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Introduction: The reality of pilot health care avoidance behavior is often common knowledge to both pilots and aeromedical physicians, but the underlying factors leading to this behavior are less understood. In the current study, we conducted a qualitative assessment of a sample of U.S. Air Force (USAF) pilots to gather firsthand perceptions of the factors that encourage and discourage disclosure during aeromedical screening and use of mental and physical health care services, as well as recommendations to improve the USAF aeromedical health care system., Materials and Methods: We conducted interviews with 21 USAF pilots on their perceptions of seeking medical care to identify factors that uniquely discourage or encourage disclosure and health care utilization to understand factors that aid the aeromedical provider/aviator relationship and to elicit interventions that could be prospectively researched. This work was reviewed by the Air Force Research Laboratory Institutional Review Board at Wright-Patterson Air Force Base and designated as exempt research, FWR20220103E., Results: The most reported factors that discourage military pilot health care disclosure and health care utilization overall were medical revocation, stigma, and lack of trust in providers. Unit-embedded services, ease of access, and severity of condition were the most reported factors encouraging disclosure and utilization. Factor descriptions and exemplary quotes from pilots and pilot recommendations to encourage health care utilization and disclosure are provided., Conclusions: Results from firsthand interviews with pilots provide valuable information for flight surgeons to focus on building trust with their pilots to reduce health care avoidance., (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 medical students participate in a separate residency match program, distinct from their civilian counterparts. There is limited information regarding factors that applicants find important when selecting a residency program in Gynecologic Surgery and Obstetrics (GSO). We aimed to identify factors that influence applicant program selection., Materials and Methods: A voluntary, anonymous, 45-question survey was distributed to military candidates pursuing GSO residency training in the fall of 2023. Participants were asked to rate the factors they considered most important when ranking residency programs., Results: Thirty-seven of the sixty (61.7%) applicants completed the survey. The culture of the residency program was deemed "important" by most participants (94.6%), followed by surgical volume (70.3%) and obstetric volume (70.3%). When asked to rank selection factors, the culture of the residency program, geographic location, and surgical volume were among the top 5 influential factors for the majority of applicants. Participants considered the following factors "not important": Salary (military pay versus civilian salary) (43.2%), research opportunities (32.4%), and availability of abortion training (21.6%). Most military applicants (62.2%) stated that abortion restrictions would not affect program selection, while 37.8% reported that this would affect their rankings., Conclusions: Gynecologic Surgery and Obstetrics military applicants deemed the residency program's culture, surgical volume, and obstetrical volume to be the most important factors impacting residency program selection. Residency programs can use these findings to promote program strengths, improve program shortfalls, and guide applicant recruitment., (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.)

Organizations today are complex, hyperdimensional, and continuously changing in response to the environment. Over the past decade, the Military Health System has seen continuous organizational change to transform healthcare delivery, and the Air Force Medical Service (AFMS) is currently transitioning to an Air Force Medical Command (AFMEDCOM) structure to best prepare for Great Power Competition and other challenges ahead. The current state of the enterprise involves decision making, resourcing, and execution of education and training that is largely decentralized in nature. To support these efforts, in February 2024, a team of diverse AFMS stakeholders gathered in Washington, D.C. to examine the future of medical education and training for the U.S. Air Force in a new way: through systems theory and ecosystem mapping. This ecosystem approach enables development of an organizational structure and process for change that considers how all stakeholders relate, what external factors threaten the desired transformation, and how the resulting enterprise could become more resilient with future uncertainty and change. This paper discusses the theory behind the ecosystem approach and how it was used to develop a transformed model for the AFMS to organize its education and training. Additionally, a dialogue is presented on how this unique methodology to understanding stakeholder relationships can be leveraged in the re-optimization efforts for Great Power Competition., (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: Post-traumatic stress disorder (PTSD) is a primary military psychiatric condition with complex etiology including strong genetic and/or environmental influences. Environmental influences and demographics can play a role in supporting underlying genetic traits for clinical utility evaluation as risk modifying factors. We are undertaking an IRB approved study to evaluate polygenic scores of PTSD risk in the adverse childhood experience and serotonin (ACES) transporter cohort., Materials and Methods: Baseline demographic characteristics and statistical modeling of 291 active duty service members from ACES cohort were used and excluded individuals with traumatic brain injury-induced loss of consciousness, pre-deployment PTSD or anxiety disorder, and pre-deployment prescription of antidepressants or psychoactive medications. Summary of categorical and numerical variables were evaluated using chi-square and t-test, respectively. We model PTSD risk and associated scores using linear and logistic regressions., Results: The ACES subset was 79.1% males, multi-ancestry, and mean age of 38.3 years. Most PTSD individuals received behavioral therapy (89.6%) and/or prescribed antidepressants (67%) had higher scores in ACES, combat exposure scales, PTSD checklist military version, neurobehavioral symptom inventory, Pittsburg sleep quality index, insomnia severity index, and composite autonomic symptom score surveys and were less likely to expect future deployment. A positive correlation between age, total months deployed, ACES, CES, PCL-M, and positive-PTSD diagnosis were consistent but not in older individuals, who were more likely and frequently deployed although increasing risk for combat exposure., Conclusion: Demographic characteristics of the ACES cohort fit a coherent model of risk for PTSD to evaluate polygenic scores. Additional research is merited to understand PTSD effects on these confounding factors., (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 coronavirus disease 2019 (COVID-19) pandemic, in addition to increased mental health difficulties for society as a whole, brought unique challenges and opportunities to mental health professionals attempting to address the issues under public health limitations. Occupationally embedded mental health professionals were uniquely challenged in quickly and creatively adjusting to physical quarantining and working from home. The purpose of this study was to inquire about and categorize the experiences of embedded mental health professionals and their clients in U.S. Air Force (USAF) operational units., Methods: We conducted a qualitative analysis of semi-structured interviews with 26 embedded mental health professionals across 24 USAF installations and 15 Airmen clients from 5 of those installations. Their experiences within the pandemic context were systemically categorized into actionable themes through thematic content analysis., Results: U.S. Air Force embedded mental health professionals and Airmen primarily identified the challenges of staying engaged when not face-to-face, higher incidence of mental health problems, decreased availability of clinical care and other support resources, technology as a face-to-face substitute, managing safety measures, delayed initiatives, and clinical boundary setting. Alternatively, embedded mental health professionals and Airmen identified strategies to alleviate pandemic limitations, such as using technology to interact, COVID-19 mitigating actions, developing initiatives to target their population needs, and using opportunities to help reduce stigma associated with seeking help for mental 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.)

In 2020, the U.S. Air Force School of Aerospace Medicine hired its first civilian dean since its founding in 1918, tasked with building the school's first strategic plan to modernize and improve the institution. Using a combination of military continuous process improvement and academic strategic thinking, the dean produced a highly successful strategic plan. However, its resource-heavy and time-consuming methodology made it difficult to replicate. This study aimed to create a novel and streamlined strategic planning model that combined best practices from continuous process improvement and strategic thinking without redundancy. A qualitative descriptive case study was used to analyze the detailed efforts through content analysis of 150 pages of documentation. A hybrid approach to coding uncovered 44 deductive codes and 5 inductive codes from 10 strategic tools. Results indicated a converging relationship between all strategic processes tested-strategic planning, strategic thinking, and continuous process improvement and their associated tools. A five-step model called the Triple "O" OODA Loop was created, combining best practice tools from strategic planning (purpose trident and SWOT analysis or strengths, weaknesses, opportunities, and threats), strategic thinking (Hot Spots scale and GOST framework or goals, objectives, strategies, and tactics) and continuous process improvement (phases 6-8)., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Inappropriate fluid management during patient transport may lead to casualty morbidity. Percent systolic pressure variation (%SPV) is one of several technologies that perform a dynamic assessment of fluid responsiveness (FT-DYN). Trained anesthesia providers can visually estimate and use %SPV to limit the incidence of erroneous volume management decisions to 1-4%. However, the accuracy of visually estimated %SPV by other specialties is unknown. The aim of this article is to determine the accuracy of estimated %SPV and the incidence of erroneous volume management decisions for Critical Care Air Transport (CCAT) team members before and after training to visually estimate and utilize %SPV., Material and Methods: In one sitting, CCAT team providers received didactics defining %SPV and indicators of fluid responsiveness and treatment with %SPV ≤7 and ≥14.5 defining a fluid nonresponsive and responsive patient, respectively; they were then shown ten 45-second training arterial waveforms on a simulated Propaq M portable monitor's screen. Study subjects were asked to visually estimate %SPV for each arterial waveform and queried whether they would treat with a fluid bolus. After each training simulation, they were told the true %SPV. Seven days post-training, the subjects were shown a different set of ten 45-second testing simulations and asked to estimate %SPV and choose to treat, or not. Nonparametric limits of agreement for differences between true and estimated %SPV were analyzed using Bland-Altman graphs. In addition, three errors were defined: (1) %SPV visual estimate errors that would label a volume responsive patient as nonresponsive, or vice versa; (2) incorrect treatment decisions based on estimated %SPV (algorithm application errors); and (3) incorrect treatment decisions based on true %SPV (clinically significant treatment errors). For the training and testing simulations, these error rates were compared between, and within, provider groups., Results: Sixty-one physicians (MDs), 64 registered nurses (RNs), and 53 respiratory technicians (RTs) participated in the study. For testing simulations, the incidence and 95% CI for %SPV estimate errors with sufficient magnitude to result in a treatment error were 1.4% (0.5%, 3.2%), 1.6% (0.6%, 3.4%), and 4.1% (2.2%, 6.9%) for MDs, RNs, and RTs, respectively. However, clinically significant treatment errors were statistically more common for all provider types, occurring at a rate of 7%, 10%, and 23% (all P < .05). Finally, students did not show clinically relevant reductions in their errors between training and testing simulations., Conclusions: Although most practitioners correctly visually estimated %SPV and all students completed the training in interpreting and applying %SPV, all groups persisted in making clinically significant treatment errors with moderate to high frequency. This suggests that the treatment errors were more often driven by misapplying FT-DYN algorithms rather than by inaccurate visual estimation of %SPV. Furthermore, these errors were not responsive to training, suggesting that a decision-making cognitive aid may improve CCAT teams' ability to apply FT-DYN technologies., (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: In the Medscape 2020 Compensation Report, family physicians ranked low for feeling fairly compensated, choosing their specialty again and choosing medicine again. However, the Medscape data may not represent military family physicians., Methods: A large survey was emailed to 2,562 military family physicians via a military professional organization list-serve from February to April 2021. The inquiry included 6 statements pertaining to professional satisfaction. The main outcome measures were proportions of "agree" and "strongly agree." The proportions were compared to the Medscape Compensation Report 2020 and 2022. Statistical analysis was completed with a two-tailed Z-score for 2 populations., Results: Sixty-one percent of military family physicians feel fairly compensated compared to 54% of civilian family physicians in 2020 and 55% in 2022 (P = .065, .119). Eighty-six percent of military family physicians would reselect medicine compared to 74% of civilian family physicians in 2020 and 73% in 2022 (P < .001 for both). Eighty percent of military family physicians would reselect their specialty again compared to 70% of civilians in 2020 and 68% in 2022 (P = .004, P = .001, respectively)., Conclusions: Military family physicians were more likely to choose medicine generally and family medicine specifically again. Military family physicians and civilian family physicians do not statistically differ in feeling fairly compensated. A strong majority of military family physicians are satisfied with their military-sponsored medical education., (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 U.S. Air Force's Intercontinental Ballistic Missile (ICBM) force stands ready to launch weapons 365 days per year. Since its inception, missileers vigilantly operate launch consoles on a 3-day cycle: minimum 24-hour alert-shift/24-hour travel-admin/24-hour off, leading to concerns that health, morale, and alertness are chronically impacted. In 2020, a Missileer Occupational Health Assessment (OHA) revealed 76% of respondents struggle with being rested for duty and 29% of respondents never feel adequately rested for duty. Later that year, 20th Air Force initiated long-duration operations to safeguard from the SARS CoV-2 (COVID-19) Pandemic, resulting in increased operations tempo, and exacerbating crew fatigue.341st Operations Group and 341st Medical Group at Malmstrom Air Force Base enacted interventions to mitigate crew fatigue and support continued readiness during pandemic operations. They recorded, analyzed, and compiled findings in this report, including recommendations for long-term ICBM operations at Missile Wings., Materials and Methods: All participants were Nuclear and Missile Operations Officers, or missileers, were continuously evaluated with qualitative and quantitative measures to ensure safety of the force during a period of unprecedented change. Interventions implemented and evaluated during the 9-month period included: environmental modifications, scheduling changes, and crew education on fatigue management, nutrition, anticipatory sleep preparation, and fitness. Most notably, the 341st Operations Group examined various 3-person and 4-person shift-length and alert duration schedules. Psychomotor vigilance testing results validated safety of operators and delta between pre- and post-shift measurements. Crew force readiness trends were analyzed for force-health awareness. Pre- and post-OHA results were compared for subjective changes. Fatigue and health-related outcomes were collected from a safety monitoring effort during standard and COVID-19 operations at 341st Missile Wing., Results: Findings from qualitative and quantitative data indicate the optimal schedule is a 3-week cycle:7-day alert/7-day recovery/7-day training-administrative utilizing 4-member or 3-member crews for low tempo operations. Crews experimented with shift-lengths of 24hrs-on/24hrs-off, 16hrs-on/8hrs-off, and 12hrs-on/12hrs-off. Maximum safe alert duration is 7 days due to task fatigue onset between 8 and 10 days. Short and long duration Duties Not to Include Flight (DNIF) (also known as Duties Not to Include Alert (DNIA) among missileers) rates decreased from the first to last month of the period by 74.6% and 79.2%, respectively. The number of alerts missed per month decreased 86% from baseline. The 2021 OHA found a 7% decline in members seeking separation, and absence of sleep, fatigue, and physical or mental health as missileer concerns., Conclusions: This analysis has identified a sustainable alert rotation of 7/7/7 with emphasis on protected recovery and training time and has been continued after concluding pandemic operations, creating consistent schedule stability where there once was none. If executed properly, this alert rotation, regardless of shift-length selected, has potential to improve trust between crews and leadership, provides adequate recovery time between alerts to maintain health, and improves wellness, family stability, morale, unit cohesion, and crew force retention. Notably, all Air Force Global Strike Missile Operations Groups adjusted scheduling practices to align with these findings., (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.)

Background: The Critical Care Air Transport (CCAT) Advanced Course utilizes fully immersive high-fidelity simulations to assess personnel readiness for deployment. This study aims to determine whether simple well-defined demographic identifiers can be used to predict CCAT students' performance at CCAT Advanced., Materials and Methods: CCAT Advanced student survey data and course status (pass/fail) between March 2006 and April 2020 were analyzed. The data included students' Air Force Specialty Code (AFSC), military status (active duty and reserve/guard), CCAT deployment experience (yes/no), prior CCAT Advanced training (yes/no), medical specialty, rank, and unit sustainment training frequency (never, frequency less often than monthly, and frequency at least monthly). Following descriptive analysis and comparative tests, multivariable regression was used to identify the predictors of passing the CCAT Advanced course for each provider type., Results: A total of 2,576 student surveys were analyzed: 694 (27%) physicians (MDs), 1,051 (40%) registered nurses (RNs), and 842 (33%) respiratory therapists (RTs). The overall passing rates were 92.2%, 90.3%, and 85.4% for the MDs, RNs, and RTs, respectively. The students were composed of 579 (22.5%) reserve/guard personnel, 636 (24.7%) with CCAT deployment experience, and 616 (23.9%) with prior CCAT Advanced training. Regression analysis identified groups with lower odds of passing; these included (1) RNs who promoted from Captain to Major (post-hoc analysis, P = .03), (2) RTs with rank Senior Airman, as compared to Master Sergeants (post-hoc analysis, P = .04), and (3) MDs with a nontraditional AFSC (P = .0004). Predictors of passing included MDs and RNs with CCAT deployment experience, odds ratio 2.97 (P = .02) and 2.65 (P = .002), respectively; and RTs who engaged in unit CCAT sustainment at least monthly (P = .02). The identifiers prior CCAT Advanced training or reserve/guard military status did not confer a passing advantage., Conclusion: Our main result is that simple readily available metrics available to unit commanders can identify those members at risk for poor performance at CCAT Advanced readiness training; these include RNs with rank Major or above, RTs with rank Senior Airman, and RTs who engage in unit sustainment training less often than monthly. Finally, MD specialties which are nontraditional for CCAT have significantly lower CCAT Advanced passing rates, reserve/guard students did not outperform active duty students, there was no difference in the performance between different RN specialties, and for MD and RN students' previous deployment experience was a strong predictor of passing., (© 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.)

In response to the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act being signed into law, several research groups in Colorado organized the First Annual PACT Act Research Symposium for Veteran Health. The 2-day symposium was interested in research relevant to military exposures with a primary focus on respiratory and mental health. Information on the PACT Act, data sources in the Department of Veteran Affairs and DOD, and research opportunities at the Veteran Affairs were presented. The morning session centered on respiratory health, highlighting research conducted over the last two decades regarding deployment-related respiratory diseases. Despite the high prevalence of mental health disorders among Veterans, information presented during the afternoon sessions on mental health highlighted the dearth of research to date regarding psychological health and military-related exposures. Policymakers, clinicians, and researchers were encouraged to adopt a life-course approach when conceptualizing physical and psychological exposures. On the second day of meetings, a smaller group of participants discussed next steps in military exposure research, as well as priorities for future research. Per the latter, recommendations for future research were made regarding the need for more precise exposure characterization, longitudinal data collection, and efforts to increase understanding regarding disease pathogenesis, as well as the impact of exposures across multiple organs. Such efforts will require interdisciplinary collaboration., (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.)

Clinicians may confuse an impaired sensitivity to thyroid hormone with hyperthyroidism and offer an inappropriate treatment. We report a diagnosis of resistance to thyroid hormone (RTH) caused by a rare mutation in the thyroid hormone receptor beta gene in a patient previously presumed to have Graves' disease. We have found only one published case of a novel point mutation, c.749T>C (p.Ile250Thr variant) associated with 50% reduction in thyroid hormone receptor binding affinity for triiodothyronine in the I250T mutant; it was found in this patient. A 66-year-old male veteran, with a history of non-ischemic cardiomyopathy and arrhythmias, was referred by a cardiologist with concerns for a possible thyrotropin (TSH) adenoma on account of elevated TSH and free thyroxine (FT4) levels. Pituitary imaging was negative. He was previously treated with radioiodine for presumptive Graves' disease in the civilian sector. Examination revealed a goiter with no nodules. Repeat TSH and FT4 levels were elevated and also free triiodothyronine (FT3) and reverse triiodothyronine. These findings and other test results were consistent with RTH, which was confirmed by genetic testing. Mutation analysis showed the patient to be heterozygous for the p.Ile250Thr variant. He later developed hypothyroidism. Resistance to thyroid hormone can be misdiagnosed as hyperthyroidism with consequent inappropriate treatment. Treatment is not needed in most RTH-beta patients. Thyroid ablation should generally be avoided. Clinicians must be cautious whenever they encounter concurrent elevation of TSH, FT4, and FT3. This RTH-beta patient has a rare I250T mutant of the thyroid hormone receptor beta gene, the second reported case in the literature., (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: Overweight and obesity trends are on the rise among both civilian and military beneficiaries. The purpose of this narrative review was to evaluate nutrition, behavioral, lifestyle, pharmacotherapy, and alternative approaches to weight management (WM) among adults with a focus toward identifying gaps and evidence-based strategies that could support or enhance current and future WM programming among military adult beneficiaries., Materials and Methods: A trained research team identified publications (January 2013-January 2020) for abstract review using key search terms and inclusion criteria. Two independent researchers conducted both the abstract review and full-paper bias scoring using selected Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. All eligible studies were assessed for bias and categorized based on key themes. The study was registered in PROSPERO, the international prospective register of systematic reviews., Results: The research team identified 741 articles, with 278 meeting final inclusion criteria. The mean bias score was 7.5 ± 3.9 (score of 0-13; higher indicating fewer bias factors), with 64% scoring ≥9. Factors contributing to low bias included intervention compliance, dropout rate, and inability to blind participants. The most common published weight-loss interventions included a combination of therapies (59%), diet/supplement (17%), other approaches (12%), behavior change (7%), and exercise (6%). Themes identified to improve WM outcomes included leveraging technology, increasing intervention interactions, community support, emphasis on early weight loss, pharmacotherapy risk-benefit, enhanced behavioral component, resistance exercise, mindfulness, and benefits of quality-of-life measures., Conclusions: Reviewers identified several validated tools and techniques to augment and update existing WM programming to improve health and weight outcomes. The review affirmed use of individualized dietary patterns and not a "one-size-fits-all approach" as well as incorporating more comprehensive and team-approached treatments to make the best use of tools and strategies to enhance outcomes., (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: Every year, approximately 35,000 recruits enter the United States Air Force Basic Military Training (BMT). Musculoskeletal problems are particularly vexing for BMT because a broad array of differentials render definitive diagnosis burdensome and while most sufferers will fully recover, healing often requires protracted training delays resulting in increased unrecoverable training costs to the program. The purpose of this study is to conduct a case-control study of basic military trainees entering service from 2012 to 2015 to assess detectable differences in demographics, retention, and health care utilization., Materials and Methods: This is a retrospective case-control study of existing data and records obtained from existing and active information record systems for individuals who attended BMT between the years 2012 and 2015. Cohort assignment was based on incidence of first stress fracture diagnosis (i.e., having a select diagnosis code in one's medical record) relative to arrival at BMT. Health care utilization is operationalized as medical encounter frequencies and associated international classification of disease (ICD) codes occurring for all patients from BMT recruit date of arrival to 6 months post-graduation (i.e., 180 days)., Results: The primary dataset includes 132,359 distinct individuals, of which 129,637 (98%) had no history of stress fracture diagnosis and 1,487 (1%) of which have a diagnosis of stress fracture more than 60 days after arrival at BMT; these are assigned to the CONTROL group. There are 1,235 (0.9%) assigned to the CASE group. CASE members presented with 30.1 unique ICD-10 codes post-graduation compared to 6.3 in the CONTROL group. Six of the top thirteen ICD-10 codes were musculoskeletal in nature and all presented significantly higher rates for the CASE group., Conclusions: Trainees who suffered a bone stress injury (BSI) during the United States Air Force BMT advanced in rank on par with trainees who did not, but BSI sufferers exhibited greater health care utilization than those who did not suffer BSI. The cost to replace a trainee unable to complete BMT is considerable; however, it is also important to consider the reduction in resiliency and readiness to the Department of Defense and the financial burdens from increased health care utilization. The 2-fold increase in BSI presentation in the graduated control group reflects that more needs to be done for all populations to identify better proactive efforts to foundationally support wellness and prevention rather than accept injury as the status quo., (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. Air Force implemented the Integrated Operational Support model, which involves embedding health care professionals within operational units to meet the health needs of the airmen. This study assessed the extent to which airmen sought out both traditional and embedded mental health services, as well as perceptions of factors that hinder or encourage health care-seeking behaviors., Materials and Methods: A mixed-methods approach including a web-based occupational psychological health assessment and semi-structured interviews was used to assess airmen's experiences with seeking mental health care services., Results: A total of 447 Remotely Piloted Aircraft operators participated in an occupational psychological health assessment (42% response rate) in 2018, and 15 airmen across five high operational tempo, restricted-access installations completed a semi-structured interview (60% participation rate) in 2021. From the occupational assessment, females (33%) sought care from the traditional mental health clinic significantly more than males (21%; χ2 = 5.10, P = .02). However, there were no significant gender differences in seeking embedded mental health services. Respondents who had not sought out help from either the traditional clinic or embedded services were significantly more likely to seek assistance from embedded mental health services (M = 4.29, SD = 2.09) over the traditional clinic (M = 3.92, SD = 1.90), t(205) = 4.94, P < .001. A resounding interview theme was the deep appreciation that airmen expressed for the availability of embedded mental health professionals. Airmen also discussed factors that hinder health care-seeking behaviors with the top-reported factor being the stigma associated with seeking mental health. The top three reported factors that encourage health care-seeking behaviors included leadership and mental health professionals normalizing care, trust in embedded mental health professionals, and ease of access to care., Conclusions: Findings suggest that having mental health professionals integrated within the unit brings the care straight to the airmen and may reduce the stigma associated with airmen asking for help., (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: Early enteral feeding in critically ill/injured patients promotes gut integrity and immunocompetence and reduces infections and intensive care unit/hospital stays. Aeromedical evacuation (AE) often takes place concurrently. As a result, AE and early enteral feeding should be inseparable., Materials and Methods: This retrospective descriptive study employed AE enteral nutrition (EN) data (2007-2019) collected from patients who were U.S. citizens and mechanically ventilated. The dataset was created from the En Route Critical Care, Transportation Command Regulating and Command and Control Evacuation System, and Theater Medical Data Store databases. Comparisons were performed between patients extracted and patients not extracted, patients treated with EN and patients treated without EN, and within the EN group, between AE Fed and AE Withheld. The impact of the nutrition support in the Joint Trauma System Clinical Practice Guidelines (CPG) was assessed using the 'before' and 'after' methodology., Results: An uptick in feeding rates was found after the 2010 CPG, 15% → 17%. With the next two CPG iterations, rates rose significantly, 17% → 48%. Concurrently, AE feeding holds rose significantly, 10% → 24%, later dropping to 17%. In addition, little difference was found between those patients not enterally fed preflight and those enterally fed across collected demographic, mission, and clinical parameters. Likewise, no difference was found between those enterally fed during AE and those withheld. Yet, 83% of the study's patients were not fed, and 18% of those that were fed had feeding withheld for AE., Conclusions: It appeared that the Clinical Practice Guidelines (CPGs) reinforced the value of feeding, but may well have sensitized to the threat of aspiration. It also appeared that early enteral feeding was underprescribed and AE feeding withholds were overprescribed. Consequently, an algorithm was devised for the Theater Validating Flight Surgeon, bearing in mind relevant preflight/inflight/clinical issues, with prescriptions designed to boost feeding, diminish AE withholding, and minimize complications., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The majority of critical care air transport (CCAT) flights are regulated, meaning that a theater-validating flight surgeon has confirmed that the patient is medically cleared for flight and that evacuation is appropriate. If the conditions on the ground do not allow for this process, the flight is unregulated. Published data are limited regarding CCAT unregulated missions to include the period of troop drawdown at the end of the Afghanistan conflict. The objective of our study was to characterize the unregulated missions within Afghanistan during troop drawdown and compare them to regulated missions during the same timeframe., Study Design: We performed a retrospective review of all CCAT medical records of patients transported via CCAT within Afghanistan between January 2017 and December 2019. We abstracted data from the records, including mission characteristics, patient demographics, injury descriptors, preflight military treatment facility procedures, CCAT procedures, in-flight CCAT treatments, in-flight events, and equipment issues. Following descriptive and comparative analysis, a Cochran-Armitage test was performed to evaluate the statistical significance of the trend in categorical data over time. Multivariable regression was used to assess the association between vasopressors and preflight massive transfusions, preflight surgical procedures, injury patterns, and age., Results: We reviewed 147 records of patients transported via CCAT: 68 patients were transported in a regulated fashion and 79 on an unregulated flight. The number of patients evacuated increased year-over-year (n = 22 in 2017, n = 57 in 2018, and n = 68 in 2019, P < .001), and the percentage of missions that were unregulated grew geometrically (14%, n = 3 in 2017; 37%, n = 21 in 2018; and 81%, n = 55 in 2019, P < .001). During the time studied, CCAT teams were being used more to decompress forward surgical teams (FST) and, therefore, they were transporting patients just hours following initial damage control surgery in an unregulated fashion. In 2 instances, CCAT decompressed an FST following a mass casualty, during which aeromedical evacuation (AE) crews assisted with patient care. For the regulated missions, the treatments that were statistically more common were intravenous fluids, propofol, norepinephrine, any vasopressors, and bicarbonate. During unregulated missions, the statistically more common treatments were ketamine, fentanyl, and 3% saline. Additional analysis of the mechanically ventilated patient subgroup revealed that vasopressors were used twice as often on regulated (38%) vs. unregulated (13%) flights. Multivariable regression analysis demonstrated that traumatic brain injury (TBI) was the only significant predictor of in-flight vasopressor use (odds ratio = 3.53, confidence interval [1.22, 10.22], P = .02)., Conclusion: During the troop drawdown in Afghanistan, the number of unregulated missions increased geometrically because the medical footprint was decreasing. During unregulated missions, CCAT providers used ketamine more frequently, consistent with Tactical Combat Casualty Care guidelines. In addition, TBI was the only predictor of vasopressor use and may reflect an attempt to adhere to unmonitored TBI clinical guidelines. Interoperability between CCAT and AE teams is critical to meet mass casualty needs in unregulated mission environments and highlights a need for joint training. It remains imperative to evaluate changes in mission requirements to inform en route combat casualty care training., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Sickle cell trait (SCT) is a heterozygotic state defined by having one normal hemoglobin gene and one sickle hemoglobin gene. Individuals with SCT are at increased risk for negative health outcomes during intense physical exertion, especially in hot climates and high-elevation locations, or when dehydrated. The U.S. Air Force mitigates this risk through universal screening after accession followed by education of SCT-positive airmen. Airmen who are SCT positive but remain asymptomatic are not restricted in occupation choice or deployment/duty locations based on their SCT status. Previous studies have analyzed the relationship between SCT and health and fitness outcomes. The objective of this study was to analyze the relationship between SCT and career and operational outcomes in a large cohort of airmen and secondarily to analyze the relationship between hemoglobin S (HgbS) percentage and these outcomes., Methods: This is a retrospective cohort study of all recruits who entered U.S. Air Force (USAF) Basic Military Training (BMT) between January 2009 and December 2013. The SCT status was assessed through a sickle solubility test. Hemoglobin electrophoresis permitted subgroup analysis of SCT-positive individuals by HgbS percentage. The following career and operational outcomes were assessed: BMT graduation; retention at 4 and 6 years; promotion to the rank of staff sergeant by 4 and 6 years; overseas deployment and number of deployments within 6 years; and high-elevation assignment and cumulative months at a high-elevation assignment within 6 years. Multivariable logistic regression was used to assess all binary outcomes, controlling for age, sex, and race, to produce adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Multivariable Poisson regression was used to assess cumulative count outcomes and to produce adjusted incidence rate ratios (aIRRs) with 95% CIs. Attrition from BMT by SCT status was also assessed as a hazards function using the Kaplan-Meier approach with Cox proportional hazards., Results: A total of 180,355 civilians entered USAF BMT during the 5-year surveillance period, of whom 169,837 graduated and had data available for analysis. Compared to their SCT-negative peers, SCT-positive airmen (n = 1,697) had 26% lower adjusted odds of promotion to staff sergeant within 4 years of BMT graduation (aOR = 0.74; 95% CI: 0.59-0.92) and served less time at a high-elevation assignment during their first 6 years (aIRR = 0.88; 95% CI: 0.85-0.91). The SCT status was not associated with statistically significant differences in BMT graduation, retention at 4 and 6 years, promotion to staff sergeant by 6 years, likelihood or number of overseas deployments, and likelihood of ever working at a high-elevation assignment. Retention at 4 and 6 years was inversely associated with HgbS percentage., Conclusions: SCT-positive and SCT-negative airmen had similar career and operational outcomes, with two exceptions: SCT-positive airmen were less likely to be promoted to staff sergeant within 4 years, and they spent less time at a high-elevation location during their first 6 years of service. The underlying explanation of these findings should be explored with an aim to support SCT-positive airmen and to reduce potentially unwarranted discrepancies. Efforts should continue to reduce the stigma associated with SCT., (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: In June of 2020, the U.S. DVA and DoD approved a new joint clinical practice guideline for assessing and managing patients with headache. This guideline provides a framework to evaluate, treat, and longitudinally manage the individual needs and preferences of patients with headache., Methods: In October of 2018, the DVA/DoD Evidence-Based Practice Work Group convened a guideline development panel that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines., Results: The guideline panel developed key questions, systematically searched and evaluated the literature, created a 1-page algorithm, and advanced 42 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system., Conclusion: This synopsis summarizes the key features of the guideline in three areas: prevention, assessing and treating medication overuse headache, and nonpharmacologic and pharmacologic management of headache., (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: There has been external criticism of the compliance of military health personnel with internationally agreed principles in military medical ethics (MME). In response, a number of authors have called for clarity on the principles and topics within the domain of MME. This complements an increased acknowledgment of the need for education in MME for military health personnel. Our paper utilizes bibliometric techniques to identify key themes in MME to inform the development of a curriculum for this subject., Materials and Methods: We designed a search strategy to find publications over the period January 1, 2000-December 31, 2020 in the domain of MME from the three databases, PubMed, Web of Science, and Scopus, using the search string (ethic* OR bioethics* OR moral*) AND military AND (medic* OR health*). We obtained a total of 1,115 publications after duplication removal. After exclusion based on topic, year, and study design, we analyzed a total of 633 publications using Scopus's embedded analysis tool and the software VOSViewer. We generated a co-occurrence word map from the abstracts of each of the publications. We deduced themes of MME based on the clusters shown in the word map, and we categorized each publication into one of these themes to analyze the change of themes over time., Results: We observed a 10-fold increase in annual publications on MME between 2000 and 2020. The majority of papers were written by U.S. (72%) and UK (13%) authors, although a total of 15 countries were represented. After using VOSViewer to identify co-occurring keywords in titles and abstracts from these publications, nine themes were identified: biomedical research, care to detained populations, disaster/triage, mental health, patient-focused foundations, technology, dual loyalty, education/training, and frameworks. The relative proportion of each of these themes changed over the study period, with mental health being dominant by the end., Conclusions: This study has identified key themes that might inform the development of a curriculum for teaching MME. It is noticeable that the majority of themes cover MME from the perspective of professional practice on military operations; noting, the research and technology themes also pertain to the generation of knowledge for military operations. There were a limited number of publications covering practice in the non-deployed or garrison settings, and these were codified under the themes of "framework" and "dual loyalty". The results are skewed toward English-speaking countries and exclude non-academic publications. Further work will search for other open-source information and non-English publications. To our knowledge, this exploratory bibliometric analysis on MME in the academic literature is the first of its kind. This article has demonstrated the use of bibliometric techniques to evaluate the evolution of knowledge in MME, including the identification of key themes. These will be used to support further work to develop a curriculum for the teaching of MME to military medical audiences., (© The Association of Military Surgeons of the United States 2021.)

Introduction: Hypocalcemia at hospital presentation is associated with increased mortality in trauma patients with hemorrhagic shock. The 2019 updates to the Joint Trauma System Damage Control Resuscitation (DCR) Clinical Practice Guideline recommend calcium supplementation for ionized calcium (iCa) measurements <1.2 mmol/L. Ionized calcium goals for en route critical care (ERCC) following DCR are less defined, and the impact of in-flight hypocalcemia events among critically injured combat wounded is unknown. This study aimed to describe the association between hypocalcemia and mortality for combat-wounded with brain injury and polytrauma requiring transport by Critical Care Air Transport Teams (CCATT)., Methods: We performed a secondary analysis of a retrospective cohort of patients with moderate-to-severe traumatic brain injury transported by CCATT out of combat theater between January 2007 and May 2014. Additional inclusion criteria included polytrauma and at least one documented in-flight iCa measurement. We categorized exposures based on the minimum in-flight iCa measurement as severe hypocalcemia (iCa <0.9 mmol/L), hypocalcemia (iCa 0.9-1.11 mmol/L), and never hypocalcemic (iCa ≥1.12 mmol/L). The primary outcome measure was mortality. We calculated descriptive statistics and performed multivariate logistic regression to assess the association between hypocalcemia and mortality., Results: We analyzed 190 subjects, with a median age of 24 years (interquartile range [IQR] 21 to 29 years) and 97.7% male gender. Explosive injuries (82.1%) and gunshot wounds (6.3%) were the most common mechanisms of injury. The median injury severity score was 34 (IQR 27 to 43). During the flight, 11.6% of patients had severe hypocalcemia, and 39.5% had hypocalcemia. Among patients with any hypocalcemia measurement in-flight (n = 97), 41.2% had hypocalcemia on pre-flight iCa, 28.9% received blood products in-flight, and 23.7% received in-flight calcium supplementation. Only 32.4% of patients with hypocalcemia or severe hypocalcemia in the setting of vasopressor administration received in-flight calcium supplementation. There was no significant difference in mortality between severe hypocalcemia (9.1%), hypocalcemia (5.3%), and never hypocalcemic (3.2%) patients even after controlling for pre-flight variables., Conclusion: In-flight hypocalcemia events were common among critically ill combat-wounded polytrauma patients transported by CCATT but were not associated with differences in mortality. Future training should emphasize the need for calcium correction among ERCC patients requiring vasopressors. Future studies with larger sample sizes of patients receiving ERCC are needed to assess the association between in-flight calcium supplementation with clinical outcomes., (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: Previous analyses of head, face, and neck (HFN) surgery in the deployed military setting have focused on the treatment of injuries using trauma databases. Little has been written on the burden of disease and the requirement for follow-up care. The aim of this analysis was to provide the most comprehensive overview of surgical workload in a contemporary role 3 MTF to facilitate future planning., Method: The operating room database and specialty surgical logbooks from a U.S.-led role 3 MTF in Afghanistan were analyzed over a 5-year period (2016-2020). These were then matched to the deployed surgical TC2 database to identify reasons for treatment and a return to theatre rate. Operative records were finally matched to the deployed Armed Forces Health Longitudinal Technology Application-Theater outpatient database to determine follow up frequency., Results: During this period, surgical treatment to the HFN represented 389/1989 (19.6%) of all operations performed. Surgery to the HFN was most commonly performed for battle injury (299/385, 77.6%) followed by disease (63/385, 16%). The incidence of battle injury-related HFN cases varied markedly across each year, with 117/299 (39.1%) being treated in the three summer months (June to August). The burden of disease, particularly to the facial region, remained constant throughout the period analyzed (mean of 1 case per month)., Conclusions: Medical planning of the surgical requirements to treat HFN pathology is primarily focused on battle injury of coalition service personnel. This analysis has demonstrated that the treatment of disease represented 16% of all HFN surgical activities. The presence of multiple HFN sub-specialty surgeons prevented the requirement for multiple aeromedical evacuations of coalition service personnel which may have affected mission effectiveness as well as incurring a large financial burden. The very low volume of surgical activity demonstrated during certain periods of this analysis may have implications for the maintenance of surgical competencies for subspecialty surgeons., (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.)

Managing patients with chest pain in deployed and austere environments can be extremely challenging for military health care providers. Limited resources, including access to equipment, emergent cardiac catheterization, and cardiac surgery, can lead to deleterious consequences, including myonecrosis and possible death. Wellens syndrome is a form of acute coronary syndrome that involves stenosis of the left anterior descending coronary artery, leading to possible acute myocardial infarction. Most cases in the literature involve the diagnosis and treatment of Wellens syndrome in the civilian, nondeployed hospital setting. We present a case of a civilian contractor who had experienced an episode of chest pain that had resolved with rest and now had new findings on electrocardiogram concerning Wellens syndrome., (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: Within the Military Health System, the process of transporting patients from an initial point of injury and throughout the entire continuum of care is called "en route care." A Committee on En Route Combat Casualty Care was established in 2016 as part of the DoD Joint Trauma System to create practice guidelines, recommend training standards, and identify research priorities within the military en route care system., Materials and Methods: Following an analysis of currently funded research, future capabilities, and findings from a comprehensive scoping study, members of a sub-working group for research identified the top research priorities that were needed to better guide evidence-based decisions for practice and policy, as well as the future state of en route care., Results: Based on the input from the entire committee, 10 en route care research topics were rank-ordered in the following manner: (1) medical documentation, (2) clinical decision support, (3) patient monitoring, (4) transport physiology, (5) transfer of care, (6) maintaining normothermia, (7) transport timing following damage control resuscitation or surgery, (8) intelligent tasking, (9) commander's risk assessment, and (10) unmanned transport. Specific research questions and technological development needs were further developed by committee members in an effort to guide future research and development initiatives that can directly support operational en route care needs. The research priorities reflect three common themes, which include efforts to enhance or increase care provider capability and capacity; understand the impact of transportation on patient physiology; and increase the ability to coordinate, communicate, and facilitate patient movement. Technology needs for en route care must support interoperability of medical information, equipment, and supplies across the global military health system in addition to adjusting to a dynamic transport environment with the smallest possible weight, space, and power requirements., Conclusions: To ensure an evidence-based approach to future military conflicts and other medical challenges, focused research and technological development to address these 10 en route care research gaps are urgently 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: Early and adequate administration of enteral nutrition (EN) improves outcomes in critical care patients. However, the environment where Critical Care Air Transport teams provide patient care poses particular challenges to achieving the same standard of nutritional support readily administered in civilian intensive care units. Providing the highest standard of nutritional care in austere military environments remains the goal for all patients despite inherent challenges. Enteral nutrition, specifically, is not currently a standard of practice in-flight because of concerns for microaspiration and the associated risk of developing ventilator-associated pneumonia. Clinical concern for aspiration combines with the lack of an EN pump approved for use through Safe-to-Fly testing to further decrease the likelihood of initiating EN in trauma patients. Early EN significantly reduces morbidity and mortality risks; therefore, the lack of nutritional support is contrary to established standards of care in civilian intensive care units. Hence, this literature review proposes to provide a clearer understanding of current EN practices as well as any associated risks within the En Route Care system., Method: A narrative review of literature related to EN in military and civilian flight settings using the PRISMA methodology., Results: A search using the key terms of critical care, air ambulance, EN, nutritional status, and aspiration returned a total of 51,990 articles. A title review followed by a more targeted abstract analysis by the research team generated 39 articles for full-text review. The full-text review then yielded a total of 10 relevant articles for inclusion in the final synthesis table., Conclusions: Overall, the consensus of the literature supports that early evaluation and initiation of standard EN feeding protocols on the ground and during transport improves patient outcomes and enhances injury recovery. However, additional research will determine the current number of patients fed in-flight along with the actual risks and benefits of EN in this population., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Recent advancements in virtual environment (VE) technology and the increasing use of VEs for treatment are opening up possibilities for rehearsal in safe and rich environments. Research has shown that VEs can be used to treat individuals with posttraumatic stress disorder (PTSD), but little research has been done to suggest guidelines for creating an effective environment. The aim of this study was to determine the design of systems that would allow military veterans to rehearse potentially stressful events in a VE before having to step into the actual environment. This research evaluated the responses to six stimuli: startle sound, direct eye contact, horizontal movement across the visual field, social conflict, an abandoned item, and a crowded auditorium. Measures used included change in heart rate (ΔHR), change in subjective unit of discomfort scores, and participant behavior., Materials and Methods: Thirty-eight participants, both with and without PTSD, experienced two VEs in first person using an Oculus Rift device. The first VE consisted of a tranquil garden, which allowed the participants to practice in the system, whereas baseline data were collected. The second VE was the experimental condition where the participant completed tasks within the VE and encountered stimuli designed to evoke responses from those with PTSD., Results: There was a significant difference in ΔHR between the PTSD and non-PTSD groups (P = .008), and the PTSD group had a higher mean ΔHR for all stimuli. The stimulus type was also significant for all participants (P < .001). Crowded auditorium and startle sound had the largest impact on the participants' ΔHR. Change in subjective unit of discomfort showed a significant interaction between the group factor (PTSD, non-PTSD) and stimulus (P = .043). Individuals with PTSD also presented more avoidance behavior than those without PTSD., Conclusions: Findings imply that VEs other than virtual combat zones can elicit behavioral, emotional, and physiological responses in individuals with PTSD, and these types of environments should be further studied for use with veterans suffering from PTSD. In future studies, systems should include initial stimuli that can be configured to allow focus on specific past traumatic experiences. Stimuli should also include both a crowded room and a startle noise scenario., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The Military Health System (MHS) is implementing a new electronic health record (EHR) which will impact 9.5 million Department of Defense (DoD) beneficiaries and over 205,000 MHS employees globally. The scale and scope of this EHR rollout is unprecedented; however, lessons learned from previous rollouts across smaller contexts in tandem with Kurt Lewin's Change Theory provide insights into critical success factors (CSFs) and critical barriers to implementation (CBIs) in which leadership may leverage to streamline future go-live efforts., Materials and Methods: The researcher conducted a narrative literature review to identify breadth of knowledge currently available surrounding EHR implementation and change management. A Boolean search of UMGC OneSearch was conducted utilizing the search string "electronic health record* OR EHR* AND change* AND implement*" which resulted in 7,084 results. Additional inclusion criteria and limiters were then applied to these results which included full-text, scholarly, and published journal articles, written in English from January 2009 to November 2019, from Europe, the United States, and Canada, in health and medicine, military history and science, and social science and humanities disciplines. 758 articles were identified through database searching. A cursory review of titles and abstracts for goodness of fit eliminated an additional 696 articles leaving 62 for full review. 18 of these articles were used for the final literature review. Through snowballing as well as Google Scholar, eight additional articles were identified and included. Finally, as a result of MHS Genesis being a new, government-backed EHR, the researcher also utilized three pieces of gray literature and non-peer-reviewed articles from professional websites, and three articles for background regarding Lewin's Theory of Change bringing the total references to 32., Results: The manuscript uncovered two main themes regarding organizational change and EHR implementation. The first theme, coined CSF, includes factors associated with positive outcomes in implementing EHRs. The three CSFs are Process Change Champions, Training, and Feedback, and definitions can be found in Table I. The second theme identified, coined CBI, includes factors associated with hindering EHR implementation. The three CBIs are Technophobia, Resistance from Leaders/Providers, and Insufficient Communication, and definitions can be found in Table II., Conclusions: By operationalizing pre-identified CSFs and CBIs, leaders of the MHS are able to streamline future waves of MHS Genesis rollouts utilizing Kurt Lewin's Change Theory and the newly crafted Conceptual Framework of MHS Genesis Implementation presented in Figure 1. Through full acceptance and use of CSFs, adapting to feedback and barriers, and dynamically adjusting strategies, the challenges associated with a large-scale phased EHR implementation can be minimized. The results and implications of this literature review are significant as the MHS Genesis rollout is still in its infancy and evidence-based best practices can still be executed. MHS Genesis continues to be phase implemented and currently only the Pacific Northwest and parts of California have gone operational. Increasing efficiency in this process provides a benefit to stakeholders at all levels: health care providers, patients, leadership, and taxpayers., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Ongoing studies are investigating the potential link between deployment to Operation Iraqi Freedom and Operation Enduring Freedom and relationship to increases in pulmonary disease. While increases in certain diseases such as asthma and airway hyperreactivity are well established, data on other chronic pulmonary diseases such as sarcoidosis have not been defined., Material and Methods: A retrospective chart review was conducted of all active duty military personnel diagnosed with sarcoidosis from 2005 to 2010. Deployment dates and locations were obtained through the Armed Forces Health Surveillance Branch. Electronic medical records were reviewed to determine the following parameters: dates of diagnosis, temporal relationship of diagnosis and deployment, symptoms (pre- and/or post-deployment), spirometry, diffusing capacity, radiographic staging, and treatment course. Pulmonary sarcoidosis incidence rates were estimated using International Classification of Diseases (ICD-9) coded medical encounter data from the Defense Medical Surveillance System and compared between Army and nonArmy personnel, as well as between ever-deployed and never-deployed personnel., Results: A cohort of 478 Army soldiers was identified with sarcoidosis based on ICD-9 codes and individual review of the medical records. The cohort was 80% male. 38.7% of soldiers with sarcoidosis never deployed. 11.7% were diagnosed prior to deployment, and 50.2% were diagnosed postdeployment. The diagnosis of sarcoidosis was established with a tissue diagnosis in 68% of the deployed cohort. Overall differences in spirometry were not identified. Obstructed spirometry was similar in all deployment groups (never, pre, and post) at 9.2%, 15.8% and 8.7%, respectively. Restrictive patterns based on total lung capacity (<70%) were similar at 9.2%, 12.5%, and 11.0%, respectively. Radiographic staging showed a similar distribution in the populations with the never/pre versus postdeployment groups having Stage 0 = 2.3 versus 3.5%, Stage I = 43.8 versus 41.6%, Stage II = 33.1 versus 41.0%, Stage III = 15.1 versus 12.1%, and Stage IV = 2.2 versus 1.7%, respectively. During 2005-2010, the estimated incidence rate of pulmonary sarcoidosis was low among active duty Army personnel (16.5 cases/100,000 person-years), and no trend in annual rates was observed, p = 0.89. Based on overall Department of Defense medical data, estimated pulmonary sarcoidosis rates were lower among ever-deployed personnel, relative to nondeployed personnel., Conclusion: Based on this analysis of Army sarcoidosis patients, there was no difference in the rates of sarcoidosis diagnosis in deployed and nondeployed soldiers. Spirometry values, total lung capacity, and radiographic staging did not show significant differences between deployment groups., (© The Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Military aircrews' health status is critical to their mission readiness, as they perform physically and cognitively demanding tasks in nontraditional work environments. Research Objectives: Our objective is to develop a broad operational risk assessment framework and demonstrate its applicability to health risks to aircrews because of airborne chemical exposure, considering stressors such as heat and exertion., Methods: Extrapolation of generic exposure standards to military aviation-specific conditions can include computation of risk-relevant internal dosimetry estimates by incorporating changes in breathing patterns and blood flow distribution because of aspects of the in-flight environment. We provide an example of the effects of exertion on peak blood concentrations of 1,2,4-trimethylbenzene computed using a physiologically based pharmacokinetic model., Results: Existing published collections on the effects of flight-related stressors on breathing patterns and blood flow address only a limited number of stressors. Although data exist that can be used to develop operational exposure limits specific to military aircrew activities, efforts to integrate this information in specific chemical assessments have been limited., Conclusions: Efforts to develop operational exposure limits would benefit from guidance on how to make use of existing assessments and expanded databases of the impact of environmental stressors on adult human physiology., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The Defense Health Agency has shifted focus of military medicine to operational readiness. As such, neurosurgery remains a critical wartime specialty. We investigate the factors impacting recruitment and retention of military neurosurgeons., Methods: Survey of military neurosurgeons was performed via the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Committee of Military Neurosurgeons and the Council of State Neurosurgical Societies. Retention and recruitment were queried., Results: 93/119 (78.2%) current or previously affiliated military neurosurgeons would recommend service as a military neurosurgeon to a colleague. Those who felt a sense of patriotism were 4.3 times more likely to recommend military service (P = 0.027, CI 1.19-16.82). Those who developed a sense of camaraderie showed a trend to recommending military neurosurgery (P = 0.058, CI 0.95-9.78). Those with a current military obligation were.28 times (P = 0.02, CI 0.09-0.85) as likely to recommend service. Military physicians who felt a need for reform to increase salary were 2.5 times less likely to be retained., Discussion: Service in the US military is a positive experience with camaraderie, patriotism, and unique military experiences predictive of recruitment. Meanwhile, focus on pay discrepancy can result in lost retention. These factors should be explored regarding recruitment and retention of military neurosurgeons., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Military training involves preparing individuals for combat, yet applying the stressors of combat while maintaining a safe training environment is exceedingly difficult. One method to induce significant anxiety while still maintaining reasonable safety has been to utilize simulated ammunition. These rounds enable force-on-force training with reasonable stress and firing accuracy while also readily allowing participants to realize they have been shot. As such, these rounds have significant value when performing force-on-force training. However, although in widespread use, there has not been a documented medical effort assessing the subjective pain experienced by individuals after being struck by one of these rounds, nor a visual record tracking recovery. The current investigation presents pilot data collected from an existing training course to provide an assessment of superficial ballistic trauma inflicted by simulated ammunition., Materials and Methods: Participants completed one-on-one duels as part of their intended course curriculum. These individuals used 9 mm pistols firing marking cartridges while wearing only prescribed protection equipment, leaving the chest, arms, and hands minimally covered by typical clothing. Participants engaged in the duels as overseen by the instructors and without guidance or interference by the experiment team. After an individual completed these drills, researchers then asked questions about subjective pain experience while also documenting the recovery via photographs., Results: Results indicated that simulated ammunition only inflicted a mild amount of subjective pain, which reduced to zero even upon palpation after only a few days. Subjective pain for the chest was rated slightly higher than any other region. The visual record documented that most contusions were reduced to minor bruising, largely dissipating as quickly as the pain., Conclusions: Participants were able to safely conduct force-on-force training with simulated ammunition by following the manufacturer recommended safety standards. Participants did rate a statistically significant level of subjective pain, although this mild pain serves as a necessary factor to create the stressful environment of simulating combat conditions. It is possible that the subjective pain was rated higher for the chest due to the increased number of total rounds striking the chest, or the more direct impact of the rounds upon this tissue. The differences in subjective pain and recovery between impact regions of the body are likely due to the specific force-on-force drill conducted as a part of this training. Additional research will be necessary to support or dispute this latter speculation., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Use of electronic secure messaging (SM) is rapidly growing in various healthcare settings. However, there is a large number of patients that choose not use SM or use it minimally. Thus, understanding preferences for patient-provider communication modalities is critically important, particularly among military healthcare beneficiaries. The purpose of this study was to assess preferences for patient-provider communication modalities (in person, telephone, SM, or mail) among a sample of patients, providers, and staff located at five Air Force military treatment facilities across the USA., Methods: We recruited patients, providers, and staff, from five family health clinics to complete a short survey. We measured participants' preferences for communication modality for various healthcare concerns, such as responses to non-urgent medical questions, test results, and medication renewal information. We also measured satisfaction with MiCare, the Air Force's SM system. We conducted chi-square analyses and Fisher's exact tests to assess differences in communication preferences by patients, providers, and staff and we computed frequencies in satisfaction responses., Results: We found that while providers and staff (N = 70) prefer to communicate with patients about various healthcare concerns online through MiCare, patients (N = 1,260) prefer to communicate in-person or through the telephone. Patients were generally satisfied with MiCare; however, there was a large proportion of patients who were undecided about MiCare's impact on the quality of care they received (40.3%). Additionally, although the majority of providers and staff believed MiCare improved their efficiency (58.0%) and communication with patients (72.3%), 65.7% of providers and staff believed MiCare had increased their workload., Conclusion: MiCare is a promising tool to improve patient-provider communication. However, future studies are needed to better understand why patients within the military healthcare system prefer communication modalities other than MiCare and to identify strategies to decrease provider and staff workloads while using MiCare.

The purpose of this article is to examine the usefulness of olfactory testing as a tool for the evaluation or stratification of traumatic brain injury (TBI) patients. Olfactory dysfunction is more likely to be overlooked by both the patient and the provider, especially in the acute setting, in contrast to deficits in other senses like vision or hearing. This is a retrospective clinical analysis (case series) of eight active duty service members referred to ear, nose, and throat clinic at Walter Reed National Military Medical Center during a 2-yr period between March 2014 and March 2016 for subspecialist evaluation of suspected olfactory impairment after an exposure to closed head trauma. Advanced neuroimaging revealed evidence of frontal lobe injury in all eight patients, which was subtle and subcentimeter in half of the cases, best demonstrated with high-resolution imaging in the coronal plane. In this article, we discuss the correlation between olfactory dysfunction and brain pathology in both TBI and non-TBI settings. We then provide our recommendation for an orbit magnetic resonance imaging (MRI) to evaluate the inferior frontal lobes and olfactory bulbs in patients with unexplained anosmia.

Background: This study examined the association of statin use and musculoskeletal conditions in statin users and nonusers within the population of U.S. Air Force active duty Service members in the military health care system., Methods: The study was a retrospective cohort analysis of Service members between 2004 and 2014 as identified from personnel data having physical fitness and cardiac risk data available and who were free of musculoskeletal diagnoses for 6 months before the study period. Based on pharmacy data, participants were divided into two groups: statin users (received a statin for at least 90 days) and nonusers (never received a statin throughout the study period). Using participants' baseline characteristics, a propensity score was generated and used to match statin users to nonusers in a 1:3 ratio. Conditional logistic regression was used to determine the odds ratio (OR) for a musculoskeletal injury., Findings: A total of 123,138 participants met study criteria (592 statin users and 122,546 nonusers). Of these, 516 statin users were propensity score matched to 1,548 nonusers. Among matched pairs, statin users had a higher OR (OR: 1.369; 95% confidence interval [CI]: 1.166-1.606) for musculoskeletal conditions. This association was driven by a higher frequency of back problems in statin users relative to nonusers. The number needed to be exposed for one additional person to be harmed was 20.104 (95% CI: 10.326-232.711)., Discussion: Statin use was associated with an increased likelihood of musculoskeletal conditions in the population of U.S. Air Force active duty Service members. Further investigations should evaluate the contribution of duty-related physical requirements as well as the duration of musculoskeletal condition-associated duty limitations., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Today, military combat medical care is the best it has ever been. Regulated U.S. Air Force aeromedical evacuation (AE) is one important reason. The Theater Validating Flight Surgeon (TVFS) validates that a patient is ready for flight. Two TVFSs' experiences, successively deployed in 2007, are the focus of this study. A unique operational worksheet used to manage the AE queue was used for approximately 5 months. A descriptive analysis of the worksheet's 1,389 patients found the majority male (94%), median age 30 years, and mostly Army enlisted soldiers (63%). U.S. civilians made up 9%. Battle Injury (55%) surpassed Disease, Non-Battle Injury (45%); most frequently seen were extremity injuries (73%) and cardiac illness (31%), respectively. Common to both Battle Injury and Disease, Nonbattle Injury were several TVFS prescriptions including no "remain overnights" (79%), head of bed elevation (78%), cabin altitude restriction (57%), no stops (44%), Critical Care Air Transport Team (27%), and supplemental oxygen (22%). This study is a first look at the TVFS experience and it offers up an initial accounting of the TVFS clinical and prescriptive practices. It is also a jumping point for future TVFS investigations using the available AE databases., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Background: The Afghanistan Surge saw NATO troops working with their Afghan partners to remove Taliban governance and replace it with a more democratic model. As part of this effort, medical support for both trauma and humanitarian cases was needed., Objective: Identify and discuss disease trends to better prepare for future combat medical care., Methods: Retrospective review of operative experience from a single neurosurgeon from November 2010 to April 2011., Results: 63 cases were performed in 20 NATO and 43 Afghan patients. Combat-related neurotrauma represented 73% (46/63) of cases, the majority of which were as a result of nonpenetrating injury (89%, 41/46). The most common area injured was the spine, accounting for 51% (21/41) of all nonpenetrating injuries. The majority of spine injuries occurred in NATO patients (61%, 13/21). The second most common area of nonpenetrating injury was the brain, occurring in 48% (20/41) of cases, primarily in Afghan troops (80%, 16/20). Overall, there were 2 deaths and 2 reoperations, for a complication rate of 8%., Conclusion: Future combat missions relying on mounted patrols may benefit from an emphasis on the use of vehicle safety equipment to decrease the incidence of brain injury, along with in theater neurosurgery care offering spine stabilization., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Background: The Afghanistan Surge saw NATO troops working with their Afghan partners to remove Taliban governance and replace it with a more democratic model. As part of this endeavor, medical support for both trauma and humanitarian cases was needed., Objective: Identify and discuss disease trends to better prepare for future combat medical treatments., Methods: Retrospective review of operative experience from a neurosurgeon from November 2010 to April 2011., Results: 63 cases were performed on 20 NATO and 43 Afghan patients. Combat-related neurotrauma represented 73% (46/63) of cases and humanitarian cases represented the remainder. The most common diseases among humanitarian cases were benign tumors (29%, 5/17), cranioplasty (23%, 4/17), obstructive hydrocephalus (11%, 2/17), nonobstructive hydrocephalus (11%, 2/17), hemifacial spasm (11%, 2/17), and cerebral angiography (11%, 2/17). There was 1 death from ventriculitis for a complication rate of 6%., Conclusion: In select well-nourished, patients with minimal risk of needing tracheostomy, humanitarian neurosurgery can be safely performed in theater with a complication rate (6%) no worse than patients operated on in the United States., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Objectives: This study described the patient population and the health care services delivered in the Air Force Flight and Operational Medicine Clinics (FOMCs) over the past 10 years., Methods: A cross-sectional analysis was performed on the retrospective cohort of patients who received care at a FOMC from 2003 to 2012., Results: A total of 714,157 individuals, generating 4,829,626 encounters, were included in the cohort. They were predominately male service members under the age of 41. One-fifth of individuals were retirees and family members, with one-third being in the pediatric age range. The cohort accessed health care services for three primary reasons: health examinations (28%), occupational dispositions (18%), and primary care (54%). When primary care was sought, the predominate health conditions were upper respiratory infections, back problems, and nontraumatic joint disorders. When services and procedures were a component of the care, they were predominately associated with health examinations involving ophthalmologic, auditory, and cardiac screening tests. Individuals accessing the FOMCs had relatively low need for access to health care services, requiring a median of two annual encounters., Conclusions: This study provided insight into the health care delivered in FOMCs and establishes a foundation for future planning and management of FOMC health care delivery., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Tuberculosis (TB) is a common disease worldwide affecting more than 2 billion people, including latent, pulmonary, and extrapulmonary TB. The presentation of disseminated TB is variable and dependent on the organs affected. Therefore, making the diagnosis and providing appropriate treatment can be delayed. We present a case of disseminated TB in a patient with Sjögren's syndrome on hydroxychloroquine monotherapy without traditional risk factors., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Retained unexploded ordnance is only one of the numerous potential threats to coalition forces while deployed in the theater of operations. Though rare, these are also very real dangers for personnel involved with patient care and movement. Principles of management include determination of device type with plain film radiography, minimizing rotational and vibratory movement, and strategic isolation of the patient from the hospital facility, hospital personnel, and other patients. Early identification of this threat, as well as early involvement of the Explosive Ordnance Disposal team is paramount to safe and successful management. We present a case of a deceased patient in the expectant triage category with a delayed identification of retained unexploded ordnance during postmortem preparation., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

The relationships and families of active duty (AD) service members have been tremendously strained by deployments and high operations' tempo. This study involves the first steps in developing a multilevel approach to preventing relationship problems that integrates universal, selective, and indicated prevention/intervention. Such an approach has tremendous empirical support for parenting problems, but no similar program exists for couple problems. We conducted two studies with U.S. Air Force Security Forces members. Study 1 elicited the target population's topics of highest interest. For almost all topics, 70% to 95% of participants who desired information reported being underserved by current prevention offerings (i.e., not receiving needed information). Using the top topics generated in Study 1, we developed prevention information/action planning sheets on 18 relationship issues. In Study 2, we had AD members who gave feedback on the form and content of the sheets. Overall, AD members believed that the sheets were moderately to very useful and were presented well, had pithy but comprehensive information and conveyed the content well. Results imply that a multilevel approach may be a useful complement to formal services in meeting underserved military members' needs and that further research and development of this dissemination vector for evidence-based information is warranted., (Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.)

The Joint Combat Casualty Research Team (JC2RT) is part of the human research protection regulatory system implemented in 2005 to oversee the conduct of research in a deployed military combatant command. In 2010, SharePoint, a web-based tool, was established to track study documents. This study conducted by JC2RT no. 13 describes characteristics of research studies under the purview of the JC2RT from 2010 through 2012. Of the 83 research studies reviewed, 34% were completed, 32% were not completed, and 34% were still in progress. Target sample sizes ranged from 12 to 70,000, with 96% of the research studying U.S. military members. The design of 61% of the studies was prospective, 20% surveys, and 14% retrospective reviews. Approximately one-half of the studies were conducted at single sites. Eighty-four percent of the studies that finished an institutional review board (IRB) were completed, whereas a large number of studies never made it to IRB approval. Even after studies have gone through the rigorous process of scientific review and IRB approval some continue to struggle for years to be completed in the theater of operations. The JC2RT is committed to helping facilitate the ethical conduct of research during war., (Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.)

The goal of this study is to repeat a survey administered in 2010 to assess for changes in mental health among United States Air Force aircrew operating Predator/Reaper remotely piloted aircraft, also commonly referred to as "drones." Participants were assessed for self-reported sources of occupational stress, levels of clinical distress using the Outcome Questionnaire-45.2, and symptoms of post-traumatic stress disorder (PTSD) using the PTSD Checklist-Military Version. A total of 1,094 aircrew responded to the web-based survey composed of the commercially available standardized instruments mentioned above. The survey also contained nonstandardized items asking participants to report the main sources of their occupational stress, as well as questions addressing demographics and work-related characteristics. The estimated response rate to the survey was 49%. Study results reveal the most problematic self-reported stressors are operational: low manning, extra duties/administrative tasks, rotating shift work, and long hours. The results also reveal 10.72% of operators self-reported experiencing high levels of distress and 1.57% reported high levels of PTSD symptomology. The results are lower than findings from the 2010 survey and from soldiers returning from Iraq and Afghanistan. Implications of the study and recommendations for United States Air Force line leadership and mental health providers are discussed., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

The primary objective in this research involves determining the Air Force Physical Fitness Test's (AFPFT) predictability of combat fitness and whether measures within the AFPFT require modification to increase this predictability further. We recruited 60 female volunteers and compared their performance on the AFPFT to the Marine Combat Fitness Test, the proxy for combat fitness. We discovered little association between the two (R(2) of 0.35), however, this association significantly increased (adjusted R(2) of 0.56) when utilizing the raw scores of the AFPFT instead of using the gender/age scoring tables. Improving on these associations, we develop and propose a simple ordinary least squares regression model that minimally impacts the AFPFT testing routine. This two-event model for predicting combat fitness incorporates the 1.5-mile run along with the number of repetitions of a 30-lb dumbbell from chest height to overhead with arms extended during a 2-minute time span. These two events predicted combat fitness as assessed by the Marine Combat Fitness Test with an adjusted R(2) of 0.82. By adopting this model, we greatly improve the Air Force's ability to assess combat fitness for women., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

Background: The underpinning pathophysiology, prevalence, and clinical relevance particular to hemorrhagic shock-induced liver damage have been explored only recently. Importantly, several investigators have revealed that an aberrant periportal endothelial response, characterized by the early release of oxidizing mediators, perpetuates and eventually amplifies the extent of hepatic reperfusion injury., Case: We present a case that illustrates the clinical impact of hepatic ischemia-reperfusion injury and a potential means of ameliorating the attendant self-propagating hepatic destruction., Conclusion: Reversal of hemorrhagic shock may lead to the induction of a hepatic oxidation response with a resultant furthering of liver injury. Antioxidants such as N-acetylcysteine may represent a tolerable and logical means of attenuating the aberrant oxidant cascade and stabilizing or reversing ischemic-reperfusion hepatopathy.

Objective: To study the illness and injury risk and healthcare utilization of male U.S. Air Force (USAF) battlefield airmen in comparison to male USAF security forces., Methods: Using data in electronic format, battlefield airmen (n = 2,089) and security forces personnel (n = 19,416) were identified and matched to data from the Military Health System, with analyses conducted to explore hospitalization risks and healthcare utilization differences., Results: Battlefield airmen were at an increased risk for hospitalizations for illnesses (HR = 1.35, 95% CI 1.03, 1.77), musculoskeletal conditions (HR = 2.28, 95% CI 1.47, 3.52), and injuries (HR = 3.34, 95% CI 2.38, 4.69) compared with security forces. Differences in the mean number of hospitalization days per person and mean outpatient medical costs also existed across the groups., Conclusions: Battlefield airmen are significantly more likely to be hospitalized for a number of illnesses and injuries in comparison to security forces. A surveillance study has been implemented to further explore these findings.

Objective: The goals were to review the effectiveness of current cooling technologies used on the battlefield to reduce or to prevent heat illness in soldiers and to discuss possible alternative or improved cooling methods., Methods: A search of the literature for 1990-2007 was performed by using the Air Force Institute of Technology and Air Force Research Laboratory search engines., Results: Several current cooling technologies are modestly effective in attenuating brain and core body temperatures, but the cooling effects are not sustained and the devices present operational problems. This review indicates that some current cooling devices are effective in lowering perceived efforts and lengthening maximal exercise time but are incompatible with current demands., Conclusions: Many of the cooling methods and devices detailed in the literature are impractical for use in the field. Future research should focus on cooling technologies that are practical in the battlefield and have sustainable cooling effects.