Abstract: Background: Twenty years ago, the original Tactical Combat Casualty Care (TCCC) article was published in this journal. Since TCCC is essentially a set of best-practice prehospital trauma care guidelines customized for use on the battlefield, the presence of a journal with a specific focus on military medicine was a profound benefit to the initial presentation of TCCC to the U.S. Military. Methods: In the two ensuing decades, which included the longest continuous period of armed conflict in our nation's history, TCCC steadily evolved as the prehospital trauma care evidence base was augmented and as feedback from user medics, corpsmen, and pararescuemen was obtained. Findings: TCCC has taken a leadership role in advocating for battlefield trauma care advances such as the aggressive use of tourniquets and hemostatic dressings to control life-threatening external hemorrhage; improved fluid resuscitation techniques for casualties in hemorrhagic shock; increased emphasis on airway positioning and surgi...

Abstract: Background: Improvised explosive devices and new directed energy weapons are changing warfare injuries from penetrating wounds to large surface area thermal and blast injuries. Acellular fish skin is used for tissue repair and during manufacturing subjected to gentle processing compared to biologic materials derived from mammals. This is due to the absence of viral and prion disease transmission risk, preserving natural structure and composition of the fish skin graft. Objectives: The aim of this study was to assess properties of acellular fish skin relevant for severe battlefield injuries and to compare those properties with those of dehydrated human amnion/chorion membrane. Methods: We evaluated cell ingrowth capabilities of the biological materials with microscopy techniques. Bacterial barrier properties were tested with a 2-chamber model. Results: The microstructure of the acellular fish skin is highly porous, whereas the microstructure of dehydrated human amnion/chorion membrane is mostly non...

Abstract: Background: Studies of medical staff members have consistently documented high levels of burnout compared to those in other professions. Although there are studies of burnout in military medical staff, there are gaps in understanding the experience of medical staff while they are deployed and few occupationally-related factors associated with decreased burnout have been identified in this population. Purpose: To assess work-related variables accounting for burnout over and above rank, post-traumatic stress disorder (PTSD) symptoms, and professional stressors in the deployed environment. Methods: U.S. military medical staff members were surveyed in Afghanistan. The survey assessed burnout (emotional exhaustion and depersonalization), PTSD symptoms, perception of professional stressors, self-care behaviors, taking care of team members (team care), general leadership, and health-promoting leadership. Participants provided informed consent under a protocol approved by the institutional review board a...

Abstract: Diarrheal disease affects a large proportion of military personnel deployed to developing countries, resulting in decreased job performance and operational readiness. Travelers' diarrhea is self-limiting and generally resolves within 5 days; however, antibiotic treatment significantly reduces symptom severity and duration of illness. Presently, azithromycin is the preferred first-line antibiotic for the treatment of acute watery diarrhea (single dose 500 mg), as well as for febrile diarrhea and dysentery (single dose 1,000 mg). Levofloxacin and ciprofloxacin are also options for acute watery diarrhea (single dose 500 mg and 750 mg, respectively) and febrile diarrhea/dysentery in areas with high rates of Shigella (500 mg once for 3 days [once daily with levofloxacin and twice daily with ciprofloxacin]), but are becoming less effective because of increasing fluoroquinolone resistance, particularly among Campylobacter spp. Another alternate for acute watery diarrhea is rifaximin (200 mg 3 times per day for 3 days); however, it should not be used with invasive illness. Use of loperamide in combination with antibiotic treatment is also beneficial as it has been shown to further reduce gastrointestinal symptoms and duration of illness. Because of regional differences in the predominance of pathogens and resistance levels, choice of antibiotic should take travel destination into consideration.

Abstract: A cohort of 207 veterans admitted to a residential substance use treatment program was followed for 5 years following discharge to determine factors associated with reduced relapse or mortality following discharge. Subsequent utilization of medical and psychiatric hospitalization and emergency room utilization was also examined. Retrospective chart review was conducted using demographic, diagnostic, and prior treatment as independent variables. Dependent variables included aftercare compliance and subsequent morbidity as measured by relapse, emergency room visits, subsequent hospitalizations, and mortality. Cox proportional hazards models were used to examine factors associated with relapse and mortality. Aftercare attendance was higher in those who completed treatment (p < 0.01). Factors associated with higher risk of relapse included comorbid disorders, failure to complete the index residential substance use treatment program, and psychiatric rehospitalization. Factors associated with higher mortality included failure to complete residential substance use treatment, longer medical rehospitalization, and nicotine dependence. Longer psychiatric rehospitalization was associated with a lower risk of mortality. Comorbid psychiatric conditions and failure to complete residential substance use treatment were associated with higher relapse. Limitations include that this population has severe substance use disorder, that subjective report of symptom severity was not assessed and that attendance at Alcoholics Anonymous aftercare was not surveyed.

Abstract: Introduction: A limitation to surgical care in an austere environment is the supply of oxygen to support mechanical ventilation and general anesthesia. Portable oxygen concentrators (OCs) offer an alternative to traditional compressed oxygen tanks. Objectives: We set out to demonstrate that a low-pressure OC system could supply the mechanical ventilation needs in an austere operating environment. Methods: An ultraportable OC (SAROS Model 3000, SeQual Technologies, Ball Ground, Georgia) was paired with an Impact 754 ventilator (Impact Instrumentation, West Caldwell, New Jersey) to evaluate the delivered fraction of inspired oxygen (FiO2) to a test lung across a range of minute ventilations and at altitudes of 1,200 and 6,500 feet above sea level. Results: The compressor-driven Impact ventilator was able to deliver FiO2 at close to 0.9 for minute ventilations equal to oxygen flow. Pairing two OCs expanded the range of minute ventilations supported. OCs were less effective at concentrating oxygen at...

Abstract: Introduction: Moral injury describes the deleterious effects of acts of commission (e.g., killing noncombatants), omission (e.g., failing to prevent a massacre), or betrayal (i.e., by a trusted authority figure) during military service that transgress accepted behavioral boundaries and norms. Transgressive acts are proposed to lead to a guilt- and shame-based syndrome consisting of post-traumatic stress disorder (PTSD) symptoms, demoralization, self-handicapping, and self-injury. In this study, we tested a frequently cited model of moral injury and assessed the associations between potentially transgressive acts, moral injury outcomes, and guilt and fear. Additionally, we sought to clarify the relative contribution of transgressive and nontransgressive/general combat exposure to moral injury. On the basis of previous research and theory, we anticipated that the transgressive acts would be related to outcomes through guilt and that nontransgressive combat exposure would be related to outcomes thro...

Abstract: Blast exposure is a prevalent cause of mild traumatic brain injury (mTBI) in military personnel in combat. However, it is more common for a service member to be exposed to a low-level blast (LLB) that does not result in a clinically diagnosable mTBI. Recent research suggests that repetitive LLB exposure can result in symptomology similar to symptoms observed after mTBI. This manuscript reports on the use of an Android-based smartphone application (AccWalker app) to capture changes in neuromotor functioning after blast exposure. Active duty U.S. Navy personnel (N = 59) performed a stepping-in-place task before repetitive LLB exposure (heavy weapons training), and again immediately after, 24 hours after, and 72 to 96 hours after the completion of the training. The AccWalker app revealed that there are changes in neuromotor functioning after LLB exposure (slower self-selected movement pace and increased stride time variability) in participants who experienced neurocognitive decline. These data sugges...

Abstract: Objective: Anger is a symptom of post-traumatic stress disorder (PTSD) associated with a range of clinical and functional impairments, and may be especially prevalent among veterans with PTSD. Effective anger management therapies exist but may be undermined by poor engagement or lack of treatment availability. Finding ways to engage veterans in anger management therapy or to improve access can be helpful in improving clinical outcomes. This randomized controlled trial compared anger management treatment (AMT) with AMT augmented by a mobile application (app) system, Remote Exercises for Learning Anger and Excitation Management (RELAX). Methods: Participants were 58 veterans enrolled in 12 sessions of either AMT alone or AMT with the RELAX system (AMT + RELAX). The RELAX system includes the RELAX app, a wearable heart rate monitor, a remote server, and a web-based therapist interface. RELAX allows the user to practice skills, monitor symptoms, and record physiological data. The server collects data...

Abstract: Introduction: This case study describes the application of a commercially available, custom myoelectric elbow–wrist–hand orthosis (MEWHO), on a veteran diagnosed with chronic stroke with residual left hemiparesis. The MEWHO provides powered active assistance for elbow flexion/extension and 3 jaw chuck grip. It is a noninvasive orthosis that is driven by the user's electromyographic signal. Experience with the MEWHO and associated outcomes are reported. Materials and Methods: The participant completed 21 outpatient occupational therapy sessions that incorporated the use of a custom MEWHO without grasp capability into traditional occupational therapy interventions. He then upgraded to an advanced version of that MEWHO that incorporated grasp capability and completed an additional 14 sessions. Range of motion, strength, spasticity (Modified Ashworth Scale [MAS]), the Box and Blocks test, the Fugl–Meyer assessment and observation of functional tasks were used to track progress. The participant also c...

Abstract: Introduction: The phenomenon recently described as “hidden hearing loss” was the subject of a meeting co-hosted by the Department of Defense Hearing Center of Excellence and MIT Lincoln Laboratory to consider the potential relevance of noise-related synaptopathic injury to military settings and performance, service-related injury scenarios, and military medical priorities. Participants included approximately 50 researchers and subject matter experts from academic, federal, and military laboratories. Here we present a synthesis of discussion topics and concerns, as well as specific research objectives identified to develop militarily relevant knowledge. Materials and Methods: We consider findings from studies to date that have demonstrated cochlear synaptopathy and neurodegenerative processes apparently linked to noise exposure in animal models. We explore the potential relevance of these findings to the prediction and prevention of military hearing injuries, and to comorbid injuries in the neurol...

Abstract: Background: After one episode of exertional heat stroke (EHS), risk factors must be identified to determine the potential for subsequent episodes. One of these risk factors, core body temperature (Tco) kinetics during strenuous exercise, may be a surrogate marker suggestive of impaired thermoregulation. This study aimed to determine the kinetics of increases in Tco among military subjects who had a history of EHS. Methods: Forty subjects (38 males, mean age 28.4 ± 4.9 years, mean body mass index 24.9 ± 2.4) who had a history of EHS ran 8 km in full combat gear with continuous monitoring of Tco and heart rate. The run was a qualifying event for military service. Tco was assessed using an ingestible sensor (Cortemp HQ Inc., Palmetto, Florida). Maximum oxygen uptake (VO2max) was measured on the day before the run. Findings: The mean performance time for the run was 44.6 ± 6.6 minutes achieved under mild climatic conditions. No neurological impairment was observed. The mean maximum Tco was 39.9 ± 0.5...

Abstract: Background: Data regarding the effect of prehospital blood administration to trauma patients during short-to-moderate time evacuations is scarce. The Israel Air Force Airborne Combat Search and Rescue is the only organization that deals with aeromedical evacuation for both military and civilian casualties in Israel and the only one with the ability to give blood in the prehospital setting. Methods: Data on packed red blood cells (PRBCs) administration in the evacuation missions from January 2003 to June 2010 were analyzed and actual transfusion practice was compared to clinical practice guidelines (CPGs). Results: Over the studied 101 months, a total of 1,721 patients were evacuated by Combat Search and Rescue. Of these, 87 (5.1%) trauma patients were transfused with PRBC. Demographics included 83% male and 17% female with a median age of 23 years. Main mechanisms of injury included gunshot wounds (36%), motor vehicle accidents (28%), and blast injuries (24%) with an average of 2.6 injured regions...

Abstract: Background: Acute diarrheal illness during deployment causes significant morbidity and loss of duty days. Effective and timely treatment is needed to reduce individual, unit, and health system performance impacts. Methods: This critical appraisal of the literature, as part of the development of expert consensus guidelines, asked several key questions related to self-care and healthcare-seeking behavior, antibiotics for self-treatment of travelers' diarrhea, what antibiotics/regimens should be considered for treatment of acute watery diarrhea and febrile diarrhea and/or dysentery, and when and what laboratory diagnostics should be used to support management of deployment-related travelers' diarrhea. Studies of acute diarrhea management in military and other travelers were assessed for relevance and quality. On the basis of this critical appraisal, guideline recommendations were developed and graded by the Expert Panel using good standards in clinical guideline development methodology. Results: New...

Abstract: Background: Air Force Critical Care Air Transport Teams (CCATTs) provide fixed-wing aeromedical evacuation for combat casualties. Multiple studies have evaluated CCATT trauma patients; however, nearly 50% of patients medically evacuated from combat theaters are for nontraumatic medical illnesses to include stroke, myocardial infarctions, overdose, and pulmonary emboli. Published data are limited regarding illness types, in-flight procedures, and adverse events. Objective: The objective of our study was to characterize patients with nontraumatic medical illnesses transferred via CCATT to include a description of in-flight procedures and events. Study Design: We performed a retrospective review of CCATT medical records of patients with nontraumatic medical illnesses transported via CCATT from theater of operations to Landstuhl Regional Medical Center between January 2007 and April 2015. We abstracted data from CCATT records to include demographics, description of current illness, vital signs, labs,...

Abstract: Introduction: The safety, feasibility, and efficacy of a 12-week structured exercise program targeting post-traumatic stress disorder (PTSD) in women Veterans of childbearing age was tested in a pilot study. Materials and Methods: Thirty-one women Veterans of childbearing age were enrolled in the study, 22 remained eligible after the baseline assessment, and 16 completed the exercise protocol. The exercise program consisted of moderate intensity aerobic exercise (brisk walking), 4 times a week, for 12 weeks. Data were collected on duration, intensity, and side effects. The Clinician Administered PTSD Scale was administered at baseline and at the end of 12 weeks. Weekly assessments provided data on PTSD and depression symptoms, pain, and quality of life. Results: Both post-traumatic and depressive symptoms improved significantly by the end of study. There were no adverse events related to exercise. A small focus group provided subjective experiences supporting positive effects of exercise on emoti...

Abstract: Objectives: To examine the incidence and the etiology of corneal and corneoscleral injuries in the setting of combat ocular trauma, and to determine what effect these injuries have on overall visual impairment from combat ocular trauma. Methods: Retrospective, noncomparative, interventional case series, analyzing U.S. service members who were evacuated to the former Walter Reed Army Medical Center (WRAMC). Primary outcome measures were types of corneal injuries, length of follow-up at WRAMC, globe survival, and anatomical causes of blindness. Secondary outcome measures included surgical procedures performed, use of eye protection, source of injury, and visual outcomes. Results: Between 2001 and 2011, there were 184 eyes of 134 patients with corneal or corneoscleral injuries. The average age was 26 years (range, 18–50); 99.3% were male, 31.9% had documented use of eye protection. The average follow-up was 428.2 days (3–2,421). There were 98 right-eye and 86 left-eye injuries. There were 169 open-gl...

Abstract: Introduction: Research has demonstrated the positive effects of exercise during pregnancy on maternal and fetal outcomes, but very little research has evaluated the effect of pregnancy on women's fitness or the length of time needed to recover prepregnancy fitness after delivery. These questions are important in providing anticipatory guidance to women, from elite athletes to women who just want to know how their bodies will change after pregnancy. To women in the military, postpartum fitness is critically important because failing the mandatory biannual physical fitness assessment (PFA) can severely damage or prematurely end a woman's career. Therefore, understanding the expected changes in fitness, the timeline required to regain prepregnancy fitness levels after delivery, and understanding risk factors for physical fitness testing failure is an important aspect of obstetrical care in military populations. The Navy PFA is a unique opportunity to measure the effect of pregnancy on women's abilit...

Abstract: Background: The Institute of Federal Health Care recently published an executive summary from a round table discussion indicating that active duty and retired female military personnel are at high risk for adverse health outcomes unique to military service including complications related to post-traumatic stress disorder (PTSD), unreported sexual trauma, and musculoskeletal problems. In 2008, the Institute of Medicine began to review, evaluate, and summarize the literature on health outcomes in Gulf War-deployed and found sufficient evidence of a causal relationship with PTSD and suggestive evidence of an association with fibromyalgia (FM). This study examines the prevalence and impact of FM in women veterans and to explore the association between other comorbidities to improve risk differentiation for treatment and improve outcomes. Methods: This study is designed as a nested, cross-sectional study within a larger project funded by the U.S. Army at the University of South Florida, College of Nur...

Abstract: Background: Organizational commitment is a psychological state that has a strong impact on the likelihood that employees will remain with an organization. Among military personnel, organizational commitment is predictive of a number of important outcomes, including reenlistment intentions, job performance, morale, and perceived readiness. Because of the unique challenges and experiences associated with military service, it may be that organizational commitment is even more critical in the military than in civilian populations. Despite the essential role that they play in protecting the health of other service members, little is known about the factors that influence Navy Corpsmen's organizational commitment. This study investigated demographic and psychosocial factors that may be associated with organizational commitment among Corpsmen. Methods: Surveys of organizational commitment and possible demographic and psychosocial correlates of organizational commitment were completed by 1,597 male, acti...

Abstract: Background: Service members who have experienced combat trauma with resulting amputation are at risk for compromised quality of life postamputation. Monitoring mental and physical health in amputees returning from the war is of paramount importance. This study examined changes in physical and mental health-related quality of life in service members following traumatic unilateral, transtibial amputation (TTA) during a 12-week period of rehabilitation before and after receiving a prosthesis. Method: This study is a secondary analysis from a randomized controlled trial (RCT) of military service members starting Military Amputee Rehabilitation Program (MARP) following a traumatic TTA. The study examined change in SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores as two aspects of health-related quality of life. Forty-four injured service members, aged 19 to 46, were recruited into the RCT. Participants were randomized into 12 weeks of MARP plus home neuromuscular electr...

Abstract: Intensivist physician involvement has been shown to improve outcomes for critically ill patients. Unfortunately, the number of Intensivists nationally is unable to meet the current demand. Similar to the civilian community, the Navy critical care workforce is limited by available resources. Tele-critical care (TCC) has recently been shown to improve outcomes for critically ill patients, and has been suggested as a suitable means of extending Intensivist expertise. Naval Hospital Camp Pendleton (NHCP) is a small community hospital located 41 miles north of Naval Medical Center San Diego (NMCSD). NHCP operates a relatively low-volume six-bed medical-surgical intensive care unit. The Intensivist staffing of NHCP has been variable, ranging from 3 Intensivists to periods of time with no on-site Intensivists. This intermittent staffing has led to (1) network disengagements, (2) unnecessary transfers to NMCSD, and (3) adverse outcomes for critically ill patients cared for at NHCP without Intensivist invo...

Abstract: Background: The U.S. Army Reserve Officers' Training Corps (ROTC) is the largest commissioning source among all branches. Physical Readiness Training (PRT) is fundamental to ROTC cadet training. However, although studies have evaluated the effectiveness of PRT in cadets with prior PRT experience, no study has examined the early phase adaptations in those cadets with no prior PRT experience. Methods: To determine the effect of PRT over the course of an academic year (9 months) in freshmen ROTC cadets, thirteen (n = 13; 7 male [180.8 ± 4.7 cm, 77.4 ± 10.0 kg; 19.8 ± 6.5 % body fat], 6 female [159.5 ± 12.1 cm; 63.4 ± 8.4 kg; 29.6 ± 6.2% body fat]) cadets with no prior PRT performed laboratory (body composition, 1-repetition maximum [1RM] bench and squat, countermovement vertical jump, maximal aerobic capacity [VO2max]) and field-based ([Army Physical Fitness Test (APFT) (2 minutes maximum push-ups and sit-ups, 2-mile run)]) measures of performance before (PRE), mid-year (MID), and at the conclusion ...

Abstract: Background: In 2009, the Army Pain Management Task Force was chartered. On the basis of their findings, the Department of Defense recommended a comprehensive pain management strategy that included development of a standardized pain assessment system that would collect patient-reported outcomes data to inform the patient-provider clinical encounter. The result was the Pain Assessment Screening Tool and Outcomes Registry (PASTOR). The purpose of this study was to assess the validity and response burden of the patient-reported outcome measures in PASTOR. Methods: Data for analyses were collected from 681 individuals who completed PASTOR at baseline and follow-up as part of their routine clinical care. The survey tool included self-report measures of pain severity and pain interference (measured using the National Institutes of Health Patient-Reported Outcome Measurement Information System [PROMIS] and the Defense and Veterans Pain Rating scale). PROMIS measures of pain correlates also were administe...

Abstract: Background: The procedure of wrapping a heat casualty in ice-water soaked bed sheets to reduce core temperature has received little investigation, despite the practice and recommendation for its use in some military settings. Thus, the purpose of this study was to investigate the cooling efficacy of ice-sheet cooling (ISC) following exertional hyperthermia. Methods: 13 (11 males, 2 females) participants (age = 23 ± 3 years, height = 176.5 ± 10.3 cm, mass = 78.6 ± 15.3 kg, body fat = 19.6 ± 8.6%, and body surface area = 1.95 ± 0.22 m2) volunteered to complete 2 randomized, crossover design trials on an outdoor recreation field (34.4 ± 1.4°C, 54.4 ± 4.1% relative humidity). Each trial consisted of exercise (self-paced 400-m warm-up, 1,609-m run, and 100-m sprints) followed by 15 minutes of either lying supine in the shade with no treatment (control [CON]) or being treated with ice-water soaked sheets wrapped around their body (ISC). Physiological (rectal temperature [Tre], heart rate, mean-weighted...

Abstract: Objectives: To compare magnetic resonance spectroscopic imaging (MRSI) findings from the hippocampal regions of military veterans with blast-related mild traumatic brain injury (blast mTBI) and post-traumatic stress disorder (PTSD) to those with PTSD only; and to examine the relationship of MRSI findings to cognitive and neuromotor impairment. Methods: 35 military veterans—23 with blast mTBI and PTSD (blast mTBI/PTSD) and 12 with PTSD only participated in the study. Whole plane MRSI data including N-acetyl aspartate (NAA) and choline (Ch) were acquired at 7T for the hippocampus. Concurrent cognitive and neuromotor data were collected using established assessments. General linear models (GLMs) with Bonferroni correction were used to compare the two groups on NAA/Ch ratios across regions of the hippocampus. Spearman's correlations were used to examine correlations between NAA/Ch and cognitive and neuromotor impairment. Results: The NAA/Ch results for the left hippocampus were lower in the blast mTBI...

Abstract: This study aimed to evaluate the capability of performing telesurgery via radio transmission for military arenas where wired internet connections may not be practical. Most existing robotic surgery systems are too large to effectively deploy with first responders. The miniature surgical platform in this study consists of a multifunctional robot suite that can fit easily into a briefcase. Methods: The focus of this study is to explore the implications of radio control of the robot. The hypothesis is that an in vivo robot and its control boards can be controlled using off-the-shelf wireless components. An experiment was designed with off-the-shelf wireless components to test the capability of our newest generation of miniature surgical robot to become battery-operated and wireless. Results: Wireless transmission of control signals has provided proof of concept and has exposed areas of the software that can be built upon to improve responsiveness. Wireless transmission of the video feed can be adequa...

Abstract: Introduction: Mixed gender basic military training (BMT) is adopted to integrate the female South African soldier into the military. This study aimed to assess gender differences before, during (12 weeks), and after a 20-week mixed BMT course and determine if BMT significantly reduced these differences. Methods: A total of 186 soldiers (114 male: mean age = 21.0 ± 1.1 year; 72 female: mean age = 20.5 ± 1.2 year) completed the BMT course and all anthropometric, physical fitness, explosive power, and hand grip strength measurements. Repeated-measures analysis of variance was used to model BMT data with main effects for gender comparison between males and females, and time main effect for evaluation of differences between weeks 1, 12, and 20 of BMT, as well as an interaction effect for differences in changes over time for males and females. Alpha was set at α ≤ 0.05. Results: Male soldiers were significantly taller (p < 0.001) and scored better in all measurements at the start of BMT, differences ra...

Abstract: Background: U.S. military service members die from a variety of causes (i.e., accidents, combat, illnesses, homicide, suicide, and terrorism) while on duty and in greater numbers during times of war, leaving behind bereaved dependent family members. Identifying characteristics of these dependent families improves our understanding of their unique needs, helps educate service providers who offer assistance to these surviving family members, and better informs policy addressing their health and well-being. This study describes deceased U.S. military service members (DSMs) who died on active duty between September 11, 2001 and September 11, 2011 and their surviving dependent spouses and children. Methods: Characteristics of DSMs (service branch, rank, and cause of death) and characteristics of spouse-with-children and spouse-only families (ages of dependents, time since loss, and distance from a military installation) were examined. Results: 15,938 DSMs died from a variety of causes (e.g., accidents...