Impact of Blast Injury on Hearing in a Screened Male Military Population

Exposure to hazardous intensity levels of combat noise, such as blast, may compromise a person's ability to detect and recognize sounds and communicate effectively. There is little previous examination of the onset of hearing health outcomes following exposure to blast in representative samples of deployed US military personnel. Data from the prospective Blast-Related Auditory Injury Database were analyzed. We included only those participants with qualified hearing tests within a period of 12 months prior to, and following, injury (n = 1,574). After adjustment for relevant covariates and potential confounders, those who sustained a blast injury had significantly higher odds of postinjury hearing loss (odds ratio = 2.21; 95% confidence interval: 1.42, 3.44), low-frequency hearing loss (odds ratio = 1.95; 95% confidence interval: 1.01, 3.78), high-frequency hearing loss (odds ratio = 2.45; 95% confidence interval: 1.43, 4.20), and significant threshold shift compared with a group with non-blast-related injury. An estimated 49% of risk for hearing loss in these blast-injured, deployed military members could be attributed to the blast-related injury event. This study reinforced that it is imperative to identify at-risk populations for early intervention and prevention, as well as to consistently monitor the effects of blast injury on hearing outcomes.

Gender Differences in Posttraumatic Stress Disorder Among U.S. Navy Healthcare Personnel

BACKGROUND

The role of women in the U.S. military has changed markedly over the course of 20th- and 21st-century conflicts. Although women frequently occupy healthcare positions in the military, little is known about gender differences in posttraumatic stress disorder (PTSD) within this occupational subgroup.

MATERIALS AND METHODS

A total of 4275 (667 women and 3608 men) U.S. Navy healthcare personnel supporting military operations in Iraq and Afghanistan were identified from electronic deployment records. Data from Post-Deployment Health Assessments were abstracted to identify PTSD screen positives, and to adjust for self-reported combat exposure and other deployment experiences.

RESULTS

The prevalence of PTSD screen positive in the sample was 8.2% (n = 351/4275). After adjusting for combat exposure, previous psychiatric history, and demographics, women had significantly higher odds of screening positive for PTSD than did men (odds ratio = 1.99, 95% confidence interval 1.34-2.96). Interactions between gender and combat exposure, and between gender and previous psychiatric history were not statistically significant.

CONCLUSIONS

This is one of the first studies to examine gender differences in PTSD among military healthcare personnel. Future research should account for additional stressors, such as long work hours, disrupted sleep patterns, and number of casualties treated. As women are further integrated into military occupations that may lead to different exposures, knowledge of gender differences in the manifestation of PTSD is paramount for prevention and treatment purposes.

Characteristics of maxillofacial injuries and safety of in-theater facial fracture repair in severe combat trauma

The study objectives were to characterize maxillofacial injuries and assess the safety of in-theater facial fracture repair in U.S. military personnel with severe combat trauma from Iraq and Afghanistan. We performed a retrospective chart review of the Expeditionary Medical Encounter Database from 2004 to 2010. 1,345 military personnel with combat-related maxillofacial injuries were identified. Injury severity was quantified with the Abbreviated Injury Scale and Injury Severity Score. Service members with maxillofacial injury and severe combat trauma (Injury Severity Score ≥ 16) were included. The distribution of facial fractures, types, and outcomes of surgical repairs, incidence of traumatic brain injury, concomitant head and neck injuries, burn rate/severity, and rates of Acinetobacter baumannii colonization and surgical site infection were analyzed. The prevalence of maxillofacial injury in the Expeditionary Medical Encounter Database was 22.7%. The most common mechanism of injury was improvised explosive device (65.7%). Midface trauma and facial burns were common. Approximately 64% of the study sample sustained traumatic brain injury. Overall, 45.6% (109/239) had at least one facial bone fracture. Of those with facial fractures, 64.2% (n = 70) underwent surgical repair. None of the service members who underwent in-theater facial fracture repair developed A. baumannii facial wound infection or implant extrusion.

Treatment of Mental or Physical Health Problems in a Combat Zone: Comparisons of Postdeployment Mental Health and Early Separation From Service

The primary aim of this study was to evaluate whether being treated for mental health or nonbattle physical injury during military combat deployment was associated with higher risk for postdeployment mental disorders and poorer career outcomes than seen in the general combat-deployed population. Service members treated in theater for mental health (n = 964) or noncombat injury (n = 853) were compared with randomly sampled personnel (n = 7,220) from the general deployed population on diagnosed mental disorders and early separation from service. Deployment, medical, and career information were obtained from Department of Defense archival databases. Over half of the personnel who received mental health treatment while deployed were diagnosed with 1 or more mental disorders postdeployment and/or were separated from service before completing their full-term enlistment. This was significantly higher than expected compared to the general deployed group, adjusting for demographic/military characteristics and mental health history (adjusted odds ratios [ORs] ranging 1.62 to 2.96). Frequencies of problems also were higher in the mental health-treated group than in the group treated for nonbattle physical injuries (significant adjusted ORs ranging 1.65 to 2.58). The documented higher risks for postdeployment adjustment problems suggested that especially those treated in theater by mental health providers might benefit from postdeployment risk-reduction programs.

Airway Management in Severe Combat Maxillofacial Trauma

OBJECTIVES

Airway stabilization is critical in combat maxillofacial injury as normal anatomical landmarks can be obscured. The study objective was to characterize the epidemiology of airway management in maxillofacial trauma.

STUDY DESIGN

Retrospective database analysis.

SETTING

Military treatment facilities in Iraq and Afghanistan and stateside tertiary care centers.

SUBJECTS

In total, 1345 military personnel with combat-related maxillofacial injuries sustained March 2004 to August 2010 were identified from the Expeditionary Medical Encounter Database using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes.

METHODS

Descriptive statistics, including basic demographics, injury severity, associated injuries, and airway interventions, were collected. A logistic regression was performed to determine factors associated with the need for tracheostomy.

RESULTS

A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was improvised explosive devices (66%), followed by gunshot wounds (8%), mortars (5%), and landmines (4%). Of the subjects, 51.4% required intubation on their initial presentation. Of tracheostomies, 30.4% were performed on initial presentation. Of those who underwent bronchoscopy, 65.2% had airway inhalation injury. There was a significant relationship between the presence of head and neck burn and association with airway inhalation injury (P < .0001). There was also a significant relationship between the severity of facial injury and the need for intubation (P = .002), as well as the presence of maxillofacial fracture and the need for tracheostomy (P = .0001).

CONCLUSIONS

There is a high incidence of airway injury in combat maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.

Airway Management in Severe Combat-Related Maxillofacial Trauma

Objectives:

Airway stabilization is critical in combat-related maxillofacial injury as normal anatomical landmarks can be obscured by blood and debris. The objective of this study was to characterize the epidemiology of airway management in maxillofacial trauma.

Methods:

A total of 1345 military personnel with combat-related maxillofacial injuries were retrospectively identified from the Expeditionary Medical Encounter Database using ICD-9-CM diagnostic codes. Maxillofacial injury severity was quantified with the Abbreviated Injury Scale (AIS). Service members with maxillofacial injury and severe combat trauma were included in the analysis (n = 239). Study variables included the frequency and timing of intubation, presence and severity of burn injury, frequency of tracheostomy, and presence of inhalational injury.

Results:

A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was Improvised Explosive Device (IED) (66%), followed by gunshot wounds (8%), mortar (5%), and landmines (4%). A total of 51.0% of the subjects required intubation on their initial presentation to triage facilities. Field surgical airways were rare, but demonstrated a 75% success rate. Of the patients who underwent bronchoscopy, 65.2% were found to have airway inhalational injury. There was a significant relationship between the severity of facial injury and the need for intubation on initial presentation ( P = .0027). Of the subjects, 19.7% had tracheostomy performed. Furthermore, 12.3% of the study subjects required surgical neck explorations.

Conclusions:

There is a high incidence of airway injury in combat-related maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.

Role of occupation on new-onset post-traumatic stress disorder and depression among deployed military personnel

The purpose of this study was to examine the role of military occupation on new-onset post-traumatic stress disorder (PTSD) and depression among U.S. combat veterans recently returned from deployment to Iraq. Enlisted, active duty Navy and Marine Corps personnel without a history of mental disorder were identified from deployment records and linked to medical databases (n = 40,600). Multivariate logistic regression was used to examine the association between occupation and postdeployment PTSD and depression diagnoses by branch of service. Navy health care specialists had higher odds of new-onset PTSD (odds ratio [OR] 4.53, 95% confidence interval [CI] 2.58-7.94) and depression (OR 2.58, 95% CI 1.53-4.34) compared with Navy functional support/other personnel. In addition, Marine combat specialists had higher odds of new-onset PTSD (OR 1.91, 95% CI 1.48-2.47) and depression (OR 1.36, 95% CI 1.10-1.68) compared with Marine functional support/other personnel. Occupation is associated with the development of new-onset PTSD and depression. The high rates of PTSD and depression among health care specialists warrant further investigation into the potential effects of caregiver stress on mental health.

Deployment-related injury and posttraumatic stress disorder in US military personnel

BACKGROUND

The current military conflicts in Iraq and Afghanistan have resulted in the most US casualties since the Vietnam War. Previous research on the association between deployment-related injury and posttraumatic stress disorder (PTSD) has yielded mixed results.

OBJECTIVES

To examine the effect of battle injury (BI) relative to non-battle injury (NBI) on the manifestation of PTSD symptoms in military personnel and to assess the demographic, injury-specific, and pre-injury factors associated with PTSD following a BI.

PATIENTS AND METHODS

A total of 3403 personnel with deployment-related injury (1777 BI and 1626 NBI) were identified from the Expeditionary Medical Encounter Database. Records were electronically matched to Post-Deployment Health Assessment (PDHA) data completed 1-6 months post-injury. The PTSD screening outcome was identified using a four-item screening tool on the PDHA.

RESULTS

Compared to those with NBI, personnel with BI had more severe injuries, reported higher levels of combat exposure, and had higher rates of positive PTSD screen. After adjusting for covariates, personnel with BI were twice as likely to screen positive for PTSD compared to those with NBI (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.60-2.75). In multivariable analysis among battle-injured personnel only, moderate and serious-severe injury (OR, 1.49; 95% CI, 1.12-2.00 and OR, 1.64; 95% CI, 1.01-2.68, respectively), previous mental health diagnosis within 1 year of deployment (OR, 2.69; 95% CI, 1.50-4.81), and previous BI (OR, 1.96; 95% CI, 1.22-3.16) predicted a positive PTSD screen.

CONCLUSIONS

Military personnel with BI have increased odds of positive PTSD screen following combat deployment compared to those with NBI. Post-deployment health questionnaires may benefit from questions that specifically address whether service members experienced an injury during combat.

Postdeployment symptom changes and traumatic brain injury and/or posttraumatic stress disorder in men

In Operation Iraqi Freedom and Operation Enduring Freedom, blast-related injuries associated with combat are frequent and can result in traumatic brain injury (TBI) symptoms that may be difficult to distinguish from psychological problems. Using data from the Post-Deployment Health Assessment and Reassessment, we identified 12,046 male U.S. Navy sailors and Marines with reported combat exposure from 2008 to 2009. Symptoms potentially associated with blast-related TBI and posttraumatic stress disorder (PTSD) that were reported immediately after deployment were compared with symptoms present several months later. Our study supports others that have found that subjects with blast-related injuries may experience the development or worsening of symptoms during the months following deployment. Additionally, our study found that those who screened positive for PTSD and TBI formed a unique group, with the presence of TBI exacerbating development of PTSD symptoms at reassessment. Providers should recognize the late development of symptoms, consider the possibility of comorbidity, and be prepared to treat multiple symptoms rather than a specific diagnostic category.

Influence of combat blast-related mild traumatic brain injury acute symptoms on mental health and service discharge outcomes

Assessment of acute mild traumatic brain injury (mTBI) symptoms after a combat blast could aid diagnosis and guide follow-up care. Our objective was to document acute mTBI symptoms following a combat blast and to examine associations between acute symptoms and mental health and service discharge outcomes. A retrospective cohort study was conducted with 1656 service personnel who experienced a combat blast-related mTBI in Iraq. Acute mTBI symptoms were ascertained from point-of-injury medical records. The associations between acute symptoms and posttraumatic stress disorder (PTSD), postconcussion syndrome (PCS), and type of service discharge were examined. Disability discharge occurred in 11% of patients, while 36% had a non-disability discharge and 52% had no recorded discharge. A PTSD and PCS diagnosis was made in 19% and 15% of the sample, respectively. The most common acute mTBI symptoms were headache (62.8%), loss of consciousness (LOC) (34.5%), and tinnitus (33.2%). LOC was predictive of PTSD (odds ratio [OR] 1.54; 95% confidence interval [CI] 1.18, 2.00) and PCS (OR 2.08; 95% CI 1.56, 2.77), while altered mental status (OR 1.53; 95% CI 1.07, 2.17) and previous blast history (OR 1.83; 95% CI 1.15, 2.90) also were predictive of PCS. While no acute mTBI symptoms were associated with discharge outcomes, injury severity was associated with disability discharge. LOC after blast-related mTBI was associated with PTSD and PCS, and injury severity was predictive of disability discharge. The assessment of cognitive status immediately after a blast could assist in diagnosing mTBI and indicate a need for follow-up care.

Blast-related mild traumatic brain injury is associated with a decline in self-rated health amongst US military personnel

INTRODUCTION

Mild traumatic brain injury (MTBI) has emerged as the preeminent injury of combat from the recent conflicts in Iraq and Afghanistan. Very little is known about short- and long-term outcomes after combat-related MTBI. As a measure of outcome after injury, self-rated health is a reliable, widely used measure that assesses perceived health. The primary aim of this study was to determine the effect of combat-related MTBI on self-reported health status after return from deployment. The secondary objective was to examine predictors of a decline in self-reported health status amongst US service members with MTBI, as compared to those service members with other minor non-TBI injuries.

PATIENTS AND METHODS

MTBI cases and an injured comparison group were identified from the Expeditionary Medical Encounter Database records of 1129 male, US service members who experienced blast-related injuries in Iraq from March 2004 to March 2008. Self-rated health was assessed from the routinely administered pre- and post-deployment health assessment questionnaires by the following question, "Overall, how would you rate your health during the past month?" Possible responses were "poor", "fair", "good", "very good", or "excellent." A distinction was made between minor and major negative changes in health (i.e., very good to fair) based on these self-rated health outcomes captured post-injury.

RESULTS

For all personnel, post-injury levels of self-rated health were statistically significantly worse than pre-injury health rating. At 6months post-injury, service members with MTBI were 5 times more likely to report a major negative change in health as compared to members with other mild injuries. This association was independent of age, rank, branch of service, Injury Severity Score, mental health diagnosis prior to injury, and having been referred to a health care professional.

DISCUSSION

Blast-related injuries, specifically MTBI, during deployment have negative consequences on service members' perception of health. Future research is needed to improve our understanding of the overall effects of MTBI on health and quality of life.

Injuries from combat explosions in Iraq: injury type, location, and severity

INTRODUCTION

Explosions have caused a greater percentage of injuries in Iraq and Afghanistan than in any other large-scale conflict. Improvements in body armour and field medical care have improved survival and changed the injury profile of service personnel. This study's objective was to determine the nature, body region, and severity of injuries caused by an explosion episode in male service personnel.

MATERIALS AND METHODS

A descriptive analysis was conducted of 4623 combat explosion episodes in Iraq between March 2004 and December 2007. The Barell matrix was used to describe the nature and body regions of injuries due to a combat explosion.

RESULTS

A total of 17,637 International Classification of Diseases, Ninth Revision (ICD-9) codes were assigned to the 4623 explosion episodes, with an average of 3.8 ICD-9 codes per episode. The most frequent single injury type was a mild traumatic brain injury (TBI; 10.8%). Other frequent injuries were open wounds in the lower extremity (8.8%) and open wounds of the face (8.2%), which includes tympanic membrane rupture. The extremities were the body regions most often injured (41.3%), followed by head and neck (37.4%) and torso (8.8%).

CONCLUSION

The results of this study support previous observations of TBI as a pre-eminent injury of the wars in Iraq and Afghanistan, with mild TBI as the most common single injury in this large cohort of explosion episodes. The extremities had the highest frequency of injuries for any one body region. The majority of the explosion episodes resulted in more than one injury, and the variety of injuries across nearly every body region and injury type suggests a complex nature of explosion injuries. Understanding the constellation of injuries commonly caused by explosions will assist in the mitigation, treatment, and rehabilitation of the effects of these injuries.

Psychiatric diagnoses and treatment of U.S. military personnel while deployed to Iraq

Military personnel deployed in support of combat operations are at significantly higher risk for mental health problems. However, much of what we know about combat-related mental health comes from postdeployment assessments. This study describes the mental health of 1,336 treatment-seeking deployed U.S. military personnel and interventions recommended by military mental health providers in Iraq from January 2006 to January 2007. Cases were primarily young enlisted men, most of whom were on their first combat deployment. Marines made up the majority of the cases (60%), but there were also large numbers of Army and Navy personnel. The most common psychiatric diagnoses were anxiety disorders (31%, including 11% with posttraumatic stress disorder), followed by adjustment (27%) and mood disorders (25%, including 22% with depression). Medication was the most commonly prescribed treatment for patients with psychiatric diagnoses but was often combined with recommendations for psychotherapy/counseling and/or behavioral modifications. The findings illustrate the distribution of mental health conditions seen among treatment-seeking troops while actively serving in a combat environment and the interventions recommended for them. Further examination of postdeployment health outcomes may help to facilitate the development of more effective acute intervention strategies in theater.

Repeated concussion among U.S. military personnel during Operation Iraqi Freedom

Concussions are a predominant injury of the conflicts in Iraq and Afghanistan. The aims of this study were to describe repeated concussive events among U.S. military personnel injured in Operation Iraqi Freedom and examine subsequent healthcare utilization. We reviewed clinical records from the Expeditionary Medical Encounter Database to identify service members with repeat concussions. We abstracted demographic and injury-specific variables, calculated time between events, and identified healthcare utilization from electronic medical databases. Overall, 113 personnel experienced more than one concussion between 2004 and 2008. A majority of these incidents were blast related. The median time between events was 40 days, with 20% experiencing a second event within 2 weeks of the first and 87% within 3 months. Time between events was not associated with severity of the second event. Greater severity of the second concussive event was associated with higher postinjury utilization of mental health and neurology services. This study is one of the first to describe repeated concussions in a combat setting. We found that repeated concussions occur within a short interval among deployed personnel, although the effects of the first event are unclear. Further research is needed to define the effect of repeated concussions on the health of combat veterans.

Effect of dwell time on the mental health of US military personnel with multiple combat tours

OBJECTIVE

We investigated the association of the length of time spent at home between deployments, or dwell time, with posttraumatic stress disorder (PTSD) and other mental health disorders.

METHODS

We included US Marine Corps personnel identified from military deployment records who deployed to Operation Iraqi Freedom once (n = 49,328) or twice (n = 16,376). New-onset mental health diagnoses from military medical databases were included. We calculated the ratio of dwell-to-deployment time (DDR) as the length of time between deployments divided by the length of the first deployment.

RESULTS

Marines with 2 deployments had higher rates of PTSD than did those with 1 deployment (2.1% versus 1.2%; P < .001). A DDR representing longer dwell times at home relative to first deployment length was associated with reduced odds of PTSD (odds ratio [OR] = 0.47; 95% confidence interval [CI] = 0.32, 0.70), PTSD with other mental health disorder (OR = 0.56; 95% CI = 0.33, 0.94), and other mental health disorders (OR = 0.62; 95% CI = 0.51, 0.75).

CONCLUSIONS

Longer dwell times may reduce postdeployment risk of PTSD and other mental health disorders. Future research should focus on the role of dwell time in adverse health outcomes.