Expeditionary Medical Encounter Database Research Articles

Demographics and Comorbidities of United States Service Members with Combat-Related Lower Extremity Limb Salvage.

This retrospective study describes the demographics and injury characteristics of a recently identified cohort of US Service members with combat-related lower extremity limb salvage (LS). US Service members with combat trauma were identified from the Expeditionary Medical Encounter Database and Military Health System Data Repository and stratified into primary amputation (PA), LS, and non-threatened limb trauma (NTLT) cohorts based on ICD-9 codes. Disparities in demographic factors and injury characteristics were investigated across cohorts and within the LS cohort based on limb retention outcome. Cohort demographics varied by age but not by sex, branch, or rank. The mechanism of injury and injury characteristics were found to be different between the cohorts, with the LS cohort exhibiting more blast injuries and greater injury burden than their peers with NTLT. A sub-analysis of the LS population revealed more blast injuries and fewer gunshot wounds in those that underwent secondary amputation. Neither demographic factors nor total injury burden varied with limb retention outcome, despite slight disparities in AIS distribution within the LS cohort. In accordance with historic dogma, the LS population presents high injury severity. Demographics and injury characteristics are largely invariant with respect to limb retention outcomes, despite secondary amputation being moderately more prevalent in LS patients with blast-induced injuries. Further study of this population is necessary to better understand the factors that impact the outcomes of LS in the Military Health System.

Combat injury profiles among U.S. military personnel who survived serious wounds in Iraq and Afghanistan: A latent class analysis

BackgroundThe U.S. military conflicts in Iraq and Afghanistan had the most casualties since Vietnam with more than 53,000 wounded in action. Novel injury mechanisms, such as improvised explosive devices, and higher rates of survivability compared with previous wars led to a new pattern of combat injuries. The purpose of the present study was to use latent class analysis (LCA) to identify combat injury profiles among U.S. military personnel who survived serious wounds.MethodsA total of 5,227 combat casualty events with an Injury Severity Score (ISS) of 9 or greater that occurred in Iraq and Afghanistan from December 2002 to July 2019 were identified from the Expeditionary Medical Encounter Database for analysis. The Barell Injury Diagnosis Matrix was used to classify injuries into binary variables by site and type of injury. LCA was employed to identify injury profiles that accounted for co-occurring injuries. Injury profiles were described and compared by demographic, operational, and injury-specific variables.ResultsSeven injury profiles were identified and defined as: (1) open wounds (18.8%), (2) Type 1 traumatic brain injury (TBI)/facial injuries (14.2%), (3) disseminated injuries (6.8%), (4) Type 2 TBI (15.4%), (5) lower extremity injuries (19.8%), (6) burns (7.4%), and (7) chest and/or abdominal injuries (17.7%). Profiles differed by service branch, combat location, year of injury, injury mechanism, combat posture at the time of injury, and ISS.ConclusionLCA identified seven distinct and interpretable injury profiles among U.S. military personnel who survived serious combat injuries in Iraq or Afghanistan. These findings may be of interest to military medical planners as resource needs are evaluated and projected for future conflicts, and medical professionals involved in the rehabilitation of wounded service members.

Burn injuries in US service members: 2001–2018

IntroductionBurns are an important cause of battlefield injury, accounting for 5–20% of the combat injury burden. To date, no report has examined the full range of burns, from mild to severe, resulting from post-9/11 conflicts. The present study leverages the Expeditionary Medical Encounter Database (EMED), a Navy-maintained health database describing all service member medical encounters occurring during deployment, to capture, quantify and characterize burn-injured service members and the injuries they sustained while deployed in support of post-9/11 operations. MethodsThe EMED was queried for all surviving service members with at least one burn injury, identified using injury-specific Abbreviated Injury Scale codes. Demographic and additional injury information were also obtained from the EMED. ResultsFrom 2001 through 2018, 2507 deployed service members sustained 5551 burns. Blasts accounted for 82% of injuries, largely attributed to the use of improvised explosive devices. Concurrent injury was common, with 30% sustaining a traumatic brain injury and 10% sustaining inhalation injury. Most burns were small, with 92% involving< 20% TBSA; 85% of burns involved< 10% TBSA. The head and the hands were the most commonly affected areas, accounting for 48% of all burns, with 80% of service members sustaining at least one burn to these areas. ConclusionThe majority of burns tend to be small in size, with the head and hands most commonly affected. As these areas are often left uncovered by the uniform, prevention measures, particularly improvement in and increased usage of personal protective gear, may help reduce these injuries and their consequences.

Postinjury Care and Complications Among U.S. Military Women With Combat-Related Major Limb Traumatic Amputation.

U.S. servicewomen may be at greater risk of injury in future conflicts as they integrate into combat occupations. More than 1,000 servicewomen were wounded during military conflicts in Iraq and Afghanistan. Some women sustained traumatic amputations, and research on their postinjury health is needed. To describe acute care, complications, and health care utilization among servicewomen with combat-related amputations, comparing them with injured men. In this retrospective matched-pairs study, women were identified from the Expeditionary Medical Encounter Database between 2003 and 2012 and matched with men on amputation injuries, injury severity, and age. Differences were assessed with nonparametric tests for paired data. Of 20 women identified for analysis, 13 received tourniquets, three were administered procoagulants, and six had massive transfusions. Women averaged 3.4 (SD = 1.6) postinjury complications, and the most frequent were heterotopic ossification (n = 17), posthemorrhagic anemias (n = 13), and bacterial wound infections (n = 10). Acute care and complications were similar among men. Women averaged more acute care days (M = 49.8, SD = 30.6) than men (M = 46.1, SD = 27.4) but fewer intensive care unit days (women: M = 2.6, SD = 4.0; men: M = 4.4, SD = 8.3). No statistical differences were observed. Postinjury care among servicewomen with combat-related amputations was comparable with servicemen, and complications were common. This information can aid providers and nursing staff in the management of these injuries.

Is Prehospital Ketamine Associated With a Change in the Prognosis of PTSD?

Ketamine is an alternative to opioids for prehospital analgesia following serious combat injury. Limited research has examined prehospital ketamine use, associated injuries including traumatic brain injury (TBI) and PTSD outcomes following serious combat injury. We randomly selected 398 U.S. service members from the Expeditionary Medical Encounter Database who sustained serious combat injuries in Iraq and Afghanistan, 2010-2013. Of these 398 patients, 213 individuals had charted prehospital medications. Clinicians reviewed casualty records to identify injuries and all medications administered. Outcomes were PTSD diagnoses during the first year and during the first 2 years postinjury extracted from military health databases. We compared PTSD outcomes for patients treated with either (a) prehospital ketamine (with or without opioids) or (b) prehospital opioids (without ketamine). Fewer patients received prehospital ketamine (26%, 56 of 213) than only prehospital opioids (69%, 146 of 213) (5%, 11 of 213 received neither ketamine nor opioids). The ketamine group averaged significantly more moderate-to-serious injuries, particularly lower limb amputations and open wounds, compared with the opioid group (Ps < .05). Multivariable regressions showed a significant interaction between prehospital ketamine (versus opioids) and TBI on first-year PTSD (P = .027). In subsequent comparisons, the prehospital ketamine group had significantly lower odds of first-year PTSD (OR = 0.08, 95% CI [0.01, 0.71], P = .023) versus prehospital opioids only among patients who did not sustain TBI. We also report results from separate analyses of PTSD outcomes among patients treated with different prehospital opioids only (without ketamine), either morphine or fentanyl. The present results showed that patients treated with prehospital ketamine had significantly lower odds of PTSD during the first year postinjury only among patients who did not sustain TBI. These findings can inform combat casualty care guidelines for use of prehospital ketamine and opioid analgesics following serious combat injury.

Prospective Evaluation of Health Outcomes in a Nationwide Sample of Aeromedical Evacuation Casualties: Methods From a Pilot Study

Although retrospective analyses have found that combat-injured service members are at high risk for mental and physical health outcomes following injury, relatively little is known about the long-term health of injured service members. To better understand long-term health outcomes after combat injury, a large, prospective observational cohort collecting both subjective and objective health data is needed. Given that a study of this nature would be costly and face many logistical challenges, we first conducted a pilot to assess the feasibility of a larger, definitive study. We ran a prospective, observational pilot study of 119 combat-injured service members and veterans who completed (1) at least one set of laboratory measurements (blood and urine sample collection and vitals measurements) at Clinical Laboratory Improvement Amendment of 1988 compliant laboratory locations and (2) at least one online assessment for the Wounded Warrior Recovery Project (WWRP), a 15-year examination of patient-reported outcomes among service members injured on combat deployment. We recruited the pilot study cohort from WWRP participants who met eligibility criteria and indicated interest in additional research opportunities. We collected laboratory values and patient-reported outcomes at baseline and again 1 year later, and obtained demographic, injury, and military service data from the Expeditionary Medical Encounter Database. The David Grant USAF Medical Center Institution Review Board (IRB) and the Naval Health Research Center IRB reviewed and approved the study protocols. During recruitment for the pilot study, 624 study candidates were identified from WWRP. Of the 397 candidates we contacted about the pilot study, 179 (45.1%) enrolled and 119 (66.4%) of those who enrolled completed the first year of participation. The second study year was suspended due to the coronavirus disease-2019 pandemic. At the time of suspension, 72 (60.5%) participants completed follow-up laboratory appointments, and 111 (93.3%) completed second-year WWRP assessments. Participants in the pilot study were predominately male (95.0%) and non-Hispanic White (55.5%), with a median (interquartile range) age of 38.3 (34.1-45.4) years. Collection of patient-reported outcomes and laboratory samples in a geographically dispersed cohort of combat-injured service members is possible. While significant challenges exist, our pilot study results indicate that a larger, longitudinal, cohort study is feasible.

A Focus on Non-Amputation Combat Extremity Injury: 2001-2018.

Extremity injuries have comprised the majority of battlefield injuries in modern U.S. conflicts since World War II. Most reports have focused on serious injuries only and, to date, no reports have described the full extent of combat extremity injuries, from mild to severe, resulting from post-9/11 conflicts. This study aims to identify and characterize the full spectrum of non-amputation combat-related extremity injury and extend the findings of previous reports. The Expeditionary Medical Encounter Database was queried for all extremity injured service members (SMs) deployed in support of post-9/11 conflicts through July 2018. Only injuries incurred during combat operations were included in this report. Major amputations were excluded as well as SMs killed in action or who died of wounds. Extremity injuries were categorized by body region, nature of injury, and severity. Demographics and injury event characteristics are also presented. A total of 17,629 SMs sustained 42,740 extremity injuries during 18,004 separate injury events. The highest number of SMs were injured in 2004 (n = 3,553), 2007 (n = 2,244), and 2011 (n = 2,023). Injured SMs were mostly young (78% under 30 years), male (97%), junior- to mid-level enlisted (89%), in the Army (69%) or Marine Corps (28%), active duty (84%), serving as infantry and gun crew (59%), and injured in support of Operation Iraqi Freedom (60%). Blast weaponry was responsible for 75% of extremity injuries. Injuries were similarly distributed between the lower (52%) and upper (48%) extremities. The most common sites of lower extremity injury were the lower leg/ankle complex (40%) and thigh (26%). The most common upper extremities sites were the shoulder and upper arms (37%), and the hand, wrist, and fingers (33%). Nearly half (48%) of all extremity injuries were open wounds (48%), followed by fractures (20%) and contusions/superficial injuries (16%). SMs sustained an average of 2.4 extremity injuries per event and 56% of injuries were considered mild, with a median Injury Severity Score (ISS) of 3. This study is the first publication to capture, review, and characterize the full range, from mild to severe, of non-amputation combat-related extremity injuries resulting from post-9/11 conflicts. The high prevalence of extremity injury, particularly in such a young population, and associated short- and long-term health outcomes, will impact military health care systems for decades to come.

Laryngotracheal and pharyngoesophageal traumatic injuries from US military operations in Iraq and Afghanistan, 2003–2017

IntroductionLaryngotracheal and pharyngo-oesophageal trauma present military providers with especially difficult, life-threatening challenges. Although effective treatment strategies are crucial, there is no clear consensus. This study of combat injuries from Iraq...

Symptom profiles following combat injury and long-term quality of life: a latent class analysis.

The purpose of this study was to identify symptom profiles among U.S. military personnel within 1year after combat injury and assess the relationship between the symptom profiles and long-term quality of life (QoL). The study sample consisted of 885 military personnel from the Expeditionary Medical Encounter Database who completed (1) a Post-Deployment Health Assessment (PDHA) within 1year following combat injury in Iraq or Afghanistan, and (2) a survey for the Wounded Warrior Recovery Project (WWRP), a longitudinal study tracking patient-reported outcomes (e.g., QoL) in injured military personnel. Fifteen self-reported symptoms from the PDHA were assessed using latent class analysis to develop symptom profiles. Multivariable linear regression assessed the predictive effect of symptom profiles on QoL using the physical (PCS) and mental (MCS) component summary scores from the 36-Item Short Form Survey included in the WWRP. Time between PDHA and WWRP survey ranged from 4.3 to 10.5years (M = 6.6, SD = 1.3). Five distinct symptom profiles were identified: low morbidity (50.4%), multimorbidity (15.6%), musculoskeletal (14.0%), psycho-cognitive (11.1%), and auditory (8.9%). Relative to low morbidity, the multimorbidity (β = - 5.45, p < 0.001) and musculoskeletal (β = - 4.23, p < 0.001) profiles were associated with lower PCS, while the multimorbidity (β = - 4.25, p = 0.002) and psycho-cognitive (β = - 3.02, p = 0.042) profiles were associated with lower MCS. Multimorbidity, musculoskeletal, and psycho-cognitive symptom profiles were the strongest predictors of lower QoL. These profiles can be employed during screening to identify at-risk service members and assist with long-term clinical planning, while factoring in patient-specific impairments and preferences.

Serious Inhalation Injuries From Military Operations in Afghanistan, Iraq, and Syria.

To characterize serious inhalation injuries seen during recent military operations, and assess whether bronchoscopic severity findings were associated with clinical presentation and outcomes. Service members who suffered inhalation injuries while deployed to Iraq, Afghanistan, or Syria from 2001-2018 were identified using ICD-9 and 10 codes from the Expeditionary Medical Encounter Database (EMED), which is abstracted from patient records in forward-deployed medical facilities. Further information including demographics, mechanism of injury, mortality, total burn surface area (TBSA), degree of facial burn, total Injury Severity Score (ISS), and first post-injury bronchoscopy notes were collected. Patients were excluded with ISS less than 16 or without sufficient details regarding bronchoscopy. Injuries were grouped based on bronchoscopic Abbreviated Injury Scores (AIS) into low-grade (AIS of 1), moderate-grade (AIS of 2), or high-grade (AIS of 3 or 4). 91 patients met inclusion criteria, with no significant differences in age, gender, paygrade, or service branch between degrees of injury. There were no statistical correlations between grade of injury and battle versus non-battle injury, blast versus non-blast mechanism, TBSA, or degree of facial burn. High-grade injuries had significantly higher ISS than low or moderate-grade injuries. After adjusting for ISS, the odds ratio of death was 10.4 (95% CI 1.47 to 74.53) for those with high-grade and 3.7 (95% CI 0.45 to 32.30) for those with moderate-grade compared to low-grade injuries. In this cohort of deployed military members with inhalation injuries, initial bronchoscopic severity findings are strongly associated with mortality even after adjusting for ISS. The AIS may be an important prognostic tool in all of those with serious inhalation injuries.

Incisional hernia incidence following laparotomy for combat trauma: Investigating 15 years of US war surgery.

While the incidence of incisional hernia (IH) following elective laparotomy has been well described, incidence following emergent laparotomy for combat trauma has been much less studied. This retrospective cohort investigates the latter to better describe the burden IH represents for the injured warfighter. Data were obtained from the Expeditionary Medical Encounter Database for service members who survived a combat-related injury between January 2002 and December 2016 and underwent abdominal surgery in the first 30 days after injury. Incisional hernia diagnosis at least 30 days after injury was determined from inpatient and outpatient records in the Military Health System's Medical Data Repository.Means and SDs were reported for age and continuous Injury Severity Score, and frequency and percentages were reported for sex, branch of service, paygrade, mechanism of injury, Injury Severity Score, and maximum abdominal Abbreviated Injury Scale. Service members with and without a hernia diagnosis were compared using t test for continuous variables and χ or Fisher exact test (depending on cell size) for categorical variables.Multivariate logistic regression models were used to examine relationships between IH diagnosis and the covariates previously mentioned. Data analysis was completed using SAS software version 9.4 (SAS Institute Inc., Cary, NC). Of the 570 laparotomy patients, 109 (19.1%) developed IH. Of these, 58 (53%) were diagnosed within the first year after injury. An additional 21 (19%) were diagnosed within the following year, and 30 (28%) were diagnosed more than 2 years after injury. Presence of gastrointestinal injury, Abbreviated Injury Scale score of 4 and 5, and 5-year increments of age were positively associated with hernia formation. The incidence of postlaparotomy IH in combat trauma is 19.1%, a considerable source of disability for injured warfighters. Further investigation into hernia-preventive closure strategies is warranted. Therapeutic study, level IV.

Outpatient Pharmacy Prescriptions During the First Year Following Serious Combat Injury: A Retrospective Analysis.

Limited research has analyzed the full range of outpatient medication prescription activity following serious combat injury. The objectives of this study were to describe (1) outpatient medication prescriptions and refills during the first 12months after serious combat injury, (2) longitudinal changes in medication prescriptions during the first-year postinjury, and (3) patient characteristics associated with outpatient prescriptions. This was a retrospective analysis of existing health and pharmacy data for a random sample of U.S. service members who sustained serious combat injuries in the Iraq and Afghanistan conflicts, 2010-2013 (n=381). Serious injury was defined by an Injury Severity Score (ISS) of 9 or greater. These patients typically participate in military rehabilitation programs (eg, amputation care) where prescription medications are essential. Data sources were the Expeditionary Medical Encounter Database for injury-specific data, the Pharmacy Data Transaction Service for outpatient medication prescriptions and refills, and the Military Health System Data Repository for diagnostic codes of pain and psychological disorders. Military trauma nurses reviewed casualty records to identify types of injuries. Using the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system, clinicians identified 13 categories of prescription medications (eg, opioid, psychotherapeutic, immunologic) for analysis. Multivariable negative binomial and logistic regression analyses evaluated significant associations between independent variables (eg, blast injury, traumatic brain injury [TBI], ISS, limb amputation, diagnoses of chronic pain, or psychological disorders) and prescription measures (ie, number or category of medication prescriptions). We also describe longitudinal changes in prescription activity postinjury across consecutive quarterly intervals (91days) during the first-year postinjury. During the first-year postinjury, patients averaged 61 outpatient prescriptions, including all initial prescriptions and refills. They averaged eight different categories of medications, primarily opioid, immunologic, gastrointestinal/genitourinary, central nervous system (CNS), nonopioid analgesic, and psychotherapeutic medications (representing 82% of prescriptions) during the first year. Prescription activity generally declined across quarters. There was still substantial prescription activity during the fourth quarter, as 79% of patients had at least one prescription. From 39 to 49% of patients had fourth-quarter prescriptions for opioid, CNS, or psychotherapeutic medications. Longitudinally, we found that 24-34% of patients had an opioid, CNS, or psychotherapeutic prescription during each of the final three quarters. In multivariable analysis, ISS, limb amputation (particularly bilateral amputation), and diagnoses of chronic pain and post-traumatic stress disorder (PTSD) were associated with significantly higher counts of individual and multiple medication prescriptions. TBI was associated with significantly lower numbers of prescriptions for certain medications. This is one of the first studies to provide a systematic analysis of outpatient medication prescriptions following serious combat injury. The results indicate substantial prescription activity from multiple medication categories throughout the first-year postinjury. Diagnoses of chronic pain, PTSD, and limb amputation and ISS were associated with significantly higher counts of prescriptions overall and more prescription medication categories. This study provides initial evidence to better understand medication prescription activity following serious combat injury. The results inform future research on medication prescription practices and planning for rehabilitation.

Occupational Therapy Practice Patterns for Military Service Members With Upper Limb Amputation.

Military Service Members (SMs) with upper limb (UL) amputation have unrestricted access to occupational therapy (OT) services. Identifying OT interventions used based on clinical rationale and patient needs can provide insight toward developing best practice guidelines. The purpose of this retrospective observational study was to identify preferred OT practice patterns for U.S. Military SMs treated in Military Treatment Facilities, who have sustained various levels of deployment-related UL amputation. The study sample was ascertained from the Expeditionary Medical Encounter Database housed at the Naval Health Research Center in San Diego, California. SMs with an immediate (within 24hours of injury) deployment-related unilateral major UL amputation (partial hand and proximal), occurring between January 2001 and December 2014 were identified. SMs with concurrent major lower limb amputation (partial foot and proximal) were excluded. Frequency of OT outpatient visits and units of treatment received were quantified in 3-month increments during the first year after amputation and compared for individuals with above elbow (at or proximal to elbow joint) and below elbow (distal to the elbow joint including partial hand) amputation. This study was approved by the Naval Health Research Center Institutional Review Board. A total of 29,878 encounters occurred during first year after amputation in 148 patients, who had sustained UL loss during the first year after amputation. Active treatments were included in 79.2% of all treatments, followed by manual therapy (13.7%) and modalities (13.5%). A higher number of OT encounters occurred in the above elbow amputation group-the first year of treatment with significantly higher mean number of treatments months 4 to12. A similar pattern in OT encounters was observed in the active therapy category with significantly higher mean number of treatments occurring in above elbow limb loss group in months 10 to 12. Findings of the current study suggest SMs with UL amputation utilize OT services often within the first year after injury and those who have sustained amputation proximal to the elbow received more therapy visits than their below elbow counterparts during months 4 to 12. Prosthetic training, therapeutic activities, and therapeutic exercise can be expected to be the highest used active interventions in the first year following UL amputation. Further research is needed to determine details on types and frequency of therapy utilization and recommended therapy strategies.

Retrospective study of cardiovascular disease risk factors among a cohort of combat veterans with lower limb amputation.

IntroductionPrevious studies have shown that veterans with lower limb amputation have a higher risk for cardiovascular disease (CVD) compared with population-based controls. American veterans who have served in Iraq and Afghanistan with lower limb amputation may be at a similarly higher risk.Patients and methodsThe Navel Health Research Center (NHRC) maintains the Expeditionary Medical Encounter Database (EMED) of military personnel who have sustained combat limb amputation or serious limb injury during the conflicts in Iraq and Afghanistan. Department of Veterans Affairs data from 2003 to April 2015 was used to analyze CVD risk factors in this cohort. Veterans with either unilateral (n=442) or bilateral (n=146) lower limb amputation were compared to those with serious lower limb trauma without amputation (n=184). Multivariate regression was used to measure associations between lower limb amputation and CVD risk factors over an average of 8 years of follow-up. Outcomes included mean arterial pressure (MAP), low-density lipoprotein, high-density lipoprotein (HDL), and serum triglycerides (TG).ResultsCompared with the limb injury group, those with unilateral lower limb amputation had significantly lower HDL (p<0.05) and higher TG (p<0.05). Those with bilateral lower limb amputation had significantly higher MAP (p<0.05), lower HDL (p<0.01), and higher TG (p<0.001). The prevalence of metabolic syndrome, defined as type 2 diabetes or a constellation of blood pressure and lipid changes consistent with metabolic syndrome, was 8.7%, 14.9%, and 21.9% for limb injury, unilateral amputation, and bilateral amputation groups, respectively. Veterans with bilateral lower limb amputation had a 2.25-increased odds ratio (95% confidence interval 1.19–5.05) of type 2 diabetes or blood pressure and lipid changes consistent with metabolic syndrome compared to those with limb injury.ConclusionsResults suggest that veterans with lower limb amputation have a higher risk for metabolic syndrome. Primary care interventions to manage weight, blood pressure, and lipid levels are fundamental in order to reduce cardiac risk in this relatively young cohort.

Clinic Use at the Departments of Defense and Veterans Affairs Following Combat Related Amputations.

Little population-based research has described the transition from Department of Defense (DoD) to Department of Veterans Affairs (VA) healthcare following combat related amputations. The objectives were to describe (1) to what extent patients used either DoD only facilities, both DoD and VA facilities, or VA only facilities during the first 5 years postinjury, (2) which specific clinics were used and (3) clinic use among patients with different levels of amputation (upper versus lower), and among patients with early or late amputation. This was a retrospective analysis of health data extracted from the expeditionary medical encounter database (EMED) and national DoD and VA databases. Patients were 649 US service members who sustained a single major limb amputation following injuries in the Iraq and Afghanistan conflicts, 2001-2008. We compared yearly DoD and VA clinic use by patient groups with different levels of amputation (upper limb: above versus below elbow or lower limb: above versus below knee), different timing of amputation (early: within 90 days postinjury versus late: more than 90 days postinjury), military component (Active Duty versus National Guard/Reserve) and race (White versus Black). For all groups, we calculated the percentage of patients using: (1) DoD only, (2) both DoD and VA or 3) VA only clinics during each of postinjury years 1 through 5. We also calculated the percentage of patients who used specific clinics (e.g., social work, prosthetics, mental health) during each postinjury year. During postinjury year 1, over 98% of patients used DoD only or both DoD and VA clinics. Most individuals (70% to 78%) used both DoD and VA clinics during postinjury year 1. Use of VA only clinics increased gradually between postinjury year 2 (15% to 30% of patient groups) and year 5 (75% to 88%). This gradual transition to use of VA only clinics was seen consistently across patient groups with different anatomical levels or timing of amputation, military component or race. Patients with lower levels of amputation (versus higher levels) and individuals with early amputations (versus late) transitioned earlier to VA only care. Overall, clinic use was high as 91% to 100% of all patient groups used one or more clinics (DoD or VA) during each of the first 5 years. For specific clinics, most patients used DoD facilities related to rehabilitation (physical therapy, prosthetics) or transitional care (social work) particularly during postinjury year 1. Use of most VA clinics studied (social work, primary care, prosthetics, mental health) showed a modest increase primarily after postinjury year 1 and remained stable through postinjury year 5. The results indicated apparent underuse of psychiatric/mental health and prosthetics between postinjury year 1 and 2. The present study indicated a gradual transition from DoD to VA only healthcare which extended across 5 years following combat related amputations. Patients with lower levels of amputation or early amputation generally transitioned earlier to VA only healthcare. These results can inform medical planning to support a timely and clinically effective transition from DoD to VA healthcare.

Risk of post-traumatic knee osteoarthritis after knee injury in military service members.

The aims of the present study were: (a) to identify the incidence of osteoarthritis (OA) after a traumatic knee injury; (b) identify the risk of post-traumatic osteoarthritis (PTOA) based on the type of injury; and (c) identify the time from injury to OA diagnosis. The Expeditionary Medical Encounter Database, containing healthcare utilization for all deployment injuries sustained by military service members, was queried for traumatic knee injuries between 2001 and 2016. Subsequent diagnosis of knee OA was identified, defined as PTOA. Time to knee PTOA diagnosis was determined and logistic regression was used to obtain odds ratios (ORs) (95% confidence interval [CI]) between knee injury type and development of PTOA. A total of 345 (9.57%) of the 3,605 subjects were diagnosed with PTOA. The median time to diagnosis was 4.10years. Four primary diagnoses remained significantly associated with PTOA after adjusting for age and injury severity score: fracture (adjusted OR [aOR]=1.36; 95% CI 1.02, 1.82), sprain (aOR=1.59; 95% CI 1.23, 2.06), dislocation (aOR=3.70; 95% CI 2.09, 6.55) and derangement (aOR=2.38; 95% CI 1.33, 4.28). Subjects were significantly less likely to develop PTOA after a soft-tissue injury (aOR=0.44; 95% CI 0.41, 0.75). A substantial number of individuals with a traumatic knee injury developed early PTOA (9.6%). Certain knee injuries have a greater association with PTOA. Future studies should implement longer surveillance periods and identify other healthcare variables associated with the risk of developing PTOA, to include appropriate and timely interventions.

Association of Specific Lower Extremity Injuries With Delayed Amputation.

Despite medical interventions to preserve viability and functionality of injured limb(s) among combat-injured service members, delayed amputations may occur. The goal of this study was to determine whether specific lower extremity (LE) injuries were associated with delayed amputations. The Expeditionary Medical Encounter Database was queried for combat-related LE injuries between 2003 and 2015. The Abbreviated Injury Scale (AIS) was used to categorize LE injuries by severity. Injury episodes with a maximum LE AIS of 1 or amputation on the day of injury were excluded. The final sample included 2,996 service members with at least one LE injury with an AIS ≥2. The frequencies of specific LE fractures and nerve and vessel injuries were determined. Logistic regression with paired independent variables was performed to examine the impact of multiple LE injuries on the odds of delayed amputation. Delayed LE amputation was identified in 308 (10.3%) service members in the sample. The delayed and no amputation groups did not differ in age and service branch. The majority of injury episodes were blast-related and with an Injury Severity Score ≥9. The most frequent fractures were tibia (34.4%) and fibula (29.3%), but the highest rates of delayed amputation were in those with navicular (36.2%), talus (30.0%), or calcaneus (28.1%) fractures. Odds of amputation were highest among service members with the calcaneus fracture and LE nerve injury (odds ratio [OR]: 41.74; 95% confidence interval [CI], 14.70, 118.55; p < 0.001), calcaneal fracture and LE vessel injury (OR: 17.99; 95% CI: 10.53, 30.74; p < 0.001), and calcaneus and tibia fractures (OR: 15.12; 95% CI: 9.54, 23.96; p < 0.001) combinations. Odds of delayed amputation increased substantially with specific injury combinations. These findings may guide clinical decision-making in the acute care period.

Preliminary study of hearing protection and non-impact, blast-induced concussion in US military personnel

ABSTRACTPrimary objective: To examine the relationship between hearing protection and non-impact, blast-induced concussion in US military personnel.Research design: Retrospective cohort study.Methods and procedures: A total of 501 US service members from the Expeditionary Medical Encounter Database with hearing protection status reported either ‘worn’ or ‘not worn’ were eligible for analysis. Clinical records were reviewed for concussion diagnoses. Univariate and multiple logistic regressions were performed.Main outcomes and results: Overall, 270 (53.9%) service members sustained non-impact, blast-induced concussion and 231 (46.1%) sustained other blast injuries. Only 39.6% (107 of 270) of service members with concussion wore hearing protection at the point of injury compared with 61.0% (141 of 231) of those with other injuries (p < 0.001). After adjusting for covariates, service members wearing hearing protection had significantly lower odds of concussion compared with those not wearing hearing protection (odds ratio = 0.42, 95% confidence interval = 0.29–0.62).Conclusions: To our knowledge, this preliminary study is the first to demonstrate that hearing protection is associated with lower odds of non-impact, blast-induced concussion. The benefits of using hearing protection in terms of force readiness could be significant since many service members wounded in recent conflicts were diagnosed with concussion.

Health-related quality of life among US military personnel injured in combat: findings from the Wounded Warrior Recovery Project.

Little is known about the long-term, health-related quality of life (HRQOL) of those wounded in combat during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. The present study described the overall HRQOL for a large group of US service members experiencing mild-to-severe combat-related injuries, and assessed the unique contribution of demographics, service- and injury-related characteristics, and mental health factors on long-term HRQOL. The Wounded Warrior Recovery Project examines patient-reported outcomes in a cohort of US military personnel wounded in combat. Participants were identified from the Expeditionary Medical Encounter Database, a US Navy-maintained deployment health database, and invited to complete a web-based survey. At the time of this study, 3245 service members consented and completed the survey. Hierarchical linear regression analyses were conducted to assess the unique contribution of each set of antecedents on HRQOL scores. HRQOL was uniquely associated with a number of demographics, and service- and injury-related characteristics. Nevertheless, screening positive for posttraumatic stress disorder (B = - .09; P < .001), depression (B = - .10; P < .001), or both as a set (B = - .19; P < .001) were the strongest predictors of lower long-term HRQOL. Postinjury HRQOL among service members wounded in combat was associated with service and injury experience, and demographic factors, but was most strongly linked with current mental health status. These findings underscore the significance of mental health issues long after injury. Further, findings reinforce that long-term mental health screening, services, and treatment are needed for those injured in combat.

Tympanoplasty following Blast Injury.

Objectives To assess outcomes following tympanoplasty for blast-induced tympanic membrane perforations in a military population. Study Design Case series with chart review. Setting Tertiary care medical centers. Subjects and Methods Military personnel (N = 254) undergoing tympanoplasty for blast-related tympanic membrane perforations sustained between April 2005 and July 2014 were identified from the Expeditionary Medical Encounter Database. Descriptive statistics were obtained regarding demographics, primary and revision surgery success rates, hearing status pre- and postsurgery, and frequency of ossicular reconstruction. Rates of successful perforation closure were assessed against perforation size and character (central vs marginal) and time to surgery. Rates and types of complications were additionally explored. Results There were a total of 352 operations among 254 subjects, with an 82.1% rate of successful closure following primary surgery. For successful primary tympanoplasty, the mean improvement in pure tone average was 11.7 ± 12.1 dB. Ossiculoplasty was performed in 9.1% (32 of 352) of cases. There was no significant relationship between successful perforation closure and perforation size, perforation character, or time between injury and surgery. Cholesteatoma complicated 4.3% (15 of 352) of cases. A significant relationship was identified between risk of cholesteatoma development and increasing perforation size and marginal perforations. Conclusion Tympanoplasty success rates for blast-induced tympanic membrane perforations are lower than for other common injury mechanisms. Due to appreciable rates of postoperative cholesteatoma development, close clinical surveillance is recommended.