Civilian Settings Research Articles

Therapeutic application of extracellular vesicles for musculoskeletal repair & regeneration

ABSTRACT Traumatic musculoskeletal injuries are common in both the civilian and combat care settings. Significant barriers exist to repairing these injuries including fracture nonunion, muscle fibrosis, re-innervation, and compartment syndrome, as well as infection and inflammation. Recently, extracellular vesicles (EVs), including exosomes and microvesicles, have attracted attention in the field of musculoskeletal regeneration. These vesicles are released by different cell types and play a vital role in cell communication by delivering functional cargoes such as proteins and RNAs. Many of these cargo molecules can be utilized for repair purposes in skeletal disorders such as osteoporosis, osteogenesis imperfecta, sarcopenia, and fracture healing. There are, however, some challenges to overcome in order to advance the successful application of these vesicles in the therapeutic setting. These include large-scale production and isolation of exosomes, long-term storage, in vivo stability, and strategies for tissue-specific targeting and delivery. This paper reviews the general characteristics of exosomes along with their physiological roles and contribution to the pathogenesis of musculoskeletal diseases. We also highlight new findings on the use of synthetic exosomes to overcome the limitations of native exosomes in treating musculoskeletal injuries and disorders.

Optimizing Limb Salvage in Shotgun Injuries to the Extremities in Civilian Trauma

Vascular trauma in civilian settings has often resulted in high rates of amputation or mortality. Although treatment was individualized, patients were managed according to the following protocol: (1) Clinical evaluation and identification of those patients that require immediate exploration. (2) Determination of ankle-ankle indices, with a threshold of 0.9 mandating further evaluation. (3) Liberal use of computed tomography angiography (CTA) evaluation of injuries. (4) Selected use of digital subtraction angiography with an attempt to treat via endovascular means if there is thought to be a reasonable likelihood of success. (5) Liberal use of fasciotomy. (6) Reconstruction of arterial injury with contralateral reversed saphenous when available. (7) Postoperative follow-up with noninvasive arterial studies. Hypothesis: Protocol-driven early assessment and intervention can lead to excellent limb salvage in patients with civilian gunshot wound to the extremities. We retrospectively reviewed our gunshot database from 2012 to 2017 for patients with noniatrogenic penetrating vascular extremity injuries. Data analyzed were demographics, mode of injury, vessels injured, physical examination, arteriography findings, ischemic time, type of arterial and venous repair, morbidity, mortality, graft patency and functional outcome. Postoperative follow-up was done with noninvasive arterial studies. Sixteen patients sustained extremity injuries inflicted by shotguns. Fifteen (94%) underwent preoperative arteriography or CTA, revealing occult arterial injury in nine patients. One patient had soft tissue only and the other five who underwent CTA had no evidence of vascular injury. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. Eighty-one percent underwent fasciotomy at time of surgery. Fasciotomy occurred in 100% of patients with combined arterial and venous injuries (100%) versus 25% with isolated arterial injury. Arterial continuity was restored by interposition grafting with reversed saphenous vein (100%). There were no deaths or amputations at in-office follow-up, which ranged from 6 months to 7 years. Two patients had saphenous nerve injures, one of which fully recovered and the other patient ambulated with a cane due to nerve injury. A protocol of preoperative imaging with either arteriography or CTA for extremity shotgun injuries, use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates of 100% after shotgun vascular trauma to the extremities.

Is Fresh Frozen Plasma Still Necessary for Management of Acute Traumatic Coagulopathy?

Massive blood loss secondary to major trauma is a leading cause of death worldwide. In recent years, multiple different strategies have evolved to counteract this life-threatening condition. In this review, we will review our understanding of trauma-induced coagulopathy and summarize current clinical transfusion regimes utilized in military and civilian settings. We will review currently available blood products used to rectify the coherent disturbances of haemostasis by outlining the characteristics of the different products. Current evidence suggests that fresh frozen plasma and fibrinogen components play a fundamental role in trauma resuscitation with recent studies suggesting pre-hospital plasma and fibrinogen administration might also be beneficial in counteracting trauma-induced coagulopathy. Based on experience out of combat zones, whole blood transfusion might experience a renaissance in the future. Multiple different plasma-based products are available to treat and prevent trauma-induced coagulation disturbances. As randomized controlled trials in trauma population are difficult to conduct, most of the evidence is currently based on relatively small studies. While the overarching result of our review suggests the early use of plasma and fibrinogen products in combination with packed red blood cells will prevent trauma-induced coagulopathy, large, multi-centre studies are warranted to evaluate the long-term effects on patients’ outcome.

Abstract A19: Opioid prescriptions in the military defense system head and neck cancer population, FY2007 - FY2014

Abstract Purpose: Head and neck cancer (HNC) pain involves nocioceptive and neuropathic inputs from both disease and treatment into a highly innervated area of the body. Hence, opioids are assumed to be used in the pain management of HNC patients. Here, we examine the rates and correlates of opioids prescribed to HNC patients who are beneficiaries of the U.S. Military Health System (MHS). Methods: We used MHS outpatient, inpatient, and pharmacy claims data, fiscal years (FY) 2007-2014, to ascertain beneficiaries with a primary ICD-9 diagnosis of HNC. Descriptive statistics were used to characterize the population with respect to sociodemographic characteristics, location and source of care, comorbid conditions, and number of filled opioid prescriptions. Analysis of variance and multiple regression were used to identify trends and predictors of the number of opioid agonist prescription(s) per year. Results: On average per year, 2,944 nonelderly MHS beneficiaries with a primary diagnosis of HNC submitted claims to TRICARE. Most were age 55-64, male, lived in southeast U.S., and received health care in civilian settings only. On average, 0.7% and 12.2% had a concurrent diagnosis indicative of a drug use disorder or alcohol use disorder, respectively, and 26.1% had a documented history of tobacco use. About 44% had head and neck surgery, 84% received radiation therapy, 43% received chemotherapy, and 15% accessed hospice care. On average, 57% of HNC patients received at least 1 opioid agonist prescription per year; this rate was stable over the 8 years of observation. Annual average number of opioid agonist prescriptions per patient ranged from 6.27 (fiscal years 2010 and 2013) to 6.73 (fiscal year 2012). Based on regression analysis, the strongest predictors (p < 0.001) of the number of opioid prescriptions were: hospice use (99% CI 2.236, 2.856), anxiety (99% CI 2.298, 3.063), drug use disorder (99% CI 7.351, 9.992), depression (99% CI 1.692. 2.363), head and neck surgery (99% CI 0.993, 1.434), chemotherapy, tobacco use, number of physical comorbidities, age, and adjustment disorder. Discussion: The results indicate that the average HNC patient treated in the community receives 6 opioid prescriptions per year. This amount, known to increase risk for prolonged opioid use, is largely related to end-of-life care and mental health and drug use disorders. HNC surgery, while significant, was not as strong a predictor. While high opioid use is expected in end-of-life care, the results suggest that all HNC patients need to be regularly screened for mental health comorbidities, particularly drug use disorders. We recommend that oncologists and primary care providers of HNC patients follow guidelines and develop management plans specific to opioid prescribing such as those found in the Veterans Administration/Department of Defense Clinical Practice Guidelines for Opioid Therapy for Chronic Pain, v. 3.0. Citation Format: Art A. Ambrosio, Diana D. Jeffery, Laura A. Hopkins, Christopher J. Spevak, Harry B. Burke. Opioid prescriptions in the military defense system head and neck cancer population, FY2007 - FY2014 [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; 2019 Apr 29-30; Austin, TX. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_2):Abstract nr A19.

Strategies and Tools to Enhance Team Performance.

The ability for teams to work together in a coordinated manner may be where the greatest improvements in health care occur in the next generation. To perform at the highest level there are several key principles that all teams must have no matter what playing field they are on, including health care. Several resources were used to identify the challenges we face in health care with respect to the delivery of quality care, improving outcomes and decreasing complications. A search of the lay press and scientific literature was evaluated to identify those key elements that lead to improvements in team performance. In addition, personal observations were accumulated with time and examples of strategies used at home institutions were identified. The teams in our pediatric orthopaedic practices are many and include those in the clinic, the operating room, research, and our administrative office. The Institute of Medicine, in their influential article in 1999, defined the alarming rates of complications/harm occurring in the US health care system. In response, the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DOD) collaborated to create the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in 2006. This was implemented in military facilities and later civilian hospital settings with varied success in civilian hospital settings. They defined key principles based around team structure, communication, leadership, situation monitoring, and mutual support. Other important foundational attributes of a successful team include identifying the vision of the team, hiring top-talent in the form of hard and soft skills, having open communication, being goal-focused, practicing accountability, and having an organized team. We can look to excellent examples in medicine, business, and sports to see where and how high-functioning teams have existed and to learn from them to implement similar successful teams. Team performance is a function of talented members who share a common vision, who have the opportunity to voice their thoughts/opinions, and have the ability to be accountable to each other. Surgeons need to lead by example, and provide each member of the team an opportunity to contribute in a meaningful way which ultimately will improve the lives of the patients we are honored to care for.

Current state of whole blood transfusion for civilian trauma resuscitation.

Whole blood (WB) is rapidly emerging as the treatment modality of choice for the initial resuscitation of civilian trauma patients across the United States. The reemergence of WB has been rapid and driven in part by recognition of the importance of early plasma transfusion in the resuscitation process. The study was designed as a critical analysis of the available literature on WB transfusion in civilian trauma patients. Studies were included if they reported on transfusion of cold-stored WB used in a civilian setting and measured safety, feasibility, or a direct clinical outcome. Examination of the available literature supports the feasibility and safety of WB used in treatment of civilian trauma patients. The evidence regarding clinical outcomes, particularly with direct comparison to equivalent doses of component therapy, is more limited. The literature is predominantly descriptive and retrospective in nature and limited by the heterogeneity of clinical WB protocols being used. Based on this limited data set, there are limited conclusions that can be used to definitely support or refute the clinical superiority of WB to component therapy. Current literature supports the safety and feasibility of WB, but prospective randomized trials comparing WB to component therapy are needed to provide the definitive evidence on this topic.

Hemolytic markers following the transfusion of uncrossmatched, cold-stored, low-titer, group O+ whole blood in civilian trauma patients.

Low-titer group O whole blood (LTOWB) is increasingly being used in the civilian trauma setting, although there is a risk of hemolysis. This study evaluated the impact on hemolytic markers following the transfusion of 4 or more units of uncrossmatched LTOWB. Civilian adult trauma patients who received four or more units of leukoreduced group O+, low-titer (<50 anti-A and anti-B), platelet-replete uncrossmatched whole blood during their initial resuscitation and who survived for more than 24 hours after the transfusion were included in this retrospective study. Lactate dehydrogenase (LDH), total bilirubin, haptoglobin, potassium, and creatinine were evaluated on the day of LTOWB transfusion (Day 0) and the next 3 days. Blood product administration over the first 24 hours of admission was recorded. There were 54 non-group O and 23 group O recipients of four or more LTOWB units. The median (interquartile range [IQR]) number of transfused LTOWB units was 4 (4-5) and 4 (4-4), respectively, the maximum number in both groups was eight. The non-group O patients received a median (IQR) volume of 1470 mL (1368-2052) of ABO-incompatible plasma. Comparing the non-group O to the group O recipients, there were no significant differences in the haptoglobin, LDH, total bilirubin, potassium, or creatinine concentrations at any of the time points. There were no reported transfusion reactions. Receiving at least four LTOWB units was not associated with biochemical or clinical evidence of hemolysis.

Whole blood transfusion versus component therapy in trauma resuscitation: a systematic review and meta-analysis.

BackgroundPatients with hemorrhagic shock from trauma often require balanced blood product transfusion with red blood cells, plasma, and platelets. Resuscitation with whole blood resuscitation is becoming a common practice. We performed a systematic review and meta‐analysis of studies comparing whole blood transfusion with balanced component therapy in patients suffering from traumatic hemorrhagic shock.MethodsWe searched MEDLINE Ovid, EMBASE, and the Cochrane Library for human studies comparing whole blood with component blood therapy published from January 2007 to June 2019. We included studies from both civilian and military settings and that reported 24‐hour, in‐hospital, or 30‐day mortality. We followed the Preferred Reporting Items in Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, assessing study quality, publication bias, and heterogeneity. We used meta‐analytic models to determine the associations (odds ratio [OR] with 95% confidence interval [CI]) between whole blood transfusion and (1) 24‐hour mortality, and (2) in‐hospital or 30‐day mortality.ResultsA total of 1759 identified studies, 12 (reporting on n = 8431 patients) met inclusion criteria. There was heterogeneity in the design, setting, interventions, and outcomes of the studies. On meta‐analysis, whole blood transfusion was not associated with 24‐hour mortality (OR = 0.83; 95% CI = 0.56–1.24) or in‐hospital/30‐day mortality (OR = 0.79; 95% CI = 0.48–1.31).ConclusionIn this systematic review and meta‐analysis, compared with conventional component transfusion, whole blood was not associated with 24‐hour or in‐hospital mortality. However, there were important limitations with and heterogeneity among the primary studies. Additional study is needed to determine the effectiveness of whole blood.

Moral Injury and Suicide Ideation Among Israeli Combat Veterans: The Contribution of Self-Forgiveness and Perceived Social Support.

Modern warfare within a civilian setting may expose combatants to severe moral challenges. Whereas most of these challenges are handled effectively, some potentially morally injurious events (PMIEs) may have deleterious psychological, spiritual, and interpersonal effects among them, which may increase the risk for suicide ideation and behaviors (SIB). In this study, we aimed to examine the protective role of self-forgiveness and perceived social support on the relationship between exposure to PMIEs and SIB among combat veterans. A sample of 191 Israeli combat veterans completed validated self-report questionnaires in a cross-sectional design study, tapping moral injury, SIB, perceived social support, and self-forgiveness. Veterans with a history of SIB revealed higher levels of exposure to PMIEs and lower levels of self-forgiveness and perceived social support than veterans with no SIB history. Moreover, beyond the contributions of the PMIE dimensions, significant contributions of self-forgiveness and perceived social support to current suicide ideation (SI) were found. Importantly, the moderating model indicated that higher social support moderated the link between PMIEs and current SI. Based on the current findings, it can be suggested that self-forgiveness and perceived social support are important contributors to lower SI levels among veterans with PMIEs. It can be further suggested that interpersonal support may help veterans develop a sense of belongingness and bonding, which is a plausible basis for diminishing the risk of SI following PMIE exposure.

Comparing the Prevalence of Poor Sleep and Stress Metrics in Basic versus Advanced Life Support Emergency Medical Services Personnel

Background: Emergency medical services (EMS) personnel frequently encounter occupational factors that increase the risk of poor sleep and stress. The national prevalence of poor sleep and stress in EMS personnel is unclear, especially differences between personnel at the basic (BLS) versus advanced (ALS) life support levels. The objectives of this study were to: (1) estimate the prevalence of sleep and stress metrics in EMS personnel; and (2) compare these metrics between BLS and ALS-certified personnel. Methods: This study was a survey of recertifying nationally-certified EMS personnel working in civilian settings. Respondents completed an electronic questionnaire assessing their sleep quality; workday, non-workday, and average sleep duration; sleep debt; perceived stress; and chronic stress. Survey-weighted Poisson regression models were used to estimate adjusted prevalence ratios (PR) comparing BLS (emergency medical technician) to ALS (advanced emergency medical technician and paramedic) for each metric. Models were adjusted for age, sex, minority status, education level, EMS agency type, service type, EMS role, and significant interactions. Results: A total of 17,913 (response rate = 19%) responses were received with 17,522 included in the analysis. Adjusted PRs were significantly higher for ALS-certified personnel compared to BLS-certified for poor sleep quality (PR: 1.23, 95% CI: 1.20–1.27) and short (<7 hours) or long (≥9 hours) workday sleep duration (PR: 1.17, 95% CI: 1.15–1.19). Significant interactions were found between certification level and sex (average sleep duration) or age category (sleep debt, perceived stress, and chronic stress). The highest prevalence of short or long average sleep duration was among ALS men. Sleep debt, perceived stress, and chronic stress differed by age group between certification levels with higher PRs for ALS regardless of age group. Conclusions: There is a high prevalence of poor sleep and stress in EMS personnel, with evidence of the highest prevalence among ALS-certified personnel. Evidence of effect modification by age category and among BLS and ALS personnel suggests that interventions could target certain subgroups, such as older ALS personnel, to be most effective. Continued focus on sleep health and stress reduction is needed to improve the health and well-being of the EMS workforce.

Effectiveness of the combat application tourniquet for arterial occlusion in young children.

Tourniquet use for extremity hemorrhage has become a mainstay in adult trauma care in last 15 years. The efforts of the Stop the Bleed campaign have increased the distribution and use of tourniquets in civilian settings in response to mass shootings and as part of disaster preparedness. Little research or published experience exists regarding the use of tourniquets in the pediatric population. This study sought to determine the minimum patient age on which the combat application tourniquet (CAT) is able to control extremity hemorrhage. A convenience sample of pediatric patients, ages 1 year to 8 years, scheduled for elective orthopedic surgery at an academic hospital, were eligible for enrollment. Subject age, weight, height, blood pressure, and arm and leg circumferences were obtained. Once under general anesthesia, the pulse of an upper and a lower limb were obtained by Doppler, a CAT was then placed at the most proximal practical location of the limb until the corresponding pulse was either no longer obtainable by Doppler or until the tourniquet was as tight as its design allows. The tourniquet was removed after 30 seconds of arterial occlusion. Thirteen children, ages 2 years to 7 years were enrolled. Weights ranged from 12.8 kg to 23.9 kg, with a mean of 16.7 kg. Leg circumferences were 24.5 cm to 34.5 cm, with a mean of 27.9 cm and arm circumferences were 13 cm to 24 cm, with a mean of 16.3 cm. Subject heights were 87 cm to 122 cm, with a mean of 103.4 cm. Twenty-four total extremities were tested, 11 arms and 13 legs. Arterial occlusion was obtained on 100% of limbs tested (95% confidence interval, 85.8-100%). This study is similar to previous adult tourniquet efficacy studies in design, size and outcomes. It is the first to show successful arterial occlusion on preschool-aged children with a commercial tourniquet in a controlled setting. The results suggest that the CAT can be used in school-aged children with severe extremity hemorrhage with a high likelihood of success. Therapeutic, level II.

Evaluating tourniquet use in Swedish prehospital care for civilian extremity trauma

PurposeThe use of tourniquet (TQ) is today a well-documented and lifesaving adjunct to control bleeding from extremity trauma in the military setting. Since August 2015, the ambulance services in Stockholm, Sweden are equipped with TQs. The implementation and potential complications related to TQ use have so far not been evaluated. The primary aim of this study was to evaluate the prehospital use of TQ for haemorrhage control in extremity trauma. Possible complications following the use of TQ were analysed.MethodsA retrospective, descriptive cohort study of extremity haemorrhage for all patients (n = 56) with a documented prehospital use of TQ admitted to the trauma centre at Karolinska University Hospital from 1st August 2015 to 31st December 2017 was conducted. Data regarding TQ use including indication, duration, bleeding volume, complications and definitive injury were analysed.ResultsOut of 63 placements of TQ in 56 patients, TQ stopped the bleeding effectively in 98.2% of the cases and the TQ time varied from 15 to 100 min. The overall complication rate was 30.1%; however, complications possibly related to TQ use were 3.6%. In 16 (28.6%) cases, the TQ were used for a non-life-threating haemorrhage which may have been stopped with direct pressure only.ConclusionThis study shows TQs to be an effective but overused tool in haemorrhage control. The use of TQ was not associated with any severe complications, implying the safety and effectiveness of the device in the civilian setting if TQ time is kept under 100 min.

Early outcomes following trauma related to sex: A matched analysis of military service members in the department of defense trauma registry.

Several studies have identified sex as a factor influencing early outcomes after trauma. With the increased representation of women in combat roles, there is a need for improved understanding of the pathophysiology of traumatic injury in women. The purpose of this study was to define sex-based differences in early combat trauma outcomes amongst military service members. A retrospective review of the Department of Defense Trauma Registry between 2008 and 2016 was performed. A 2:1 case control match was performed to match for Injury Severity Score, mechanism of injury, and age. The primary outcome of the study was mortality. A total of 4,625 patients were included in the study, 2.2% of whom were women. Women were less significantly injured than men (Injury Severity Score, 7.7 vs. 11, p = 0.003) and more likely to sustain blunt trauma (81% vs. 62.5%, p = 0.01). After case-control matching, 202 men and 101 women were evaluated. There was no statistical difference in the primary outcome of mortality. There was no statistical difference in Glasgow Coma Scale score, crystalloid or colloid administration, Packed Red Blood Cells (PRBC), platelet, cryoprecipitate, or plasma usage between men and women. Contrary to the civilian trauma literature, our study demonstrated no significant difference in early mortality between male and female combat casualties in a matched cohort. This finding may represent a difference in injury patterns, resuscitation practices, or lifesaving interventions in a deployed setting as compared with civilian setting. As the proportion of women involved in combat operations continues to increase, prospective studies should be performed to better define injury patterns, as well as early and late outcomes related to military trauma in the female population. Retrospective, Level IV.

Fresh frozen plasma attenuates lung injury in a novel model of prolonged hypotensive resuscitation.

Hemorrhagic shock remains a leading cause of early death among severely injured in both civilian and military settings. As future military operations will require strategies allowing prolonged field care of the injured, we sought to develop an in vivo model of prolonged hypotensive resuscitation (PHR) and to evaluate the role of plasma-based resuscitation in this model. We hypothesized that resuscitation with fresh frozen plasma (FFP) would mitigate lung injury when compared with Hextend in a rodent model of PHR. Mice underwent laparotomy and hemorrhagic shock (mean arterial blood pressure, 35 ± 5 mm Hg × 90 minutes) followed by PHR with either FFP or Hextend to maintain a mean arterial blood pressure of 55 mm Hg to 60 mm Hg for 6 hours. Sham animals underwent cannulation only. At the end of 6 hours, animals were euthanized, and lung tissue harvested for measurement of histopathologic injury, inflammation and permeability using hematoxylin and eosin staining, myeloperoxidase immunofluorescence staining and Evans Blue dye. Pulmonary syndecan-1 immunostaining was assessed as an indicator of endothelial cell integrity. All animals in the FFP, Hextend, and sham groups survived to the end of resuscitation. Resuscitation with FFP mitigated lung histopathologic injury compared with Hextend (histologic injury score of 4.38 ± 2.07 vs. 7.5 ± 0.93, scale of 0-9, p = 0.002) and was comparable to shams (histologic injury score of 4.0 ± 1.93, scale of 0-9, p = 0.99). Fresh frozen plasma also reduced lung inflammation (0.116 ± 0.044 vs. 0.308 ± 0.054 relative fluorescence of myeloperoxidase, p = 0.002) and restored pulmonary syndecan-1 (0.514 ± 0.061 vs. 0.059 ± 0.021, relative syndecan-1 fluorescence, p < 0.001) when compared with Hextend. Consistently, FFP mitigated lung hyperpermeability compared with Hextend (7.30 ± 1.34 μg vs. 14.91 ± 5.55 μg Evans blue/100 mg lung tissue, p = 0.005). We have presented a novel model of PHR of military relevance to the prolonged field care environment. In this model, FFP maintains its pulmonary protective effects using a PHR strategy compared with Hextend, which supports the need for further development and implementation of plasma-based resuscitation in the forward environment. Basic science.

Couples in arms: Marital distress, psychopathology, and suicidal ideation in active-duty Army personnel.

Although distress in intimate relationships such as marriage is positively associated with psychiatric symptoms and disorders and suicidal ideation in probability samples of the civilian population in the United States, relatively little is known regarding these associations in probability samples of active-duty military personnel. The present study evaluated the association between marital distress and past-30-day prevalence of psychiatric disorders (i.e., mood, anxiety, and substance use disorders) and suicidal ideation in a sample of 8,669 married active-duty soldiers in the U.S. Army who participated in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Results indicated that marital distress was significantly and positively associated with past-30-day prevalence of major depressive disorder, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and substance use disorder, as well as past-30-day prevalence of suicidal ideation. These associations were incremental to shared associations with demographics and co-occurring psychiatric disorders. The findings support continued research on the association between relationship distress and psychopathology in active-duty service personnel, and suggest the potential utility of adapting existing, evidence-based couple interventions for the prevention and treatment of psychopathology or relationship distress, currently in use in veteran and civilian settings, for use with active-duty military personnel and their partners. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Are shots or squats utilized more often in the 4 years prior to knee replacement surgery?

Purpose: Exercise therapy is strongly recommended as a core treatment for knee osteoarthritis, though recent studies show an increase in utilization of medications including opioids over the past 10 years in the general population. The recommendation for corticosteroid injections is conditional or neutral in most guidelines, but their use is common in clinical practice. Some clinicians advocate the use of the latter immediately prior to exercise in order to improve exercise tolerance. Little is known about utilization of either of these interventions in the Military Health System for knee osteoarthritis. The purpose of this study was to compare utilization rates, to include order and timing, of two common interventions, corticosteroid injection and exercise therapy, delivered 4 years prior to knee replacement surgery. We also examined the relationship between order and timing of each intervention with the fill of an opioid prescription. Methods: We identified all eligible TRICARE beneficiaries that underwent a knee replacement surgical procedure in either a military or civilian hospital, where TRICARE was the payer, for a 3-year period from 1 January 2016 through 31 December 2018. We used the Military Health System Data Repository which is a single-payer data repository capturing all medical care at the person-level, whether it occurs in a military or civilian hospital all around the world. We identified all persons with a current procedural terminology (CPT) code for a knee replacement surgical procedure. We also abstracted all CPT codes that reflected CSI and therapeutic exercise. We ensured that these procedure codes were present with knee-related International Classification of Disease (ICD) 9th and 10th revision codes. We also utilized the Pharmacy Data Transaction Service (PDTS) with MDR to identify all opioid prescription fills using the American Hospital Formulary Service therapeutic class codes 280808 and 280812. We identified all healthcare utilization in any setting (military or civilian clinic) for the full 4-year period prior to the knee replacement procedure (1 January 2013 through 30 December 2018). We reported means, medians, and frequency counts for each variable, and chi-square with 95% confidence intervals for odds ratio calculations. Results: Out of 54,422 unique persons that underwent a total knee replacement surgery during the surveillance period, 16,999 (31.2%) received at least 1 CSI (mean [SD] = 4.6 [4.5]), while 9668 (17.8%) received at least 1 ET session (mean [SD] = 10.0 [13.4]). Only 7379 had both CSI and ET (13.6%), but in the majority of cases (72.5%) there was more than 60 days between the CSI and the ET session. The first CSI occurred a mean of 729 days (2 years) before surgery, whereas the first ET session occurred a mean of 598 days (1.6 years) before surgery. In patients that received both CSI and ET, receiving a CSI before receiving ET was associated with higher odds of also filling at least 1 opioid prescription (OR = 1.46; 95CI 1.32 to 1.61). The results were not different based on whether care occurred in a military or civilian hospital setting. Conclusions: In this cohort across a large health system, CSI was utilized as an intervention at a rate almost double that of ET for individuals with knee osteoarthritis prior to joint replacement. When patients did receive both interventions, 60.2% of the time the CSI was administered 60 or more days before the ET, perhaps outside the window of optimal relief from the injection. These Results challenge claims of guideline-adherent care occurring within the Military Health System. Future research is necessary to better understand clinical decision-making that is guiding the use of these interventions within this health system.

Prehospital Mortality Due to Hemorrhagic Shock Remains High and Unchanged: A Summary of Current Civilian EMS Practices and New Military Changes.

Mortality secondary to trauma-related hemorrhagic shock has not improved for several decades. Underlying the stall in progress is the conundrum of effective prehospital interventions for hemorrhage control. As we know, neither pressing hard on the gas nor "stay and play" has changed mortality over the last 20 years. For this reason, when dealing with effective changes that will improve severe hemorrhage mortality outcomes, there is a need for the creation of a hybrid prehospital model. Improvements in mortality outcomes for patients with severe hemorrhage based on evidence for common civilian prehospital procedures such as in-field intubation and immediate fluid resuscitation with crystalloid solution are weak at best. The use of tourniquets, once considered too risky to use, however, has risen dramatically in large part due to success seen during their use in the military. Their use in the civilian setting shows promising results. Recently updated military Advanced Resuscitative Care guidelines propose the use of prehospital whole blood transfusion as well as in-field use of Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta. Several case studies from Europe suggest these strategies are feasible for use in the civilian population, but could they be implemented in the US?

Predictors of hemodynamic decompensation in progressive hypovolemia: Compensatory reserve versus heart rate variability.

Hemorrhage remains the leading cause of death following traumatic injury in both civilian and military settings. Heart rate variability (HRV) and heart rate complexity (HRC) have been proposed as potential "new vital signs" for monitoring trauma patients; however, the added benefit of HRV or HRC for decision support remains unclear. Another new paradigm, the compensatory reserve measurement (CRM), represents the integration of all cardiopulmonary mechanisms responsible for compensation during relative blood loss and was developed to identify current physiologic status by estimating the progression toward hemodynamic decompensation. In the present study, we hypothesized that CRM would provide greater sensitivity and specificity to detect progressive reductions in central circulating blood volume and onset of decompensation as compared with measurements of HRV and HRC. Continuous, noninvasive measurements of compensatory reserve and electrocardiogram signals were made on 101 healthy volunteers during lower-body negative pressure (LBNP) to the point of decompensation. Measures of HRV and HRC were taken from electrocardiogram signal data. Compensatory reserve measurement demonstrated a superior sensitivity and specificity (receiver operator characteristic area under the curve [ROC AUC] = 0.93) compared with all HRV measures (ROC AUC ≤ 0.84) and all HRC measures (ROC AUC ≤ 0.86). Sensitivity and specificity values at the ROC optimal thresholds were greater for CRM (sensitivity = 0.84; specificity = 0.84) than HRV (sensitivity, ≤0.78; specificity, ≤0.77), and HRC (sensitivity, ≤0.79; specificity, ≤0.77). With standardized values across all levels of LBNP, CRM had a steeper decline, less variability, and explained a greater proportion of the variation in the data than both HRV and HRC during progressive hypovolemia. These findings add to the growing body of literature describing the advantages of CRM for detecting reductions in central blood volume. Most importantly, these results provide further support for the potential use of CRM in the triage and monitoring of patients at highest risk for the onset of shock following blood loss.

Applying trauma systems concepts to humanitarian battlefield care: a qualitative analysis of the Mosul trauma pathway

BackgroundTrauma systems have been shown to save lives in military and civilian settings, but their use by humanitarians in conflict settings has been more limited. During the Battle of Mosul (October 2016–July 2017), trauma care for injured civilians was provided through a novel approach in which humanitarian actors were organized into a trauma pathway involving echelons of care, a key component of military trauma systems. A better understanding of this approach may help inform trauma care delivery in future humanitarian responses in conflicts.MethodologyA qualitative study design was used to examine the Mosul civilian trauma response. From August–December 2017, in-depth semi-structured interviews were conducted with stakeholders (n = 54) representing nearly two dozen organizations that directly participated in or had first-hand knowledge of the response. Source document reviews were also conducted. Responses were analyzed in accordance with a published framework on civilian battlefield trauma systems, focusing on whether the response functioned as an integrated trauma system. Opportunities for improvement were identified.ResultsThe Mosul civilian trauma pathway was implemented as a chain of care for civilian casualties with three successive echelons (trauma stabilization points, field hospitals, and referral hospitals). Coordinated by the World Health Organization, it comprised a variety of actors, including non-governmental organizations, civilian institutions, and at least one private medical company. Stakeholders generally felt that this approach improved access to trauma care for civilians injured near the frontlines compared to what would have been available. Several trauma systems elements such as transportation, data collection, field coordination, and post-operative rehabilitative care might have been further developed to support a more integrated system.ConclusionsThe Mosul trauma pathway evolved to address critical gaps in trauma care during the Battle of Mosul. It adapted the concept of echelons of care from western military practice to push humanitarian actors closer to the frontlines and improve access to care for injured civilians. Although efforts were made to incorporate some of the integrative components (e.g. evidence-based pre-hospital care, transportation, and data collection) that have enabled recent achievements by military trauma systems, many of these proved difficult to implement in the Mosul context. Further discussion and research are needed to determine how trauma systems insights can be adapted in future humanitarian responses given resource, logistical, and security constraints, as well as to clarify the responsibilities of various actors.

Cold-stored Whole Blood: A Better Method of Trauma Resuscitation?

In the setting of trauma with hemorrhagic shock, balanced blood product resuscitation requires transfusing a high ratio of plasma and platelets to red blood cells. Multiple units of blood products must be transfused rapidly, each product is separately packaged, and each product has a different volume, preparation method, shelf-life, and availability. Despite limited initial data comparing whole blood (WB) to blood component therapy (BCT), recent military medicine shows both a survival benefit and safety of warm WB transfusion over component therapy. This has sparked a renewed interest in the practice of using cold-stored type-O WB (CWB) for resuscitation of hemorrhagic shock in the civilian setting. While recent studies have demonstrated benefits and safety when comparing type-specific and type-O CWB verses component therapy, they have not evaluated the acute resuscitative period. The purpose of this study was to report the impact of CWB on initial resuscitation.