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Introduction: The National Guard (NG) served as a critical component of the U.S. response to the coronavirus disease 2019 pandemic. Understanding the impact of types of pandemic-related disaster work on mental health responses can aid in sustaining NG service members' health and preparation for subsequent activations and future pandemics., Materials and Methods: We surveyed 1,363 NG unit (NGU) service members (88% Army; 80% enlisted; 32% 30 to 39 years old; 84% male) following activation in response to the pandemic. Surveys were administered between August and December 2020, which was approximately 2 to 3 months post-activation. Surveys assessed overall activation stress, participation in different types of disaster work, probable post-traumatic stress disorder (PTSD), anxiety and depression, and anger. A disaster work stress scale assessed different types of disaster work during activation and associated stress levels. For each individual, we calculated an overall work task stress (WTS) scaled score, with a maximum score of 100. Logistic regression analyses were conducted to examine the relationship of high-stress disaster work tasks to post-activation PTSD, anxiety and depression, and anger, adjusting for socio-demographic and service-related variables. The study was approved by the Institutional Review Board of the Uniformed Services University (USU) in Bethesda, MD., Results: Among NGU service members, 12.7% (n = 172) described their activation as very/extremely stressful. The work tasks with the highest scaled scores were as follows: (1) Patient transportation (WTS scaled score = 100); (2) working with the dead (WTS = 82.2); and (3) working with families of coronavirus disease 2019 patients (WTS = 72.7). For each individual's work tasks, we identified the work task associated with the highest WTS score. The top one-third of WTS scores were classified as the high-stress group. Approximately 9% of participants (n = 111) had probable PTSD, 6.7% (n = 85) had clinically significant anxiety and depression, and 12.3% (n = 156) had high anger. Multivariable logistic regression analyses, adjusting for covariates, found that NGU service members exposed to the highest level of disaster WTS were more likely to report PTSD (odds ratio [OR] = 1.48 [95% confidence interval [CI] = 1.13-1.94], χ2 = 7.98), anxiety and depression (OR = 1.91 [95% CI = 1.17-3.13]; χ2 = 6.67), and anger (OR = 1.63 [95% CI = 1.13-2.37]; χ2 = 6.66) post-activation., Conclusions: Identifying work tasks associated with high levels of stress can help detect individuals at risk for adverse mental health responses post-exposure. Distinguishing features of high-stress work conditions can be generalized to other types of work conditions and disaster response and are important targets for planning and preventive efforts., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Introduction: The National Guard (NG) was an important component of the U.S. emergency response for the coronavirus (COVID-19) pandemic. Understanding how the personal COVID-19 experiences of NG members may be associated with posttraumatic stress symptoms (PTSS) and disorder (PTSD) can inform approaches to identifying and sustaining service members' mental health., Materials and Methods: We surveyed 3,993 NG service members (75% Army; 79% enlisted; 33% 30-39 years old; 81% male) during the pandemic. Forty-six percent of participants were activated in response to COVID-19. Surveys were administered between August and December 2020. We defined personal COVID-19 experiences as having COVID-19, a family member(s) having COVID-19, and/or having a close relationship with someone who died from COVID-19. In addition, using a 4-item form of the PTSD Checklist for DSM-5 (PCL-5), current posttraumatic stress symptoms (PTSS) and probable PTSD were assessed. Linear and logistic regression analyses were conducted to examine the relationship of COVID-19 experiences to PTSS and probable PTSD, respectively., Results: Approximately 32% of participants reported at least one personal COVID-19 experience. Univariable linear regression analyses indicated that NG service members who had a personal COVID-19 experience reported more PTSS than those with no personal experience (B = 0.53, SE = 0.12, P < .001). After adjusting for demographics and service-related characteristics, having a personal COVID-19 experience continued to be associated with higher PTSS (B = 0.48, SE = 0.12, P < .001). When examining the relationships of distinct types of personal COVID-19 experiences to PTSS and PTSD together in multivariable models, those who had a close relationship with someone who died from COVID-19 had higher levels of PTSS (B = 1.31, SE = 0.22, P < .001) and were almost 3 times more likely to have PTSD (OR = 2.94[95%CI = 1.93-4.47], P < .001)., Conclusions: Personal COVID-19 experiences are associated with increased PTSS and PTSD risk in NG service members. Such knowledge may aid in selection of service members for activation and identifying those in need of care., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Despite the advancement of eye-tracking technology for smooth pursuit (SP) eye movement evaluation, qualitative observation offers much information that is not captured by computers; hence, both objective and qualitative information should be utilized to evaluate SP. This study examined the consistency among our clinicians when evaluating SP using normal (N), grossly normal (GN), mildly abnormal (MA), and abnormal (AB) as classifications. We then evaluated the effect of combining GN and MA into a single subclinical (SUBC) category. We also evaluated the computerized percent saccade (PS) metric by determining its sensitivity and specificity in classifying SP., Materials and Methods: Retrospective horizontal and vertical SP test videos and numerical data for 70 participants were obtained from the Neuro Kinetics Neuro-Otologic Test Center and de-identified. From this, eye-tracking videos, time plots of eye-tracking positional data, and tables of SP eye-tracking performance data were generated for 0.1, 0.3, and 0.5 Hz in both horizontal and vertical planes, totaling 6 tests per subject. Three clinicians rated each subject's SP performance as N, GN, MA, or AB for a total of 6 ratings (3 frequencies, horizontal and vertical). This process was repeated using N, SUBC, and AB as rating categories. Clinicians also provided an overall SP rating for each plane as follows: AB if the results were abnormal for 2 or more frequencies tested. Alternatively, if fewer than 2 frequencies presented with a rating of AB, then an overall rating of MA, GN, or N was determined at the respective clinician's discretion., Results: When the 3 clinicians were tasked with classifying SP videos using 4 clinical categories, fair overall agreement was demonstrated. However, when MA and GN categories were combined into an SUBC category, the overall agreement for the 3 clinicians improved slightly for both horizontal SP (HSP) and vertical SP (VSP). This pattern of agreement did not differ considerably when comparing HSP versus VSP, and good consistency and reliability was observed across clinicians. Again, inter-rater consistency was smaller for VSP versus HSP despite the reduction in clinical categories. Cut-off values were generated for the PS metric and demonstrated good specificity and sensitivity when they were exceeded for 2 or more frequencies in a particular plane when evaluating a subject's SP test., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: There have been nearly 1,600 new diagnoses of Human Immunodeficiency Virus (HIV) across the US Armed Forces between 2017 and 2022. While treatment has improved overall survival, self-perception of acquiring HIV may not align with actual risk of acquiring HIV, thus slowing diagnosis and treatment. We aim to evaluate self-perceived risk (SPR) versus calculated risk (CR) of HIV infection in US Air Force (USAF) members with incident HIV diagnosis., Methods: All USAF members with new HIV diagnosis evaluated at a specialty care military medical center between January 2015 and March 2020 with case report forms were included (n = 142). SPR was compared to CR using the Denver HIV Risk Score (DHRS). The study was approved by the Army Public Health Center's Public Health Review Board (#14-311) and the Walter Reed Army Institute of Research Human Subjects Protection Branch (#1861E)., Results: Patients were predominantly male (98%), with a median age of 26 (IQR 22-30) years, and the majority (85%) reported same-sex partners. Most patients reported a low SPR (n = 78; 55%). A higher proportion of low SPR patients were married or partnered than high SPR patients (29% versus 14%; P = 0.04). Both groups had median DHRS scores in the highest risk category with similar results by reason for HIV screening., Conclusion: The majority of USAF members with incident HIV infection reported a low SPR despite risk factors and CRs identical to high SPR patients. In order to inform HIV prevention strategies in the military, further efforts are needed to educate the military population and providers about HIV risk perception., (© The Association of Military Surgeons of the United States 2024.)

Introduction: In accordance with ADP 6-22-001 and ATP 6-22.1, counseling is the process routinely executed by Army leaders to develop, mentor, and coach subordinate Soldiers and Army civilians within their organization. When implemented effectively, the counseling process can be utilized to produce capable, resilient, and satisfied subordinates who are prepared and motivated to meet mission-essential responsibilities. Training opportunities that specifically focus on optimizing this key leader competence, particularly with non-commissioned officers, are limited. The Directorate of Prevention, Resilience and Readiness (Headquarters, Department of the Army, G-9) offers a specific training, the Counseling Enhancement Workshop, and requested an evaluation to determine the effectiveness of the current training and identify opportunities for improvement., Materials and Methods: A longitudinal 360-degree approach was deployed as a common multisource methodology intended to produce triangulated feedback from participants, as well as their subordinates and supervisors. Quantitative surveys and qualitative structured interviews were conducted. Performance psychology professional facilitators who train this workshop were also administered a questionnaire to capture instructional feedback. Measures include a knowledge assessment of the workshop content, Counseling Self-Efficacy Survey, as well as original measures related to the workshop experience. Completed written developmental counseling forms and observations from the evaluation team were also reviewed to ensure fidelity of the training implementation and delivery. The current study reports on survey responses from participants and facilitators., Results: Results suggested a strong and positive correlation between the pre- and post-workshop Counseling Self-Efficacy Scale. Because of a small sample size, data were analyzed as planned but interpreted with caution because of limited validity. There was a significant increase between the pre- and post-tests knowledge comprehension test scores. Facilitators reported confidence in teaching resilience skills, but not coaching Soldiers to apply those skills as part of the developmental counseling process., Conclusions: The Army counseling process can be utilized to produce capable, resilient, and satisfied subordinates who are prepared and motivated to meet mission-essential responsibilities. Quantitative results on the content of the CEW present opportunities for meaningful training that increases leaders' confidence in delivering counseling sessions, as well as mastering specific skills that benefit the subordinate Soldier and improve unit health. Furthermore, performance psychology professionals provided feedback on focus areas to meet the instructional objective of the training more efficiently and effectively. Ultimately, the counseling process is considered the most important tool available to current leaders to build the capacity of future leaders and an investment in the training to enhance these skills will provide great returns to the U.S. Army as a whole., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Suicide is a prevalent problem impacting the military community. The U.S. Army recognized the need to address this complex issue; one line of effort has been to provide suicide prevention and intervention education and training that is informed by current research, doctrine, and implementation best practices. The purpose of this article is to outline and present the genesis of the Army's new suicide prevention and intervention training-"Ask, Care, Escort (ACE) Base +1"-that aligns with the DoD newly published regulation-driven initiatives., Materials and Methods: The development of the "ACE Base +1" curriculum was a collaborative effort between two organizations within the Defense Health Agency: The Defense Centers for Public Health-Aberdeen and the WRAIR. A multidisciplinary team was formed by selecting specific operational and subject-matter experts from each organization based on educational qualifications and practical experiences expected to aid the development of curriculum content (e.g., subject-matter experts) and/or the training design. Revisions to the curriculum were informed by the Army's existing suicide prevention training module, current research in suicide prevention and public health, updated and relevant Army regulations, and current public health policy guidance from the CDC and the Department of Suicide Prevention Office. A detailed account of the systematic and iterative curriculum development process is provided., Results and Conclusions: The interagency collaborative efforts resulted in a suite of training products, "ACE Base +1" version 1.3 that is modernized in training content, delivery methods, and design. Four primary elements shaped the final products: (1) A modular framework allowing a tailored approach to mandatory training, (2) a public-health approach that focuses on earlier intervention opportunities while building trust and cohesion, (3) a training design centered on peer discussions and behavioral rehearsal, and (4) an expansion of the curriculum to be inclusive of the entire Army community. Practical implications for each element are discussed.As the program of record, "ACE Base +1" training satisfies the annual requirement for all Active Army, Army National Guard, U.S. Army Reserve, and Department of the Army (DA) civilians. Both the training content (e.g., public-health concepts) and design of "ACE Base +1" reflect a comprehensive approach, focused on developing concrete, applicable skills that support the shared responsibility to suicide prevention and intervention. Limitations, such as delayed interagency collaboration and time constraints, are discussed. Future directions include recommendations for future curriculum projects, specifically within military populations, such as interprofessional, interagency collaboration, and selecting a multidisciplinary team of subject-matter experts. Additionally, WRAIR plans to continue their support to Directorate of Prevention, Resilience and Readiness with the expansion of the +1 menu of trainings, ongoing program evaluation, and longitudinal analysis to inform future revisions and ensure the content and delivery methods remain modernized, relevant, and effective., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Bloodstream infections are a significant threat to soldiers wounded in combat and contribute to preventable deaths. Novel and combination therapies that can be delivered on the battlefield or in lower roles of care are urgently needed to address the threat of bloodstream infection among military personnel. In this manuscript, we tested the antibacterial capability of silver ions (Ag+), with long-appreciated antibacterial properties, against ESKAPEE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species, and Escherichia coli) pathogens., Materials and Methods: We used the GENESYS (RAIN LLC) device to deliver Ag+ to Gram-positive and Gram-negative ESKAPEE organisms grown in broth, human blood, and serum. Following the Ag+ treatment, we quantified the antibacterial effects by quantifying colony-forming units., Results: We found that Ag+ was bactericidal against 5 Gram-negative organisms, K pneumoniae, A baumannii, P aeruginosa, E cloacae, and E coli, and bacteriostatic against 2 Gram-positive organisms, E faecium and S aureus. The whole blood and serum inhibited the bactericidal activity of Ag+ against a common agent of bloodstream infection, P aeruginosa. Finally, when Ag+ was added in conjunction with antibiotic in the presence of whole blood, there was no significant effect of Ag+ over antibiotic alone., Conclusions: Our results confirmed that Ag+ has broad-spectrum antibacterial properties. However, the therapeutic value of Ag+ may not extend to the treatment of bloodstream infections because of the inhibition of Ag+ activity in blood and serum., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Military personnel frequently experience stressful, morally challenging situations that can lead to posttraumatic stress disorder (PTSD). The relationships between moral identity, transgressive acts, and symptoms related to posttraumatic stress disorder (i.e., posttraumatic stress symptoms; PTSS) among U.S. Army Soldiers were assessed., Materials and Methods: A convenience cohort of 1,547 soldiers completed a survey assessing moral identity and PTSS before deployment. A subset of 505 soldiers completed another survey assessing transgressive acts and PTSS during deployment. Exploratory and confirmatory factor analyses were conducted to determine the underlying factor structure of the measures of moral identity and transgressive acts. Generalized linear modeling, robustness checks, and sensitivity analysis were used to evaluate the predictive relationships., Results: Moral identity did not directly predict PTSS during deployment. However, self-attributed and betrayal-based transgressive acts were significant predictors. Specifically, self-attributed transgressive acts and PTSS were moderated by internalized moral identity; individuals with a higher internalized moral identity experienced more severe PTSS following self-attributed transgressive acts. These findings were consistent across various model checks, including covariate adjustments, data imputation, and the application of a data quality filter., Conclusions: The study highlights the significant role of self-attributed moral transgressions during deployment in the development of PTSS among military service members-especially in those with a strong internalized moral identity. This finding suggests a "target of opportunity" for the development of intervention strategies that mitigate PTSS by addressing the moral dimensions of military service., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Introduction: Extensive trauma, commonly seen in wounded military Service Members, often leads to a severe sterile inflammation termed systemic inflammatory response syndrome (SIRS), which can progress to multiple organ dysfunction syndrome (MODS) and death. MODS is a serious threat to wounded Service Members, historically causing 10% of all deaths in trauma admissions at a forward deployed combat hospital. The importance of this problem will be exacerbated in large-scale combat operations, in which evacuation will be delayed and care of complex injuries at lower echelons of care may be prolonged. The main goal of this study was to optimize an existing mouse model of lethal SIRS/MODS as a therapeutic screening platform for the evaluation of immunomodulatory drugs., Materials and Methods: Male C57BL/6 mice were euthanized, and the bones and muscles were collected and blended into a paste termed tissue-bone matrix (TBX). The TBX at 12.5%-20% relative to body weight of each recipient mouse was implanted into subcutaneous pouches created on the dorsum of anesthetized animals. Mice were observed for clinical scores for up to 48 hours postimplantation and euthanized at the preset point of moribundity. To test effects of anesthetics on TBX-induced mortality, animals received isoflurane or ketamine/xylazine (K/X). In a separate set of studies, mice received TBX followed by intraperitoneal injection with 20 mg/kg or 40 mg/kg Eritoran or a placebo carrier. All Eritoran studies were performed in a blinded fashion., Results: We observed that K/X anesthesia significantly increased the lethality of the implanted TBX in comparison to inhaled anesthetics. Although all the mice anesthetized with isoflurane and implanted with 12.5% TBX survived for 24 hours, 60% of mice anesthetized with K/X were moribund by 24 hours postimplantation. To mimic more closely the timing of lethal SIRS/MODS following polytrauma in human patients, we extended observation to 48 hours. We performed TBX dose-response studies and found that as low as 15%, 17.5%, and 20% TBX caused moribundity/mortality in 50%, 80%, and 100% mice, respectively, over a 48-hour time period. With 17.5% TBX, we tested if moribundity/mortality could be rescued by anti-inflammatory drug Eritoran, a toll-like receptor 4 antagonist. Neither 20 mg/kg nor 40 mg/kg doses of Eritoran were found to be effective in this model., Conclusions: We optimized a TBX mouse model of SIRS/MODS for the purpose of evaluating novel therapeutic interventions to prevent trauma-related pathophysiologies in wounded Service Members. Negative effects of K/X on lethality of TBX should be further evaluated, particularly in the light of widespread use of ketamine in treatment of pain. By mimicking muscle crush, bone fracture, and necrosis, the TBX model has pleiotropic effects on physiology and immunology that make it uniquely valuable as a screening tool for the evaluation of novel therapeutics against trauma-induced SIRS/MODS., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The DoD has prioritized programs to optimize readiness by enhancing resilience of its service members. Problematic anger in the military is an issue that impacts psychological well-being and resilience. Leader support is a potential tactic for reducing anger and its effects. Currently military resilience training is focused on individual level resilience. A gap exists in such training and there is a need to train leaders to provide mental health and resilience support to their subordinates. The present study developed and tested a theory-based training aimed at platoon leaders that focused on how to engage in proactive and responsive mental health and resilience-supportive behaviors through guided discussion, scenarios, and computer-based training with embedded quizzes., Materials and Methods: We conducted an Institutional Review Board-approved cluster randomized controlled trial to test the effects of a leadership training with Army platoon leaders (n = 99) and soldiers (n = 276) in 2 brigades at an active duty military installation in the USA. Training was conducted in person with a computer-based component. Soldiers completed online surveys 1 month prior and again 3 months after the leader training., Results: Post-training results demonstrated significant leader learning effects (Cohen's d = 1.56) and leader positive reactions to the training information, with leaders reporting the information as useful and relevant to their work. Service members in the treatment group reported significantly lower levels of anger at time 2 (b = -0.18, SE = 0.06, P = .002, pseudo ΔR2 = 0.01; d = 0.27) compared to the control group. We also found an indirect effect of the intervention on increased life satisfaction at time 2 via decreased anger (b = 0.035, SE = 0.023, 95% CI = [0.004-0.24])., Conclusions: This study provides an initial evaluation of training for platoon leaders that educates them on proactive and responsive behavioral strategies to support the mental health and resilience of their service members via decreased problematic anger and increased well-being. Further adaptations and evaluations should be conducted with other military branches and civilian occupations, as the benefits of the relatively brief and noninvasive training could be widespread., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Introduction: Destructive interpersonal relationships at work may result in negative feelings among employees that hinder personal and organizational productivity, which may also result in high levels of job disengagement and subsequent career turnover intentions. Leaders play a key role in creating work environments conducive to optimizing employee performance, organizational culture, and workplace well-being. Social support, which may include support from one's supervisor, colleagues, and loved ones, has been shown to reduce strains and perceived stressors at work. In the Army, the Judge Advocate General's Corps (JAGC) personnel have a unique position as lawyers and legal staff and have been shown to have high rates of burnout. To promote soldier health, well-being, and career longevity, it is important to understand the impact interpersonal relationships have on career intentions. The current study assesses the relationship between perceived leadership effectiveness and career intentions as moderated by burnout measured by job disengagement and team care activities in JAGC personnel., Materials and Methods: The Walter Reed Army Institute of Research conducted a survey to understand factors affecting the well-being of the JAGC's soldier and civilian personnel as requested by the JAGC. JAGC personnel were administered several questionnaires covering a range of work and mental health topics. Job disengagement, career intentions, team care activities, and general leadership were assessed. A total of 831 JAGC personnel completed the survey, the majority (92%) of which were soldiers. Among soldiers, first lieutenants and captains (∼49%) were the majority. The sample largely consisted of men (∼63%), White individuals (∼76%), married individuals, (70%), and individuals with graduate degrees (∼81%)., Results: One in four participants (∼29%) experienced high levels of disengagement, with their work. Over two-thirds of participants agreed that their immediate supervisor is an effective leader. When asked about career intentions, the majority of JAGC participants (54%) indicated that they would probably or definitely stay in the JAGC until retirement. Ordinal logistic regressions were conducted to assess the relationship between perceived leader effectiveness and career intentions, assessing the main effects of job disengagement and team care activities, and the interactions between those variables. No interaction effects were found to be significant, but main effects for perceived leader effectiveness were significant., Conclusions: JAGC personnel reported higher levels of job disengagement for those with career intentions that were undecided or definitely leaving the JAGC after their current obligation. Those who were engaged in more team care activities had lower levels of disengagement. While the majority of the JAGC participants indicated career intentions to stay in the JAGC until retirement, increasing perceived effectiveness of leaders could help increase attrition and career intentions to stay in the JAGC beyond one's current obligation., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Presently, traumatic brain injury (TBI) triage in field settings relies on symptom-based screening tools such as the updated Military Acute Concussion Evaluation. Objective eye-tracking may provide an alternative means of neurotrauma screening due to sensitivity to neurotrauma brain-health changes. Previously, the US Army Medical Research and Development Command Non-Invasive NeuroAssessment Devices (NINAD) Integrated Product Team identified 3 commercially available eye-tracking devices (SyncThink EYE-SYNC, Oculogica EyeBOX, NeuroKinetics IPAS) as meeting criteria toward being operationally effective in the detection of TBI in service members. We compared these devices to assess their relative performance in the classification of mild traumatic brain injury (mTBI) subjects versus normal healthy controls., Materials and Methods: Participants 18 to 45 years of age were assigned to Acute mTBI, Chronic mTBI, or Control group per study criteria. Each completed a TBI assessment protocol with all 3 devices counterbalanced across participants. Acute mTBI participants were tested within 72 hours following injury whereas time since last injury for the Chronic mTBI group ranged from months to years. Discriminant analysis was undertaken to determine device classification performance in separating TBI subjects from controls. Area Under the Curves (AUCs) were calculated and used to compare the accuracy of device performance. Device-related factors including data quality, the need to repeat tests, and technical issues experienced were aggregated for reporting., Results: A total of 63 participants were recruited as Acute mTBI subjects, 34 as Chronic mTBI subjects, and 119 participants without history of TBI as controls. To maximize outcomes, poorer quality data were excluded from analysis using specific criteria where possible. Final analysis utilized 49 (43 male/6 female, mean [x̅] age = 24.3 years, SD [s] = 5.1) Acute mTBI subjects, and 34 (33 male/1 female, x̅ age = 38.8 years, s = 3.9) Chronic mTBI subjects were age- and gender-matched as closely as possible with Control subjects. AUCs obtained with 80% of total dataset ranged from 0.690 to 0.950 for the Acute Group and from 0.753 to 0.811 for the Chronic mTBI group. Validation with the remaining 20% of dataset produced AUCs ranging from 0.600 to 0.750 for Acute mTBI group and 0.490 to 0.571 for the Chronic mTBI group., Conclusions: Potential eye-tracking detection of mTBI, per training model outcomes, ranged from acceptable to excellent for the Acute mTBI group; however, it was less consistent for the Chronic mTBI group. The self-imposed targeted performance (AUC of 0.850) appears achievable, but further device improvements and research are necessary. Discriminant analysis models differed for the Acute versus Chronic mTBI groups, suggesting performance differences in eye-tracking. Although eye-tracking demonstrated sensitivity in the Chronic group, a more rigorous and/or longitudinal study design is required to evaluate this observation. mTBI injuries were not controlled for this study, potentially reducing eye-tracking assessment sensitivity. Overall, these findings indicate that while eye-tracking remains a viable means of mTBI screening, device-specific variability in data quality, length of testing, and ease of use must be addressed to achieve NINAD objectives and DoD implementation., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Future multidomain operational combat environments will require combat medics to play a larger role in managing behavioral health (BH) conditions in forward environments, as soldiers in small teams may have them as their sole medical support for extended periods of time. Previously they were not expected to serve in this role, and thus, they receive minimal BH training. It is unknown to what extent combat medics consider BH tasks as falling within their scope of practice and how often they engage with their soldiers currently related to BH. Qualitative research suggests that many medics feel inadequately prepared to handle BH problems. Our aim is to further assess medic attitudes and behaviors related to BH to better understand the landscape of medic preparedness to fill an expanded role., Materials and Methods: Data from 292 medics were collected before their participation in the BH Guidelines for mEdic Assessment and Response training, a day-long training for medics expected to deploy to far-forward environments. We investigated whether combat medics engage with their soldiers in areas related to BH, the extent to which they consider BH-related tasks as part of their scope of practice, and how confident they feel engaging in various BH-related tasks. We explored associations between medics' attitudes related to BH scope of practice and confidence performing BH tasks with gender, rank, component (National Guard vs. Active Duty), work-related BH experience, having suicide training in the past year, and having ever sought help for BH., Results: Results indicated that in the past month, 61.4% of medics discussed BH issues, 48.3% assessed BH problems, and 41.3% provided interventions for BH problems with at least one soldier in their unit. Assessment tasks were more frequently endorsed as falling within medic's scope of practice (75%-95%) than intervention tasks (62%-83%). More medics felt confident doing assessments (39%-49% moderately confident or greater) than providing interventions (31%-37% moderately confident or greater). Medics expressed highest confidence in assessing for suicide risk (49% moderate confidence or greater). Medics with a lot of prior BH work experience and non-commissioned officers (as compared to junior enlisted) reported greater confidence in most tasks. Receiving suicide training in the past year was associated with greater confidence assessing for suicide, as well as providing interventions for suicide, general BH problems, and substance abuse., Conclusions: Most medics agreed that numerous BH tasks fell within the scope of their work, but few felt confident engaging in those tasks. These findings support a need for additional training in BH-related tasks across the force. Exploring ways to provide medics BH-related work rotations would augment their general proficiency as first-line treatment providers for soldiers in combat units, and increased training in BH-related tasks should be studied to determine its ability to increase competency and confidence. If medics can learn to assess and recognize BH concerns before they escalate to needing specialty BH care, this could potentially reduce the burden on BH clinics, as well as strengthen the overall force., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Blast overpressure and accelerative impact can produce concussive-like symptoms in service members serving both garrison and deployed environments. In an effort to measure, document, and improve the response to these overpressure and impact events, the U.S. Army Medical Material Development Activity is evaluating body-worn sensors for use by the Joint Conventional Force. In support, the WRAIR completed a qualitative end-user evaluation with service members from high-risk mission occupational specialties to determine the potential needs, benefits, and challenges associated with adopting body-worn sensors into their job duties., Materials and Methods: WRAIR staff led hour-long semi-structured focus groups with 156 Army, Navy, and Marine Corps participants, primarily representing infantry, combat engineer, explosive ordnance disposal, artillery, mortar, and armor job specialties. Topics included their sensor needs, concepts of operations, and recommended design features for implementing sensors into the force. Dialogue from each focus group was audio recorded and resulting transcripts were coded for thematic qualitative analysis using NVivo software., Results: Users recommended a single, unobtrusive, rugged, multi-directional sensor that could be securely mounted to the helmet and powered by a battery type (such as rechargeable lithium or disposable alkaline batteries) that was best suited for their garrison and field/deployed environments. The sensors should accurately measure low-level (∼1.0 pounds per square inch) blasts and maintain a record of cumulative exposures for each service member. Discussions supported the need for immediate, actionable feedback from the sensor with the option to view detailed blast or impact data on a computer. There were, however, divergent opinions on security issues regarding wireless versus wired data transfer methods. Participants also expressed a need for the exposure data to integrate with their medical records and were also willing to have their data shared with leadership, although opinions differed on the level of echelon and if the data should be identifiable. Regarding accountability, users did not want to be held fiscally liable for the sensors and recommended having the unit be responsible for maintenance and distribution. Concerns about being held fiscally liable, being overly burdened, and having one's career negatively impacted were listed as factors that could decrease usage. Finally, participants highlighted the importance of understanding the purpose and function of the sensors and supported a corresponding training module., Conclusions: Participating service members were generally willing to adopt body-worn sensors into their garrison and deployed activities. To maximize adoption of the devices, they should be convenient to use and should not interfere with service members' job tasks. Providing a clear understanding of the benefits (such as incorporating exposure data into medical records) and the function of sensors will be critical for encouraging buy-in among users and leaders. Incorporating end-user requirements and considering the benefits and challenges highlighted by end users are important for the design and implementation of body-worn sensors to mitigate the risks of blast overpressure and accelerative impact on service members' health., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Modern warfare operations are volatile, highly complex environments, placing immense physiological, psychological, and cognitive demands on the warfighter. To maximize cognitive performance and warfighter resilience and readiness, training must address psychological stress to enhance performance. Resilience in the face of adversity is fundamentally rooted in an individual's psychophysiological stress response and optimized through decreased susceptibility to the negative impact of trauma exposure. The current project aims to optimize warfighter expertise, resilience, adaptability, and performance by utilizing a validated Full Dive Virtual Reality (FDVR) training platform to provide high-fidelity, safe, and scalable, controlled stress exposure in highly realistic simulated training scenarios with the most advanced, immersive technology available., Materials and Methods: Following Institutional Review Board approval and consent, 2 operators were fitted with high-fidelity virtual reality headsets with hand and eye tracking, full-body haptic feedback suits, a 360° omnidirectional treadmill, and Food and Drug Administration (FDA) cleared biometric monitors. Following acclimation, operators were placed in an industrial fire scenario and instructed to respond as a firefighter and paramedic, to search for and resuscitate any casualties, extinguish the fire, and exfiltrate safely. Following initial acclimation and after each demonstration (n = 2), 3 semistructured interviews asked operators their perceptions and experiences related to FDVR, focusing on usability, feasibility, and safety. Biometric data were continuously recorded using the Caretaker Medical VitalStream., Results: Proof-of-concept (POC) testing proved that the FDVR training platform is usable, safe, and feasible. It creates an immersive environment with physiological responses to mimic realistic Mass Casualty Events (MCEs). Using a case study approach, transcript data were analyzed using thematic analysis. Three major themes emerged: Sensory deficits reduced realism, but sensory feedback improved fidelity, vestibular discord affected the virtual reality experience but only when the system did not respond naturally to operator movement after acclimation, and movement accommodations were made by operators to enhance usability, especially for fine motor movements. Biometric data analysis correlated timestamps from the VitalStream unit with operator responses to stress-inducing events (i.e., explosions, fires, and a deceased victim). Both operators exhibited significant physiological responses, including elevated heart rate, systolic blood pressure, and mean arterial pressure, particularly following explosions, encountering fire, and encountering the deceased victim within the training environment., Conclusions: The FDVR training platform overcomes the obstacles of in-person simulation training and provides the closest to real-life experience available. It will allow warfighters to train with their teams in immersive environments that replicate the conditions in which they are expected to perform their duties. The POC demonstrated that physiological responses can be mapped to scenario events to allow tracking of stress responses, cognitive load, as well as performance, and decision-making of the warfighter. The POC only involved 2 operators, but served to prove that the platform was safe and effective. Future testing plans to include 200 warfighters in operational teams of 10 to 12 to further validate the training effectiveness of the FDVR platform., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Introduction: Military trainees are at increased risk for infectious disease outbreaks because of the unique circumstances of the training environment (e.g., close proximity areas and physiologic/psychologic stress). Standard medical countermeasures in military training settings include routine immunization (e.g., influenza and adenovirus) as well as chemoprophylaxis [e.g., benzathine penicillin G (Bicillin) for the prevention of group A streptococcal disease] for pathogens associated with outbreaks in these settings. In a population of U.S. Army Infantry trainees, we evaluated changes in the oral microbiome during a 14-week military training cycle., Materials and Methods: Trainees were enrolled in an observational cohort study in 2015-2016. In 2015, Bicillin was administered to trainees to ameliorate the risk of group A Streptococcus outbreaks, whereas in 2016, trainees did not receive a Bicillin inoculation. Oropharyngeal swabs were collected from participants at days 0, 7, 14, 28, 56, and 90 of training. Swabs were collected, flash frozen, and stored. DNA was extracted from swabs, and amplicon sequencing of the 16s rRNA gene was performed. Microbiome dynamics were evaluated using the QIIME 2 workflow along with DADA2, SINA with SILVA, and an additional processing in R., Results: We observed that microbiome samples from the baseline (day 0) visit were distinct from one another, whereas samples collected on day 14 exhibited significant microbiome convergence. Day 14 convergence was coincident with an increase in DNA sequences associated with Streptococcus, though there was not a significant difference between Streptococcus abundance over time between 2015 and 2016 (P = .07), suggesting that Bicillin prophylaxis did not significantly impact overall Streptococcus abundance., Conclusions: The temporary convergence of microbiomes is coincident with a rise in communicable infections in this population. The dynamic response of microbiomes during initial military training supports similar observations in the literature of transient convergence of the human microbiome under cohabitation in the time frame including in this experiment. This population and the associated longitudinal studies allow for controlled studies of human microbiome under diverse conditions., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Combat-related wound infections complicate the recovery of wounded military personnel, contributing to overall morbidity and mortality. Wound infections in combat settings present unique challenges because of the size and depth of the wounds, the need to administer emergency care in the field, and the need for subsequent treatment in military facilities. Given the increase in multidrug-resistant pathogens, a novel, broad-spectrum antibiotic is desired across this continuum of care when the standard of care fails. Omadacycline was FDA-approved in 2018 for treatment of adults with acute bacterial skin and skin structure infections (ABSSSI), as well as community-acquired bacterial pneumonia (CABP). It is a broad-spectrum antibiotic with activity against gram-positive, gram-negative, and atypical bacterial pathogens, including multidrug-resistant species. Omadacycline can overcome commonly reported tetracycline resistance mechanisms, ribosomal protection proteins, and efflux pumps, and is available in once-daily intravenous or oral formulations. In this review, we discuss the potential role of omadacycline, which is included in the Department of Defense Formulary, in the context of combat wound infections., Materials and Methods: A literature review was undertaken for manuscripts published before July 21, 2023. This included a series of publications found via PubMed and a bibliography made publicly available on the Paratek Pharmaceuticals, Inc. website. Publications presenting primary data published in English on omadacycline in relation to ESKAPEE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Escherichia coli, and Enterobacter species) pathogens and Clostridioides difficile, including in vitro, in vivo, and clinical data were included., Results: Of 260 identified records, 66 were included for evidence review. Omadacycline has in vitro activity against almost all the ESKAPEE pathogens, apart from P. aeruginosa. Importantly, it has activity against the four most prevalent bacterial pathogens that cause wound infections in the military healthcare system: S. aureus, including methicillin-resistant S. aureus, A. baumannii, K. pneumoniae, and E. coli. In vivo studies in rats have shown that omadacycline is rapidly distributed in most tissues, with the highest tissue-to-blood concentration ratios in bone mineral. The clinical efficacy of omadacycline has been assessed in three separate Phase 3 studies in patients with ABSSSI (OASIS-1 and OASIS-2) and with CABP (OPTIC). Overall, omadacycline has an established safety profile in the treatment of both ABSSSI and CABP., Conclusions: Omadacycline has broad-spectrum activity, the option to be orally administered and an established safety profile, making it a potentially attractive replacement for moxifloxacin in the military individual first aid kit, especially when accounting for the increasing resistance to fluoroquinolones. Further studies and clinical evaluation are warranted to support broader use of omadacycline to treat combat wound infections in the military healthcare system., (© The Association of Military Surgeons of the United States 2023.)

Introduction: Considering the potential of weaponized opioids, evaluating how prophylactic countermeasures affect military-relevant performance is necessary. Naltrexone is a commercially available Food and Drug Administration-approved medication that blocks the effects of opioids with minimal side effects. However, the effects of naltrexone on the health and performance of non-substance abusing military personnel are not well described in the existing literature., Methods: Active duty U.S. Army Soldiers (n = 16, mean ± SD, age: 23.1 ± 5.3 y) completed a series of physical, cognitive, and marksmanship tasks during a 4-day pretrial, a 7-day active trial, and a 4-day post-trial phase. During the active trial, participants were administered 50 mg of oral naltrexone daily. Physiological and biological processes were monitored with a daily review of systems, sleep monitoring, biochemistry, and hematology blood panels., Results: Naltrexone did not negatively affect physical performance, cognitive functioning, marksmanship, or sleep duration (P > 0.05). Improvements were observed during the active trial compared to the pretrial phase in cognitive tasks measuring logical relations (P = 0.05), matching to sample (P = 0.04), math speed (P < 0.01), math percent correct (P = 0.04), and spatial processing (P < 0.01). Results from biochemistry and hematology blood panels remained within clinically normative ranges throughout all phases of the study. No participants were medically withdrawn; however, one participant voluntarily withdrew due to nausea and reduced appetite., Conclusions: Temporary (7-day) daily use of naltrexone was safe and did not negatively affect physical performance, cognitive functioning, marksmanship ability, or sleep in a healthy cohort of U.S. Army Soldiers., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The coronavirus disease 2019 (COVID-19) pandemic disrupted U.S. Military operations and potentially compounded the risk for adverse mental health outcomes by layering unique occupational stress on top of general restrictions, fears, and concerns. The objective of the current study was to characterize the prevalence of COVID-19 concerns and information needs, demographic disparities in these outcomes, and the degree to which COVID-19 concerns and information needs were associated with heightened risk for adverse mental health outcomes among U.S. Army soldiers., Materials and Methods: Command-directed anonymous surveys were administered electronically to U.S. soldiers assigned to one of three regional commands in the Northwest United States, Europe, and Asia-Pacific Region. Surveys were administered in May to June 2020 to complete (time 1: n = 21,294) and again in December 2020 to January 2021 (time 2: n = 10,861). Only active duty or active reservists/national guard were eligible to participate. Members from other branches of service were also not eligible., Results: Highly prevalent COVID-19 concerns included the inability to spend time with friends/family, social activities, and changing rules, regulations, and guidance related to COVID-19. Some information needs were endorsed by one quarter or more soldiers at both time points, including stress management/coping, travel, how to protect oneself, and maintaining mission readiness. COVID-19 concerns and information needs were most prevalent among non-White soldiers. Concerns and information needs did not decline overall between the assessments. Finally, COVID-19 concerns were associated with greater risk of multiple adverse mental health outcomes at both time points., Conclusions: COVID-19 concerns and information needs were prevalent and showed little evidence of decrement over the course of the first 6 months of the pandemic. COVID-19 concerns were consistently associated with adverse mental health outcomes. These data highlight two targets and potential demographic subgroups such that local leadership and Army medicine and public health enterprises can be better prepared to monitor and address to maintain force health and readiness in the face of possible future biomedical threats., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: A small body of research conducted mostly among civilians has shown that adequate training and preparation can prevent or reduce the development of behavioral health problems in first responders. Several civilian studies have shown that social support is protective against behavioral health problems. However, very few studies have examined the impact of these factors on the behavioral health of military first responders. Military first responders, who serve in the aftermath of natural disasters and disease outbreaks such as the coronavirus disease 2019 (COVID-19) pandemic, are often members of the National Guard (NG). The purpose of this study was to examine the impact of mortuary affairs training/handling human remains, role preparation, equipment preparation, and unit social support provided to families on the behavioral health of New York (NY) NG personnel deployed to assist the NY Office of Chief Medical Examiner with handling the remains of COVID-19 decedents., Materials and Methods: We invited 410 NYNG personnel who deployed for the Office of Chief Medical Examiner mission to complete an anonymous online questionnaire 3 to 6 months post-mission. Of the 158 participants, we used the data of the 141 participants who provided consent. Standard behavioral health measures (depression, anxiety, post-traumatic stress disorder, alcohol misuse, and insomnia) as well as study-specific items designed to understand the unique dynamics of this deployment were included. Hierarchical logistic regression analysis was used to examine the relationships between mortuary training, role preparation, equipment preparation, and unit support with behavioral health., Results: Close to two-thirds of the sample reported that they had not been trained in mortuary affairs/handling human remains before the mission. We also found that that lower levels of role preparation and unit support provided to the service members' families increased the odds of meeting criteria for one or more behavioral health problems, but that training in mortuary affairs and equipment preparation was unrelated to behavioral health., Conclusions: Our research points to the importance of emotionally and cognitively preparing service members for the specific dynamics of a deployment and the roles that that they are expected to play. Furthermore, it suggests that supporting the families of NG personnel during domestic missions can benefit the behavioral health of the NG personnel. Additional research is needed to corroborate these findings, particularly the impact of unit support provided to family members on service members' behavioral health., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The National Guard (NG) served as a critical component of the USA's response to the Coronavirus Disease 2019 (COVID-19) pandemic, while concurrently managing their personal responses to the pandemic. Determining whether the activation of NG service members in response to the COVID-19 pandemic was associated with a greater psychological strain can identify NG's needs for mental health support., Materials and Methods: We surveyed 3993 NG unit (NGU) service members (75% Army NG, 79% enlisted, 52% 30-49 years old, and 81% males) during the COVID-19 pandemic, with surveys administered between August and November 2020. Almost half (46%) of NGU service members reported being activated in response to COVID-19 (mean activation length = 18.6 weeks). Activated service members completed the survey approximately 2 to 3 months post-activation. Surveys assessed demographics, service-related characteristics, unit cohesion and positive leadership skills (leadership), and COVID-19 activation, and outcomes including probable post-traumatic stress disorder (PTSD), clinically significant anxiety and depression, and anger. Descriptive and logistic regression analyses were conducted. The study was approved by the Institutional Review Board of the Uniformed Services University of the Health Sciences in Bethesda, MD., Results: In all, 9.7% met the criteria for probable PTSD, 7.6% reported clinically significant anxiety and depression, and 13.2% reported feeling angry/anger outbursts. Multivariate logistic regression analyses, adjusting for demographic and service-related characteristics, indicated that COVID-19 activation was not associated with a greater risk of PTSD, anxiety and depression, or anger. Regardless of activation status, NGU service members with low levels of unit cohesion and leadership were more likely to report PTSD and anger, and low levels of unit cohesion were associated with clinically significant anxiety and depression., Conclusions: COVID-19 activation did not increase the risk of mental health difficulties among NGU service members. However, low levels of unit cohesion were associated with the risk of PTSD, anxiety and depression, and anger, and low levels of leadership were associated with the risk of PTSD and anger. The results suggest a resilient psychological response to COVID-19 activation and the potential for strengthening all NG service members through enhancing unit cohesion and leadership support. Future research on specific activation exposures, including the type of work tasks in which service members are engaged, particularly those associated with high-stress work conditions, is needed to help better understand their activation experience and how it may influence post-activation responses., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The U.S. Army developed a new tool called the Behavioral Health Readiness and Suicide Risk Reduction Review (R4) for suicide prevention. A 12-month evaluation study with the primary objective of testing the hypothesis (H1) that Army units receiving R4 would demonstrate improved outcomes in suicidal-behavior measures following the intervention, relative to control, was then conducted. The results of analyses to answer H1 are herein presented., Materials and Methods: The R4 intervention (R4-tools/instructions/orientation) evaluation study, Institutional Review Board approved and conducted in May 2019-June 2020, drew samples from two U.S. Army divisions and employed a repeated measurement in pre-/post-quasi-experimental design, including a nonequivalent, but comparable, business-as-usual control. Intervention effectiveness was evaluated using self-report responses to suicide-related measures (Suicide Behaviors Questionnaire-Revised/total-suicide behaviors/ideations/plans/attempts/non-suicidal self-injuries) at 6-/12-month intervals. Analyses examined baseline to follow-up linked and cross-sectional cohorts, incidence/prevalence, and intervention higher-/lower-use R4 subanalyses., Results: Both divisions demonstrated favorable in-study reductions in total-suicide burden, with relatively equivalent trends for total-suicide behaviors, total-suicide risk (Suicide Behaviors Questionnaire-Revised), suicidal ideations, and non-suicidal self-injuries. Although both demonstrated reductions in suicide plans, the control showed a more robust trend. Neither division demonstrated a significant reduction in suicide attempts, but subgroup analyses showed a significant reduction in pre-coronavirus disease 2019-attempt incidence among those with higher-use R4 relative to control., Conclusions: There is no evidence of harm associated with the R4 intervention. R4 effectiveness as a function of R4 itself requires confirmatory study. R4 is judged an improvement (no evidence of harm + weak evidence of effectiveness) over the status quo (no safety data or effectiveness studies) with regard to tool-based decision-making support for suicide prevention in the U.S. Army., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The Cohesion Assessment Team (CAT) provides battalion and brigade command teams with actionable insight into the climate of their unit and the presence of certain harmful behaviors. This assessment, initiated by the Vice Chief of Staff of the Army and initially managed by the Headquarters Department of the Army's People First Task Force, employs a framework from the Center for Army Professional Leadership to structure data and findings., Materials and Methods: This manuscript describes how to conduct a CAT assessment. To start, two battalions within the same brigade are selected or volunteer for observation based on various metrics. Data are collected from multiple sources including (1) army metrics, such as promotion rates and Uniformed Code of Military Justice actions, (2) subject matter expert in-person observations and interactions, (3) discussions with battalion and brigade staff, (4) survey data from approximately 90% of the soldiers in participating units, and (5) targeted interviews, focus groups, and listening sessions. Onsite data are collected and synthesized with the survey results within a week. Results are presented to battalion and brigade command teams. Briefs highlight key elements of the unit climate that should be maintained or improved. In addition, summarized results are presented to progressively higher echelons of leadership, culminating with the Vice Chief of Staff of the Army for consideration of army-wide changes., Results and Conclusions: The CAT focuses on providing leaders at brigade and below with relevant and actionable information to help inform their internal decision-making to improve their unit's climate. This capability is distinct in many ways, including its non-attributional systems focus and its methodical approach to quickly collecting and triangulating multiple data points. Additionally, the CAT helps leaders identify areas under their control that will impact unit climate, similar to the feedback that training events provide on unit readiness. Army leadership deemed the CAT pilot a success, and responsibility for future CATs was transferred to the Training and Doctrine Command (TRADOC) in October 2022., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: This prospective, multi-site, observational study describes ongoing efforts in support of the Fiscal Year 2018 National Defense Authorization Act (NDAA) Section 734 Blast Overpressure Study (BOS) to identify the acute effects impulse and blast exposure have on hearing abilities of the Warfighter in various military training environments., Materials and Methods: Hearing thresholds, a binaural tone detection task, and auditory symptoms were collected before and immediately following weapons exposure across nine military training environments from January 2020 to October 2022. An additional 25 non-exposed control participants also completed the behavioral test battery. A boothless audiometer was used to measure hearing ability in the field. Sound level meters were attached on-body to record the exposure environment throughout training., Results: Mean threshold change for the blast-exposed group was worse than the control group. Of the 188 blast-exposed participants, 23 experienced a temporary threshold shift (TTS) acutely after exposure. A decrease in binaural tone detection performance and increased symptom severity was found when comparing blast-exposed participants with a TTS versus those without a significant change in hearing. A complex but consistent relationship between measured exposure level (LAeq8hr) and the magnitude of the resulting TTS is suggested in the available data., Conclusions: Recent discussions on Section 734 studies examining the effects of repetitive blast exposure have indicated that hearing-related issues were a critical problem that needed additional research. Study outcomes provide highly repeatable results across various weapons systems with hazardous blast exposure. This standardized set of hearing assessment tools for evaluating acute effects of noise under field conditions has been critically important in improving our understanding of TTS in prospective human subject research., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: To support soldier readiness and mitigate the mental health consequences of deployments, Army regulation mandates soldiers to receive Deployment Cycle Resilience Training (DCRT) throughout their deployment cycle. A recent evaluation revealed several issues with the existing version that threatened the relevancy and usefulness of the training. The present article details the systematic approach taken by the Research Transition Office at the Walter Reed Army Institute of Research to revise the DCRT curriculum and presents the revision updates that are now included in DCRT version 3., Method: Curriculum developers (n = 2) with subject matter expertise relevant to the project followed an iterative process that was critical to the efficacy of the revisions. Developers used the existing DCRT modules as the curriculum framework and utilized several materials to inform the revisions to include Army doctrine, data from the quality improvement evaluation conducted by the Walter Reed Army Institute of Research, and the current research related to the deployment cycle, resilience, and behavior change. Internal and external stakeholders (n = 31) provided iterative feedback to ensure each of the six modules met DCRT revision objectives., Results: The revised DCRT curriculum was implemented in August 2021. The resulting revisions included an increase in inclusivity, an emphasis on growth opportunities, an integrative approach to the deployment cycle phases, and greater practical application. Additionally, the curriculum incorporates best practices found to enhance the delivery of resilience-based psychoeducational interventions, specifically within high-risk occupational settings like the military., Conclusions: The revisions outlined in this article enhance the training quality and potential effectiveness of DCRT, which can positively influence soldier and family readiness and mission success. Furthermore, the deliberate and iterative curriculum revision process can serve as a guide to other curriculum development projects, specifically within the military context. Implementation considerations and potential limitations are provided, and future directions are discussed to include the ongoing evaluation., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Experiences by service members in recent conflicts and training environments illuminate concerns about the possible effects of blast overpressure (BOP) exposure on brain health. Section 734 of the National Defense Authorization Act for Fiscal Year (FY) 2018 (Public Law 115-91) requires that the Secretary of Defense conducts a longitudinal medical study on blast pressure exposure of members of the Armed Forces during combat and training, and the Assistant Secretary of Defense for Health Affairs was assigned responsibility for fulfilling requirements. The study's goal is to improve DoD's understanding of the impact of BOP exposure from weapon systems on service members' brain health and inform policy for risk mitigation, unit readiness, and health care decisions. This article focuses on the activities of the Weapon Systems Line of Inquiry (LOI) and the development of a prototype BOP Tool., Materials and Methods: The DoD established the Section 734 Workgroup, which developed a program structure with five LOIs. The Weapon Systems LOI coordinated, collated, and analyzed information on BOP resulting from heavy weapons and blast events to inform strategies, and accounted for emerging research on health effects and performance. Ongoing research was leveraged to develop a BOP Tool as a standalone module and for integration into the Range Managers Toolkit., Results: The effort identified opportunities for the DoD to improve the clarity of communications about BOP exposure, risk, and safety; establish methods to leverage emerging research; and develop a prototype BOP Tool to predict exposure loads when firing heavy weapons in training., Conclusions: It is recommended that the DoD revises requirements and policy to improve and standardize safety guidance throughout research, development, testing, and evaluation; acquisition; and training. The validated BOP Tool allows users to generate a scenario to predict BOP exposure and allows service members to modify them during planning for safer training., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Although the US Government considers threats of misinformation, disinformation, and mal-information to rise to the level of terrorism, little is known about service members' experiences with disinformation in the military context. We examined soldiers' perceptions of disinformation impact on the Army and their units. We also investigated associations between disinformation perceptions and soldiers' sociodemographic characteristics, reported use of fact-checking, and perceptions of unit cohesion and readiness., Methods: Active-duty soldiers (N = 19,465) across two large installations in the Southwest US completed an anonymous online survey., Results: Sixty-six percent of soldiers agreed that disinformation has a negative impact on the Army. Thirty-three percent of soldiers perceived disinformation as a problem in their unit. Females were more likely to agree that disinformation has a negative impact on the Army and is a problem in their unit. Higher military rank was associated with lower odds of agreeing that disinformation is a problem in units. Most soldiers were confident about their ability to recognize disinformation (62%) and reported using fact-checking resources (53%), and these factors were most often endorsed by soldiers who agreed that disinformation is a problem for the Army and their unit. Soldiers' perceptions of unit cohesion and readiness were negatively associated with the perception that disinformation is a problem in their unit., Conclusion: While the majority of soldiers viewed disinformation as a problem across the Army, fewer perceived it as problematic within their units. Higher levels of reported fact-checking were most evident among those who perceived disinformation as a problem, suggesting that enhancing awareness of the problem of disinformation alone could help mitigate its deleterious impact. Perceptions of disinformation problems within units were associated with soldiers' perceptions of lower unit cohesion and readiness, highlighting misinformation, disinformation, and mal-information's impact on force readiness. Limitations and future directions are discussed., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Simulation of blast exposure in the laboratory has been inconsistent across laboratories. This is primarily because of adoption of the shock wave-generation techniques that are used in aerodynamic tests as opposed to application of blast exposures that are relevant to combat and training environments of a Warfighter. Because of the differences in blast signatures, characteristically different pathological consequences are observed among the preclinical studies. This is also further confounded by the varied exposure positioning of the animal subject (e.g., inside the blast simulator vs. at the mouth of the simulator). In this study, we compare biomechanical responses to blast exposures created in an advanced blast simulator (ABS) that generates "free-field"-like blast exposure with those produced by a traditionally applied cylindrical blast simulator (CBS) that generates a characteristically different blast signature. In addition, we have tested soft-armor vest protective responses with the ABS and CBS to compare the biomechanical responses to this form of personal protective equipment in each setting in a rodent model., Materials and Methods: Anesthetized male Sprague-Dawley rats (n = 6) were surgically probed with an intrathoracic pressure (ITP) transducer and an intracranial pressure (ICP) transducer directed into the lateral cerebral ventricle (Millar, Inc.). An ABS for short-duration blast or a CBS for long-duration blast was used to expose animals to an incident blast overpressure of 14.14 psi (impulse: 30.27 psi*msec) or 16.3 psi (impulse: 71.9 psi*msec) using a custom-made holder (n = 3-4/group). An external pitot probe located near the animal was used to measure the total pressure (tip) and static gauge (side-on) pressure. Data were recorded using a TMX-18 data acquisition system (AstroNova Inc.). MATLAB was used to analyze the recordings to identify the peak amplitudes and rise times of the pressure traces. Peak ICP, peak ITP, and their impulses were normalized by expressing them relative to the associated peak static pressure., Results: Normalized impulse (ABS: 1.02 ± 0.03 [vest] vs. 1.02 ± 0.01 [no-vest]; CBS: 1.21 ± 0.07 [vest] vs. 1.01 ± 0.01 [no-vest]) and peak pressure for ICP (ABS: 1.03 ± 0.03 [vest] vs. 0.99 ± 0.04 [no-vest]; CBS: 1.06 ± 0.08 [vest] vs. 1.13 ± 0.06 [no-vest]) remained unaltered when comparisons are made between vest and no-vest groups, and the normalized peak ITP (ABS: 1.50 ± 0.02 [vest] vs. 1.24 ± 0.16 [no-vest]; CBS: 1.71 ± 0.20 [vest] vs. 1.37 ± 0.06 [no-vest]) showed a trend of an increase in the vest group compared to the no-vest group. However, impulses in short-duration ABS (0.94 ± 0.06 [vest] vs. 0.92 ± 0.13 [no-vest]) blast remained unaltered, whereas a significant increase of ITP impulse (1.21 ± 0.07 [vest] vs. 1.17 ± 0.01 [no-vest]) in CBS was observed., Conclusions: The differences in the biomechanical response between ABS and CBS could be potentially attributed to the higher dynamic pressures that are imparted from long-duration CBS blasts, which could lead to chest compression and rapid acceleration/deceleration. In addition, ICP and ITP responses occur independently of each other, with no evidence of thoracic surge., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Combat injuries are complex and multimodal. Most injuries to the extremities occur because of explosive devices such as improvised explosive devices. Blast exposure dramatically increases the risk of infection in combat wounds, and there is limited available information on the best antibiotic treatments for these injuries. We previously demonstrated that mice exposed to blast displayed a delayed clearance of cefazolin from the plasma and liver; further semi-mechanistic modeling determined that cefazolin concentrations in the skin of these mice were reduced. Our objective was to investigate the effects of blast on the pharmacokinetics of antibiotics of different types used for the treatment of combat wounds in the rat model., Materials and Methods: Male Sprague Dawley rats were exposed to blast overpressure followed by injection of a bolus of animal equivalent doses of an antibiotic (cefazolin, cefepime, ertapenem, or clindamycin) into the tail vein at 1-hour post-blast exposure. Blood was collected at predetermined time points via repeated sampling from the tail vein. Animals were also euthanized at predetermined time points, at which time liver, kidney, skin, and blood via cardiac puncture were collected. Antibiotic concentrations were determined by ultra-performance liquid chromatography-tandem mass spectrometry., Results: Blast-exposed rats exhibited a similar rate of clearance compared to non-blasted rats in the blood, liver, kidney, and skin, which is inconsistent with the data regarding cefazolin in blast-exposed mice., Conclusions: Our results in rats do not recapitulate our previous observation of delayed cefazolin clearance in mice following the blast overpressure exposure. Although using rats permitted us to collect multiple blood samples from the same animals, rats may not be a suitable model for measuring the pharmacokinetics of antibiotics following blast. The interpretation of the results may be challenging because of variation in data among rat subjects in the same sample groups., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

We report a case of febrile Plasmodium falciparum malaria in a 36-year-old male patient occurring 14 years after immigration from and more than 12 months since a return visit to the endemic area. The critical need for awareness regarding late presentations of P. falciparum is discussed., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: This study evaluated the use of an online learning platform [Joint Knowledge Online (JKO)] for dissemination of the Veterans Affairs and Department of Defense Clinical Practice Guidelines for Management of Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD). User satisfaction with the training program was assessed, users were asked to estimate their knowledge base about PTSD and ASD, and users provided comments about how they might use the course material in their clinical practice., Materials and Methods: A total of 4,442 users took at least one of three courses offered via JKO related to the PTSD Clinical Practice Guidelines (CPG) between July 1, 2019 and June 25, 2020. A total of 1,663 users took the post-test after the JKO courses and 235 applied to a second website (J7) which granted Continuing Education (CE) credits. Data were gathered from the JKO post-course survey, as well as the J7 course survey, which also asked for respondents' written comments., Results: User satisfaction was analyzed using the JKO survey Likert scale data for each course, and results found most users rated the courses as "good" or "great." Users were also asked to evaluate their knowledge about PTSD management before and after the course. Results from all three courses showed a statistically significant change in pre-post knowledge with a medium effect size. Thematic analysis was performed on the write-in comments from each course. Comments indicated participants found the assessment tools provided in the courses to be of particular value., Conclusions: The VA/DoD's online learning platform (JKO) was a user-friendly, effective tool for training users on PTSD and ASD clinical practice guidelines. Users were satisfied with their experience of the trainings on JKO and improved their knowledge base about the CPG. This study did not evaluate patient data for CPG compliance, but the future study may benefit from these outcomes to demonstrate provider adherence to the guidelines., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Acute Stress Reactions (ASRs) affect a subgroup of individuals who experience traumatic stress. In the context of military operations, such reactions are often termed Combat and Operational Stress Reactions (COSRs). COSRs not only encompass all symptoms of ASRs but also include additional symptoms related to military combat and may develop at a rate higher than the general public experiences ASRs. Despite an obvious need, there are currently no approved pharmacologic treatments or guidelines for ASR and/or COSR. Preclinical rodent stress models and behavioral assessments are used to evaluate pharmacotherapies and elucidate underlying mechanisms. Here, we combined established traumatic stress models to develop a model of traumatic stress relevant to military trauma exposure and measured behavioral outcomes that reflect outcomes observed in ASRs and COSRs., Materials and Methods: Adult male rats underwent exposure to either a combination of two or three traumatic stress exposures (e.g., predator exposure, underwater trauma (UWT), and/or inescapable shock) or control procedures. Behavioral performance on the open field, elevated plus maze, and acoustic startle response (SR) was then assessed 24- and 48-hours following stress/control procedures., Results: In Experiment 1, rats were exposed to a two-stressor model, where predator exposure was coupled with UWT. Minor behavioral deficits were observed in SR for stress-exposed rats as compared to controls. In Experiment 2, inescapable shock was added to predator exposure and UWT. Behavioral performance deficits were observed across all behavioral tests. In Experiment 3, procedures from Experiment 2 were repeated with the only major modification being a shortened predator exposure duration, which resulted in performance deficits in SR only., Conclusions: We found that the three-stressor model of Experiment 2 resulted in the greatest overall behavioral disturbance (both in the number of variables and magnitude of stress effects). Interestingly, behavioral deficits elicited from the shorter predator exposure were distinct from those observed with longer predator exposure times. Together, these results generally suggest that combined preclinical stressors with military-relevant elements result in behavioral performance deficits reflective of post-trauma phenotypes in Soldiers. The present findings support the use of both physical and psychological stressors to model operationally relevant traumatic stress exposure., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Mental skills such as focusing attention and managing emotions are essential for optimal performance in high-stress occupations. Studies with military samples have demonstrated that mindfulness training (MT) led to improved computer-based cognitive performance., Materials and Methods: To examine the impact of MT on operational performance, mental skills, and psychological health, a short-form program, Mindfulness-Based Attention Training (MBAT), was delivered to active duty soldiers as part of two randomized trials. Participants in study 1 (n = 121) and study 2 (n = 77) were randomized to one of three conditions: MT with proctored practice, MT with unproctored practice, or a waitlist control. Weekly 2-hour MBAT sessions were offered to participants in both MT conditions for 4 weeks. Beyond these sessions, participants also engaged in mindfulness practice that was proctored (within the occupational context) or unproctored (left up to the individual) for four subsequent weeks., Results: Overall, the frequency of mindfulness practice was generally associated with better performance and improvements in mental skills. In study 1, those who practiced 3 or more days per week performed better on marksmanship under physical stress and reported fewer attentional lapses, less emotion regulation difficulties, greater mental toughness, and higher self-reported mindfulness compared to those who did not practice. In study 2, the frequency of mindfulness practice was associated with fewer attentional lapses and emotion regulation difficulties., Conclusions: Consistent with prior findings, results suggest that regular engagement in MT practice may help to optimize operational performance and improve mental skills in military cohorts., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: At the start of the coronavirus disease 2019 (COVID-19) pandemic, Walter Reed Army Institute of Research (WRAIR) mobilized to rapidly conduct medical research to detect, prevent, and treat the disease in order to minimize the impact of the pandemic on the health and readiness of U.S. Forces. WRAIR's major efforts included the development of the Department of Defense (DoD) COVID-19 vaccine candidate, researching novel drug therapies and monoclonal antibodies, refining and scaling-up diagnostic capabilities, evaluating the impact of viral diversity, assessing the behavioral health of Soldiers, supporting U.S. DoD operational forces overseas, and providing myriad assistance to allied nations. WRAIR personnel have also filled key roles within the whole of government response to the pandemic. WRAIR had to overcome major pandemic-related operational challenges in order to quickly execute a multimillion-dollar portfolio of COVID-19 research. Consequently, the organization learned lessons that could benefit other leaders of medical research organizations preparing for the next pandemic., Materials and Methods: We identified lessons learned using a qualitative thematic analysis of 76 observation/recommendation pairs from across the organization. These lessons learned were organized under the Army's four pillars of readiness (staffing, training, equipping, and leadership development). To this framework, we added organizing and leading to best capture our experiences within the context of pandemic response., Results: The major lessons learned for organizing were: (1) the pandemic created a need to rapidly pivot to new scientific priorities; (2) necessary health and safety precautions disrupted the flow of normal science and put programs at risk of missing milestones; (3) relationships with partners and allies facilitated medical diplomacy and advancement of U.S. national military and economic goals; and (4) a successful response required interoperability within and across multiple organizations. For equipping: (1) existing infrastructure lacked sufficient capacity and technical capability to allow immediate countermeasure development; (2) critical supply chains were strained; and (3) critical information system function and capacity were suddenly insufficient under maximum remote work. For staffing and training: (1) successful telework required rapid shifts in management, engagement, and accountability methods; and (2) organizational policies and processes had to adapt quickly to support remote staffing. For leading and leadership development (1) engaged, hopeful, and empathetic leadership made a difference; and (2) the workforce benefitted from concerted leadership communication that created a shared understanding of shifting priorities as well as new processes and procedures., Conclusions: An effective pandemic response requires comprehensive institutional preparedness that facilitates flexibility and surge capacity. The single most important action leaders of medical research organizations can take to prepare for the next pandemic is to develop a quick-reaction force that would activate under prespecified criteria to manage reprioritization of all science and support activities to address pandemic response priorities at the velocity of relevance., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Drill sergeants work under mentally and physically challenging conditions. The current study examined self-reported rates of physical injuries in drill sergeants; rates of treatment-seeking for injuries; perceived barriers toward treatment-seeking; and associated demographic and environmental factors., Materials and Methods: Drill sergeants from across all Army basic training locations completed self-report surveys from September to November of 2018. In total, 726 drill sergeants were included in analyses. Drill sergeants indicated whether they had acquired an injury during their time in the drill sergeant role and whether they had sought treatment for all such injuries. Furthermore, drill sergeants rated their agreement with a number of possible perceived barriers to treatment-seeking for physical injuries. Regression models examining each phenomenon included hours of sleep obtained per day; general- and health-specific leadership behaviors of the company command teams; unit cohesion; time as a drill sergeant; duty location; gender; military operational specialty; years in the military; previous combat deployments; and route of assignment. The study was approved by the Walter Reed Army Institute of Research Institutional Review Board., Results: In total, 38% of respondents reported acquiring an injury during their time as drill sergeants. Of those who had acquired an injury, 61% reported seeking medical help for all injuries acquired. Injuries were more likely in females (49%) than in males (34%) and less likely in drill sergeants reporting at least 6 hours of sleep (27%) versus those reporting 5 hours (40%) and 4 hours or less (43%). Reported comparisons were significant after controlling for demographic and environmental variables in regression models. The most strongly endorsed perceived barriers to treatment-seeking were "Seeking help would place too much burden on the other drill sergeants" (69%) and "Seeking help would interfere with my ability to train the recruits" (60%). Both of these perceived barriers were significantly associated with reduced treatment-seeking in injured drill sergeants, after controlling for demographic and environmental variables., Conclusions: This study is the first to examine injury occurrence, treatment-seeking, and perceived barriers to treatment-seeking in U.S. Army drill sergeants. Building on previous studies that showed the negative effects of sleep deprivation on the safety and behavioral health of drill sergeants, the current study gives further evidence of the negative effects of such sleep deprivation, this time in the domain of physical injuries. The results suggest that pursuing strategies that allow for healthier sleep duration may contribute to injury reduction., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Musculoskeletal injuries (MSKIs) are a significant health problem in the military. Accordingly, identifying risk factors associated with MSKI to develop targeted strategies that attenuate injury risk remains a top priority within the military. Insufficient sleep has garnered increased attention as a potential risk factor for MSKI in both civilians and military personnel. Yet, there are no systematic evaluations of the potential association between sleep and MSKI in the military. The purpose of this review is to examine the relationship between sleep and injury in military personnel., Materials and Methods: Literature searches were performed in multiple electronic databases using keywords relevant to sleep quantity and quality, MSKI, and military populations. Two investigators independently assessed the methodological quality of each study using the Newcastle-Ottawa Scale for cohort studies or an adapted form of this scale for cross-sectional studies., Results: The search yielded 2402 total citations, with 8 studies (3 cohort and 5 cross-sectional) fitting the inclusion criteria. Overall, the systematic review found 5 of the 8 reviewed studies supporting an association between sleep (quality and duration) and MSKI in military personnel. Specifically, poor sleep was associated with increased injury incidence in 2 cohort and 3 cross-sectional studies., Conclusion: This is the first systematic review to evaluate the published literature on the association between sleep and MSKI risk in military populations. Although there is currently limited research on this topic, findings suggest that sleep is associated with MSKI and should be considered when designing strategies aimed at reducing MSKI risk in military personnel., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The glia-operated glymphatic system, analogous to but separate from the lymphatics in the periphery, is unique to brain and retina, where it is very closely aligned with the arteriolar system. This intimate relationship leads to a "blood vessel like" distribution pattern of glymphatic vessels in the brain. The spatial relationship of glymphatics, including their essential component aquaporin-4 with vascular pericytes of brain arterioles is critical to functionality and is termed "polarization"., Materials and Methods: We review the available literature on the factors affecting the resting state of glymphatics under normal conditions, including the important role of sleep in supporting normal glymphatic function (including waste removal) as well as the critical role of "polarization" under normal conditions. We then examine the effects of traumatic brain injury (TBI) or seizures on the glymphatic system and its state of "polarization"., Results: Injury, such as TBI, can disrupt polarization resulting in "depolarization" leading to brain edema., Conclusion: Damage to the glymphatic system might explain the brain edema so often seen following TBI or other insult. Moreover, similar damage should be expected in response to seizures, which can often be associated with chemical exposures as well as with TBI. Military operations, whether night operations or continuous operations, quite often impose limitations on sleep. As glymphatic function is sleep-dependent, sleep deprivation alone could compromise glymphatic function, as well, and might in addition, explain some of the well-known performance deficits associated with sleep deprivation. Possible effects of submarine and diving operations, chemical agents (including seizures), as well as high altitude exposure and other threats should be considered. In addition to the brain, the retina is also served and protected by the glymphatic system. Accordingly, the effect of military-related risks (e.g., exposure to laser or other threats) to retinal glymphatic function should also be considered. An intact glymphatic system is absolutely essential to support normal central nervous system functionality, including cognition. This effects a broad range of military threats on brain and retinal glymphatics should be explored. Possible preventive and therapeutic measures should be proposed and evaluated, as well., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Sleep disorders are common in the military, and there is a gross shortage of sleep specialists in the military health system. The purposes of the present study were to (1) understand perceptions and expectations surrounding sleep telehealth approaches and (2) solicit feedback to optimize and refine a proposed novel sleep telehealth management platform. To accomplish these objectives, we investigated the perceptions, expectations, and preferences of active duty service members (ADSMs) with sleep disorders, primary care managers (PCMs), and administrative stakeholders regarding sleep telehealth management., Materials and Methods: Using convenience sampling, we conducted five focus groups with 26 ADSMs and 11 individual interviews with PCMs from two military treatment facilities in the U.S National Capital Region and 11 individual interviews with administrative sleep stakeholders (9 military and 2 civilian)., Results: Active duty service members, PCMs, and administrative stakeholders provided insight regarding expectations for sleep telehealth as well as suggestions to optimize the novel sleep telehealth platform. In terms of outcomes, ADSMs expected sleep telehealth to improve sleep and convenience. Primary care managers expected improved sleep and other comorbidities, enhanced operational readiness, and reduced mortalities among their patients. Administrators expected increased access to care, optimized utilization of health services, realized cost savings, reduced accidents and errors, and improved military performance. In terms of the platform, for ADSMs, desired characteristics included delivery of timely clinical reports, improved patient-provider communication, and enhanced continuity of care. For PCMs and administrators,an ideal sleep telehealth solution will improve the diagnosis and triage of sleep patients, save PCM time, be easy to use, and integrate with the electronic health record system., Conclusion: The proposed sleep telehealth platform appealed to nearly all participants as a significant force multiplier to enhance sleep disorder management in the military. Stakeholders offered valuable recommendations to optimize the platform to ensure its successful real-world implementation., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: United States Air Force Academy (USAFA) cadets are at risk for sustaining concussions; however, several factors inhibit disclosure. We aimed to better understand the role of social support in concussion disclosure., Methods and Materials: We used a mixed methods approach with an electronic survey and interviews. The survey used a 9-point Likert scale (1 = strongly disagree and 9 = strongly agree) to assess concussion disclosure. Survey items asked cadets whom they felt most comfortable disclosing a concussion or bell-ringer/ding to, how quickly they would seek medical attention for a suspected concussion or bell-ringer/ding, whether cadets would be generally supportive/unsupportive of another cadet disclosing a concussion to medical staff, and whether other cadets important to them would be generally supportive/unsupportive if they reported a concussion to medical staff. Two multivariate linear regressions, one for concussion and one for bell-ringers/dings, were calculated to determine whether cadet choice of the person they felt most comfortable disclosing a concussion or bell-ringer/ding to predicted whether they would immediately seek medical attention for either condition. Choice of person included Air Officer Commanding (AOC)/Academy Military Trainer (AMT), upper classmen, cadet who had recovered from a concussion, cadet, closest friend, teammate, and squadmate. Descriptive analyses assessed whether cadets felt supported or unsupported by other cadets and by those who were important to them concerning concussion reporting. Thirty-four semi-structured interviews were conducted with cadets to explore their views on concussion disclosure., Results: Increased comfort with disclosing a suspected concussion to an AOC/AMT had higher agreement seeking medical attention (β = 0.28, P < .001). For every 1-point increase in being comfortable disclosing a potential bell-ringer/ding to an AOC/AMT (β = 0.272, P < .001), squadmate (β = 0.241, P = .002), and teammate (β = -0.182, P = .035), agreement for seeking medical attention immediately increased 0.27, increased 0.24, and decreased 0.18, respectively. Interviews indicated cadets would often speak to a peer before seeking medical attention., Conclusions: Our results suggested that cadets felt comfortable reporting a suspected concussion or bell-ringer/ding to various peers and that those peers would be supportive of that choice, indicating social support. Future interventions should include educating cadets that peers may come to them, especially if they are AOCs/AMTs or squadmates., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Sleep disorders' are highly prevalent among U.S. active duty service members (ADSMs) and present well-documented challenges to military health, safety, and performance. In addition to increased need for sleep medicine services, a major barrier to effective sleep management has been a lack of alignment among patients, health providers, and economic-decision-makers. To address this gap in knowledge, the purpose of the present study was to engage diverse stakeholders vested in improving sleep disorders' management in the military., Materials and Methods: We elicited feedback from ADSMs with sleep disorders (five focus group discussion, n = 26) and primary care managers (PCMs) (11 individual semi-structured interview) in two military treatment facilities (MTFs) in the National Capitol Region, in addition to national level military and civilian administrative stakeholders (11 individual semi-structured interview) about their experiences with sleep disorders' management in U.S. MTFs, including facilitators and barriers for reaching a definitive sleep diagnosis, convenience and effectiveness of sleep treatments, and key desired outcomes from interventions designed to address effectively sleep disorders in the U.S. military health care system (MHS). Recordings from focus groups and semi-structured interviews were transcribed verbatim and analyzed using QSR International's NVivo 12 software using inductive thematic analysis. The study was approved by Walter Reed National Military Medical Center Department of Research Programs., Results: Active duty service members with sleep disorders often fail to recognize their need for professional sleep management. Whereas PCMs identified themselves as first-line providers for sleep disorders in the military, patients lacked confidence that PCMs can make accurate diagnoses and deliver effective sleep treatments. Active duty service members cited needs for expeditious treatment, educational support and care coordination, and support for obtaining sleep treatments during deployment. Challenges that PCMs identified for effective management include insufficient time during routine care visits, delays in scheduling testing procedures, and limited number of sleep specialists. Primary care managers suggested offering evidence-based telehealth tools and enhanced care coordination between PCMs and specialists; standardized medical education, materials, and tools; patient preparation before appointments; self-administered patient education; and including behavioral sleep specialists as part of the sleep management team. For administrative stakeholders, key outcomes of enhanced sleep management included (1) improved resource allocation and cost savings, and (2) improved ADSM safety, productivity, and combat effectiveness., Conclusion: Current military sleep management practices are neither satisfactory nor maximally effective. Our findings suggest that solving the military sleep problem will require sustained effort and ongoing collaboration from ADSM patients, providers, and health systems leaders. Important potential roles for telehealth and technology were identified. Future research should seek to enhance implementation of sleep management best practices to improve outcomes for patients, providers, MHS, and the military as a whole., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: During the wars in Iraq and Afghanistan, increased incidence of multidrug-resistant (MDR) organisms, as well as polymicrobial wounds and infections, complicated the management of combat trauma-related infections. Multidrug resistance and wound microbiology are a research focus of the Trauma Infectious Disease Outcomes Study (TIDOS), an Infectious Disease Clinical Research Program, Uniformed Services University, research protocol. To conduct comprehensive microbiological research with the goal of improving the understanding of the complicated etiology of wound infections, the TIDOS MDR and Virulent Organisms Trauma Infections Initiative (MDR/VO Initiative) was established as a collaborative effort with the Brooke Army Medical Center, Naval Medical Research Center, U.S. Army Institute of Surgical Research, and Walter Reed Army Institute of Research. We provide a review of the TIDOS MDR/VO Initiative and summarize published findings., Methods: Antagonism and biofilm formation of commonly isolated wound bacteria (e.g., ESKAPE pathogens-Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.), antimicrobial susceptibility patterns, and clinical outcomes are being examined. Isolates collected from admission surveillance swabs, as part of infection control policy, and clinical infection workups were retained in the TIDOS Microbiological Repository and associated clinical data in the TIDOS database., Results: Over the TIDOS study period (June 2009 to December 2014), more than 8,300 colonizing and infecting isolates were collected from military personnel injured with nearly one-third of isolates classified as MDR. At admission to participating U.S. military hospitals, 12% of wounded warriors were colonized with MDR Gram-negative bacilli. Furthermore, 27% of 913 combat casualties with ≥1 infection during their trauma hospitalization had MDR Gram-negative bacterial infections. Among 335 confirmed combat-related extremity wound infections (2009-2012), 61% were polymicrobial and comprised various combinations of Gram-negative and Gram-positive bacteria, yeast, fungi, and anaerobes. Escherichia coli was the most common Gram-negative bacilli isolated from clinical workups, as well as the most common colonizing MDR secondary to extended-spectrum β-lactamase resistance. Assessment of 479 E. coli isolates collected from wounded warriors found 188 pulsed-field types (PFTs) from colonizing isolates and 54 PFTs from infecting isolates without significant overlap across combat theaters, military hospitals, and study years. A minority of patients with colonizing E. coli isolates developed subsequent infections with the same E. coli strain. Enterococcus spp. were most commonly isolated from polymicrobial wound infections (53% of 204 polymicrobial cultures). Patients with Enterococcus infections were severely injured with a high proportion of lower extremity amputations and genitourinary injuries. Approximately 65% of polymicrobial Enterococcus infections had other ESKAPE organisms isolated. As biofilms have been suggested as a cause of delayed wound healing, wound infections with persistent recovery of bacteria (isolates of same organism collected ≥14 days apart) and nonrecurrent bacterial isolates were assessed. Biofilm production was significantly associated with recurrent bacteria isolation (97% vs. 59% with nonrecurrent isolates; P < 0.001); however, further analysis is needed to confirm biofilm formation as a predictor of persistent wound infections., Conclusions: The TIDOS MDR/VO Initiative provides comprehensive and detailed data of major microbial threats associated with combat-related wound infections to further the understanding of wound etiology and potentially identify infectious disease countermeasures, which may lead to improvements in combat casualty care., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Dengue fever, caused by any of the four dengue viruses (DENV1-4), is endemic in more than 100 countries around the world. Each year, up to 400 million people get infected with dengue virus. It is one of the most important arthropod-borne viral diseases. Dengue's global presence poses a medical threat to deploying military personnel and their dependents. An accurate diagnosis followed by attentive supportive care can improve outcomes in patients with severe dengue disease. Dengue diagnostic tests based on PCR and ELISA platforms have been developed and cleared by the U.S. FDA. However, these diagnostic assays are laborious and usually require highly trained personnel and specialized equipment, which presents a significant challenge when conducting operations in austere and resource-constrained areas. InBios International, Inc. (Seattle, WA) has developed two rapid and instrument-free immunochromatographic test prototype devices (multiplex and traditional formats) for dengue diagnosis., Materials and Methods: To determine the performance of the InBios immunochromatographic tests, 183 clinical samples were tested on both prototype devices. Both assays were performed without any instruments and the results were read in 20 minutes., Results: The traditional format had better overall performance (sensitivity: 97.4%; specificity: 90%) than the multiplex format (sensitivity: 86.9%; specificity: 63.3%). The traditional format was superior in serotype-specific detection with 100% overall sensitivity for DENV1, DENV3, and DENV4 and 93.3% sensitivity for DENV2 compared to the multiplex format (91.7%, 78.3%, 83.3%, and 96.3% for DENV1, 2, 3, and 4, respectively). The traditional format was easier to read than the multiplex format. The multiplex format was simpler and faster to set up than the traditional format., Conclusions: The InBios traditional format had a better overall performance and readability profile than the multiplex format, while the multiplex format was easier to set up. Both formats were highly sensitive and specific, were easy to perform, and did not require sophisticated equipment. They are ideal for use in resource-limited settings where dengue is endemic. Based on our overall assessment, the traditional format should be considered for further development and used in the upcoming multicenter clinical trial toward FDA clearance., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Decision-making related to the utilization of host-nation medical resources in austere forward-deployed environments is complex. Clinical circumstances, local medical intelligence availability, transportation assets, uncertainty regarding standard-of-care variations, military/host-nation funding complications, and regional security concerns all factor into consideration. A case of a U.S. active duty military service member who suffered a cardiac arrest on a military base in Southwest Asia is described in this report. After return of circulation following defibrillation, he was administered thrombolytic therapy for an electrocardiogram-identified ST-elevation myocardial infarction and transported to a local host-nation cardiac hospital for emergent percutaneous coronary intervention. During his subsequent transportation back to the USA, surveillance testing identified that he was colonized with a rare strain of Pseudomonas aeruginosa, demonstrating New Delhi metallo-beta-lactamase-1 and 16S RNA methyltransferase-2 enzymes, which confer significant resistance to carbapenem and aminoglycoside antibiotics, respectively.1-3 This combination of antibiotic resistance has been reported very rarely in the medical literature and has never been reported within the deployed military health system until now. The risk of exposure to multidrug-resistant organisms was not a factor initially considered in the decision to utilize host-nation medical resources in this case, which provided lesson learned and raised new questions, for future operational medical planning., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: It is expected that future multi-domain operational (MDO) combat environments will be characterized by limited capabilities for immediate combat stress control support services for soldiers or immediate evacuation from theater. The operational requirements of the future battlefield make it unlikely that current models for behavioral health (BH) treatment could be implemented without significant adjustments. We conducted a qualitative study with Special Forces medics and operators and soldiers who had deployed to austere conditions in small groups in an effort to inform construction of a BH service delivery model for an MDO environment. The objectives of this study were (1) characterizing stressors and BH issues that were encountered and (2) describing mitigation strategies and resources that were useful or needed in these types of deployments., Materials and Methods: Six focus groups were conducted at three army installations with 23 active duty soldiers, including three groups of medics using a semi-structured interview guide focused on stressors they encountered during deployments to austere conditions, and the impact of those stressors on mission and focus. Focus group recordings were transcribed, imported into NVivo software (version 12), and independently coded by two researchers. An analysis was then conducted to develop themes across participants. The study was reviewed by the Walter Reed Army Institute of Research Human Subjects Protection Board., Results: Behavioral health concerns were commonly cited as a stressor in far forward environments. Other common stressors included ineffective or inexperienced leaders, as well as poor team dynamics (e.g., communication and cohesion). Four primary strategies were mentioned as mitigations for deployment stressors: leadership, morale, resilience training, and strength of the team. When asked about resources or training that would have helped with these types of deployments, participants frequently mentioned the availability of BH providers and development of new and realistic BH skills trainings for non-providers and leaders., Conclusions: Current models for treating BH problems need to be adapted for the future MDO environments in which soldiers will be expected to deploy. Understanding what issues need to be addressed in these environments and how they can best be delivered is an important first step. This study is the first to use qualitative results from those who have already deployed to such environments to describe the stressors and BH issues that were most commonly encountered, the mitigation strategies used, and the resources that were useful or needed., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Multidrug-resistant (MDR) Gram-negative infections complicate care of combat casualties. We describe the clinical characteristics, resistance patterns, and outcomes of Pseudomonas aeruginosa infections in combat casualties., Methods: Combat casualties included in the Trauma Infectious Disease Outcomes Study with infections with and without P. aeruginosa isolation during initial hospitalization were compared. Pseudomonas aeruginosa from initial wound, blood, and serial isolates (≥7 days from previous isolate) collected from June 2009 through February 2014 was subjected to antimicrobial susceptibility testing, pulsed-field gel electrophoresis, and whole genome sequencing for assessing clonality. Multidrug resistance was determined using the CDC National Healthcare Safety Network definition., Results: Of 829 combat casualties with infections diagnosed during initial hospitalization, 143 (17%) had P. aeruginosa isolated. Those with P. aeruginosa were more severely injured (median Injury Severity Score 33 [interquartile range (IQR) 27-45] vs 30 [IQR 18.5-42]; P < .001), had longer hospitalizations (median 58.5 [IQR 43-95] vs 38 [IQR 26-56] days; P < .001), and higher mortality (6.9% vs 1.5%; P < .001) than those with other organisms. Thirty-nine patients had serial P. aeruginosa isolation (median 2 subsequent isolates; IQR: 1-5), with decreasing antimicrobial susceptibility. Ten percent of P. aeruginosa isolates were MDR, associated with prior exposure to antipseudomonal antibiotics (P = .002), with amikacin and colistin remaining the most effective antimicrobials. Novel antimicrobials targeting MDR Gram-negative organisms were also examined, and 100% of the MDR P. aeruginosa isolates were resistant to imipenem/relabactam, while ceftazidime/avibactam and ceftolozane/tazobactam were active against 35% and 56% of the isolates, respectively. We identified two previously unrecognized P. aeruginosa outbreaks involving 13 patients., Conclusions: Pseudomonas aeruginosa continues to be a major cause of morbidity, affecting severely injured combat casualties, with emergent antimicrobial resistance upon serial isolation. Among MDR P. aeruginosa, active antimicrobials remain the oldest and most toxic. Despite ongoing efforts, outbreaks are still noted, reinforcing the crucial role of antimicrobial stewardship and infection control., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

This is a case report of a 42-year-old woman who presented to a clinic with a history of progressive left foot and ankle swelling. She had a suspected history of myectoma, but had never been officially diagnosed despite repeated cultures and debridements over the course of decades. The inciting event occurred approximately 30 years prior in her home country of Belize. Her wound culture revealed Scedosporium apiospermum as the causative agent. Treatment included surgical debridement and oral antifungal therapy. This case represents an interesting adjunct to the differential diagnosis for military physicians, as mycetomas are prevalent in many of the areas where our forces are deployed and may only present after the service member has left active service because of its naturally indolent course., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: U.S. Army healthcare providers' use of profiles to document and communicate behavioral health (BH) condition limitations to commanders is vital to understanding both the individual soldier's BH readiness for missions and, as an aggregate, the unit's overall BH readiness status. Quantitative work exploring the link between soldier attitudes toward BH profiles and treatment utilization found that profiles may actually promote increases in treatment-seeking behavior in those receiving conventional BH services. BH provider attitudes on the subject, however, have not been quantitatively explored. Using data from the recently described Behavioral Health Readiness and Decision-Making Instrument (B-REDI) study, the current inquiry addresses this by examining BH providers' pre-/post-B-REDI attitudes toward BH profiles, including therapeutic alliance, to better understand how BH profiles may impact BH treatment., Methods: This study was approved by the WRAIR Institutional Review Board and is part of the larger B-REDI study. BH providers (n = 307) across five installations supporting active duty U.S. Army Divisions completed surveys longitudinally across three time points from September 2018 to March 2019. The survey specific to this study included five items, developed by WRAIR, assessing BH provider attitudes toward BH profiles. Of the providers who completed the survey, 250 (81%) consented to participate in the study and 149 (60%) completed the 3-month follow-up survey., Results: Over 80% of BH providers expressed agreement with each of three items assessing rationale for issuing BH profiles in both the pre- and post B-REDI period. Specifically, most providers agreed that profiles facilitate commander support to the soldier, afford soldiers resources for recovery, and give commanders increased understanding of soldier health for mission planning. Twenty-six percent of BH providers agreed, 46% were neutral, and 28% disagreed on whether profile impact on the soldier was positive or not in the pre-B-REDI period, but there was a significant positive trend relative to baseline in the post B-REDI period. The vast majority of providers (≥94%) did not endorse agreement that BH profiles negatively impact therapeutic alliance in either the pre- or post-B-REDI period., Conclusions: Assuming that therapeutic alliance and perceptions of BH profile impact on soldiers are useful proxy measures of how treatment utilization may be affected by profiling, this inquiry fails to establish any meaningful negative association between them. This may provide some additional reassurance to BH providers and policymakers that efforts to improve readiness decision-making, such as B-REDI, and increased profiling in conventional military BH settings may not negatively impact treatment utilization rates., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Pharmacogenomics (PGx) plays a fundamental role in personalized medicine, providing an evidence-based treatment approach centered on the relationship between genomic variations and their effect on drug metabolism. Cytochrome P450 (CYP450) enzymes are responsible for the metabolism of most clinically prescribed drugs and a major source of variability in drug pharmacokinetics and pharmacodynamics. To assess the prevalence of PGx testing within the Military Health System (MHS), testing of specific CYP450 enzymes was evaluated. Data were retrospectively obtained from the Military Health System Management Analysis and Reporting Tool (M2) database. Patient demographics were identified for each test, along with TRICARE status, military treatment facility, clinic, and National Provider Identifier. A total of 929 patients received 1,833 PGx tests, predominantly composed of active duty/guard service members (N = 460; 49.5%), with highest testing rates in the army (51.5%). An even distribution in testing was observed among gender, with the highest rates in Caucasians (41.7%). Of the CYP enzymes assessed, CYP2C19 and CYP2D6 accounted for 87.8% of all PGx CYP testing. The majority of patients were tested in psychiatry clinics (N = 496; 53.4%) and primary care clinics (N = 233; 25.1%), accounting for 56.4% and 24.8% of all tests, respectively. Testing was found to be provider driven, suggesting a lack of a standardized approach to PGx and its application in patient care within the MHS. We initially recommend targeted education and revising testing labels to be more uniform and informative. Long-term recommendations include establishing pharmacy-driven protocols and point-of-care PGx testing to optimize patient outcomes., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)