Operation Enduring Freedom Research Articles

Development and evaluation of an 1-day Acceptance and Commitment Therapy workshop for Veterans with comorbid chronic pain, TBI, and psychological distress: Outcomes from a pilot study

ObjectivesTo 1) develop and refine a 1-day trans-diagnostic psychotherapeutic “ACT on Life” workshop tailored for Veterans with mild traumatic brain injury, stress-based psychopathology, and pain; 2) examine the feasibility, acceptability, and preliminary effects of this intervention. SettingA Veterans Health Administration medical center. ParticipantsVeterans returning from Operations Iraqi Freedom, Enduring Freedom, and New Dawn with mild TBI, stress-based psychopathology, and chronic pain. DesignPhase I involved development of the intervention by experts and subsequent refinement based on Veteran feedback (N = 11). Phase II was a pilot randomized controlled trial comparing the effects of the revised intervention (N = 20) to treatment as usual (TAU; N = 12). Main measuresFor phase I, qualitative feedback at 2 weeks and 3 months post-workshop was obtained from Veterans. For phase II, quantitative measures included the PTSD Checklist, Depression Anxiety and Stress Scale, Military-to-Civilian Questionnaire, WHO-Disability Assessment Schedule, Brief Pain Inventory, Acceptance and Action Questionnaire. ResultsVeterans found the workshop acceptable, innovative and useful. Quantitative data from phase II suggested that participants in the ACT group, relative to TAU, showed improvement in psychiatric symptoms, functioning, and reintegration 3 months post-workshop. Unexpectedly, pain interference was lower in the TAU group at follow-up. ConclusionsPreliminary results support the feasibility, acceptability, and promising effects on psychological distress and community reintegration of this 1-day, transdiagnostic workshop for Veterans. Future research examining the effectiveness of this workshop with a larger sample size is necessary.

How Much Is Enough? Trauma Recall and the Exposure Therapy Process.

Theoretical models of posttraumatic stress disorder (PTSD) as well as exposure therapy (EXP) methodology suggest that trauma recall is crucial to altering the conditioned fear response associated with PTSD. However, it is unclear whether limited recall of the trauma event attenuates treatment outcomes. This study examined whether the extent of difficulty recalling aspects of a traumatic event affected fear activation, habituation, number of sessions, session length, and diagnostic outcomes in 166 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans. Extent of trauma recall difficulty neither attenuated veterans' ability to achieve fear activation and habituation nor affected treatment outcomes. Findings suggest that even veterans who reported greater difficulty recalling their trauma event can engage successfully and benefit from EXP. This research is the first to examine trauma event recall in the context of the EXP process and contributes to the current body of literature that aims to address the question: "For whom do treatments work?"

Military Environmental Exposure Concerns, Posttraumatic Stress Disorder, and Somatic Symptoms: Their Interrelation Among Treatment-Seeking Veterans.

Research suggests military environmental exposure concerns are associated with negative health outcomes. This study investigated the relationship among exposure concerns, Posttraumatic Stress Disorder (PTSD), and somatic symptoms to enhance post-deployment health care programs for veterans. We analyzed intake health data from a heterogeneous sample of predominantly Operation Desert Storm/Shield and Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) veterans (N = 247). Individual exposure concerns and somatic symptoms were associated with higher PTSD symptom severity. Regression modeling demonstrated total exposure concerns and PTSD symptom severity linked with total somatic symptom severity. Mediation modeling revealed PTSD symptom severity to partially explain the relation between exposure concerns and somatic symptoms. These findings illustrate the need for integrative treatment approaches incorporating physiological and exposure-related concerns associated with PTSD among veterans.

Orbital Fractures and Associated Ocular Injuries in Operation Iraqi Freedom and Operation Enduring Freedom Referred to a Tertiary Care Military Hospital and the Effect on Final Visual Acuity.

To update the incidence of orbital fractures in U.S. Soldiers admitted to the former Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any U.S. Soldier or Department of Defense civilian with an orbital fracture injured in Operation Iraqi Freedom/Operation Enduring Freedom. Primary outcome measures were final visual acuity and the effect of orbital fracture, number of fractures, and anatomic location of fracture on final visual acuity. Eight-hundred ninety eye injuries occurred in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. Orbital fractures occurred in 304 eyes (34.2%). A single wall was fractured in 140 eyes (46.05%), 2 in 99 (32.6%) eyes, 3 in 31 (10.2%), 4 in 28 (9.2%), and unknown in 6 (1.9%) eyes. Roof fractures were found in 74 (24.34%), medial wall in 135 (44.41%), lateral wall in 109 (35.9%), and floor fractures in 217 (71.4%). Final visual acuity was analyzed and 140 (46.05%) eyes had greater than 20/40 vision, 17 (5.59%) were 20/50 to 20/200, 26 (8.5%) were count fingers to light perception, and 95 (31.3%) were no light perception. In logistic regression analysis, roof (p = 0.001), medial (p = 0.009), and lateral fractures (p = 0.016) were significantly associated with final visual acuity less than 20/200, while floor fractures were not (p = 0.874). Orbital fracture and all fracture subtypes were significantly associated with traumatic brain injury, retrobulbar hematoma, optic nerve injury, but not for vitreous hemorrhage, commotio, hyphema, and choroidal rupture. Fracture repair was noted in 45 (14.8%). Orbital fractures occurred in a third of Operation Iraqi Freedom/Operation Enduring Freedom eyes of ocular trauma patients referred to one tertiary care military hospital. This resulted in approximately 40% of these eyes remaining legally blind after injury.Orbital fractures occur commonly during combat trauma and a significant number are legally blind despite appropriate treatment.

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The questions of the relationship and correspondence of the development of two components of military theory: theory of military art and theory of weapons and equipment are considered. On the historical examples of Falklands War in 1982, the 1991 Gulf War, air offensive operation of the NATO coalition group against the Socialist Federal Republic of Yugoslavia in 1999, Operation Enduring Freedom launched in 2001 by a multinational group in Afghanistan, wars in Iraq in 2001, ongoing armed conflict in the Syrian Arab Republic, compliance degree of development of the designated components of military theory of the participants in the conflicts with the results of these armed conflicts is compared.The correspondence between the development of the theory of weapons and the technology of the development of the theory of military art is presented by the authors of this article as one of the principles of the development of military theory. The cited historical examples of armed conflicts of the last forty years, to a large extent, indicate that success in conflicts is achieved by the side in which military concepts of the use of troops (forces) developed and implemented during the conflict corresponded to the level of development of the theory of weapons and military equipment. In other words, the capabilities of weapons and equipment systems involved in the conflict met the requirements of the use concepts of troops (forces) implemented during the conflict, namely the inherent forms and methods of using certain military formations.Separately, with regard to Ukraine, examples of attempts to implement the above principle in different historical periods are presented, taking into account the military and historical situation that is developing in and around Ukraine, a judgment is made about the justification of a certain dominant impact of the process of developing concepts of the use of security and defense on the development trends of weapons and equipment.

Freeze Dried Plasma Administration Within the Department of Defense Trauma Registry.

Hemorrhage is common among the combat injured, and plasma plays a vital role in blood product resuscitation. Regarding freeze dried plasma (FDP), US forces have had limited access to this product compared with other countries. In 2018, the US Food and Drug Administration provided emergency authorization for Department of Defense (DoD) use through the newly congressionally directed military use pathway. We describe the documented uses of FDP by US forces by performing a secondary analysis of two previously described datasets from the DoD Trauma Registry. In 11 identified cases, the median age was 28; cases were most frequently male, part of Operation Enduring Freedom, with US military affiliation, and injured by explosive or gunshot wound. The median injury severity score was 21; most did not receive a massive transfusion. Most survived to hospital discharge. Ongoing surveillance is warranted to optimize the implementation of FDP into military prehospital guidelines, training, and doctrine.

Hyphema in Open-Globe Versus Closed-Globe Injuries in Operation Iraqi Freedom and Enduring Freedom: 2001-2011.

The goal of this study is to update the incidence of hyphema in Operation Iraqi (OIF) and Enduring Freedom (OEF). We wanted to assess associated ocular injuries and final visual acuity (VA) in open-globe versus closed-globe injuries with a hyphema. We performed a retrospective review of the Walter Reed Ocular Trauma Database (WRTOD) to identify U.S. Service members and DoD civilians with hyphema who were evacuated to Walter Reed Army Medical Center between 2001 and 2011. Primary outcome measures were the final VA and differences in concomitant ocular injuries in open-globe hyphema and closed-globe hyphema. 168 of 890 eyes (18.9%) in the WROTD had a hyphema. Closed-globe injuries were noted in 64 (38.1%) eyes and open-globe injuries in 104 (61.9%) eyes. A final VA of less than 20/200 was noted in 88 eyes (51.8%). Eyes with hyphema were more likely to have traumatic cataract formation (odds ratio (OR) 6.2, 95% confidence interval (CI) 4.2-9.2, P<0.001), retinal detachment (OR 4.2, CI 2.8-6.4, P<0.001), angle recession (OR 8.1, CI 2.9-24.3, P<0.001), and final VA of less than 20/200 (OR 3.7, CI 2.6-5.4, P<0.001). Traumatic cataract formation (OR 7.4, CI 2.9-18.7, P<0.001), retinal detachment (OR 6.1, CI 2.1-17.5, P<0.001), and a final VA less than 20/200 (OR 6.1, CI 2.4-15.4 P<0.001) were statistically more likely to occur with an open-globe hyphema than with a closed-globe hyphema. Close follow-up in patients with hyphema is important due to the associated development of traumatic cataract and retinal detachment and poor final visual outcome.

"Picnics with the Mujaheddin"

This article considers the stated motivations for travel in the case of three examples of travel writing about Afghanistan. Jason Elliot’s An Unexpected Light documents his travel in 1984 during the war between the Afghan Mujaheddin and the Soviets; Jonny Bealby’s For a Pagan Song, first published in 1998, takes place during the civil war between Mujaheddin and the Taleban; Rory Stewart’s The Places In Between was written about travel between 2000 and 2002, during which time Operation Enduring Freedom was launched against the Taleban. The article deploys Genette’s concept of paratexts in order to show how the acknowledgments, blurbs, and other paratextual material, when read against the grain, undermine the relationship between the writer and their stated motivations and, thus, destabilize the self-representation of each writer in the course of the narrative. The outcome of these readings is a critique of the three texts, arguing that each one works to justify their travel through a combination of self-narration and paratextual material but that none of them address the implications of their travel for the Afghan people or that the purpose of the travel is to write the text.

Prospective cohort study examining the use of regional anesthesia for early pain management after combat-related extremity injury

BackgroundNo studies have examined the long-term benefits of regional anesthesia (RA) for pain management after combat-related injury. The objective of this prospective cohort study was to examine the relationship between...

Traumatic brain injury and sleep disturbances in combat-exposed service members and veterans: Where to go next?

To synthesize the current evidence on sleep disturbances in military service members (SMs) and veterans with traumatic brain injury (TBI). An electronic literature search first identified abstracts published from 2008-2018 inclusively referencing sleep, TBI, and military personnel from Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn, and Persian Gulf veterans. Selection criteria eliminated studies on non-combat TBI, open or penetrating injuries, and articles where the relationship between sleep and TBI was not directly examined. Articles on all military branches and components, those currently serving and veterans-ranging from medical chart reviews to clinical trials, were included. Forty-one articles were selected for full text-review. Twenty-four papers estimated the prevalence of sleep disturbances in TBI. Eight studies demonstrated the contribution of common co-occurring conditions, most notably posttraumatic stress disorder, to the relationship between disrupted sleep and TBI. Ten studies differentiated sleep profiles between military SMs and veterans with and without acute TBI and detected significant differences in sleep disturbances across the course of injury. Longitudinal studies were scarce but helped to establish the temporal relationship between sleep disturbances and TBI and isolate sleep-related mechanisms influencing TBI prognosis. Only three studies reported on interventions for improving sleep quality and TBI symptoms. Systematic research testing assessments and interventions that target sleep disturbances for improving sleep, TBI symptoms, and long-term functional outcomes were identified as critical knowledge gaps. Findings unequivocally establish that sleep disturbances are highly prevalent in SMs and veterans with TBI. However, studies testing the effectiveness of treatments for improving sleep in military groups with TBI have been limited and their results inconsistent. This review highlights a critical opportunity for advancing military medicine through future research aimed at identifying and testing sleep-focused treatments in SMs and veterans with combat-related TBI.

The Efficacy of Cognitive Processing Therapy for PTSD Related to Military Sexual Trauma in Veterans: A Review

ABSTRACTWomen currently comprise 12% of the total number of service personnel who have served in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. Presently, 15% of active duty personnel, 17% of National Guard personnel, and 20% of new recruits are female. The number of female veterans utilizing the Veterans Health Administration has more than doubled, from 159,000 to 337,000 from 2000–2011 and is expected to double again within the next decade. Similar overall numbers of female and male service members report experiencing military sexual trauma (MST). Prevalence rates vary by study where 20 to 68% of female service members and 1% to 6% of male service members have experienced MST. Many of these service members subsequently develop mental health issues and are diagnosed with conditions related to MST.Purpose: The purpose of this review was to summarize outcome studies examining Cognitive Processing Therapy (CPT) for the treatment of Post-traumatic Stress Disorder (PTSD) related to Military Sexual Trauma.Methods: The informational databases that were utilized for the current review were ERIC (EBSCO), ERIC (ProQuest), Google Scholar, and PsycINFO. The dates for literature inclusion was from 2010 to March of 2019. The literature search was initiated in March and was terminated in April of 2019.Results: The results indicated that CPT is an effective intervention for the reduction of MST related PTSD symptoms, including negative cognitions, compared to Present-Centered Therapy (PCT). Additionally, at 6-month post-treatment follow-up symptom reduction was stable. Results were mixed for CPT associated with quality of life and exposure to child Sexual abuse (CSA). Veterans who self-identified as African-American and Caucasian female veterans experienced significant reductions in PTSD symptomology with no differences between groups.Discussion: All studies included in the review resulted in significant reductions in PTSD but four of five also suffered from treatment fidelity in the CPT treatment condition. Researchers chose to exclude participant data from the therapists who did not adhere to CPT protocol resulting in a reduction of statistical power in these studies. The final study included in the review administered multiple treatment modalities concurrently.

Information Operations Increase Civilian Security Cooperation

Information operations are considered a central element of modern warfare, yet there remains little, if any, systematic evidence of their effectiveness. Using a geographic quasi-experiment conducted during Operation Enduring Freedom in Afghanistan, we demonstrate that civilians exposed to the government’s information campaign resulted in more civilian security cooperation, which in turn increased bomb neutralizations. These results are robust to a number of alternative model specifications that account for troop presence and operations and other confounding factors. The core findings are also corroborated with evidence from a nationwide survey and large-scale analysis of intelligence reports and counterinsurgent operations. This note demonstrates that information campaigns can lead to welfare-enhancing attitudinal and behavioral changes in an adversarial environment and can substantially improve battlefield outcomes.

Spinal Cord Injury Veterans' Disability Benefits, Outcomes, and Health Care Utilization Patterns: Protocol for a Qualitative Study.

BackgroundAn estimated 42,000 people currently living with chronic spinal cord injury (SCI) are veterans. SCI was a common combat-related injury in the World Wars and Vietnam era and now affects more than 11% of military personnel injured in Operation Iraqi Freedom and Operation Enduring Freedom. The Veterans Benefits Administration primarily offers financial compensation for disabilities sustained or re-aggravated during military service, called service-connected disability compensation. With the overwhelming cost of living with an SCI, this monthly financial compensation can provide service-connected veterans and their families with access to additional supportive resources (eg, assistive devices and personal aide) and maintain their quality of life (QOL). Little is known about personal, health, functional, and QOL outcomes associated with service-connected and nonservice-connected status for veterans living with an SCI.ObjectiveThe aim of this study is to compare the ways in which Veterans Affairs’ (VA) service-connected and nonservice-connected status may be associated with health and functional outcomes, choice of health care provider, and overall QOL for veterans living with an SCI and their caregivers.MethodsThis cross-sectional qualitative study will gather data using retrospective chart reviews, semistructured interviews, and focus groups. After obtaining institutional review board (IRB) approval, purposeful sampling techniques will be used to recruit and enroll the following key stakeholders: veterans living with an SCI, family caregivers, and SCI health care providers. Concurrent data collection will take place at 2 sites: Veterans Administration New Jersey Healthcare System and Northern New Jersey Spinal Cord Injury System.ResultsThis study was funded in July 2015. IRB approval was obtained by November 2016 at both sites. Enrollment and data collection for phase 1 to phase 4 are complete. A total of 69 veterans, 18 caregivers, and 19 SCI clinicians enrolled in the study. Data analyses for these phases are underway. In phase 5, the follow-up focus group activities are scheduled. The final results are expected by the end of 2019.ConclusionsThe factors that contribute to veterans living with SCI seeking and not seeking VA disability compensation benefits are not well understood in rehabilitation research. Triangulation of these data sources will allow us to compare, contrast, and integrate the results, which can be used to develop clinical guidelines, caregiver training, and patient education programs.International Registered Report Identifier (IRRID)DERR1-10.2196/14039

Morally Injurious Events, Moral Injury, and Suicidality among Recent-Era Veterans: The Moderating Effects of Rumination and Mindfulness

The present study used mediation analysis to examine the associations among morally injurious events (MIEs), moral injury, and suicidality in a sample of 285 Operation Enduring Freedom and Operation Iraqi Freedom veterans. Additionally, moderated mediation analysis was used to examine rumination and mindfulness as potential moderators of the MIE, moral injury, suicidality associations. Participants were largely male (n = 174, 61.1%), White (n = 197, 69.1%), and reported a mean age of 32.01 years (SD = 6.90 years). The most represented branch of the military was the Army (n = 136, 47.7%), followed by the Navy (n = 87, 30.5%) and participants on average reported completing 3.05 (SD = 1.38) deployments in support of OIF and 3.15 (SD = 1.42) deployments in support of OEF. Moral injury mediated the association between MIEs and suicidality, such that higher levels of exposure to potential MIEs were associated with higher levels of moral injury; which in turn was associated with higher suicidality. Our moderated mediation models revealed that this indirect effect was attenuated among individuals with higher mindfulness (i.e., the nonjudging of experience and acting with awareness dimensions of mindfulness) and strengthened among those who reported higher rumination. Results point to the potential utility of mindfulness-based therapies among service members who serve in combat and who report moral injury.

Evaluating thoracolumbar spine response during simulated underbody blast impact using a total human body finite element model

In a study of spine injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) from 2001-09, spinal fractures sustained by mounted soldiers accounted for 26% of all injuries, and of that, 43% were caused by explosions [1]. The thoracolumbar region is the most vulnerable area of the spine [2], and injuries are often incapacitating, making egress from vehicles difficult. Injury prediction from such events continues to remain a challenge due to the limited availability of studies specifically focused on underbody blasts (UBB) and criteria on related injuries. This study focuses on developing and validating the spine response of an updated 50th percentile male Global Human Body Models Consortium (GHBMC) Finite Element (FE) model using instrumented post-mortem human subject (PMHS) laboratory tests under two unique conditions. The model was validated against response corridors created using scaled thoracic (T12, T8, T5, T1) and sacrum (S1) spine Z-axis accelerations obtained from WSU whole-body PMHS tests. The scores for the updated spine model ranged from 0.557 – 0.756 for condition 1 (Seat- 4 m/s in 10 ms; Floor- 6 m/s in 5 ms) and 0.639–0.849 for condition 2 (Seat- 4 m/s in 55 ms; Floor- 8 m/s in 2 ms). The PMHS tests sustained spinal injuries in the thoracolumbar region. The validated model indicates high stress and strain concentrations at the same locations, providing an explanation for the fractures sustained in the PMHS tests.

Risk Factors of Obesity in Veterans of Recent Conflicts: Need for Diabetes Prevention.

To identify factors associated with obesity in veterans of the recent, Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) war conflicts. Over 44% OEF/OIF/OND veterans are obese (BMI > 30kg/m2), which exceeds the national obesity prevalence rate of 39% in people younger than 45. Obesity increases morbidity, risk for type 2 diabetes (T2D), and mortality as well as decreases quality of life. A scoping review method was used to identify factors associated with obesity in young veterans. Military exposures, such as multiple deployments and exposure to combat, contribute to challenges in re-integration to civilian life in all veterans. Factors that contribute to increased risk for obesity include changes in eating patterns/eating disorders, changes in physical activity, physical disability, and psychological comorbidity. These conditions can contribute to a rapid weight gain trajectory, changes in metabolism, and obesity. Young veterans face considerable challenges related to obesity risk. Further research is needed to better understand young veterans' experiences and health needs in order to adapt or expand existing programs and improve access, engagement, and metabolic outcomes in this vulnerable population.

A Descriptive Analysis of Causalities Undergoing CASEVAC from the Point-of-Injury in the Department of Defense Trauma Registry.

The recent conflicts in Iraq and Afghanistan entail an asymmetric battlefield without clearly defined forward lines of troops as seen in previous wars. Accordingly, the United States military medical services have increasingly adopted casualty evacuation (CASEVAC) platforms. We describe CASEVAC events reported within the Department of Defense Trauma Registry (DODTR). This is a secondary analysis of previously published data from two datasets spanning from 2007 through 2017. We isolated casualties within our dataset that had a documented evacuation method from the point-of-injury other than dedicated medical evacuation platforms (e.g., MEDEVAC, etc.). During OPERATION IRAQI FREEDOM, three casualties underwent CASEVAC. The median age was 30 and all were male. Most sustained injuries from explosives (67%) and the median composite injury scores were low (10). The most frequent seriously injured body region was the thorax (67%). All survived to hospital discharge. During operations in Afghanistan (OPERATION ENDURING FREEDOM, OPERATION FREEDOMS SENTINEL, OPERATION NEW DAWN), 248 casualties underwent CASEVAC. The median age was 28 and most (96%) were male. Most sustained injuries from explosives (58%) and the median injury score was low (9). The most frequent seriously injured body region was the extremities (24%). Most (97%) survived to hospital discharge. During OPERATION INHERENT RESOLVE, 247 casualties underwent CASEVAC. The median age was 21 and most (96%) were male. The majority sustained injuries from explosives (61%) and the median injury score was low (9). The most frequent seriously injury body region was the extremities (27%). Most survived to hospital discharge (94%). In our dataset, CASEVAC events most frequently involved US military personnel service members with most surviving to hospital discharge. Developing new terminology that distinguishes different types of CASEVAC would allow for more accurate future analyses of casualty evacuation and outcomes - such as those transports that are truly in a non-medical versus the various medical platforms that do not fall with into the confines of the MEDEVAC platforms.

Structural neuroimaging in mild traumatic brain injury: A chronic effects of neurotrauma consortium study.

The chronic effects of neurotrauma consortium (CENC) observational study is a multisite investigation designed to examine the long-term longitudinal effects of mild traumatic brain injury (mTBI). All participants in this initial CENC cohort had a history of deployment in Operation Enduring Freedom (Afghanistan), Operation Iraqi Freedom (Iraq), and/or their follow-on conflicts (Operation Freedom's Sentinel). All participants undergo extensive medical, neuropsychological, and neuroimaging assessments and either meet criteria for any lifetime mTBI or not. These assessments are integrated into six CENC core studies-Biorepository, Biostatistics, Data and Study Management, Neuroimaging, and Neuropathology. The current study outlines the quantitative neuroimaging methods managed by the Neuroimaging Core using FreeSurfer automated software for image quantification. At this writing, 319 participants from the CENC observational study have completed all baseline assessments including the imaging protocol and tertiary data quality assurance procedures. The preliminary findings of this initial cohort are reported to describe how the Neuroimaging Core manages neuroimaging quantification for CENC studies.

Enucleations and Eviscerations for Combat Ocular Trauma Performed During Operations Iraqi and Enduring Freedom: 2001 to 2011.

To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011. The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification. One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%). Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.

The Burden of Dental Emergencies, Oral-Maxillofacial, and Cranio-Maxillofacial Injuries in US Military Personnel.

High numbers of dental emergencies (DE) in military service members (approximately 15% per annum) prompted the inclusion of Dental Readiness as one of six conditions that determine service members' Individual Medical Readiness (IMR). Additionally, even with the advances in body armor and helmet design, Cranio- and Oral-maxillofacial (CMF, OMF) injuries continue to occur in hostile environments. The objectives of this report are (1) to provide a comprehensive review of the incidence of DE and CMF/OMF injuries in US military personnel deployed in multiple environments and (2) to compare the rates of DE and CMF/OMF injuries occurring in the 20th century with the rates observed in the early 21st century. Published and unpublished studies, as well as military reports of DE, OMF, and CMF injuries occurring in US military personnel were evaluated. Study publication dates included 1955 to 2017, with data collection periods from 1941 through 2014. The results of 30 investigations were reviewed. Overall, the reported annual DE rates varied widely among US military personnel between 1966 and 2012, ranging from 26 to 324 (mean 152.2) DE per 1,000 personnel per year (PPY). The average annual incidence of DE for personnel in hostile environments was 125.1 per 1,000 PPY. Thirteen studies reported rates of OMF-CMF injuries from 1941 to 2014. The overall mean OMF injury rate in Operation Enduring Freedom (OEF) was 2.8 per 1,000 PPY, while the mean rate during Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) was 3.2 per 1,000 PPY. A mean of 22.3 CMF injuries per 1,000 PPY was calculated from two reports during OIF. The percentage of DE and OMF casualties that can be expected in hostile environments is approximately 12%. Using the most recent data since 2000, the mean DE rate was 118.2 per 1,000 PPY and the OMF rate was 3.0 per 1,000 PPY. Future research should yield information which is representative of the evolving military environment. This information should be used to enhance military-specific dental therapies and to guide protection of the craniofacial region. More importantly, quality data are necessary (1) to enable the accurate prediction of DE, CMF, and OMF casualties to insure that troop levels are sufficient for mission success and (2) to insure that all outcome variables are available to measure policy success or failure.