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Introduction: With a rise in gun violence across the United States, facial gunshot wounds (GSWs) present a challenging reconstructive problem that was once seldom encountered in civilian populations. Reconstruction of facial GSW injuries requires a combination of both microvascular and craniofacial surgical techniques. The aim of this study is to explore our experience with facial GSW injuries through an anatomic classification scheme and investigate the surgical techniques necessary to complete such reconstructions. Methods: A retrospective review was conducted at a tertiary academic center. All subjects who suffered facial GSWs and underwent definitive reconstruction at our institution were included. Facial GSWs were classified into 4 distinct anatomical zones of injury: lower (mandible), middle (maxilla and orbit), upper (above the orbit), and multi-zone injury. Microvascular reconstruction was further investigated based on the types of flaps used and the location of flap inset. Surgical outcomes, numbers of procedures, and complications were assessed, and statistical comparisons were made. Results: Thirty-six subjects underwent a total of 322 surgeries. Twenty subjects had multi-zone injury; 16 had single zone injury. Eighteen of the 36 subjects (50%) required microvascular reconstruction. These 18 subjects underwent a significantly increased number of reconstructive procedures ( P = .023). Twenty-six flaps were used, as multiple subjects required >1 flap. Fourteen of the 26 flaps were used in the middle third (54%), 7 in the lower third (27%), and 5 in the upper third (19%). Six flap complications required further surgical revision. On average, multi-zone injuries required more surgical procedures to complete reconstruction ( P = .018). Conclusion: Composite multi-zone facial GSW injuries present a higher degree of reconstructive complexity, and thus often require more surgical procedures, especially when the midface is involved. In our experience, microvascular reconstruction is more often used in multizone injury, and in our series was associated with an increased number of reconstructive procedures.

War in Ukraine started in March 2014 when Russia annexed Crimea and continues today in the Donbass region of Eastern Ukraine. Over 1.5 million people in these regions have been displaced from their homes. We conducted this study 36 months after the conflict began and interviewed civilians residing in Ukraine. This study examines the prevalence of exposure to war trauma, rates of PTSD by symptom clusters, and whether socio-demographic factors are associated with positive scores for PTSD among civilian urban-dwelling and internally displaced persons in Ukraine during the ongoing conflict in its Donbass region. Face-to-face interviews were conducted using a multi-stage random sample of the general population in two large cities (Kharkiv and Lviv) in Ukraine (n = 1247) and a purposive sample of internally displaced persons (n = 300), half living in each city. Exposure to trauma, symptom clusters for Posttraumatic Stress Disorder (PTSD), and overall PTSD were assessed. We found widespread direct exposure to conflict-related traumatic events (65%) among internally displaced people (IDPs) compared to a sizable minority (23%) of urban-dwelling people (UDPs). We found elevated prevalence of PTSD symptoms that were also uniformly spread within several socio-demographic factors. There were, however, significant differences in PTSD between (1) IDPs compared to UDPs and (2) those UDPs with Ukrainian compared to Russian ethnic identity, the former of each pair showing increased likelihoods of positive PTSD scores. Ukraine’s adult civilians, enduring the prolonged engagement in war with Russia and Russian separatists, have elevated rates of PTSD. Moreover, those who have been displaced by the ongoing conflict (IDPs) have significantly higher levels of PTSD compared to UDPs.

The aim of the study is to improve the organization and provision of surgical care to civilians with gunshot wounds to the chest in the context of armed conflict on the example of the Chechen campaign.Materials and methods. The work is based on the analysis of medical care provided to 106 wounded with gunshot wounds to the chest from the civilian population in the period from 1991 to 2000. Medical care was provided on the basis of the surgical hospital of the city hospital No. 9 in Grozny.Results and discussion. Found that providing medical care to wounded with gunshot wounds of the chest when massive flow in terms of actual hostilities rendered by the forces and means of civil hospitals, has a certain specificity. It is due to the fact that in such conditions, in contrast to military medical organizations, there are no stages of evacuation, often the wounded are delivered by non-specialized and unsuitable vehicles on destroyed roads, while they are not given or given insufficient pre-medical care. In such conditions, the workload of medical personnel of civil medical institutions associated with the provision of medical care increases. In this regard, in our opinion, it is necessary to develop measures aimed at improving the algorithm aimed at minimizing various errors that occur in civilian medical institutions during the mass admission of wounded.

Background Hemorrhage accounts for >30% of trauma-related mortalities. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemostasis in the civilian population remains controversial. We aim to investigate REBOA practices through analysis of surgeon and trauma center characteristics, implementation, patient characteristics, and overall opinions. Methods An anonymous 30-question standardized online survey on REBOA use was administered to active trauma surgeon members of the Eastern Association for the Surgery of Trauma. Results A total of 345 responses were received, and 130/345 (37.7%) reported REBOA being favorable, 42 (12.2%) reported REBOA unfavorably, and 173 (50.1%) were undecided. The majority of respondents (87.6%) reported REBOA performance in the trauma bay. 170 (49.3%) of respondents reported having deployed REBOA at least once over the past 2 years. 80.0% reported blunt trauma being the most common mechanism of injury in REBOA patients. Resuscitative endovascular balloon occlusion of the aorta deployment in zone 3 of the aorta was significantly higher in patients reported to suffer a pelvic fracture or pelvic hemorrhage, whereas REBOA deployment in zone 1 was significantly higher among patients reported to suffer hepatic, splenic, or other intra-abdominal hemorrhage ( P < .05). Conclusion Among survey respondents, frequency of REBOA use was low along with knowledge of clear indications for use. While current REBOA usage among respondents appeared to model current guidelines, additional research regarding REBOA indications, ideal patient populations, and outcomes is needed in order to improve REBOA perception in trauma surgeons and increase frequency of use.

To evaluate the pattern of sensorineural hearing loss (SNHL) in patients attending ENT OPD in a military setup as well as to compare the incidence of hearing loss in Military Personnel with civilian population. This observational cross sectional comparative study was conducted over a period of April 2018 to July 2019. A total of 300 patients with hearing loss (HL) were included. Demographic characteristics along with laterality of sensorineural hearing impairment were compared between military personnel and civilians. Data was statistically compared between civilians and military personnel. A P-value of

Introduction The incidence of carpal tunnel syndrome (CTS) is increased in occupations exposed to repetitive motion, poor wrist posture, and vibration exposure. While all pilots are exposed to these factors, helicopter pilots are especially exposed to vibration. The study is to identify the incidence and risk factors for CTS in military aviators. Materials and Methods Clearance was obtained from Tripler Army Medical Center IRB. The Defense Medical Epidemiological Database was queried for all new cases of CTS from 2006 to 2015. Incidence rates (IRs) were determined for helicopter pilots, fixed-wing pilots, and nonpilot officers. Poisson regression analysis was used to calculate adjusted IR in order to control for demographic factors. Race was also taken into account, where pilots would classify themselves into a white or non-white race, defined by each individual. Race was assessed in the study to see if there were any differences in IR of CTS between white and non-white pilots. Results We identified 7,398 new cases of CTS among 2,319,352 person-years within the study period. Increasing age, female gender, and non-white race were significantly correlated with higher IR. Fixed-wing pilots demonstrated significantly lower adjusted IR than nonpilot officers in each age group. Helicopter pilots demonstrated higher IR than fixed-wing pilots in each age group. Helicopter pilots had lower incidence of CTS early in their career compared to nonpilot officers, but by age 40+, their IR ratio was significantly higher (1.21). Conclusion Analysis of the database indicates that fixed-wing pilot status is a protective factor against development of CTS among U.S. military officers. In contrast, helicopter pilots were found to be at an increased rate of CTS than their fixed-wing counterparts. Their incidence is comparable to their nonpilot officer peers early in their career, but is significantly increased at the senior level. Increasing age and female gender are risk factors in the military officer population as expected. Non-white race was found to increase risk in the military population, in contrast to reports of the civilian population.

espanolIntroduccion El suicidio representa la decimosexta causa de muerte en todo el mundo. A partir del 2008, sabemos la tasa de suicidios en los soldados estadounidenses comenzo a superar a la de la poblacion civil. Hasta donde sabemos no hay estudios que describan la conducta suicida en militares mexicanos. Objetivo Estimar la frecuencia de la ideacion suicida y el intento de suicidio en los ultimos 12 meses en militares navales mexicanos y determinar las variables asociadas con la ideacion y el intento de suicidio. Metodo El estudio transversal incluyo 246 pacientes ambulatorios enviados para una evaluacion psiquiatrica. Se realizo una entrevista psiquiatrica utilizando los criterios diagnosticos de la Clasificacion Internacional de Enfermedades en su decima edicion, que incluyo la presentacion de ideacion suicida e intento de suicidio en los ultimos 12 meses. Resultados La frecuencia en los ultimos 12 meses de ideacion suicida e intento de suicidio fue de 24.39% y 9.76%, respectivamente. Las variables asociadas con la ideacion suicida fueron: grado militar (clases y marineria, p = .03), antecedente familiar de suicidio (p Discusion y conclusion Se requiere un mayor enfasis en la deteccion de problemas de salud mental en la poblacion militar y estudios mas representativos a nivel nacional. EnglishIntroduction Suicide represents the sixteenth cause of death worldwide. Until a few years ago the suicide rate in the US military has been below that of the civilian population, but in 2008 the suicide rate among US soldiers began to outpace the civilian population. To our knowledge, there are no studies that describe suicidal behavior among Mexican military personnel. Objective To know the frequency of suicidal ideation and suicide attempt in the last 12 months in Mexican naval military and determine the variables associated with both ideation and suicide attempt. Method This cross-sectional study included 246 outpatients who were sent for psychiatric assessment from their operating units. A psychiatric interview was conducted using the diagnostic criteria of the International Classification of Diseases in its tenth edition, which included the presentation of suicidal ideation and attempted suicide in the last 12 months. Results Suicidal ideation in the last 12 months occurred in 60 cases (24.39%). Twenty-four cases (9.76%) presented a suicide attempt in the last 12 months. Variables associated with suicidal ideation were military grade (seaman and classes, p = .03), suicide family history (p Discussion and conclusion Greater emphasis in the detection of mental health problems, including suicidality among the military population and more representative studies at the national level are needed.

BACKGROUND: A single 2-year National Health and Nutrition Examination Survey (NHANES) cycle is designed to provide accurate and stable estimates of conditions with prevalence of at least 10%. Recent NHANES-based estimates of a tuberculin skin test ≥10 mm in the noninstitutionalized U.S. civilian population are at most 6.3%. METHODS: NHANES included a tuberculin skin test in 1971–1972, 1999–2000, and 2011–2012. We examined the robustness of NHANES-based estimates of the U.S. population prevalence of a skin test ≥10 mm with a bias analysis that considered the influence of non-U.S. birth distributions and within-household skin test results, reclassified borderline-positive results, and adjusted for tuberculin skin test item nonresponse. RESULTS: The weighted non-U.S. birth distribution among NHANES participants was similar to that in the overall U.S. population; further adjustment was unnecessary. We found no evidence of bias due to sampling multiple participants per household. Prevalence estimates changed 0.3% with reclassification of borderline-positive tuberculin skin test results and 0.2%–0.3% with adjustment for item nonresponse. CONCLUSIONS: For estimating the national prevalence of a tuberculin skin test ≥10 mm during these three survey cycles, a conventional NHANES analysis using the standard participant weights and masked design parameters that are provided in the public-use datasets appears robust.

The article presents the results of a retrospective analysis of materials and documents of ambulance stations of the Lugansk People’s Republic for the period of the active phase of the armed conflict (2014– 2015) in organizing the provision of medical care for a military trauma. A brief description of sanitary losses among the civilian population and the militia is presented, as well as the problematic issues identified during the medical-evacuation provision of the population are indicated.

ZusammenfassungHäufiger als vielfach angenommen tritt – nach Berechnungen von 2 Metaanalysen – im Mittel bei ca. 25% der PTBS-Fälle das Vollbild der Posttraumatischen Belastungsstörung (PTBS) erst nach mehr als 6 Monaten auf. Die Prävalenzzahlen variieren stark je nach untersuchter Population. Im militärischen Bereich tritt eine PTBS mit verzögertem Beginn deutlich häufiger auf als im zivilen (38,2 vs. 15,3%). Für das Spektrum an Prävalenzzahlen werden Unterschiede in der Definition, der Methodik, den Untersuchungskollektiven wie auch den Traumaformen selbst verantwortlich gemacht. Je länger die Beobachtungszeit, um so eher die Erfassung von verzögertem Beginn einer PTBS. Für die Entstehung und Aufrechterhaltung wurden einige Einflußfaktoren identifiziert. In der Begutachtung wird bei verzögertem Beginn die Forderung nach „Brückensymptomen“ gestellt. Diese sind zwar häufig, jedoch nicht zwingend erforderlich. Am Beispiel von politischer Inhaftierung in der DDR werden Verlaufsformen der PTBS wie auch des Subtyps des „verzögerten Beginns“ dargestellt.

With the increased number of mass shootings in recent years, this paper seeks to review recent literature on the management of active shooter settings and the care for pediatric victims. Tactical Combat Casualty Care (TCCC) functions on the principal of expeditious recognition and aggressive treatment of preventable death on the battlefield. The Committee for Tactical Emergency Casualty Care (C-TECC) was formulated to translate the TCCC guidelines to the civilian population. The adaptation of C-TECC’s guidelines have also considered the importance of real-world demographics, including the pediatric population. Pediatric C-TECC guidelines advise, if possible, that the patient should move to a position of safety. If not possible, risks and benefits should be weighed for rescue attempts in terms of the activity and safety of the situation. The practitioner should realize that time may be more limited for pediatric patients in terms of rescue and medical salvage. Prompt placement of tourniquets, hemostatic agents, and wound packing for hemorrhage control, especially in ongoing active threat scenarios, is recommended. However, guidelines like C-TECC are reactionary. The prevention of traumatic injury is still paramount and the goal will always be minimizing the chance of harm to the public prior to the injury occurring.

The incidence of self-inflicted gunshot wounds has increased significantly in the civilian population. In this case, we present a 25-year-old male with a self-inflicted gunshot wound to the neck exiting to the left shoulder. Penetrating injuries to the neck carry a high likelihood of severe injury and death. Exsanguination due to damage to the carotid or vertebral arteries is the most common cause of immediate death. Traumas caused by gunshot wounds can be complicated by an unusual path and can be devastating, depending on the extent of the injury. Our patient presents with a unique singular outcome of a spinal cord injury from anterior penetrating neck trauma. The aim of this case report is to raise awareness of a unique outcome from a self-inflicted gunshot wound, as it is vital to be aware of all possible outcomes because these injuries become more prevalent in our communities.

Objective Firearm violence has a high economic impact, representing the third most expensive injury and associated with the fourth highest hospitalisation cost. This study was performed to determine the clinical and epidemiological characteristics of patients with injuries due to firearm projectile during a period of increased violence related to organised crime in our country. Methods A retrospective study (2010–2017) was conducted to analyse the clinical data of patients admitted due to firearm projectile injury. Clinical and epidemiological characteristics of each patient were recorded, and patients were stratified by sex and age. Compared low-energy versus high-energy gunshot injuries, complications and treatment. Results A total of 1309 gunshot wounds in appendicular skeleton and spine fractures. The mean age of the patients was 29 ± 11.5 years. Upper extremities wounds in 358 cases, lower extremities wounds in 727 cases and 224 fractures in spine region. There were no significant differences between low-velocity and high-velocity projectiles in anatomic affected region, complications and treatment. Conclusions We concluded that firearm projectiles cause a variety of injuries both in soft and bone tissues and caused a major rate of complications in our patients even with low- or high-energy weapons. The majority of patients affected were the civilian population. Most patients with gunshot wounds were young males. We observed a low mortality rate in our patients. Level of evidence III; retrospective cohort study.

Objective Firearm violence has a high economic impact, representing the third most expensive injury and associated with the fourth highest hospitalization cost. This study was performed to determine the clinical and epidemiological characteristics of patients with injuries due to firearm projectile during a period of increased violence related to organized crime in our country. Methods A retrospective study (2010–2017) was conducted to analyze the clinical data of patients admitted due to firearm projectile injury. Clinical and epidemiological characteristics of each patient were recorded, and patients were stratified by sex and age. Compared low-energy versus high-energy gunshot injuries, complications and treatment. Results A total of 1309 gunshot wounds in appendicular skeleton and spine fractures. The mean age of the patients was 29 ± 11.5 years. Upper extremities wounds in 358 cases, lower extremities wounds in 727 cases and 224 fractures in spine region. There were no significant differences between low-velocity and high-velocity projectiles in anatomic affected region, complications and treatment. Conclusions We concluded that firearm projectiles cause a variety of injuries both in soft and bone tissues and caused a major rate of complications in our patients even with low- or high-energy weapons. The majority of patients affected was the civilian population. Most patients with gunshot wounds were young males. We observed a low mortality rate in our patients. Level of evidence III; Retrospective cohort study.

The prevalence of tuberculosis among military health system (MHS) and Veterans Affairs (VA) beneficiaries in Hawaii and the Pacific Islands has not been previously reported. Our analysis evaluates the prevalence of M. tuberculosis (MTB) among acid fast bacilli culture(s) (AFB) tested at Tripler Army Medical Center (TAMC) on Oahu, HI and describes demographic factors associated with positive samples. We analyzed 9,768 AFBs from 4,129 individuals with AFB specimens processed at TAMC from January 2002 to November 2019: of those who were tested 3,178 were MHS beneficiaries and 951 were VA beneficiaries. There were a total of 40 individuals with MTB-positive cultures over the period of study: 31 MHS beneficiaries and 9 VA beneficiaries. Of the MTB-positive specimens, 93% were from pulmonary samples while the remainder were from lymph node aspirates (5%) and peritoneal samples (2%). Cumulative incidence rates of MTB-isolation were 1.8 per 100,000 MHS beneficiaries and 1.2 per 100,000 VA beneficiaries, both of which were lower than reported incidence rates in Hawaii, the U.S.-affiliated Pacific Islands and the United States for the study period. MHS beneficiaries of Asian-Pacific Islander race or ethnicity had nearly 20 times higher odds of positive AFB than white MHS beneficiaries (OR = 19.56, 95% CI 5.52, 69.29, p = < 0.001). This study demonstrated a higher odds of MTB-positivity associated with Asian-Pacific Islander race or ethnicity and low incidence rates of TB among MHS and VA beneficiaries in Hawaii and the Pacific Islands when compared with the civilian population.

Opiates are addicting and have a high potential for dependency. In the past decades, opiates remained the first-line pharmaceutical option of prehospital treatment for acute traumatic pain in the civilian population. Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist that has analgesic properties and may serve as an alternative agent for the treatment of acute traumatic pain in prehospital settings. This study aims to assess the safety and efficacy of ketamine administration by paramedics in civilian prehospital settings for the treatment of acute traumatic pain. This was a prospective observational study in San Bernardino, Riverside and Stanislaus counties. Patients were included if they were > 15 years of age with complaints of traumatic or burn-related pain. Patients were excluded if they received opiates up to six hours prior to or concurrently with ketamine administration. The dose administered was 0.3 mg/kg intravenously over five minutes with a maximum dose of 30 mg. The option to administer a second dose was available to paramedics if the patient continued to have pain after 15 minutes following the first administration. Paired-T tests were conducted to assess the change in the primary outcome (pain score) and secondary outcomes (e.g. systolic blood pressure, pulse, and respiratory rate). P-value

Canadian Blood Services (CBS) operates a national rare blood program to meet the needs of a highly diverse Canadian civilian population. This program manages the frozen inventory of red blood cell products maintaining upwards of 800 units of strategically identified phenotypes for patient use. Red cell concentrates (RCCs) are collected from identified donors with rare blood types as whole blood and are further processed into leukocyte reduced red cell concentrates in SAGM. These units can be stored for up to 21 days prior to glycerolization and frozen storage. The use of the ACP 215, a closed system cell processor, for cryopreservation using the high glycerol method allows for an extended expiry date of 14 days post deglycerolization when RBCs are suspended in AS-3 and stored hypothermically prior to transfusion. This method produces units that meet all Canadian regulatory standards. Introduction of extended outdates has allowed CBS to decrease operational costs and improve cryopreserved RCC product quality.

Cold traumas (CT) were once primarily military problems, but are becoming increasingly prevalent among the civilian population. It is associated with a growing interest in outdoor activities such as skiing, hiking, mountaineering and increase in the numbers of homeless. Occurrence of CT grows up in winter, when number of injured reaches more then 12 000 people. Most of the injured need hospital treatment, mortality is excess 10 % of cases. Research as to the pathophysiology of frostbite has revealed notable similarities with the inflammatory processes seen in burn injuries and ischaemia/reperfusion injury. Evidence for the role of tromboxanes and prostaglandins has resulted in a more active approach to the medical treatment of frostbite. Considering the role of eicosanoids in the development of CT we can assume positive influence of arachidonic acid cascade inhibitors for such pathology. The aim of the work is to compare the power of frigoprotective effect of NSAIDs with different selectivity and paracetamol using the model of acute general cooling. The experiment was carried out using healthy white male mice weighing 20–24 g during single day from 12.00 till 18.00. Mice were put into individual 500 cm3 plastic cages with free access to air and without movement restriction. Cages were situated inside the freezer «Nord Inter-300» with transparent top and at a temperature of –18 °C. An integral index of frigoprotective effect was chosen the duration of life. Drugs and substances that were used in the experiment: nonselective inhibitors of COX – acetylsalicylic acid (Aspirin, tablets, «Bayer», Germany), diclofenac sodium (Voltaren, tablets, «Novartis», Switzerland); highly selective inhibitor of COX-2 – celecoxib (Celebrex, tablets, «Pfizer», USA), etoricoxib (Arcoxia, tablets, «Merck Sharp & Dohme Idea Inc», USA); inhibitor of COX-3: paracetamol (Panadol, tablets, «Glaxo Smith Kline plc», Ireland); double inhibitor of COX-2/5-LOX – darbufelone, darbufelone mesylate, 5-(3,5-di-tret-butyl-4-hydroxybenziliden)-2-(thiazol-2-ilimino)-thiazolidin-4-on (substances). The results of the present study show that paracetamol doesn’t demonstrate frigoprotective activity. Etoricoxib render the highest frigoprotective effect among traditional NSAIDs. Darbufelone mesylate shows the highest frigoprotective activity among all used inhibitors of arachidonic acid cascade. Considering that we can suppose important role of 5-LOX and leukotrienes in pathogenesis of cold trauma.

Background: The mortality rate of US Veterans is greater than that of civilians, and US Veterans experience disproportionately higher burden of medical comorbidities. Disparities in coronary artery disease (CAD) incidence and its risk factors between US veterans and civilians has not previously been reported. This study seeks to identify disparities in the incidence of CAD and CAD risk factors in US veterans and the general population. Methods: A total of 1535 consecutive US Veterans presenting for left heart catheterization (LHC) were reviewed. We present risk factor burden, LHC outcome, and mortality with mean follow-up time of 112 ± 65.2 months. Results: At mean follow-up of 112 months (9.3 years), all-cause mortality was 68.3%. 12.7% had normal coronaries (NC), 14.9% had non-obstructive coronary artery disease and 72.3% had obstructive coronary artery disease (ObCAD). Mean BMI was 30.0; 87.8% had hypertension (HTN), 78.1% had hyperlipidemia (HLD), 52.2% has reduced ejection fraction (rEF), 45.5% had diabetes (DM), and 17.5% had chronic kidney disease (CKD). In order of decreasing Cox hazard, six risk factors (CKD, rEF, PVD, HTN, obesity and DM) were independent predictors of mortality. Conclusion: Mortality and incidence of ObCAD in US veterans are notably greater than in the American general population (per the CDC National Health Report) and other developed countries (per the WHO NCD Report). Compared to the general population, there is greater burden of HTN, HLD, DM and CKD in US Veterans. Among US Veterans, CKD carried a greater HR compared to HTN and DM, with no significant HR for HLD. This differs markedly from the general population studied in the REACH registry which established HTN, HLD and DM as the greatest predictors of cardiovascular mortality. The low hazard of HLD was likely secondary to its ubiquity in most patients in the cohort, regardless of CAD status. US Veterans have unique healthcare needs and our study guides which risk factors need to be managed to improve disparities in US Veteran health.

During the First World War, from 1914 until 1915, Serbia has been subjected to aggression and occupation by the Austro-Hungarian Empire. During the entire period of aggression and occupation, the Austro-Hungarian army and the local authorities carried out severe war crimes against wounded, sick, medical personnel and the civilian population. In addition to the aforementioned in the year of 1915, a major epidemic of all three types of typhoid occurred in Serbia. Because of the war and epidemic of typhoid the medical situation in Serbia was very difficult so a large number of medical missions from Allied and neutral countries have come to Serbia to help. The medical missions came from Russia, Great Britain, Canada, Greece Australia and New Zealand, as well as from neutral countries such as Switzerland, the USA, Netherlands and Denmark. These medical missions have managed to provide great assistance in rescuing wounded and sick in Serbia. Also, a large number of doctors and medical personnel from these missions have died or suffered from infectious diseases.

The experience of organizing the treatment of wounded and sick military men of the Red army in Saratov at the final stage of the Great Patriotic War is studied. Priority tasks that were solved in conditions of the location of medical institutions in the deep rear are given. The structure of injuries and injuries with which soldiers and officers of the Red Army were sent from the front to the evacuation hospitals of the city and the region was investigated. Attention is drawn to the change the severity and location of wounds, depending on the progress of our units towards Germany. The factors that contributed to the successful treatment and return to the system of heavy contingents of the wounded and sick are indicated. The importance of the initiative work, which was carried out by medical personnel of evacuation hospitals on the development and introduction of new methods to improve the effectiveness of medical measures in everyday clinical practice, was stressed. Published data on the number of beds that were transferred from the Saratov hospital base in the army. In addition, evacuation hospitals and the Saratov Medical Institute were those institutions of which, even at the final stage of the war, medical personnel were sent for service to the front. At the same time, many honorably and honorably fulfilled their civic duty to the Motherland. Examples of patronage over hospitals from industrial enterprises and public organizations of Saratov and the region are given. A brief overview of the treatment and prophylactic tasks, which were solved in the interests of the civilian population of the city and the region, is given.

BACKGROUND AND PURPOSE: Cerebral microhemorrhages are a known marker of mild traumatic brain injury. Blast-related mild traumatic brain injury relates to a propagating pressure wave, and there is evidence that the mechanism of injury in blast-related mild traumatic brain injury may be different from that in blunt head trauma. Two recent reports in mixed cohorts of blunt and blast-related traumatic brain injury in military personnel suggest that the prevalence of cerebral microhemorrhages is lower than in civilian head injury. In this study, we aimed to characterize the prevalence of cerebral microhemorrhages in military service members specifically with chronic blast-related mild traumatic brain injury. MATERIALS AND METHODS: Participants were prospectively recruited and underwent 3T MR imaging. Susceptibility-weighted images were assessed by 2 neuroradiologists independently for the presence of cerebral microhemorrhages. RESULTS: Our cohort included 146 veterans (132 men) who experienced remote blast-related mild traumatic brain injury (mean, 9.4 years; median, 9 years after injury). Twenty-one (14.4%) reported loss of consciousness for 2 episodes. No cerebral microhemorrhages were identified in any subject, as opposed to the frequency of SWI-detectable cerebral microhemorrhages following blunt-related mild traumatic brain injury in the civilian population, which has been reported to be as high as 28% in the acute and subacute stages. CONCLUSIONS: Our results may reflect differences in pathophysiology and the mechanism of injury between blast- and blunt-related mild traumatic brain injury. Additionally, the chronicity of injury may play a role in the detection of cerebral microhemorrhages.

Foram estudados 417 casos de ferimentos craniencefálicos por projétil de arma de fogo ocorridos em população civil, com o objetivo de determinar os fatores que influenciam a mortalidade. Foram selecionados pacientes com ferimento único, que chegaram com vida ao hospital em um período de até seis horas após o trauma e que evoluíram para o óbito após a internação ou permaneceram internados por pelo menos 48 horas. A mortalidade global foi de 63,1% – 263 casos que foram analisados separadamente. Constatou-se que mortalidade não foi influenciada, significativamente, por variáveis como idade ou sexo do paciente, causa da ocorrência, calibre do projétil, local de entrada no crânio, presença de hematoma intracraniano ou pelo tratamento instituído. Foram considerados como fatores prognósticos significativos o estado neurológico do paciente, quando de sua internação, e a trajetória do projétil – morreram 93,2% dos pacientes comatosos com ECG < 6 e 91,4% entre os que apresentaram ferimentos em que o projétil cruzou tanto o plano coronal como o sagital. Por outro lado, apenas 1,9% dos pacientes acordados sem sinais neurológicos focais e 3,8% entre os que o projétil não atravessou nenhum dos planos evoluíram para óbito. Levando-se em consideração que o prognóstico quanto à mortalidade é considerado um dos critérios mais importantes a influir sobre a decisão cirúrgica, concluiu-se que pacientes em coma profundo, com lesões bi-hemisféricas e de vários lobos cerebrais, apresentam muito mau prognóstico, com elevada taxa de mortalidade e que, provavelmente, devam ser considerados como fora de possibilidades terapêuticas.

Many healthcare providers are not familiar with the Food and Drug Administration (FDA) vaccine licensure process, the Advisory Committee on Immunization Practices (ACIP) vaccine recommendation process, and how FDA vaccine licensure and ACIP recommendations are related. Vaccines for use in the United States military and civilian populations are licensed by the FDA by several potential pathways but use of licensed vaccines in the civilian population should be based on recommendations made by the ACIP. In performing these distinct activities, FDA and ACIP function under different mandates. In this article, we discuss whether the FDA licensure pathways used to approve a vaccine impacts ACIP recommendation categories for vaccines licensed from 2006 to 2016.

Exposure to war can lead to numerous traumatic experiences affecting the daily lives and personal well-being of the civilian population. However, no research to date has examined the associations between postwar well-being and posttraumatic stress disorder (PTSD) symptoms, tendency to forgive, and social support during and following war. Authors examined a sample of 160 Israeli civilians who were exposed to rocket and missile fire during the 2014 Gaza War. Time 1 (Tl) started approximately one week after the beginning of the war and ended four weeks later following the first 72-hour ceasefire declaration by the United Nations. Respondents were re-approached by personal e-mail approximately one month after T1. A structural equation model design showed that higher postwar tendency to forgive, and social support, are associated with higher postwar well-being. It is notable that higher social support during the war had a negative effect on postwar well-being. In addition, higher posttraumatic symptoms and well-being during the war had a positive effect on higher postwar well-being. The study findings reinforce the importance of personal variables in postwar well-being. However, increased awareness of both social support and PTSD symptoms as "double-edged sword" resources is advisable, considering the different effects of social support and PTSD symptoms on well-being both during and after the war.

Purpose Injured Syrian patients are commonly transferred to local hospitals and field clinics immediately after being injured. Since February 2011, more than 2,000 injured Syrian patients have been transferred to and treated in northern Israeli medical centers. The aim of the present study was to evaluate the epidemiology and general nature of the injuries, with special attention to maxillofacial (MF) injuries. Patients and Methods The medical files of all injured Syrian patients who were treated in 2 major medical centers in northern Israel from December 2012 through December 2015 were reviewed. Computerized data were collected and analyzed based on the cause of injury, anatomic location, Injury Severity Score (ISS) at admission, hospitalization duration, and duration in the intensive care unit. Results The study cohort included 227 patients (204 male [90%], 23 female [10%]; mean age, 24.5 ± 11 yr). The median calculated ISS was 20.6 ± 13.9. The mean interval from injury to recorded admission time was 86.37 hours. Fifty patients had MF injuries (22%). Of these, 45 were adults (44 men, 6 women). Patients' age ranged from 16 to 27.3 years. The mean interval from injury to time of admission was 24 hours and the mean ISS on admission was 24.5 ± 12.7, which was significantly higher than the overall ISS (median, 24.5 vs 16; P = .005). Conclusion Several features observed in the present study had a direct effect on treatment quality and success. Those features included delay from injury to hospital admission; lack of body armor protection, including helmets, which explained the high prevalence of MF injuries; and the multiple sites of injury.

Nonfreezing cold injury has been primarily described in military populations as a result of prolonged exposure to wet environments and cold, but not freezing, temperatures. This type of injury occurs less commonly in the civilian population and in children, but poses a risk for short-term debilitating extremity pain, tissue damage, and infection and for long-term chronic neuropathic pain and temperature intolerance. We describe a case of nonfreezing cold injury in a pediatric hiker.

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

BackgroundIn the United States (U.S.), the overall death rate in 1-4 year-olds had been steadily declining until 2011, after which it ceased to improve. To understand this trend reversal, we investigated trends in the causes of their deaths.MethodsMortality data were obtained from the U.S. Centers for Disease Control and Institute for Health Metrics and Evaluation, firearm background check data from the National Instant Criminal Background Check System, and civilian firearm prevalence from the Small Arms Survey.FindingsIn 1-4 year-olds, the rate of fatal firearm accidents during 2002-2017 increased exponentially at an average rate of 6.0%/year (p=0.0003). The rate of increase was the greatest of all evaluable causes of death in the age group. Both the rate increase and most recent absolute rate in firearm accidental deaths in young children were correlated with the concurrent corresponding rate of firearm background checks (p = 0.0002 and 0.003, respectively). Also, the firearm accidental death rate in countries with high civilian firearm prevalence was correlated with the number of guns per civilian population (p=0.002).InterpretationPrior to 2004, the childhood firearm death rate did not increase during the Federal Assault Weapons Ban. Since 2004 when the Ban ended, the steadily increasing rate of sales and concomitant availability of, and access to, firearms in the U.S. has been associated with an increase in fatal firearm accidents in its youngest children. The acceleration of firearm deaths and injuries among young Americans requires urgent, definitive solutions that address firearm prevalence.FundingNo external funding.KEY POINTSQuestionIn the U.S., how has the escalation of both firearm sales and firearm death rates affected the country’s youngest population?FindingsWhile the steadily increasing rate of sales and concomitant availability of, and access to, firearms in the U.S. has increased since 2004, fatal firearm accidents in 1 to 4 year-olds increased exponentially and at a rate greater than all other evaluable causes of death in the age group.InterpretationThe ominous acceleration of firearm deaths and injuries among young Americans requires urgent, definitive solutions from multiple stakeholders to effectively reduce firearm access.

The authors study the connections between salt resources, salt exploitation and Roman army in Dacia. Even though salt resources are attested almost across the entire province of Dacia (excepting perhaps the western part), the eastern part is the richest not only in salt deposits, but also salt springs. Salt was important not only for the troops (food — nutrition and preservation, hide and leather processing, horses’ and other animals’ alimentation), but also for the civilian population. The army needed salt not only for its own purposes, but for distributing it in the rest of the province. However, despite the important role of the army concerning the salt resources’ protection, we have to pay attention also at he other missions the troops were charged with.

Category: Ankle Arthritis, Orthosis Introduction/Purpose: When it comes to ambulation, the dynamic interplay of anatomy at the foot and ankle affords weight acceptance, stability and force production. The outcome is gait efficiency. Various musculoskeletal injuries challenge gait biomechanics. While surgical management may address the fault in kinetic chain, it may not fully address the problem of pain, functional outcome and patient satisfaction. Non-surgical interventions such as bracing using ankle foot orthoses (AFO) aim to assist, restore and redirect weightbearing forces with immobility in mind. As an energy-storing AFO, however, the IDEO was created to improve functional performance in veterans after limb salvage procedures. The goal of the study was to evaluate outcomes following use of Exosym (or IDEO) bracing for foot and ankle pathologies in the civilian population. Methods: Through review of one institution’s electronic medical record, 29 patients ages 18 years or older who were prescribed the Exosym brace by a single foot and ankle surgeon over a 5-year period were identified. A composite questionnaire including patient-reported outcomes of PROMIS SF Physical Function, PROMIS SF Pain Interference, Brace Use, and EQ-5D was obtained over the phone or by email. Results: A total of 29 patients were prescribed the brace over a 5-year period with only 18 patients receiving the brace. Insurance denying coverage was the most common reason (n=7) for patients not receiving the brace. Of the 18 patients that received the brace, 17 of them were willing to answer the questionnaire. The average age of patients with the Exosym brace was 42.3 (sd=13.8) years old with 6 (35%) being female. Patients with the Exosym brace reported an average score of 47.2 (sd=6.0) for the PROMIS Physical Function and 53.6 (sd=8.4) for the PROMIS Pain Interference. The average satisfaction with the Exosym brace was 65.5 (sd=17.6) out of a possible 100. Conclusion: Exosym bracing in various foot and ankle pathologies provides functionality and pain modulation in the civilian population that rivals respective subpopulation norms. One of the acknowledged limitations of the study is that not obtaining pre- bracing patient reported outcomes precluded evaluation of a minimum clinically important difference. However, the study was not designed to provide such data. It did, however, provide impetus to pursue a follow-up study evaluating plantar pressure changes with and without brace use, which is currently ongoing. Such knowledge may help identify which injuries would be best suited for Exosym bracing.

Key Points Question Is enactment of medical marijuana laws in the United States associated with changes in nonmedical prescription opioid use and prescription opioid use disorder among prescription opioid users overall and by age and racial/ethnic group? Findings This cross-sectional study using individual-level restricted data from the 2004 to 2014 US National Survey on Drug Use and Health showed small increases in nonmedical prescription opioid use and no significant change in prescription opioid use disorder among users after medical marijuana law enactment. Similar patterns were observed across age and racial/ethnic groups. Meaning Medical marijuana law enactment was not associated with a reduction in individual-level nonmedical prescription opioid use, contradicting the hypothesis that people would substitute marijuana for prescription opioids., This cross-sectional study uses data from the US National Survey on Drug Use and Health to estimate changes in nonmedical prescription opioid use and prescription opioid use disorder in states that have legalized the use of medical marijuana., Importance Between 1997 and 2017, the United States saw increases in nonmedical prescription opioid use and its consequences, as well as changes in marijuana policies. Ecological-level research hypothesized that medical marijuana legalization may reduce prescription opioid use by allowing medical marijuana as an alternative. Objectives To investigate the association of state-level medical marijuana law enactment with individual-level nonmedical prescription opioid use and prescription opioid use disorder among prescription opioid users and to determine whether these outcomes varied by age and racial/ethnic groups. Design, Setting, and Participants This cross-sectional study used restricted data on 627 000 individuals aged 12 years and older from the 2004 to 2014 National Survey on Drug Use and Health, a population-based survey representative of the civilian population of the United States. Analyses were completed from March 2018 to May 2018. Exposures Time-varying indicator of state-level medical marijuana law enactment (0 = never law enactment, 1 = before law enactment, and 2 = after law enactment). Main Outcomes and Measures Past-year nonmedical prescription opioid use and prescription opioid use disorder among prescription opioid users. Odds ratios of nonmedical prescription opioid use and prescription opioid use disorder comparing the period before and after law enactment were presented overall, by age and racial/ethnic group, and adjusted for individual- and state-level confounders. Results The study sample included 627 000 participants (51.51% female; 9.88% aged 12-17 years, 13.30% aged 18-25 years, 14.30% aged 26-34 years, 25.02% aged 35-49 years, and 37.50% aged ≥50 years; the racial/ethnic distribution was 66.97% non-Hispanic white, 11.83% non-Hispanic black, 14.47% Hispanic, and 6.73% other). Screening and interview response rates were 82% to 91% and 71% to 77%, respectively. Overall, there were small changes in nonmedical prescription opioid use prevalence after medical marijuana law enactment (4.32% to 4.86%; adjusted odds ratio, 1.13; 95% CI, 1.06-1.20). Prescription opioid use disorder prevalence among prescription opioid users decreased slightly after law enactment, but the change was not statistically significant (15.41% to 14.76%; adjusted odds ratio, 0.95; 95% CI, 0.81-1.11). Outcomes were similar when stratified by age and race/ethnicity. Conclusions and Relevance This study found little evidence of an association between medical marijuana law enactment and nonmedical prescription opioid use or prescription opioid use disorder among prescription opioid users. Further research should disentangle the potential mechanisms through which medical marijuana laws may reduce opioid-related harm.

The effects of a period without physical training on the civilian population are well established. However, no studies show the effects of a period without mandatory physical training on maximum oxygen uptake (VO2 max) and anthropometric parameters in naval cadets. This study aimed to investigate changes in VO2 max and anthropometric parameters after 12 weeks without mandatory physical training in naval cadets. The sample was 38 healthy and physically active naval cadets. The measured variables, including VO2 max and anthropometric parameters, were evaluated through the 12-minute race test (12MRT) and the somatotype. Both variables had a separation of 12 weeks without mandatory physical training. A t-test for related samples was used to evidence changes between the test and post-test; effect size was calculated through Cohen’s d-test. Distance in 12MRT and VO2 max showed significant decreases at the end of 12 weeks without mandatory physical training (p < 0.001). Likewise, the tricipital skinfold thickness and the endomorphic component showed significant increases (p < 0.05). 12 weeks without mandatory physical training significantly reduces the VO2 max in naval cadets. Simultaneously, the same period without physical training increases both the tricipital skinfold thickness and the endomorphic component in this population.

PURPOSEY: The majority of research efforts centering on injury among older adults focus on fall-related injuries and short-term consequences of injury. Little is known about the long-term consequences of all-cause nonfatal injuries, including minor injuries. Using a recent, large, and nationally representative sample of the U.S. non-institutionalized civilian population, the current study examines whether older adults who sustained a nonfatal injury (serious and minor) have higher risk of long-term morbidity and mortality outcomes compared with noninjured seniors. METHODS: Linked National Health Interview Survey-Medical Expenditure Panel Survey (NHIS-MEPS) data were used to fit logistic and 2-part models to estimate associations between injury incidence and later injury, hospitalization incidence, and length of hospital stay during the 2.5 years following the NHIS interview among 16,109 older adults. Data from the linked National Health Interview Survey-National Death Index (NHIS-NDI) files were used to estimate a Cox proportional hazards model to examine the association between injury incidence and mortality for up to 11 years after the initial interview among 79,504 older adults. RESULTS: Relative to no injury, serious nonfatal injury was significantly associated with increased risk of another injury, hospitalization, and mortality. Minor injuries were significantly related to higher risk of later injury and mortality. IMPLICATIONS: Because even minor injuries are strongly associated with increased risks of later injury and mortality, preventing injury among seniors may be an effective way to improve quality of life and reduce declines in functional capacity.

Prevalence and patterns of dietary supplement (DS) use by U.S. Army soldiers differ from the civilian population. Longitudinal trends in use of DSs by civilians have been examined, but are unavailable in subpopulations such as military service members. The present study examined longitudinal changes in DS use by soldiers. A standardized questionnaire on DS use was administered in 2006–2007 (N = 989) and 2010–2011 (N = 1196) to convenience samples of active duty soldiers. Data were weighted for total population demographics of age, sex, and rank. Regular use of DSs by soldiers increased significantly (56% ± 1.6% vs. 64% ± 1.7%; p ≤ 0.001) over the 4 years primarily because of an increase of DS use among the youngest 18- to 24-year-old soldiers (43.0% ± 2.5% vs 62.3% ± 2.4%; p ≤ 0.01). Protein (22% ± 1.4% vs. 26% ± 1.5%; p ≤ 0.001) and combination (10.0% ± 1.0% vs. 24% ± 1.4%; p ≤ 0.001) product consumption also increased over the 4 years. Individual vitamin and mineral use — including iron, magnesium, selenium, and vitamins A, B6, B12, and D — significantly increased as well (p ≤ 0.05). In addition, expenditures on DSs by soldiers increased over time (p < 0.01). Reasons reported by soldiers for DS use suggest use increased to meet the occupational demands of military service. Educational interventions to minimize inappropriate use of DSs by soldiers are necessary to reduce adverse events resulting from unnecessary use of DSs and the financial burden associated with their use.

This year, 2016, marks the centenary of some of the worst battles of World War I. It Is timely to reflect on the experiences of those who lived through those events, and the significant effects on the development of that occurred as a result. War has been a catalyst that has accelerated the development of medicine and surgery throughout history. The challenges of the Western Front, with its massive numbers of injured, saw progress In the understanding and management of trauma and shock, and significant Improvement in the provision of anaesthesia and the training of anaesthesia providers. The result was Increased anaesthetic safety for the civilian population after the war and further development of anaesthesia and resuscitation as a specialised area of medicine.

The low percentage of men in nursing is not a problem outside of the United States or in the U.S. military, which, at 35%, has substantially more men in nursing than the civilian population. 1 In other countries—such as Jordan, New Zealand, the Philippines, and the United Kingdom—the percentage of men in nursing ranges from a high of 38% (in Jordan) to about 9% (in New Zealand). 2,3 In fact, because of the unprecedented surplus of male nurses in Jordan, that country restricted men's admissions into nursing schools to 30%. 2

Background Invasive fungal infections (IFI) following traumatic injury are devastating complications that threaten life and limb. In military combat wounds, post-traumatic IFI patients have up to 6 times higher mortality rates and 2.6-5.1 times higher rate of high-level amputations compared to non-IFI patients, though no such data exists for the civilian population. This study is the first cohort to analyze a post-traumatic civilian population for IFI, its epidemiology and outcomes. Methods We conducted a single-center retrospective cohort study of all trauma patients over the age of 18 years admitted to a large tertiary referral hospital between 2004 to 2015 who required surgery for their injury and had operative cultures submitted from their wounds. Patient demographics, comorbid conditions, mechanisms of trauma, environmental exposures, and laboratory data were included for analysis. Patients with positive culture for fungus from a site compatible with IFI were considered IFI patients. Data was analyzed using descriptive statistics with p≤0.05 considered significant. Results Our cohort includes 1,107 patients that met inclusion criteria. Of these, 120 patients had a positive culture for fungus, 454 patients had a positive culture for bacteria and 533 patients had no positive culture from a site of interest. Basic patient demographics, geographical setting of the trauma, and anatomical site of injury were not significantly associated with having a positive fungal culture. Necrosis was present in 19 (15.8%) IFI vs. 74 (7.5%) non-IFI patients (p=0.002). Soil contamination of a wound was present in 6 (5.0%) IFI vs. 11 (1.1%) non-IFI patients (p=0.001). 55.8% of 120 IFI wounds penetrated below fascial layers compared to 26.7% of 987 non-IFI wounds (p< 0.001). Presence of IFI increased likelihood of requiring amputation (6.7% vs. 2.7%, p=0.02) and prolonged hospitalization >14 days (77.5% vs. 57.4%, p< 0.001) compared to those without. Conclusion IFI significantly increased patient risk for amputation and prolonged hospital length of stay following traumatic injury in a civilian population. Presence of IFI was associated with wounds penetrating below the fascial layer, presence of wound necrosis, and soil contamination of a wound. Disclosures Andrej Spec, MD, MSCI, Astellas (Grant/Research Support)Mayne (Consultant)Scynexis (Consultant)

Background: In the U.S. civilian population, sex differences have been identified in cardiovascular health; these differences have been used to inform care. Our objective is to determine i...

Background: Cranial firearm injuries (CFAIs) are expected to be frequent during warfare; however, it is becoming increasingly common among civilian population in our part of the world. These injuries are associated with significant morbidity and mortality in addition to financial loss. The objective of our study is to evaluate the pattern of gunshot injuries to cranium and their outcome. Methods: The study was conducted on 114 patients presenting with CFAIs to Jinnah Postgraduate Medical Centre, Karachi, Pakistan, between June 2015 and January 2019. Patients were evaluated with respect to age, gender, pattern of injury, Glasgow coma scale on arrival, radiological and clinical assessment, surgical intervention, and Glasgow outcome score measured at 6 months follow-up. Results: Among patients with cranial gunshot, injuries most were males (76.3%). More than 50% patients aged between 18 and 35 years. About 46.5% of patients presented with moderate traumatic brain injury commonly involving the temporal lobe (36.8%). Of total 114 patients, 84.2% were managed conservatively but wound debridement was done in all patients. At 6 months, the overall mortality in our patients was 33.3%. Patients with good outcome (GOS 4 and 5) were 30.7% and 35.9% patients had bad outcome (GOS 2 and 3). Complication rate was 14.9% and the most common complication was disseminated intravascular coagulation in 5.2%. Conclusion: Surgical intervention has no significant benefit over conservative management on long-term mortality and should be limited to patients with large intracranial hematomas and intraventricular hematomas causing hydrocephalus.

Studies have shown stress may lead to diabetes-related morbidities. In recent years during enhanced hostility periods, the population of Southern Israel experienced alert sirens and rocket fire on a daily basis. We investigated whether the exposure to these stressful circumstances, which peaked during three large military operations (MO), was associated with increased glucose levels among the civilian population. We included all fasting serum glucose tests taken between 2007–2014, of Clalit Health Services members in Southern Israel who had at least one fasting glucose test during an MO period and at least one test drawn at other times. We analyzed the association between MO periods and glucose using linear mixed-effects models. We included 408,706 glucose tests (10% during MO periods). Among subjects who reside in proximity to Gaza, glucose levels were 2.10% (95% CI 1.24%; 2.97%) higher in MO days compared to other times. A weaker effect was observed among subjects in more remote locations. In conclusion, we found stress to be associated with increased fasting glucose levels, especially among those who reside in locations in which the intensity of the threat is higher. Since glucose may be a marker of the population at cardiovascular risk, further studies are required.

Meniscal injuries in the young, active patient are often challenging injuries for the orthopaedic surgeon whose goal is to provide pain-free return to play/military duty and preserve maximal meniscal integrity. In the U.S. military, the incidence rate of meniscal tears is almost 10 times higher than that of the civilian population; although, the rates of reoperation following meniscal repair are fairly similar. The decision to pursue meniscal debridement versus repair is multifactorial depending on tear characteristics, concomitant injury, patient characteristics, and goals. Meniscal allograft transplantation remains reserved as a salvage procedure but with limited goals for potential to return to complete unrestricted military duties. The purpose of this article is to review treatment principles for the military athlete with meniscal pathology.

Veterans are more likely than the general civilian population to become homeless (Veteran homelessness: a supplemental report to the annual homeless assessment report to Congress, US Department of Housing and Urban Development and the US Department of Veterans’ Affairs, 2009). While veterans represent 8% of the US population, in 2010, 17% of the homeless were veterans. Nearly 50% of homeless veterans experience mental illness, and two-thirds meet the criteria for substance use disorders (National Survey of Homeless Veterans in 100,000 Homes Campaign Communities, 100,000 Homes, November 2011). Additionally, veterans on average spend nearly 6 years homeless, compared with 4 years for non- veterans. This chapter will summarize the mental health challenges of working with homeless veterans, as well as the initiatives that have recently been implemented to reduce homeless, prevent loss of housing, and address the risk factors associated with veteran homelessness.

The assessment and management of military and veteran traumatic brain injury (TBI) involves the same principles for the civilian population with a few notable caveats. Deployment-related blast injury has resulted in more complex injury patterns and highlighted the need for enhanced care for TBI in the Department of Defense and Department of Veterans Affairs. Both agencies have invested resources to establish systems of care to identify and provide adequate treatment for veterans and service members with traumatic brain injury. Efforts to improve and standardize mild traumatic brain injury diagnosis and treatment include development of clinical practice guidelines utilizing available scientific evidence.

This study investigated the prevalence of eight OGSR compounds in a civilian and a police population. Specimens were collected from the hands and sleeves of 122 civilians and 115 individuals working in police services using carbon stubs. Data was acquired using liquid chromatography coupled to tandem mass spectrometry. Results indicated a non-negligible prevalence in the civilian sample, with 18% of the 122 civilians sampled having one or more OGSR related compounds on their hands and 11.5% on their wrists or sleeves. For the police population, the prevalence was logically higher than for civilians, with 36.5% of the hand specimens and 33% of the wrist specimens positive for one or more compounds. A higher prevalence was expected for the second population due to the possession of service weapons regularly used during shooting exercises. These results demonstrate that the presence of one OGSR compound is not a rare occurrence, even in a civilian population. Considering the results of this research together with information on alternative sources of the targeted OGSR compounds can serve as a basis for OGSR interpretation in casework.

Introduction The proportion of Hispanics in the U.S. Veteran population is expected to increase rapidly in the next several decades. Although Veterans have a heightened smoking risk relative to the civilian population, few studies have examined whether this risk extends to Hispanic Veterans. The aims of the present study were to examine differences in the smoking and cessation characteristics of Hispanic Veterans and Hispanic non-Veterans, and to determine whether these differences persist after controlling for demographics and markers of acculturation. Materials and Methods This was a secondary analysis of the 2014–2015 Tobacco Use Supplement of the Current Population Survey administered by the U.S. Census Bureau. The main analysis included Hispanics aged 18 or older (N = 27,341). Additional analyses were restricted to participants who had smoked at least 100 cigarettes in their lifetime (N = 4,951), and current smokers (N = 2,345). Regressions modeled the associations between Veteran status and demographics, markers of acculturation, smoking characteristics, and cessation behaviors. Additional regressions modeled the associations between Veteran status and the smoking and cessation outcomes while adjusting for demographics and the acculturation variables of U.S. nativity, U.S. citizenship, and English interview language. Probability weights produced nationally representative findings. Results Hispanic Veterans were older, more likely to be male, and more acculturated than Hispanic non-Veterans. Unadjusted analyses revealed that Hispanic Veterans were more likely to be current daily smokers (8.6% vs. 5.7%, p = 0.015) and much less likely to be never smokers (59.3% vs. 81.0%, p < 0.001) compared to Hispanic non-Veterans. These differences were reduced after adjusting for the demographic and acculturation characteristics of the two groups. However, Hispanic Veterans were still less likely to be never smokers compared to non-Veterans after this adjustment (74.3% vs 80.7%, p < 0.001). In unadjusted analyses, Veterans were less likely to have stopped smoking for one day or longer as part of a quit attempt than non-Veterans (33.2% vs 45.4%, p = 0.056), although this was not a significant difference. Use of telephone quit line was very low for both Hispanic Veterans and Hispanic non-Veterans (4.3%). After adjustment, the difference in the likelihood of stopping smoking for one day or longer as part of a quit attempt was increased, becoming statistically significant (31.4% vs 45.8%, p = 0.030). Conclusion Demographic and acculturation differences account for much, but not all, of the differences in the smoking characteristics and cessation behaviors of Hispanic Veterans and Hispanic non-Veterans. These findings suggest that Hispanic Veterans, and Veterans more broadly, should be a focal point for cessation efforts. These efforts should include facilitating access to under-utilized cessation treatments, and providing coordinated cessation care for Veterans being treated for comorbid health conditions.

Background The Advisory Committee on Immunization Practices (ACIP) recommends all persons aged ≥6 months get vaccinated for influenza annually, placing particular emphasis on persons who are at increased risk for influenza-related complications and persons living with or caring for them. Methods Data from the 2016 National Internet Flu Survey (NIFS), a nationally representative, probability-based Internet panel survey of the noninstitutionalized U.S. civilian population aged ≥18 years, was used to compare influenza vaccination coverage among adults who live with household members at high-risk for complications from influenza with those who do not. Logistic regression was used to evaluate the difference in the adjusted vaccination coverage prevalence between persons living with and without high-risk household members. Results From the 2016 NIFS (n = 4,113), we estimated that 29.2% of noninstitutionalized U.S. adults had at least one household member at increased risk for influenza-related complications. Unadjusted influenza vaccination coverage was significantly higher for adults with a high-risk household member compared with those without (46.7% vs 38.6%, respectively). After adjustment for demographic and access-to-care factors, adults with high-risk household members were more likely to be vaccinated than those without (adjusted prevalence difference = 5.3 [0.3, 10.3]). Among vaccinated respondents with high-risk household members, 88.7% reported that protection of their family and close contacts was one of the reasons they were vaccinated. Conclusion Approximately half of adults living with someone at increased risk of complications from influenza did not report receiving an influenza vaccination. Vaccination reminder/recall for persons at increased risk should include reminders for their household contacts.