still deserves to be analysed today: the healthcare of troops. The Italian army, which came close to half a million men, was the largest European army that had ever fought in tropical or sub-tropical territories. Many Cassandras expected a health catastrophe, even more than a military one. But Mussolini decided to entrust Sir Aldo Castellani, the famous tropicalist doctor who had been living between Italy and England for years, with the role of Inspector General of Military and Civilian Health Services for East Africa. At the end of the seven-month victorious military campaign, the very low number of casualties recorded due to illness or injury evoked amazement and admiration. This was not just propaganda, as proved by the uncountable invitations from military and health authorities all over the world (including some of the nations that had imposed economic sanctions against Italy a few months earlier) for Castellani to reveal his secret through lectures, articles and conferences. Even US President Franklyn D. Roosevelt, who as a polio sufferer was particularly sensitive to public health issues, asked for and obtained a long private interview with Castellani, the "man who won the war".

Cooling Modality Effectiveness and Mortality Associate With Prehospital Care of Exertional Heat Stroke Casualities.

BACKGROUND: Cold-water immersion is the gold standard for field treatment of an exertional heat stroke (EHS) casualty. Practical limitations may preclude this method and ice sheets (bed linens soaked in ice water) have emerged as a viable alternative. Laboratory studies suggest that this is an inferior method; however, the magnitude of hyperthermia is limited and may underestimate the cooling rate in EHS casualties. OBJECTIVE: Our aim was to determine the prehospital core cooling rate, need for continued cooling on arrival to the emergency department, and mortality rate associated with ice sheet use. METHODS: De-identified retrospective data were obtained from emergency medical services (EMS) and included presence or absence of altered mental status, cooling measures applied prior to EMS arrival, and time and core temperature (Tc; rectal) on-scene and on hospital arrival. Cooling rate was calculated from time and temperature data. Mortality data were obtained from the U.S. Army Combat Readiness Center. RESULTS: There were 462 casualties that met inclusion criteria. The cooling rate for the entire sample was 0.07°C ± 0.08°C · min-1. EHS casualties with an observed initial Tc < 39°C had an en route cooling rate of 0.03°C ± 0.04°C · min-1 vs. initial Tc ≥ 39°C cooling rate of 0.16°C ± 0.08°C · min-1. There was one fatality due to EHS, for a mortality rate of 0.20% (95% CI 0.01-1.20%). CONCLUSIONS: The cooling rate in EHS casualties with initial Tc ≥ 39°C was approximately double that reported in laboratory studies. The observed mortality rate was comparable with casualties treated with cold-water immersion. Our data suggest that ice sheets provide a viable alternative when practical constraints preclude cold-water immersion.

Rates of Lapidus Procedures in the US Military Before and After the Advent of and Advocacy for Tri-Plane Lapidus Corrective Surgery.

Tri-plane corrective Lapidus surgery has been described as advantageous with respect to its anatomic basis and outcomes. Because the procedure has been broadly publicized, changes in overall Lapidus procedure rates due to increased numbers of patients opting for the tri-plane approach could have occurred. Data supporting this possibility appears lacking. We employed official personnel and health records of the total active-duty US military to conduct a retrospective cohort study of Lapidus surgery rates before and after the advent of the tri-plane corrective Lapidus procedure. Least-squares and locally-weighted scatterplot smoother regression functions were used to confirm time trends. Sociodemographic and occupational traits of Lapidus patients were compared using 2-sided t tests and chi square tests. Lapidus surgery rates among hallux valgus patients decreased during 2014 to 2016 and increased during 2017 to 2021. While multiple factors might explain these trends, they coincide with the advent of and advocacy for tri-plane Lapidus surgery. The results support the possibility that its rise influenced overall Lapidus rates in this population. As these findings represent limited evidence of such an influence, further research is required to confirm a causal link. If such a link is found, and if the ongoing research suggests that superior outcomes are associated with tri-plane Lapidus surgery, substantial implications could exist for this population. Benefits might include enhanced medical readiness due to the importance of lower extremity function during military duties. Additional research is needed to confirm the impact of the procedure and to determine whether Lapidus surgery rate patterns in civilian populations mirror these findings.

ASSESSMENT OF THE CONSEQUENCES OF THE DETERIORATION OF THE EPIDEMIOLOGICAL SITUATION DURING HOSTILITIES.

OBJECTIVE: The aim: Scientific substantiation of the methodology for predicting the consequences of the worsening of the epidemic situation on the territory of Ukraine during military operations for the timely adoption of measures for the medical protection of military personnel in conditions of biological contamination. PATIENTS AND METHODS: Materials and methods: Determination and generalization of the impact of biological contamination due to the use of biological weapons were carried out considering the main determinants of the epidemic process using the index and coefficient of medical protection. Applied methods of scientific research: epidemiological, system, and information approach. RESULTS: Results: The authors proposed indicators that consider the pathogenicity of the infectious agent, contagiousness, the degree of non-specific protection of servicemen, specific protection of servicemen, and the sanitary-epidemiological state of the area of operations of troops (forces). Relevant epidemic situations were simulated, and the index and coefficient of medical protection were calculated to predict the consequences of the worsening of the epidemic situation to make timely decisions regarding the implementation of medical protection measures for military personnel in conditions of biological contamination during the repulsion of armed aggression. CONCLUSION: Conclusions: In the conditions of biological contamination, when biological weapons and biological terrorism are used, the epidemic process in the army is intensified, which requires timely decisions regarding the implementation of medical protection measures for military personnel in conditions of biological contamination.

[Infusion therapy with reamberin in military conditions]. / Ispol'zovanie rastvora reamberina v voennykh usloviyakh.

The article is devoted to infusion therapy with Reamberin 1.5% (Meglumine sodium succinate) in patients with various traumatic injuries. The authors substantiate the relevance and significance of this issue. Specifics and purposes of therapy are considered. The authors reviewed national studies devoted to clinical aspects and determined the main directions of therapy in emergency patients with mechanical injuries, burns, traumatic brain injury and cognitive impairment caused by combat trauma. Moreover, experimental studies of protective properties of Reamberin under combined action of cold, vibration and immobilization, as well as acute massive blood loss are analyzed.

Perspective: the top 11 priorities to improve trauma outcomes, from system to patient level.

BACKGROUND: The Haemorrhage, Airway, Breathing, Circulation, Disability, Exposure/Environmental control approach to individual patient management in trauma is well established and embedded in numerous training courses worldwide. Further improvements in trauma outcomes are likely to result from a combination of system-level interventions in prevention and quality improvement, and from a sophisticated approach to clinical innovation. TOP ELEVEN TRAUMA PRIORITIES: Based on a narrative review of remaining preventable mortality and morbidity in trauma, the top eleven priorities for those working throughout the spectrum of trauma care, from policy-makers to clinicians, should be: (1) investment in effective trauma prevention (likely to be the most cost-effective intervention); (2) prioritisation of resources, quality improvement and innovation in prehospital care (where the most preventable mortality remains); (3) building a high-performance trauma team; (4) applying evidence-based clinical interventions that stop bleeding, open & protect the airway, and optimise breathing most effectively; (5) maintaining enough circulating blood volume and ensuring adequate cardiac function; (6) recognising the role of the intensive care unit in modern damage control surgery; (7) prioritising good intensive care unit intercurrent care, especially prophylaxis for thromboembolic disease; (8) conducting a thorough tertiary survey, noting that on average the intensive care unit is where approximately 15% of injuries are detected; (9) facilitating early extubation; (10) investing in formal quantitative and qualitative quality assurance and improvement; and (11) improving clinical trial design. CONCLUSION: Dramatic reductions in population trauma mortality and injury case fatality rate over recent decades have demonstrated the value of a comprehensive approach to trauma quality and process improvement. Continued attention to these principles, targeting areas with highest remaining preventable mortality while also prioritising functional outcomes, should remain the focus of both clinician and policy-makers.

A history of neurosurgical capabilities in the United States Pacific Command: from World War II to present.

Neurosurgery has benefited from innovations as a result of military conflict. The volume and complexity of injuries sustained on the battlefield require medical teams to triage, innovate, and practice beyond their capabilities in order to treat wartime injuries. The neurosurgeons who practiced in the Pacific Command (PACOM) during World War II, the Korean War, and the War in Vietnam built upon field operating room knowledge and influenced the logistics of treating battle-injured patients in far-forward environments. Modern-day battles are held on new terrain, and the military neurosurgeon must adapt. War in the PACOM uniquely presented significant obstacles due to geographic isolation, ultimately accelerating the growth and adaptability of military neurosurgery and medical evacuation. The advancements in infrastructure and resource mobilization made during PACOM conflicts continue to inform modern-day practices and provide insight for future conflicts. In this historical article, the authors review the development and evolution of neurosurgical care, forward surgical teams, and mobile field hospitals with surgical capabilities through US conflicts in the PACOM.