A Retrospective Comparison of Five‐Year Health Outcomes Following Upper Limb Amputation and Serious Upper Limb Injury in the Iraq and Afghanistan Conflicts

Outpatient Prescriptions for Insomnia Medications During the First Year Following Combat-Related Amputations

INTRODUCTION

Sleep-related disorders are associated with pain, fatigue, and deficits in cognitive performance, which may interfere with successful rehabilitation. The study objectives were to (1) quantify outpatient prescriptions for insomnia medications during the first year following combat-related amputations, (2) examine longitudinal changes in prescriptions for insomnia medications, and (3) analyze patient characteristics associated with prescriptions for insomnia medications.

MATERIAL AND METHODS

This was a retrospective study of DoD casualty records from the Expeditionary Medical Encounter Dataset and prescriptions for outpatient medications from the Pharmacy Data Transaction Service. Patients were a total of 1,651 U.S. service members who sustained major limb amputations in Operations Iraqi and Enduring Freedom from 2001 through 2017 and had outpatient prescriptions for any medication during the first year postinjury. Prescriptions for medications recommended for insomnia were low-dose antidepressants, anxiolytic sedatives, benzodiazepines, melatonin receptor agonist, and low-dose quetiapine. These prescription medications were analyzed by medication type, postinjury time, and patient characteristics during the first year postinjury.

RESULTS

During the first year postinjury, 78% of patients (1,291 of 1,651) had outpatient prescriptions for insomnia medications, primarily anxiolytic sedative drugs (e.g., zolpidem), averaging a total of 86 prescription days (median = 66). The prevalence of these prescriptions declined substantially during the first year, from 57% of patients during the first quarter to 28% during the fourth quarter postinjury. In univariate analyses, multiple patient characteristics, including high Injury Severity Score, continued opioid and non-opioid analgesic prescriptions, and diagnoses of chronic pain, mood disorder, and posttraumatic stress disorder, were significantly associated with higher prevalence and duration of outpatient prescriptions for insomnia medications.

CONCLUSIONS

The present results indicate a high prevalence of outpatient prescriptions for insomnia medications following combat-related amputations, a prevalence that is substantially higher than previously reported among active duty personnel. These findings can inform DVA/DoD guidelines for amputation care and insomnia among military subpopulations. The results highlight the need for more research on the treatment of insomnia during early postinjury rehabilitation among patients who sustained serious combat injuries.

Health Care Utilization After Major Limb Loss in Adults (18-64) Receiving Care in the Military Health System From 2001 to 2017

OBJECTIVE

To characterize and quantify health care utilization of Military Health System beneficiaries with major limb loss.

DESIGN

Retrospective cohort study.

SETTING

Military treatment facilities and civilian health care facilities that accept TRICARE insurance across the United States.

PARTICIPANTS

A total 5950 adult Military Health System beneficiaries with major limb amputation(s) acquired between January 1st, 2001, and September 30th, 2017 (N=5950).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

This study was an exploratory analysis designed to identify common care specialties, services, and devices utilized by Military Health System beneficiaries with major limb loss.

RESULTS

Most beneficiaries were retirees/dependents (63.3%), men (73.1%), and had a single amputation (88.7%), with a mean age of 42 years. Differences between beneficiary categories were found. Active-duty service members used a larger proportion of inpatient, emergency, primary care, physical and occupational therapy, prosthetics and orthotics, physical medicine and rehabilitation, and psychiatry services than retirees/dependents. Most common procedures included "revision of amputation stump" (57.2%) for the active-duty population and "other amputation below knee" (24.3%) for the retirees/dependents.

CONCLUSIONS

These findings highlight the rehabilitation trajectories of beneficiaries receiving treatment for major limb loss in military and civilian care settings. The results could inform staffing decisions and training programs for military treatment facilities, American trauma centers, rehabilitation hospitals, and outpatient health care providers treating individuals with amputation.

Healthcare Utilization Following Hemipelvectomy or Hip Disarticulation in the Military Health System

INTRODUCTION

Amputations at the hip and pelvic level are often performed secondary to high-energy trauma or pelvic neoplasms and are frequently associated with a prolonged postoperative rehabilitation course that involves a multitude of health care providers. The purpose of this study was to examine the health care utilization of patients with hip- and pelvic-level amputations that received care in the U.S. Military Health System.

MATERIALS AND METHODS

We performed a retrospective review of all patients who underwent a hip- or pelvic-level amputation in the Military Health System between 2001 and 2017. We compiled and reviewed all inpatient and outpatient encounters during three time points: (1) 3 months pre-amputation to 1 day pre-amputation, (2) the day of amputation through 12 months post-amputation, and (3) 13-24 months post-amputation. Health care utilization was defined as the average number of encounter days/admissions for each patient. Concomitant diagnoses following amputation including post-traumatic stress disorder, traumatic brain injury, anxiety, depression, and chronic pain were also recorded.

RESULTS

A total of 106 individuals with hip- and pelvic-level amputations were analyzed (69 unilateral hip disarticulation, 6 bilateral hip disarticulations, 27 unilateral hemipelvectomy, 2 bilateral hemipelvectomies, and 2 patients with a hemipelvectomy and contralateral hip disarticulation). Combat trauma contributed to 61.3% (n = 65) of all amputations. During the time period of 3 months pre-amputation, patients had an average of 3.8 encounter days. Following amputation, health care utilization increased in both the year following amputation and the time period of 13-24 months post-amputation, averaging 170.8 and 77.4 encounter days, respectively. Patients with trauma-related amputations averaged more total encounter days compared to patients with disease-related amputations in the time period of 12 months following amputation (203.8 vs.106.7, P < .001) and the time period of 13-24 months post-amputation (92.0 vs. 49.0, P = .005). PTSD (P = .02) and traumatic brain injuries (P < .001) were more common following combat-related amputations.

CONCLUSIONS

This study highlights the increased health care resource demand following hip- and pelvic-level amputations in a military population, particularly for those patients who sustained combat-related trauma. Additionally, patients with combat-related amputations had significantly higher rates of concomitant PTSD and traumatic brain injury. Understanding the extensive needs of this unique patient population helps inform providers and policymakers on the requirements for providing high-quality care to combat casualties.

All-cause and cause-specific mortality rates after severe extremity injuries among previously deployed active duty service members

BACKGROUND

Previous research has shown that active duty military personnel who sustain extremity injuries while in service are at elevated risk for serious physical and psychological health issues that could affect their long-term functioning and quality of life yet longer-term mortality has not been studied in this population.

OBJECTIVE

To determine whether rates of all-cause and cause-specific mortality are elevated for active duty U.S. service members who sustained traumatic limb injuries in service, compared to the broader population of deploying service members. To assess differences in mortality rates between service members with traumatic limb injuries that did versus did not result in amputation.

DESIGN

Retrospective cohort study; archival Department of Defense deployment, personnel, medical, and death records were combined and analyzed. Standardized mortality ratios (SMR) adjusted for age, sex, and ethnoracial group, along with associated 95% confidence intervals (CIs), were calculated to directly compare all-cause and cause-specific mortality rates in each of the two injury groups to rates in the total study population.

SETTING

Not applicable.

PARTICIPANTS

Service members who deployed in support of the global war on terror between 2001 and 2016 were eligible for inclusion; the final sample included 1,875,206 individuals surveilled through 2019.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

All-cause and cause-specific mortality rates.

RESULTS

Overall, the number of deaths was over three times higher than expected among service members with amputations (SMR = 3.01; CI: 2.36-3.65), and nearly two times higher among those with serious limb injuries not resulting in amputation (SMR = 1.72; CI: 1.54-1.90) when compared to the larger study population. Rates for both internal and external causes of death were significantly elevated among those with limb injuries.

CONCLUSIONS

Long-term mortality rates are elevated among service members with traumatic limb injuries, though mortality patterns may differ based on whether the injury results in amputation. Although further research into causal mechanisms is needed, these results may inform the development of interventions to improve long-term health outcomes among injured military personnel.

Adjustment disorder in the Armed Forces: a systematic review

BACKGROUND

In the UK military, adjustment disorder (AjD) is reported as one of the most diagnosed mental disorders, alongside depression, in personnel presenting to mental health services. Despite this, little is understood about what may predict AjD, common treatment or outcomes for this population.

AIM

The systematic review aimed to summarise existing research for AjD in Armed Forces (AF) populations, including prevalence and risk factors, and to outline clinical and occupational outcomes.

METHOD

A literature search was conducted in December 2020 to identify research that investigated AjD within an AF population (serving or veteran) following the PRISMA guidelines.

RESULTS

Eighty-three studies were included in the review. The AjD prevalence estimates in AF populations with a mental disorder was considerably higher for serving AF personnel (34.9%) compared to veterans (12.8%). Childhood adversities were identified as a risk factor for AjD. AjD was found to increase the risk of suicidal ideation, with one study reporting a risk ratio of 4.70 (95% Confidence Interval: 3.50-6.20). Talking therapies were the most common treatment for AjD, however none reported on treatment effectiveness.

CONCLUSION

This review found that AjD was commonly reported across international AF. Despite heterogeneity in the results, the review identifies several literature gaps.

Acute stress disorder in patients with accidental traumatic fractures: What can we do

AIM

To evaluate the potential influencing factors of acute stress disorder (ASD) in patients with accidental traumatic fractures to provide evidence for clinical nursing care.

DESIGN

A retrospective study.

METHODS

Patients with traumatic fractures treated in our hospital from 1 January 2020 to 30 November 2021 were included. The characteristics of ASD and no ASD patients were assessed.

RESULTS

A total of 468 patients with traumatic fractures were included, the incidence of ASD was 28.20%. Logistic regression analysis showed that age ≤50 years (OR2.918, 95% CI1.994 ~ 3.421), female (OR2.074, 95% CI1.489 ~ 3.375), AIS-ISS at admission ≥20 (OR3.981, 95% CI2.188 ~ 5.091), VAS at admission≥7 (OR2.804, 95% CI2.027 ~ 3.467), introverted personality (OR1.722, 95%CI1.314 ~ 2.432) and CD-RISC at admission≤60 (OR3.026, 95% CI2.338 ~ 4.769) were the risk factors of ASD in patients with traumatic fractures (all p < .05).

CONCLUSIONS

The development of ASD in patients with traumatic fractures is affected by multiple factors. Medical workers should take early and timely management and nursing measures for related risk factors to reduce the occurrence of ASD.

DoD-VA Trauma Infection Research Collaboration

BACKGROUND

In the aftermath of wars, there is a surge in the number of wounded service members who leave active duty and become eligible for healthcare through the Department of Veterans Affairs (VA). Collaborations between the Department of Defense (DoD) and VA are crucial to capture comprehensive data and further understand the long-term impact of battlefield trauma. We provide a summary of the development, methodology, and status of an effective collaboration between the Infectious Disease Clinical Research Program and the St. Louis VA Health Care System with the multicenter, observational Trauma Infectious Disease Outcomes Study (TIDOS), which examines the short- and long-term outcomes of deployment-related trauma.

METHODS

As part of TIDOS, wounded service members who transitioned to participating military hospitals in the United States (2009-2014) were given the opportunity to enroll in a prospective follow-up cohort study to continue to capture infection-related data after their hospital discharge. Enrollees in the TIDOS cohort who left military service and received health care through the VA also had the option of consenting to have relevant VA medical records abstracted and included with the study data. Infections considered to be complications resulting from the initial trauma were examined.

RESULTS

Among 1,336 TIDOS enrollees, 1,221 (91%) registered and received health care through the VA with 633 (47%) consenting to follow-up using VA records and comprising the TIDOS-VA cohort. Of the first 337 TIDOS-VA cohort enrollees, 38% were diagnosed with a new trauma-related infection following hospital discharge (median: 88 days; interquartile range: 18-351 days). Approximately 71% of the infections were identified through DoD sources (medical records and follow-up) and 29% were identified through VA electronic medical records, demonstrating the utility of DoD-VA collaborations. The TIDOS DoD-VA collaboration has also been utilized to assess intermediate and long-term consequences of specific injury patterns. Among 89 TIDOS-VA cohort enrollees with genitourinary trauma, 36% reported sexual dysfunction, 21% developed at least one urinary tract infection, 14% had urinary retention/incontinence, and 8% had urethral stricture. The rate of urinary tract infections was 0.05/patient-year during DoD follow-up time and 0.07/patient-year during VA follow-up time.

CONCLUSIONS

Wider capture of infection-related outcome data through the DoD-VA collaboration provided a clearer picture of the long-term infection burden resulting from deployment-related trauma. Planned analyses include assessment of osteomyelitis among combat casualties with amputations and/or open fractures, evaluation of mental health and social factors related to injury patterns, and examination of health care utilization and cost in relation to infectious disease burdens.

Development of overuse musculoskeletal conditions after combat-related upper limb amputation: a retrospective cohort study

STUDY DESIGN

Retrospective cohort study INTRODUCTION: Service members who have sustained traumatic amputations are typically young and otherwise healthy. Beyond standard care, these individuals desire long, highly active, and relatively pain-free lifestyle, whether that is returning to active duty or transitioning to civilian life. Development of overuse musculoskeletal conditions could have a significant influence on quality of life for Service members with traumatic upper limb amputation.

PURPOSE OF THE STUDY

Compare one-year incidence of overuse musculoskeletal injuries in Service members with different levels of combat-related upper limb amputation to Service members with minor combat-related upper limb injuries.

METHODS

Service members with deployment-related upper limb injury (N = 519), 148 major upper limb amputation (55 with amputation at or above elbow, 93 with amputation below elbow) and 371 minor upper limb injury were included in the study. Outcomes of interest clinical diagnosis codes associated with overuse conditions of the upper limb, neck and upper back, lower limb, low back pain, and all regions combined, one year before and one year after injury.

RESULTS

Overall, the one-year incidence of developing at least one musculoskeletal overuse condition after upper limb amputation was between 60% and 65%. Service members with upper limb amputations were 2.7 to 4.7 times more likely to develop an overuse upper limb condition, 3.6 to 3.8 times more likely to develop a neck and upper back condition, 2.8 to 4.4 times more likely to develop a lower limb condition, and 3.3 to 3.9 times more likely to develop low back pain as compared those who sustained minor combat-related injuries. No significant differences in the odds of developing a musculoskeletal condition was found between the above elbow and below elbow amputation groups.

CONCLUSIONS

Incidence of secondary overuse conditions is elevated in Service members with upper limb amputation and warrants focused research efforts toward preventative and rehabilitative interventions.

A Focus on Non-Amputation Combat Extremity Injury: 2001-2018

INTRODUCTION

Extremity injuries have comprised the majority of battlefield injuries in modern U.S. conflicts since World War II. Most reports have focused on serious injuries only and, to date, no reports have described the full extent of combat extremity injuries, from mild to severe, resulting from post-9/11 conflicts. This study aims to identify and characterize the full spectrum of non-amputation combat-related extremity injury and extend the findings of previous reports.

METHODS

The Expeditionary Medical Encounter Database was queried for all extremity injured service members (SMs) deployed in support of post-9/11 conflicts through July 2018. Only injuries incurred during combat operations were included in this report. Major amputations were excluded as well as SMs killed in action or who died of wounds. Extremity injuries were categorized by body region, nature of injury, and severity. Demographics and injury event characteristics are also presented.

RESULTS

A total of 17,629 SMs sustained 42,740 extremity injuries during 18,004 separate injury events. The highest number of SMs were injured in 2004 (n = 3,553), 2007 (n = 2,244), and 2011 (n = 2,023). Injured SMs were mostly young (78% under 30 years), male (97%), junior- to mid-level enlisted (89%), in the Army (69%) or Marine Corps (28%), active duty (84%), serving as infantry and gun crew (59%), and injured in support of Operation Iraqi Freedom (60%). Blast weaponry was responsible for 75% of extremity injuries. Injuries were similarly distributed between the lower (52%) and upper (48%) extremities. The most common sites of lower extremity injury were the lower leg/ankle complex (40%) and thigh (26%). The most common upper extremities sites were the shoulder and upper arms (37%), and the hand, wrist, and fingers (33%). Nearly half (48%) of all extremity injuries were open wounds (48%), followed by fractures (20%) and contusions/superficial injuries (16%). SMs sustained an average of 2.4 extremity injuries per event and 56% of injuries were considered mild, with a median Injury Severity Score (ISS) of 3.

CONCLUSION

This study is the first publication to capture, review, and characterize the full range, from mild to severe, of non-amputation combat-related extremity injuries resulting from post-9/11 conflicts. The high prevalence of extremity injury, particularly in such a young population, and associated short- and long-term health outcomes, will impact military health care systems for decades to come.

Risk factors of persistent insomnia among survivors of traumatic injury: a retrospective cohort study

STUDY OBJECTIVES

Insomnia is a diagnosis with broad health and economic implications that has been increasingly recognized in military service members. This trend was concurrent with an increase in traumatic wartime injuries. Accordingly, we sought to determine longitudinal predictors of persistent insomnia in combat veterans who sustained traumatic injuries.

METHODS

Retrospective cohort study of service members deployed to conflict zones from 2002-2016, with longitudinal follow-up in the Veterans Affairs and Military Health Systems. Two cohorts were derived: 1) service members who sustained traumatic injuries and 2) an age, sex, and service component matched cohort of uninjured service members who deployed to a combat zone. Insomnia was defined using International Classification of Diseases Ninth Revision or International Classification of Diseases Tenth Revision Clinical Modification codes.

RESULTS

The final population of 17,374 service members was followed from date of injury (or date of matched participant's injury) for a median of 8.4 (IQR 5.3-10.7) years. Service members with traumatic injury were at significantly greater risk of developing insomnia than uninjured service members (HR=1.43, 95% CI 1.30-1.58) after adjustment. Traumatic brain injury (TBI) was associated with insomnia when compared to patients without TBI in the multivariable model: mild/unclassified TBI (HR=2.07, 95% CI 1.82-2.35), moderate/severe/penetrating TBI (HR=2.43, 95% CI 2.06-2.86). Additionally, burn injury (HR=1.95, 95% CI 1.47-2.59) and amputation (HR=1.61, 95% CI 1.26-2.06) significantly increased the risk of a diagnosis.

CONCLUSIONS

Traumatic injuries significantly predicted a diagnosis of insomnia after controlling for mental health disorders. Our findings strongly suggest the need for long-term surveillance of sleep disorders in trauma survivors.

Clinical evaluation of the revolutionizing prosthetics modular prosthetic limb system for upper extremity amputees

Individuals with upper extremity (UE) amputation abandon prostheses due to challenges with significant device weight-particularly among myoelectric prostheses-and limited device dexterity, durability, and reliability among both myoelectric and body-powered prostheses. The Modular Prosthetic Limb (MPL) system couples an advanced UE prosthesis with a pattern recognition paradigm for intuitive, non-invasive prosthetic control. Pattern recognition accuracy and functional assessment-Box & Blocks (BB), Jebsen-Taylor Hand Function Test (JHFT), and Assessment of Capacity for Myoelectric Control (ACMC)-scores comprised the main outcomes. 10 participants were included in analyses, including seven individuals with traumatic amputation, two individuals with congenital limb absence, and one with amputation secondary to malignancy. The average (SD) time since limb loss, excluding congenital participants, was 85.9 (59.5) months. Participants controlled an average of eight motion classes compared to three with their conventional prostheses. All participants made continuous improvements in motion classifier accuracy, pathway completion efficiency, and MPL manipulation. BB and JHFT improvements were not statistically significant. ACMC performance improved for all participants, with mean (SD) scores of 162.6 (105.3), 213.4 (196.2), and 383.2 (154.3), p = 0.02 between the baseline, midpoint, and exit assessments, respectively. Feedback included lengthening the training period to further improve motion classifier accuracy and MPL control. The MPL has potential to restore functionality to individuals with acquired or congenital UE loss.

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

BACKGROUND

No studies have examined the long-term benefits of regional anesthesia (RA) for pain management after combat-related injury. The objective of this prospective cohort study was to examine the relationship between RA administration and patient-reported pain-related outcomes among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members sustaining a combat-related extremity injury.

METHODS

Between 2007 and 2013, n=358 American military personnel injured in OEF/OIF were enrolled at two military treatment facilities. Individuals were followed for up to 2 years after injury. Cohorts were defined based on whether participants were administered RA within 7 days after sustaining a combat-related injury, or not. Linear mixed effects models examined the association between RA and average pain intensity. Secondary outcomes included pain relief, pain interference, neuropathic pain symptoms, treatment outcomes related to pain management, and mental health symptoms.

RESULTS

Receiving early RA was associated with improved average pain over the first 6 months after injury (β=-0.57; p=0.012) adjusting for injury severity and length of stay at the primary treatment facility. This difference was observed up to 24 months after injury (β=-0.36; p=0.046). Individuals receiving early RA reported greater pain relief, improved neuropathic pain intensity, and higher satisfaction with pain outcomes; however, by 24 months, mean scores did not significantly differ between cohorts.

CONCLUSION

Findings indicate that when administered soon after traumatic injury, RA is a valuable pain management intervention. Future longitudinal studies investigating the timely delivery of RA for optimal pain management in civilian trauma settings are needed.

TRIAL REGISTRATION NUMBER

NCT00431847.