Multimorbidity and quality of life after blast-related injury among US military personnel: a cluster analysis of retrospective data

Value-based healthcare from a military health system perspective: a systematic review

OBJECTIVES

The aim of this systematic review was to provide an overview of value-based healthcare (VBHC) strategies and/or components within military medicine. For this purpose, the extent to which VBHC has been applied within a military health system (MHS), with emphasis on military trauma care was assessed.

DESIGN

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Medline, Embase, Web of Science CC and the Cochrane CRCT databases were searched from 1946 to present for VBHC strategies and/or components and military settings, including associated keywords.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included observational and trial studies focused on the presence of VBHC components and/or system, and the presence of acute/trauma operational care or definitive postoperational care regarding combat injured service members. The included articles were classified into injury-related and system-level studies.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised methods to search, screen and code included studies. For quality assessment, the Mixed Methods Appraisal Tool version 2018 was used.

RESULTS

A total of 3241 publications were screened, and 18 were included for data extraction. 15 studies focused on (military) medical trauma-related conditions (injury groups), and 3 studies focused on an MHS approach. Four articles contained the two VBHC components ('creating an integrated practice unit' and 'measuring outcomes and costs for every patient') considered the basis for successful implementation. The 'outcomes and costs' and 'patient-centred care' components were most prevalent as respectively mentioned in 17 and 8 included studies.

CONCLUSION

The systematic review showed the application of VBHC components in military medicine, although use of standard VBHC terminology is not consistently applied. This study suggests that implementing VBHC as a concept in military healthcare, could enhance benchmarking to provide insight in health outcomes (both clinically and patient-reported), and overall quality of care.

Anxiety-like Characteristics, Forepaw Thermal Sensitivity Changes and Glial Alterations 1 Month After Repetitive Blast Traumatic Brain Injury in Male Rats

Background

Many military service members are victims of repetitive blast traumatic brain injuries (rbTBI) and endure diverse altered psychological and behavioural conditions during their lifetime. Some of these conditions include anxiety, post-traumatic stress and pain. Thus, this study attempts to fill the knowledge gap on enduring behavioural and neuroinflammatory marker alterations 1 month after rbTBI.

Purpose

Although previous rbTBI animal studies have shown behavioural and histopathological changes either a few days (acute) or many months (chronic) after trauma, knowledge related to post-traumatic changes during the intermediate timeframe, i.e. a month after rbTBI is less clear or unavailable.

Methods

Sprague-Dawley rats (male; n = 12) were assigned to either rbTBI or sham conditions. Animals assigned to the rbTBI group were subjected to 1 blast exposure per day for three consecutive days, while animals in the sham group were exposed to identical experimental conditions sans blast exposure. All animals were tested for anxiety at baseline. 30 days post-injury, animals were tested again for anxiety and paw thermal sensitivity, followed by brain harvest for immunohistochemical analyses.

Results

Animals exposed to rbTBI showed signs of anxiety-like behaviour on parameters of elevated plus-maze and behavioural signs of pain indicated by reduced thermal withdrawal latency of the forepaw. Histologically, brain sections from animals exposed to rbTBI showed a significantly increased number of microglial/macrophage and astrocytic counts in the medial prefrontal cortex.

Conclusion

Data from this initial preclinical study support the prevalence of putative anxiety-like behaviour, enhancement in forepaw thermal sensitivity and increase in the number of glial cells even 1 month after rbTBI. These findings have potential implications in the treatment evaluation of blast-exposed military and civilian populations and emphasise the need for devising protective measures for people susceptible to single or repeated exposures. A greater further understanding of rbTBI-related chronic concurrent behavioural and neuropathological sequela is warranted.

Sex Differences in Postinjury Health Profiles Among U.S. Military Personnel Following Deployment-Related Concussion

Background: Women in the U.S. military are now authorized to serve in direct combat occupations. This may increase their risk of combat injuries, such as concussion, in future conflicts. Knowledge of sex differences in health profiles after concussion is paramount for military medical planning efforts. The purpose of this study was to assess sex-related differences in health profiles among U.S. military personnel following deployment-related concussion. Materials and Methods: We conducted a retrospective study of service members who sustained a concussion during combat deployment between 2004 and 2013. Postinjury diagnoses were abstracted from outpatient encounters in electronic health records for 24 months after concussion. We used hierarchical clustering to identify clusters, termed "health profiles," and logistic regression to determine whether sex predicted membership in the health profiles. Results: The study sample included 346 women and 4536 men with deployment-related concussion. Five postinjury health profiles were identified and classified as no morbidity, back pain, tinnitus/memory loss, posttraumatic stress disorder/postconcussion syndrome, and multimorbidity. Women relative to men had higher odds of membership in the back pain (odds ratio [OR] = 1.32; 95% confidence interval [CI] = 1.05-1.67) and multimorbidity profiles (OR = 1.44; 95% CI = 1.03-2.00) and lower odds than men in the tinnitus/memory loss profile (OR = 0.62; 95% CI = 0.42-0.91). Conclusions: Postinjury health profiles among U.S. service members differ by sex following deployment-related concussion, particularly with a higher burden of multimorbidity among women than men, which may require interdisciplinary care. Women also had higher odds of membership in the back pain profile and lower odds in the tinnitus/memory loss profile than men. To prepare for future military operations where women may have greater exposure to combat, continued research elucidating health-related sex differences after deployment-related concussion is imperative.

Blast-related mild TBI: LIMBIC-CENC focused review with implications commentary

BACKGROUND

A significant factor for the high prevalence of traumatic brain injury (TBI) among U.S. service members is their exposure to explosive munitions leading to blast-related TBI. Our understanding of the specific clinical effects of mild TBI having a component of blast mechanism remains limited compared to pure blunt mechanisms.

OBJECTIVE

The purpose of this review is to provide a synopsis of clinical research findings on the long-term effects of blast-related mild TBI derived to date from the Long-Term Impact of Military-Relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC).

METHODS

Publications on blast-related mild TBI from LIMBIC-CENC and the LIMBIC-CENC prospective longitudinal study (PLS) cohort were reviewed and their findings summarized. Findings from the broader literature on blast-related mild TBI that evaluate similar outcomes are additionally reviewed for a perspective on the state of the literature.

RESULTS

The most consistent and compelling evidence for long-term effects of blast-related TBI is for poorer psychological health, greater healthcare utilization and disability levels, neuroimaging impacts on brain structure and function, and greater headache impact on daily life. To date, evidence for chronic cognitive performance deficits from blast-related mild TBI is limited, but futher research including crucial longitudinal data is needed.

CONCLUSION

Commentary is provided on: how LIMBIC-CENC findings assimilate with the broader literature; ongoing research gaps alongside future research needs and priorities; how the scientific community can utilize the LIMBIC-CENC database for independent or collaborative research; and how the evidence from the clinical research should be assimilated into clinical practice.

Military Exposures Predict Mental Health Symptoms in Explosives Personnel but Not Always as Expected

OBJECTIVE

The aim of this study was to determine the unique and combined associations of various military stress exposures with positive and negative mental health symptoms in active duty service members.

MATERIALS AND METHODS

We investigated 87 male U.S. Navy Explosive Ordnance Disposal (EOD) technicians (age M ± SE, range 33.7 ± 0.6, 22-47 years). Those who endorsed a positive traumatic brain injury diagnosis were excluded to eliminate the confounding effects on mental health symptoms. Using a survey platform on a computer tablet, EOD technicians self-reported combat exposure, deployment frequency (total number of deployments), blast exposure (vehicle crash/blast or 50-m blast involvement), depression, anxiety, posttraumatic stress, perceived stress, and life satisfaction during an in-person laboratory session.

RESULTS

When controlling for other military stressors, EOD technicians with previous involvement in a vehicle crash/blast endorsed worse mental health than their nonexposed counterparts. The interactions of vehicle crash/blast with deployment frequency and combat exposure had moderate effect sizes, and combat and deployment exposures demonstrated protective, rather than catalytic, effects on negative mental health scores.

CONCLUSIONS

Military stressors may adversely influence self-reported symptoms of negative mental health, but deployment experience and combat exposure may confer stress inoculation.

Double Blast Wave Primary Effect on Synaptic, Glymphatic, Myelin, Neuronal and Neurovascular Markers

Explosive blasts are associated with neurological consequences as a result of blast waves impact on the brain. Yet, the neuropathologic and molecular consequences due to blast waves vs. blunt-TBI are not fully understood. An explosive-driven blast-generating system was used to reproduce blast wave exposure and examine pathological and molecular changes generated by primary wave effects of blast exposure. We assessed if pre- and post-synaptic (synaptophysin, PSD-95, spinophilin, GAP-43), neuronal (NF-L), glymphatic (LYVE1, podoplanin), myelin (MBP), neurovascular (AQP4, S100β, PDGF) and genomic (DNA polymerase-β, RNA polymerase II) markers could be altered across different brain regions of double blast vs. sham animals. Twelve male rats exposed to two consecutive blasts were compared to 12 control/sham rats. Western blot, ELISA, and immunofluorescence analyses were performed across the frontal cortex, hippocampus, cerebellum, and brainstem. The results showed altered levels of AQP4, S100β, DNA-polymerase-β, PDGF, synaptophysin and PSD-95 in double blast vs. sham animals in most of the examined regions. These data indicate that blast-generated changes are preferentially associated with neurovascular, glymphatic, and DNA repair markers, especially in the brainstem. Moreover, these changes were not accompanied by behavioral changes and corroborate the hypothesis for which an asymptomatic altered status is caused by repeated blast exposures.

Differences in quality-of-life scores across injury categories by mental health status among injured U.S. military service members and veterans

PURPOSE

Posttraumatic stress disorder (PTSD) and depression are strong predictors of poor health-related quality of life (HRQOL) among injured U.S. military service members (SMs). Patterns of HRQOL between injury categories and injury categories stratified by mental health (MH) symptoms have not been examined. Among deployment-injured SMs and veterans (n = 4353), we examined HRQOL and screening data for PTSD and/or depression within specific injury categories.

METHODS

Participants included those enrolled in the Wounded Warrior Recovery Project with complete data for HRQOL (SF-36) from June 2017 to May 2020. Injuries were categorized using the Barell Injury Diagnosis Matrix (Barell Matrix). Mean physical component summary (PCS) and mental component summary (MCS) scores were calculated for each injury category and stratified by the presence or absence of probable PTSD and/or depression.

RESULTS

The average follow-up time that participants were surveyed after injury was 10.7 years. Most participants were male, non-Hispanic White, served in the Army, and enlisted rank. Mechanism of injury for 77% was blast-related. Mean PCS and MCS scores across the entire sample were 43.6 (SD = 10.3) and 39.5 (SD = 13.3), respectively; 50% screened positive for depression and/or PTSD. PCS and MCS scores were significantly lower within each injury category among individuals with probable PTSD and/or depression than those without.

CONCLUSION

Among deployment-injured SMs, those with probable PTSD and/or depression reported significantly lower HRQOL within injury categories and HRQOL component (i.e., physical or mental) than those without. Findings are consistent with prior reports showing mental health symptoms to be strongly associated with lower HRQOL and suggest integration of mental health treatment into standard care practices to improve long-term HRQOL.

Caring again: Support for parent caregivers of wounded, ill, and/or injured adult children veterans

BACKGROUND

Parents often provide care to adult children veterans with polytrauma, traumatic brain injury, and/or post-traumatic stress disorder.

OBJECTIVE

This two-arm randomized clinical trial compared interventions to help parent caregivers improve their depression, anxiety, and burden and manage care by decreasing troubling and concerning behaviors.

METHODS

Interventions were six one-hour structured one-on-one behavioral sessions (REACH) or six 30-minute prerecorded online educational webinars. Both focused on knowledge, strategies for care, and coping, but REACH sessions were targeted, interactive, and skills-based. Quantitative and qualitative data were collected by telephone. Quantitative analyses included chi-squared test or independent samples t-test and repeated measures mixed linear modeling, with theme development for qualitative data.

RESULTS

There were 163 parent caregivers, mostly mothers. During six months, participants in both arms improved significantly in depression, anxiety, burden, and reported veteran troubling and concerning behaviors. REACH caregivers showed a group by time improvement in concerning behaviors. Benefits included resources, self-reflection, not feeling alone, new skills, improved self-efficacy, and helping others. Specific concerns include exclusion from military and veteran care briefings and concern for the future.

CONCLUSION

The positive response to both interventions provides opportunities for organizations with varying resources to provide support for parent caregivers. Interventions need to be targeted to parents' particular concerns and needs.

Nanowired Delivery of Cerebrolysin with Mesenchymal Stem Cells Attenuates Heat Stress-Induced Exacerbation of Neuropathology Following Brain Blast Injury

Blast brain injury (bBI) following explosive detonations in warfare is one of the prominent causes of multidimensional insults to the central nervous and other vital organs injury. Several military personnel suffered from bBI during the Middle East conflict at hot environment. The bBI largely occurs due to pressure waves, generation of heat together with release of shrapnel and gun powders explosion with penetrating and/or impact head trauma causing multiple brain damage. As a result, bBI-induced secondary injury causes breakdown of the blood-brain barrier (BBB) and edema formation that further results in neuronal, glial and axonal injuries. Previously, we reported endocrine imbalance and influence of diabetes on bBI-induced brain pathology that was significantly attenuated by nanowired delivery of cerebrolysin in model experiments. Cerebrolysin is a balanced composition of several neurotrophic factors, and active peptide fragment is capable of neuroprotection in several neurological insults. Exposure to heat stress alone causes BBB damage, edema formation and brain pathology. Thus, it is quite likely that hot environment further exacerbates the consequences of bBI. Thus, novel therapeutic strategies using nanodelivery of stem cell and cerebrolysin may further enhance superior neuroprotection in bBI at hot environment. Our observations are the first to show that combined nanowired delivery of mesenchymal stem cells (MSCs) and cerebrolysin significantly attenuated exacerbation of bBI in hot environment and induced superior neuroprotection, not reported earlier. The possible mechanisms of neuroprotection with MSCs and cerebrolysin in bBI are discussed in the light of current literature.

Otologic Injuries Secondary to Explosive Attack

The frequency of injuries secondary to terrorist attack explosion is globally increasing. Like any other country, our country experienced multiple suicide bombings in recent years. Otologic injuries may be observed after these kinds of attacks. Considering otologic complaints are well known medical results of explosion attacks, routine otologic evaluation in the first examining hospital-even in case of no relevant complaint- is crucial for establishing causal relation in following forensic medicine evaluation. In this study, 33 cases from 6 suicide bomber attacks in 4 different incidents that happened in Turkey were evaluated for otologic injuries. Two out of three patients were not evaluated for otologic injuries in their first hospital visit. It was considered that 8 cases had a loss of hearing and 9 cases had tympanic membrane rupture secondary to the explosion. Complaints such as hearing loss and tinnitus very often after a bomb attack, we saw that 22 of 33 included patients did not have an ear nose, and throat examination at the time of the incident. In this kind of attack, there can be various life-threatening injuries and therefore relatively less important evaluations such as ENT examination can often be overlooked.

Combat injury profiles among U.S. military personnel who survived serious wounds in Iraq and Afghanistan: A latent class analysis

Background

The U.S. military conflicts in Iraq and Afghanistan had the most casualties since Vietnam with more than 53,000 wounded in action. Novel injury mechanisms, such as improvised explosive devices, and higher rates of survivability compared with previous wars led to a new pattern of combat injuries. The purpose of the present study was to use latent class analysis (LCA) to identify combat injury profiles among U.S. military personnel who survived serious wounds.

Methods

A total of 5,227 combat casualty events with an Injury Severity Score (ISS) of 9 or greater that occurred in Iraq and Afghanistan from December 2002 to July 2019 were identified from the Expeditionary Medical Encounter Database for analysis. The Barell Injury Diagnosis Matrix was used to classify injuries into binary variables by site and type of injury. LCA was employed to identify injury profiles that accounted for co-occurring injuries. Injury profiles were described and compared by demographic, operational, and injury-specific variables.

Results

Seven injury profiles were identified and defined as: (1) open wounds (18.8%), (2) Type 1 traumatic brain injury (TBI)/facial injuries (14.2%), (3) disseminated injuries (6.8%), (4) Type 2 TBI (15.4%), (5) lower extremity injuries (19.8%), (6) burns (7.4%), and (7) chest and/or abdominal injuries (17.7%). Profiles differed by service branch, combat location, year of injury, injury mechanism, combat posture at the time of injury, and ISS.

Conclusion

LCA identified seven distinct and interpretable injury profiles among U.S. military personnel who survived serious combat injuries in Iraq or Afghanistan. These findings may be of interest to military medical planners as resource needs are evaluated and projected for future conflicts, and medical professionals involved in the rehabilitation of wounded service members.

Military Injuries-Understanding Posttraumatic Epilepsy, Health, and Quality-of-Life Effects of Caregiving: Protocol for a Longitudinal Mixed Methods Observational Study

BACKGROUND

Veterans with posttraumatic epilepsy (PTE), particularly those with comorbidities associated with epilepsy or traumatic brain injury (TBI), have poorer health status and higher symptom burden than their peers without PTE. One area that has been particularly poorly studied is that of the role of caregivers in the health of veterans with PTE and the impact caring for someone with PTE has on the caregivers themselves.

OBJECTIVE

In this study, we aim to address the following: describe and compare the health and quality of life of veterans and caregivers of veterans with and without PTE; evaluate the change in available supports and unmet needs for services among caregivers of post-9/11 veterans with PTE over a 2-year period and to compare support and unmet needs with those without PTE; and identify veteran and caregiver characteristics associated with the 2-year health trajectories of caregivers and veterans with PTE compared with veterans without PTE.

METHODS

We conducted a prospective cohort study of the health and quality of life among 4 groups of veterans and their caregivers: veterans with PTE, nontraumatic epilepsy, TBI only, and neither epilepsy nor TBI. We will recruit participants from previous related studies and collect information about both the veterans and their primary informal caregivers on health, quality of life, unmet needs for care, PTE and TBI symptoms and treatment, relationship, and caregiver experience. Data sources will include existing data supplemented with primary data, such as survey data collected at baseline, intermittent brief reporting using ecological momentary assessment, and qualitative interviews. We will make both cross-sectional and longitudinal comparisons, using veteran-caregiver dyads, along with qualitative findings to better understand risk and promotive factors for quality of life and health among veterans and caregivers, as well as the bidirectional impact of caregivers and care recipients on one another.

RESULTS

This study was approved by the institutional review boards of the University of Utah and Salt Lake City Veterans Affairs and is under review by the Human Research Protection Office of the United States Army Medical Research and Development Command. The Service Member, Veteran, and Caregiver Community Stakeholders Group has been formed and the study questionnaire will be finalized once the panel reviews it. We anticipate the start of recruitment and primary data collection by January 2022.

CONCLUSIONS

New national initiatives aim to incorporate the caregiver into the veteran's treatment plan; however, we know little about the impact of caregiving-both positive and negative-on the caregivers themselves and on the veterans for whom they provide care. We will identify specific needs in this understudied population, which will inform clinicians, patients, families, and policy makers about the specific impact and needs to equip caregivers in caring for veterans at home.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/30975.

Health Profiles of Military Women and the Impact of Combat-Related Injury

PURPOSE

The role of women in the United States military is expanding. Women are now authorized to serve in all military occupations, including special operations and frontline combat units, which places them at increased risk of combat exposure and injury. Little is known regarding the impact of these injuries on the health of military women.

METHODS

We conducted a retrospective matched cohort study of women service members who were injured during combat operations in Iraq and Afghanistan. Injured women were individually matched to non-injured controls at a 1:4 ratio. Medical diagnostic codes were abstracted from outpatient encounters in electronic health records, and hierarchical clustering was conducted to identify clusters of diagnostic codes, termed "health profiles." Conditional logistic regression was used to determine whether combat-related injury predicted membership in the profiles.

RESULTS

The study sample included 590 injured women and 2360 non-injured controls. Cluster analysis identified six post-deployment health profiles: low morbidity, anxiety/headache, joint disorders, mixed musculoskeletal, pregnancy-related, and multimorbidity. Combat-related injury predicted membership in the anxiety/headache (odds ratio, 1.73; 95% confidence interval, 1.38-2.16) and multimorbidity (odds ratio, 3.43; 95% confidence interval, 2.65-4.43) profiles.

CONCLUSIONS

Combat-related injury is associated with adverse post-deployment health profiles among military women, and women with these profiles may experience increased health care burden. As future conflicts will likely see a greater number of women with combat exposure and injury, health outcomes research among military women is paramount for the purposes of medical planning and resource allocation.

Symptom profiles following combat injury and long-term quality of life: a latent class analysis

PURPOSE

The purpose of this study was to identify symptom profiles among U.S. military personnel within 1 year after combat injury and assess the relationship between the symptom profiles and long-term quality of life (QoL).

METHODS

The study sample consisted of 885 military personnel from the Expeditionary Medical Encounter Database who completed (1) a Post-Deployment Health Assessment (PDHA) within 1 year following combat injury in Iraq or Afghanistan, and (2) a survey for the Wounded Warrior Recovery Project (WWRP), a longitudinal study tracking patient-reported outcomes (e.g., QoL) in injured military personnel. Fifteen self-reported symptoms from the PDHA were assessed using latent class analysis to develop symptom profiles. Multivariable linear regression assessed the predictive effect of symptom profiles on QoL using the physical (PCS) and mental (MCS) component summary scores from the 36-Item Short Form Survey included in the WWRP. Time between PDHA and WWRP survey ranged from 4.3 to 10.5 years (M = 6.6, SD = 1.3).

RESULTS

Five distinct symptom profiles were identified: low morbidity (50.4%), multimorbidity (15.6%), musculoskeletal (14.0%), psycho-cognitive (11.1%), and auditory (8.9%). Relative to low morbidity, the multimorbidity (β =  - 5.45, p < 0.001) and musculoskeletal (β =  - 4.23, p < 0.001) profiles were associated with lower PCS, while the multimorbidity (β =  - 4.25, p = 0.002) and psycho-cognitive (β =  - 3.02, p = 0.042) profiles were associated with lower MCS.

CONCLUSION

Multimorbidity, musculoskeletal, and psycho-cognitive symptom profiles were the strongest predictors of lower QoL. These profiles can be employed during screening to identify at-risk service members and assist with long-term clinical planning, while factoring in patient-specific impairments and preferences.

Long-Term Outcomes of Service Women Injured on Combat Deployment

Sex- and gender-based health disparities are well established and may be of particular concern for service women. Given that injured service members are at high risk of adverse mental and behavioral health outcomes, it is important to address any such disparities in this group, especially in regard to patient-reported outcomes, as much of the existing research has focused on objective medical records. The current study addressed physical and mental health-related quality of life, mental health symptoms, and health behaviors (i.e., alcohol use, sleep, and physical activity) among a sample of service women injured on deployment. Results indicate that about half of injured service women screened positive for a mental health condition, and also evidenced risky health behaviors including problematic drinking, poor sleep, and physical inactivity. Many of the mental and behavioral health variables demonstrated statistically significant associations with each other, supporting the relationships between psychological health and behaviors. Results provide additional evidence for the importance of access to integrated and effective mental healthcare treatment for injured service women and the need for screening in healthcare settings that address the multiple factors (e.g., mental health symptoms, alcohol use, poor sleep) that may lead to poor outcomes.