Military Medicine

Moldenhauer, Matthew R; Gupta, Pankaj; Ma, Helen

doi: 10.1093/milmed/usaf061pmid: 40036785

ABSTRACTIntroductionIn Vietnam veterans, exposure to military toxicants, such as Agent Orange, may be associated with lymphoid malignancies. Toxicant exposure may increase the likelihood of being diagnosed with concurrent lymphoid malignancies, which can occur as composite, discordant, or transformed lymphomas.Materials and MethodsWe conducted a large, retrospective case-control study using the national VA Central Cancer Registry to identify cases of concurrent lymphoid malignancies compared to controls of single lymphoid malignancies and the association with Agent Orange.ResultsThe occurrence of concurrent lymphoid malignancies was rare (n = 128/32,889, 0.4%). The most common concurrent lymphoid malignancy combinations were chronic lymphocytic leukemia (CLL) and diffuse large B-cell lymphoma, CLL and plasma cell neoplasms, CLL and marginal zone lymphoma, and diffuse large B-cell lymphoma and follicular lymphoma. Agent Orange exposure was not associated with increased odds of being diagnosed with concurrent lymphoid malignancies. Though limited in sample size, patients with concurrent lymphoid malignancies did not appear to have a worse survival compared to patients with single lymphoid malignancies. In our qualitative analysis of treatments for those with concurrent diagnoses, veterans primarily underwent first-line treatment for the more aggressive diagnosis, with few requiring treatments for both diagnoses during their clinical course.ConclusionsIn this Vietnam Era cohort, Agent Orange exposure did not appear to influence the development of concurrent lymphoid malignancies. Having a diagnosis of concurrent lymphoid malignancies did not appear to significantly affect patient survival. This will inform counseling of veterans with Agent Orange exposure and has implications for future policy development.

Bowers, Andreanna E; O’Boyle, Ethan; Garg, Rahul; Lyons, James

doi: 10.1093/milmed/usae432pmid: 39825864

ABSTRACTIntroductionHealth Professions Scholarship Program (HPSP) medical students typically enter the military with minimal military experience, commissioning specifically for the scholarship. During medical school, the only required training is a 5- to 6-week officer training course, which is neither specific to medicine nor guaranteed to be at the beginning of school, since it can be taken at any time. This lack of prior experience can lead to decreased confidence and understanding of the HPSP, specifically the medical school timeline leading up to the military match process and overall military. Our study investigated the effect of implementing a new military-specific orientation module on improving students’ confidence and specific knowledge about the HPSP and military training.Materials and MethodsTwo current HPSP students gave a 1-h presentation on the following topics: medical school reimbursements and finances, active duty training, military training, deferrals, the medical school timeline, and the types of medical residencies available associated with the HPSP. The orientation was held for first- and second-year medical students who were either enrolled or interested in the HPSP. The study participants (n = 21) completed a pre- and post-survey that assessed case-based knowledge (12 questions) and students’ confidence levels regarding the program (1 question each for the HPSP, overall military, and medical school timeline leading to the residency match). The pre- and post-survey results were analyzed using Fisher’s exact test to assess the change in students’ confidence and knowledge change after the presentation.ResultsThe program significantly improved students’ confidence in understanding the HPSP (P = .0004), military (P = .003), and medical school timeline leading to the residency match (P = .002). Our study also significantly improved participants’ knowledge regarding reimbursements for medical school supplies (P = .041) and board exams (P = .001), active duty definition (P = .039), and deferment because of failure (P = .010) or fellowship (P = .025).ConclusionOverall, the students felt more confident regarding the HPSP and showed improved knowledge after the orientation program. We found higher baseline knowledge regarding active duty tours, which their coordinators communicate well with HPSP students. Similar orientation programs could effectively improve the onboarding process of incoming HPSP students and those interested in applying for HPSP across multiple medical schools. Such programs can improve long-term student satisfaction and the duration of service following the minimum service commitments. Future research with a larger sample size and prospective design is needed to understand the long-term effects of this increased confidence on overall program satisfaction and military career.

Reed, Grace M; Strickland, Amanda K; Mutchler, Cameron T; Ochoa, Anna R; Asin, Susana N; Blackburn, August N

doi: 10.1093/milmed/usaf046pmid: 39953827

ABSTRACTIntroductionUpper respiratory tract infections are a strain on military that results in lost duty days and an overall reduced readiness of the force. Improved diagnostic testing would enable better force health protection measures and earlier treatment of illness. Lightweight portable devices are preferred for diagnostic testing in austere environments where they are sometimes needed during military deployment. Current diagnostic testing is targeted to specific pathogens despite multiple pathogens that present with similar symptoms. In practice the pathogens that cause upper respiratory tract infections often go unidentified, which could be improved using agnostic or semi-agnostic diagnostic testing. Here, we performed an evaluation of shotgun metagenomic sequencing using the Oxford Nanopore Technologies (ONT) Rapid Sequencing Kit as a method for diagnostic testing of upper respiratory tract infections. This sequencing library preparation kit was chosen because of its ease of use and compatibility with the ONT MinION, a lightweight portable sequencer.Materials and MethodsSamples from patients with symptoms of upper respiratory tract infections were collected at Wilford Hall Ambulatory Surgical Center under an approved IRB protocol. Nasal rinse samples from 59 study participants were tested using the BioFire FilmArray Respiratory 2.1 Panel as well as shotgun metagenomic sequencing using ONT Rapid Sequencing Kit and ONT R9.4.1 flow cells.ResultsA mixture of various viral pathogens was present among the 59 samples used in this study. We observed high specificity and modest sensitivity to detect the identified pathogens using shotgun metagenomic sequencing. Shotgun metagenomic sequencing detected additional pathogens that were missed by the BioFire FilmArray Respiratory 2.1 Panel, which are discussed. Lastly, we observe modest evidence of nonuniformity of the proportion of reads belonging to the pathogen during the duration of sequencing runs, which has implications for improving sensitivity by increasing the amount of sequencing performed.ConclusionsOverall, ONT Rapid Sequencing Kit combined with alignment to a known panel of pathogens has shown great potential utility in our hands for quickly and accurately identifying viral respiratory pathogens. This, combined with its ease of use and portability, makes it a great candidate for further research and development toward a deployable agnostic diagnostic testing platform.

Mu, Thornton S; Romano, Celeste J; Hall, Clinton; Gumbs, Gia R; Conlin, Ava Marie S; Vereen, Rasheda J; Leyenaar, JoAnna K; Goodman, David C

doi: 10.1093/milmed/usaf043pmid: 39994970

ABSTRACTIntroductionMilitary Health System (MHS)-insured newborns receive care in military and civilian hospitals. Differences in delivery location and corresponding payment schemas raise questions regarding possible health system effects on utilization and outcomes. We hypothesize that newborn utilization and clinical outcomes differ between military and civilian hospitals and that the differences may be more pronounced among lower risk newborns (i.e., late preterm and non-preterm infants).Material and MethodsThe newborn cohort comprised live births captured in DoD Birth and Infant Health Research program data from October 2015 through December 2020. Population characteristics, hospital measures, and newborn clinical outcomes were examined using administrative medical data. Descriptive statistics for birth hospitalization and post-discharge events were calculated by the birth hospital (military or civilian) and gestational age cohort (very preterm, 23–31 weeks; moderate preterm, 32–33 weeks; late preterm, 34–36 weeks; and non-preterm ≥37 weeks). Risk-adjusted Poisson regression models compared select birth hospitalization events by birth hospital type, accounting for differences in the newborn population with regard to predicted mortality and diagnoses/procedures associated with the use of special care. Adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) were stratified by gestational age cohort.ResultsOverall, 470,175 singleton live births were included, and the majority of births occurred at civilian vs. military hospitals (63.2% vs. 36.8%), with civilian hospitals caring for a higher percentage of preterm infants (7.2% vs. 5.4%). The use of ancillary imaging studies was higher across all gestational age cohorts at civilian hospitals, whereas hospital admission or an emergency room visit within 30 and 90 days of discharge from the birth hospitalization was more likely to occur among infants born at military hospitals. Compared with newborns born at military hospitals, late preterm and non-preterm infants born at civilian hospitals demonstrated an increased risk for longer birth hospitalizations (late preterm aRR = 1.21, 95% CI, 1.17–1.25; non-preterm aRR = 1.04, 95% CI, 1.03–1.05), more special care days (late preterm: aRR = 1.38, 95% CI, 1.31–1.45; non-preterm: aRR = 1.22, 95% CI, 1.17–1.28), and neonatal intensive care unit admission (late preterm: aRR = 1.31, 95% CI, 1.27–1.35; non-preterm: aRR = 1.42, 95% CI, 1.38–1.45); differences were not observed for very and moderate preterm infants.ConclusionsIn this study of MHS-insured newborns, we observed longer lengths of stay, more special care days, and increased neonatal intensive care unit admissions among late preterm and non-preterm infants born at civilian vs. military hospitals. Across all gestational age cohorts, we observed lower rates of ancillary imaging studies and higher rates of post-discharge hospital admission and emergency room visits among military hospital births. Differences by birth hospital type highlight both improved care opportunities and cost considerations for MHS leadership regarding direct and purchased care for this population.

Frost, Melanie J; Boeke, Danielle K; Flerlage, Erin M; Nores, Brittaney R; Amos, Eric J; Baumgartner, Neal

doi: 10.1093/milmed/usaf006pmid: 39841580

ABSTRACTIntroductionPhysical fitness is an integral part of military readiness, and failure to meet military Physical Fitness Assessment (PFA) standards can severely damage or end careers. Postpartum active duty service members experience a drop in PFA scores and passing rates compared to their pre-pregnancy assessments. Each branch recently extended recovery time to 12 months, but more research is required to see if this change alone is enough to return both active duty and reserve component postpartum personnel to their own preconception PFA outcomes (scores, passing rates, and injury rates) and those of a control group of nullpartum female airmen.Materials and MethodsThe Air Force Fitness Management System II database contains PFA records including demographic data and PFA outcomes among airmen from the total force: active duty, Air Force Reserve (AFR), and Air National Guard (ANG). We extracted data from 2015 to 2019 for three successive PFAs per individual, consisting of 12,971 records for perinatal Airmen and 308,155 records for nulliparous female airmen. We calculated overall PFA scores, passing rates, and exemption rates for active duty and AFR/ANG postpartum and nullpartum airmen, and then performed regressions to determine if differences between these groups persisted when accounting for demographic and prior physical fitness variables.ResultsAlthough 92% of postpartum airmen scored high enough to pass the PFA, their scores decreased from pretest scores by a larger margin than those for nullpartum airmen. Out of a possible 100 points, postpartum AFR/ANG members’ scores decreased more (−4.5 points) than active duty scores (−2.8 points), while nullpartum members’ scores decreased by −0.4 and −0.7, respectively. Nullpartum passing rates remained stable but decreased for both active duty and AFR/ANG postpartum airmen (−4% and −8%). Active duty postpartum airmen experienced a larger increase in component exemptions, which may indicate injury, (+8%) than nullpartum female airmen (+6%). These results were maintained when we controlled for age, officer status, previous pregnancies, and prior physical fitness. Compared with active duty nullpartum female airmen, active duty and AFR/ANG postpartum women had lower scores (−3.23, −6.79), and more than twice the odds of failure (2.44 and 5.42 times higher). AFR/ANG generally are less than half as likely to have a component exemption, but active duty postpartum airmen had 29% higher odds of having a component exemption than nullpartum active duty airmen.ConclusionEven with a 12-month recovery period, postpartum airmen fare worse on all PFA outcome dimensions studied compared to nulliparous airmen and with preconception selves. Perinatal airmen with more experience, education, and access to resources have better PFA outcomes. The U.S. Air Force should consider a comprehensive maternal wellness program including physical fitness programming and medical preventative health accessible to total force perinatal airmen. This would increase operational readiness, retainability, and well-being while decreasing musculoskeletal injuries and associated medical costs.

Gottula, Jessica L; Downey, Abigail G; Shah, Shenika P; Munisteri-Duff, Meghan K; Keyser, Erin A

doi: 10.1093/milmed/usae575pmid: 39774724

ABSTRACTObjectiveFemale sterilization is a common form of contraception in the United States. On June 24, 2022, the United States Supreme Court eliminated the federal standard protecting a woman’s right to abortion via Dobbs v. Jackson Women’s Health Organization. Since that time, there have been anecdotal increases in sterilization requests across the country, although there are no publications demonstrating this change. This study hypothesized that there would be increased female sterilization rates at a Texas military hospital post-Dobbs decision due to state restrictions as compared with a Washington military hospital.MethodsThis study retrospectively reviewed female sterilization rates from March 2022 to April 2023. The average rate of sterilization procedures performed pre-Dobbs decision was compared to the average rate following the Dobbs decision in a Texas and Washington military facility due to different state restrictions. The rates of sterilization were also stratified among demographic groups at the Texas military facility.ResultsFemale sterilizations encompassed 24/230 (10.4%) of the gynecologic surgeries performed pre-Dobbs compared to 110/629 (17.5%) cases performed post-Dobbs (P = .01) in Texas. However, sterilization rates in Washington state remained the same, with 15/80 (18.7%) benign gynecologic surgeries pre-Dobbs and 28/185 (15.1%) post-Dobbs (P = .59). The average age of sterilization pre-Dobbs was 35 years compared to 33 years post-Dobbs (P = .04). Post-Dobbs group was less likely to use a barrier method prior to sterilization (P = 0.01).ConclusionThe reproductive health of military medical beneficiaries at one military hospital was significantly impacted by the Dobbs v. Jackson Women’s Health Organization decision. Rates of female sterilization increased significantly. In addition, patients choosing permanent sterilization were younger and were less likely to use alternative, reversible contraceptive methods prior to surgery. This study demonstrates a significant change in contraceptive choices toward methods that incur greater surgical risks and potential for regret, as well as greater financial costs to the military health system.

Hood, Courtney R; Baxter, Brian J; Puccia, Alyssa R; Patzkowski, Michael S

doi: 10.1093/milmed/usae545pmid: 40037517

ABSTRACTIntroductionThe prophylactic use of oxytocin after cesarean delivery has been shown to reduce maternal blood loss by 40 to 50%, yet there remains significant clinical deviation in how the medication is dosed. In January, 2021, the Defense Health Agency issued Procedural Instruction 6025.35 entitled Guidance for Implementation of the Postpartum Hemorrhage Bundle. This directive established a set of processes and procedures for the risk assessment and treatment of postpartum hemorrhage, including a new standardized oxytocin protocol for vaginal and cesarean deliveries. The purpose of this study was to compare quantitative blood loss after elective cesarean deliveries using the new standardized oxytocin protocol versus the historically unregimented, high-dose strategy. A secondary outcome was the incidence of postpartum hemorrhage, defined as quantitative blood loss greater than 1 l at the time of calculation.MethodsThis single-center, retrospective cohort study compared quantitative blood loss in healthy parturients undergoing elective cesarean deliveries under neuraxial anesthesia that received either high-dose oxytocin (40 international units [IU]) given over an unregulated amount of time via wide open IV infusion (Group H), or a low-dose oxytocin protocol (Group L): 3 IU of oxytocin administered over 3 min, with a second 3 IU bolus if inadequate tone, then oxytocin infused at 18 IU/h for 1 h followed by 3.6 IU/h for 3 h. Exclusion criteria included failed labor induction converted to cesarean delivery, high-risk pregnancy (placental abnormalities, maternal bleeding disorders, gestational hypertension, and pre-eclampsia), those who received general anesthesia, and multiple gestation pregnancies.ResultsSixty-two patients were included for analysis in Group H, and thirty-seven in Group L. A multivariate linear regression model controlling for patient age, gestational age at time of delivery, cesarean section indication, and hemorrhagic medications given found the regimen of oxytocin a patient received did not predict their blood loss (R2 = 0.08, adjusted R2 of −0.003, P = .48). Additionally, the low-dose group had less blood loss by estimated marginal means (769 mL, 95% CI, 526–1011, versus 944 ml, 95% CI, 724–1164, P = .14). The incidence of postpartum hemorrhage was 21.0% in Group H and 13.5% in Group L, P = .09.ConclusionsThis study concludes the low-dose oxytocin protocol released in the Defense Health Agency hemorrhage bundle does not correlate with increased blood loss due to uterine atony when compared to a high-dose strategy for an elective, low-risk cesarean delivery. Future research should be aimed at capturing the side effect profile of this oxytocin dosing strategy, quantitative blood loss analyses in high-risk patients, and its effect on blood transfusion rates.

Penney, Scott W; Watson, Nora L; Brooks, Daniel I; Whiteway, Susan L; Warwick, Anne B; Zanetti, Richard C; Vasta, Lauren M

doi: 10.1093/milmed/usaf054pmid: 40036776

ABSTRACTIntroductionThere is limited research on cancer incidence in pediatric and adolescent/young adult patients using health care claims data and no standard algorithm for such a query. This study aimed to establish an algorithm to estimate incidence rates for multiple cancer types from 2013 to 2017 within the Military Health System and compare them to rates reported from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program.MethodsThe Military Health System Data Repository was queried by International Classification of Diseases 9 and 10 codes using look-back-periods to identify incident cases of leukemia and lymphoma diagnoses. Age-specific incidence rates within the Military Health System were compared to SEER incidence rates using standardized incidence ratios (SIRs).ResultsMilitary Health System incidences derived from our algorithm were similar to SEER incidences for all evaluated cancers in primary analyses. For pediatric dependents: Acute lymphoblastic leukemia (ALL) SIR 1.01 (95% CI, 0.91–1.12), acute myeloid leukemia (AML) 1.10 (95% CI, 0.86–1.36), Hodgkin’s lymphoma 0.93 (95% CI, 0.73–1.16), and non-Hodgkin’s lymphoma (NHL) 1.07 (95% CI, 0.88–1.28). For adult dependents: ALL SIR 1.09 (95% CI, 0.79–1.43), AML 1.19 (95% CI, 0.86–1.59), Hodgkin’s lymphoma 1.19 (95% CI, 1.00–1.40), and NHL 0.85 (95% CI, 0.66–1.06). For active duty patients: ALL SIR 1.38 (95% CI, 0.96–1.87), AML 1.35 (95% CI, 0.94–1.84), Hodgkin’s lymphoma 1.23 (95% CI, 1.01–1.48), and NHL 0.88 (95% CI, 0.67–1.12).DiscussionPediatric incidence rates were similar when compared to SEER rates for leukemia and lymphoma type, suggesting that this algorithm may be used to capture the burden in the military pediatric population and serve as a research tool to evaluate cancer epidemiology and patient outcomes.

Stoffel, Steven T; Juhasz, Sarah A; Wood, Matthew E; Danciu, Theodor; Wiggins, Amanda R; O’Neil, Erika R; Manninen, Erik S

doi: 10.1093/milmed/usaf045pmid: 39985237

ABSTRACTAcute Respiratory Distress Syndrome (ARDS) is a known and severe complication of thoracic trauma. Many patients, despite appropriate ventilator and medical support, continue to worsen requiring additional cardiopulmonary support with extracorporeal membrane oxygenation (ECMO). Additionally, obesity adds a layer of complexity in the management of trauma ARDS on ECMO. We describe the first U.S. Military air transportation mission via Critical Care Air Transport (CCAT) involving the cannulation and transportation of 2 obese trauma patients requiring ECMO support. We reviewed a cohort of 2 obese patients with ARDS secondary to trauma cannulated for venovenous ECMO and simultaneously transferred via Critical Care Air Transport to a DoD ECMO Center. We describe the logistics involved in the transport and management of obese trauma patients on ECMO. Both patients were safely cannulated and transported without complications, and survived their ECMO run and hospital stay. This is the first air transport of 2 obese ECMO patients simultaneously in U.S. Military history. This transport highlights the safety of cannulation and transportation of obese trauma patients, in addition to the flexibility and logistics needed to successfully complete an ECMO military transport.

Exley, Lt Shannon L; Schvey, Natasha A; Ricker, Emily; Raiciulescu, Sorana; Barrett, Amelia S; de la Motte, Sarah J

doi: 10.1093/milmed/usaf025pmid: 39869082

ABSTRACTIntroductionActive duty service members (ADSMs) may be at heightened risk for eating disorders (EDs) and sub-clinical disordered eating (DE). ADSMs are also at a high risk for musculoskeletal injury (MSK-I). Given the risk for EDs/DE among ADSMs as well as robust physical requirements of military training, additional research is needed to elucidate links between DE and risk for MSK-I among ADSMs. The aim of the present study was to assess the prevalence of DE and associations with MSK-I among Marine Corps officers entering a 6 month leadership course.Materials and MethodsThe current cross-sectional study is part of a large, prospective study, the Initiation of Marine Physiological Assessment of Combat Training (IMPACT) study. Participants completed the Eating Disorder Examination-Questionnaire Short (EDE-QS) and self-reported the presence of a recent (≤6 months) MSK-I upon entry to an officer training course. A logistic regression was used to assess the association between elevated DE (EDE-QS ≥15) and recent MSK-I, adjusting for age, race, sex, and commissioning source.ResultsN = 1,382 officers (11.6% female, MAge: 24.8 ± 2.9 years, 26.6% racial/ethnic minority) completed the questionnaires. Seven percent had elevated DE (EDE-QS score ≥15) (female: 10.6%, male: 6.9%, P = .10); 18.3% self-reported recent MSK-I (female: 26.3%, male: 17.3%; P = .009). Females had 17% greater odds of MSK-I compared to males (aOR: 1.17, 95% CI: 1.03-1.33, P = .02). Moreover, females with elevated DE had greater odds of MSK-I than males with elevated DE (aOR= 1.38); among females, odds of MSK-I were greatest among those with elevated DE (aOR= 1.35).ConclusionsIn this sample of Marine officers, DE was associated with greater odds of a recent MSK-I among women only. Results align with previously reported relationships between DE and skeletal health in female athletes. Prospective research is needed to elucidate the temporal nature of these relationships.