Military Medicine

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ISSN / EISSN : 0026-4075 / 1930-613X
Published by: Oxford University Press (OUP) (10.1093)
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David S Priemer, Daniel P Perl
Published: 11 October 2021
Abstract:
We read with great interest the series of manuscripts collectively entitled “Delayed-Onset Neuropathological Complications from a Foramen Magnum & Occipital Crest Focused Traumatic Brain Injury of the Vietnam War,” written by Burkle et al.1–3 The series is broken down into three parts: Part I provides a case report of what the authors state is the first reported human case report of a foramen magnum and occipital crest-focused blast traumatic brain injury (TBI) from the Vietnam war, Part II provides an analysis of recent animal research into similar injury, and Part III addresses current TBI clinical criteria and pertinent controversies that surround the said criteria. The writings are worthy of significant praise on several levels. For one, the case report is self-authored and, therefore, unique not only in terms of the nature of the injury described but also in breadth, detail, and insight. Furthermore, in the case reported, the authors make a specific attempt to understand the biological/anatomical underpinnings of the constellation of symptoms suffered by the subject in the aftermath of his TBI experience. The authors ultimately highlight the complex nature of TBI, particularly in the military experience owing to blast exposure, calling for more study into its biology and urging that diagnostic criteria and subsequent patient care reflect an understanding of emerging scientific knowledge. As neuropathologists of the Department of Defense (DOD)/Uniformed Services University (USU) Brain Tissue Repository wherein we are in active study of the neuropathology of TBI amongst Military Members, we could not agree more with these sentiments. Nevertheless, there are several important points we must address about the specific neuropathological interpretations/assertions made in this manuscript series and, in general, the nature of military TBI and our current understanding of its associated neuropathology.
, Jeroen Van Cutsem, Emilie Lacroix, Nathalie Pattyn
Published: 11 October 2021
Abstract:
Introduction Modafinil is an eugeroic drug that has been examined to maintain or recover wakefulness, alertness, and cognitive performance when sleep deprived. In a nonmilitary context, the use of modafinil as a nootropic or smart drug, i.e., to improve cognitive performance without being sleep deprived, increases. Although cognitive performance is receiving more explicit attention in a military context, research into the impact of modafinil as a smart drug in function of operationality is lacking. Therefore, the current review aimed at presenting a current state-of-the-art and research agenda on modafinil as a smart drug. Beside the question whether modafinil has an effect or not on cognitive performance, we examined four research questions based on the knowledge on modafinil in sleep-deprived subjects: (1) Is there a difference between the effect of modafinil as a smart drug when administered in repeated doses versus one single dose?; (2) Is the effect of modafinil as a smart drug dose-dependent?; (3) Are there individual-related and/or task-related impact factors?; and (4) What are the reported mental and/or somatic side effects of modafinil as a smart drug? Method We conducted a systematic search of the literature in the databases PubMed, Web of Science, and Scopus, using the search terms “Modafinil” and “Cognitive enhance*” in combination with specific terms related to the research questions. The inclusion criteria were studies on healthy human subjects with quantifiable cognitive outcome based on cognitive tasks. Results We found no literature on the impact of a repeated intake of modafinil as a smart drug, although, in users, intake occurs on a regular basis. Moreover, although modafinil was initially said to comprise no risk for abuse, there are now indications that modafinil works on the same neurobiological mechanisms as other addictive stimulants. There is also no thorough research into a potential risk for overconfidence, whereas this risk was identified in sleep-deprived subjects. Furthermore, eventual enhancing effects were beneficial only in persons with an initial lower performance level and/or performing more difficult tasks and modafinil has an adverse effect when used under time pressure and may negatively impact physical performance. Finally, time-on-task may interact with the dose taken. Discussion The use of modafinil as a smart drug should be examined in function of different military profiles considering their individual performance level and the task characteristics in terms of cognitive demands, physical demands, and sleep availability. It is not yet clear to what extent an improvement in one component (e.g., cognitive performance) may negatively affect another component (e.g., physical performance). Moreover, potential risks for abuse and overconfidence in both regular and occasional intake should be thoroughly investigated to depict the trade-off between user benefits and unwanted side effects. We identified that there is a current risk to the field, as this trade-off has been deemed acceptable for sleep-deprived subjects (considering the risk of sleep deprivation to performance) but this reasoning cannot and should not be readily transposed to non-sleep-deprived individuals. We thus conclude against the use of modafinil as a cognitive enhancer in military contexts that do not involve sleep deprivation.
Frederick M Burkle, Kevin S Hadley, Leah L Ridge, Jan K Herman, Firas H Kobeissy
Published: 11 October 2021
Abstract:
Introduction The diagnosis of traumatic brain injuries is typically based on hemispheric blasts resulting in degrees of unconsciousness and associated cerebral injuries. This case report describes a Vietnam War era setting in which a traumatic blast wave struck the posterior cranium in the region of the foramen magnum, occipital crest, and other skull openings (orbit, oronasal, and ear) and the unique secondary clinical signs and symptoms experienced over time. Materials and Methods This case report describes secondary delayed-onset clinical signs and symptoms consistent with progressive decades-long physical and functional complications. The traumatic blast resulted in brief unconsciousness, decreased vision in left eye, confusion, right sided hemotympanum, deafness, severe tinnitus, severe nasopharynx pain and difficulty swallowing, pain in right posterior and occipital area of the head, and loss of dental amalgams. Subsequent exams revealed progressive hyperacusis, sea sickness, dysdiadochokinesis, diagnosis of 9th and 10th cranial nerve traumatic schwannomas, hyperdense changes to the frontal lobe white matter, progressive tinnitus, chronic vertigo, right-sided high-frequency hearing loss, progressive oculo-gyric crisis of Tumarkin-like seizures, left-sided chronic vitreous hemorrhage, and diminished right hemisphere performance of the brain based on neurophysiological assessment. No post-traumatic stress, depression, or other emotional or psychiatric difficulties were claimed. Conclusion This case report, unique to the English language scientific literature, discusses in detail the secondary signs and symptoms of a foramen magnum and occipital crest focused-associated blast injury.
Pete Riley, Michal Ben-Nun, James Turtle, David Bacon, Akeisha N Owens, Steven Riley
Published: 11 October 2021
Abstract:
Introduction The CoronaVirus Disease 2019 (COVID-19) pandemic remains a formidable threat to populations around the world. The U.S. Military, in particular, represents a unique and distinguishable subset of the population, primarily due to the age and gender of active duty personnel. Current investigations have focused on health outcome forecasts for civilian populations, making them of limited value for military planning. Materials and Methods We have developed and applied an age-structured susceptible, exposed, infectious, recovered, or dead compartmental model for both civilian and military populations, driven by estimates of the time-dependent reproduction number, R(t), which can be both fit to available data and also forecast future cases, intensive care unit (ICU) patients, and deaths. Results We show that the expected health outcomes for active duty military populations are substantially different than for civilian populations of the same size. Specifically, while the number of cases is not expected to differ dramatically, severity, both in terms of ICU burdens and deaths, is substantially lower. Conclusions Our results confirm that the burden placed on military health centers will be substantially lower than that for equivalent-sized civilian populations. More practically, the tool we have developed to investigate this (https://q.predsci.com/covid19/) can be used by military health planners to estimate the resources needed in particular locations based on current estimates of the transmission profiles of COVID-19 within the surrounding civilian population in which the military installation is embedded. As this tool continues to be developed, it can be used to assess the likely impact of different intervention strategies, as well as vaccine policies; both for the current pandemic as well as future ones.
Cherrie B Boyer, Charlotte A Gaydos, Amy B Geller, Eric C Garges, Sten H Vermund
Published: 9 October 2021
Abstract:
To address the ongoing epidemic of sexually transmitted infections (STIs) in the United States, the National Academies of Sciences, Engineering, and Medicine (National Academies) conducted a consensus study on STI control and prevention in the United States to provide recommendations to the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. The culminating report identified military personnel as one of the priority groups that require special consideration given the high prevalence of STIs and their associated behaviors (e.g., concurrent sexual partners and infrequent condom use) that occur during active duty service. Universal health care access, the relative ease and frequency of STI screening, and the educational opportunities within the military are all assets in STI control and prevention. The report offers a comprehensive framework on multiple and interrelated influences on STI risk, prevention, health care access, delivery, and treatment. It also provides an overview of the multilevel risk and protective factors associated with STIs that could be applied using a sexual health paradigm. The military context must integrate the multilevel domains of influences to guide the effort to fill current gaps and research needs. The Department of Defense, with its large clinical and preventive medicine workforce and its well-established universal health care system, is well positioned to enact changes to shift its current approach to STI prevention, treatment, and control. STI control based on highlighting behavioral, social, cultural, and environmental influences on service members’ sexual health and wellness may well drive better STI care and prevention outcomes.
Sarah A Fogleman, Cory Janney, Lynn Cialdella-Kam, James H Flint
Published: 9 October 2021
Abstract:
Vitamin D is critically important to numerous physiologic functions, including bone health. Poor vitamin D status is a common but underrecognized problem that predisposes the military population to stress fracture and completed fracture. This has significant implications for force health protection, warfighter readiness, attrition, and cost. Despite this, vitamin D deficiency is still underdiagnosed and undertreated in the military. This is a major hindrance to military readiness and one that could easily be modified with awareness, prevention, and early treatment. In this commentary, we review the literature on vitamin D deficiency and critically examine the current status of policies and clinical practice related to vitamin D in the military health system. We offer several practical recommendations to increase awareness and readiness while decreasing musculoskeletal injury and the associated costs.
Vasudha Ram, Jagruti P Bhakta, Scott Roesch, Jeffrey Millegan
Published: 9 October 2021
Abstract:
Introduction A 6-week mindfulness training course, the Mind–Body Medicine (MBM) pilot program for staff, was implemented at a large military treatment facility to examine the preliminary efficacy of the program in reducing stress and burnout in military healthcare professionals. Materials and Methods A retrospective analysis was conducted of data collected from a single-arm prospective MBM pilot program. The program was designed to help staff members increase their awareness of burnout and its consequences and to learn how to utilize mindfulness-based self-care practices as a means for reducing stress and preventing burnout at work. Participants attended a 2-hour MBM group each week for a total duration of 6 weeks. Assessments of stress, resilience, anxiety, somatic symptoms, functional impairment, sleep quality, quality of life, and burnout were administered at baseline (T1), upon completion of the 6-week program (T2), and at least 3 months after program completion (T3). Multilevel modeling was used as the primary statistical model to assess changes in outcomes. Fifty-nine staff members completed assessments at T1, 31 (52.5%) at T2, and 17 (28.8%) at T3. Results Participants showed improvements on scores of perceived stress, resilience, anxiety, somatic symptoms, quality of life, and burnout variables from T1 to T2 and from T1 to T3 (P < .05). Additionally, they reported improvements in their knowledge, understanding, and utilization of MBM concepts and practices from T1 to T2 and from T1 to T3 (P < .05). Conclusions Results from this pilot suggest that the MBM program has the potential to reduce occupational stress and burnout and improve well-being in military healthcare professionals.
Soyun Nam, , Hyun-Chul Kim
Published: 9 October 2021
Abstract:
Dermatofibrosarcoma protuberans (DFSP) is an uncommon, soft tissue sarcoma with a high rate of local recurrence, low rate of distant metastasis, and infiltrative growth. We report two cases of DFSP in young active duty military personnel. Both cases underwent primary excision at the Armed Forces Capital Hospital with positive surgical margins and underwent re-excision at Samsung Medical Center. Dermatofibrosarcoma protuberans is a rare finding, and wide local excision with or without skin flap remains the procedure of choice. Awareness of DFSP in young patients is important for proper diagnosis and treatment and to achieve local control. Complete excision of the tumor with a clear surgical margin and thorough surveillance after surgery are recommended for service members to maintain their active duty status and to prevent ineffective combat conditions.
Melinda C Power, Alia E Murphy, Kan Z Gianattasio, Y i Zhang, , Paul K Crane, Eric B Larson, Laura E Gibbons, Raj G Kumar, Kristen Dams-O’Connor
Published: 9 October 2021
Abstract:
Introduction As the number of U.S. veterans over age 65 has increased, interest in whether military service affects late-life health outcomes has grown. Whether military employment is associated with increased risk of cognitive decline and dementia remains unclear. Materials and Methods We used data from 4,370 participants of the longitudinal Adult Changes in Thought (ACT) cohort study, enrolled at age 65 or older, to examine whether military employment was associated with greater cognitive decline or higher risk of incident dementia in late life. We classified persons as having military employment if their first or second-longest occupation was with the military. Cognitive status was assessed at each biennial Adult Changes in Thought study visit using the Cognitive Abilities Screening Instrument, scored using item response theory (CASI-IRT). Participants meeting screening criteria were referred for dementia ascertainment involving clinical examination and additional cognitive testing. Primary analyses were adjusted for sociodemographic characteristics and APOE genotype. Secondary analyses additionally adjusted for indicators of early-life socioeconomic status and considered effect modification by age, gender, and prior traumatic brain injury with loss of consciousness TBI with LOC. Results Overall, 6% of participants had military employment; of these, 76% were males. Military employment was not significantly associated with cognitive change (difference in modeled 10-year cognitive change in CASI-IRT scores in SD units (95% confidence interval [CI]): −0.042 (−0.19, 0.11), risk of dementia (hazard ratio [HR] [95% CI]: 0.92 [0.71, 1.18]), or risk of Alzheimer’s disease dementia (HR [95% CI]: 0.93 [0.70, 1.23]). These results were robust to additional adjustment and sensitivity analyses. There was no evidence of effect modification by age, gender, or traumatic brain injury with loss of consciousness. Conclusions Among members of the Adult Changes in Thought cohort, military employment was not associated with increased risk of cognitive decline or dementia. Nevertheless, military veterans face the same high risks for cognitive decline and dementia as other aging adults.
Suthee Wiri, Charles Needham, David Ortley, Josh Duckworth, Andrea Gonzales, Timothy Walilko, Timothy B Bentley
Published: 9 October 2021
Abstract:
Introduction The Office of Naval Research sponsored the Blast Load Assessment-Sense and Test program to develop a rapid, in-field solution that could be used by team leaders, commanders, and medical personnel to make science-based stand-down decisions for service members exposed to blast overpressure. However, a critical challenge to this goal was the reliable interpretation of surface pressure data collected by body-worn blast sensors in both combat and combat training scenarios. Without an appropriate standardized metric, exposures from different blast events cannot be compared and accumulated in a service member’s unique blast exposure profile. In response to these challenges, we developed the Fast Automated Signal Transformation, or FAST, algorithm to automate the processing of large amounts of pressure–time data collected by blast sensors and provide a rapid, reliable approximation of the incident blast parameters without user intervention. This paper describes the performance of the FAST algorithms developed to approximate incident blast metrics from high-explosive sources using only data from body-mounted blast sensors. Methods and Materials Incident pressure was chosen as the standardized output metric because it provides a physiologically relevant estimate of the exposure to blast that can be compared across multiple events. In addition, incident pressure serves as an ideal metric because it is not directionally dependent or affected by the orientation of the operator. The FAST algorithms also preprocess data and automatically flag “not real” traces that might not be from blasts events (false positives). Elimination of any “not real” blast waveforms is essential to avoid skewing the results of subsequent analyses. To evaluate the performance of the FAST algorithms, the FAST results were compared to (1) experimentally measured pressures and (2) results from high-fidelity numerical simulations for three representative real-world events. Results The FAST results were in good agreement with both experimental data and high-fidelity simulations for the three case studies analyzed. The first case study evaluated the performance of FAST with respect to body shielding. The predicted incident pressure by FAST for a surrogate facing the charge, side on to charge, and facing away from the charge was examined. The second case study evaluated the performance of FAST with respect to an irregular charge compared to both pressure probes and results from high-fidelity simulations. The third case study demonstrated the utility of FAST for detonations inside structures where reflections from nearby surfaces can significantly alter the incident pressure. Overall, FAST predictions accounted for the reflections, providing a pressure estimate typically within 20% of the anticipated value. Conclusions This paper presents a standardized approach—the FAST algorithms—to analyze body-mounted blast sensor data. FAST algorithms account for the effects of shock interactions with the body to produce an estimate of incident blast conditions, allowing for direct comparison of individual exposure from different blast events. The continuing development of FAST algorithms will include heavy weapons, providing a singular capability to rapidly interpret body-worn sensor data, and provide standard output for analysis of an individual’s unique blast exposure profile.
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